What is a nursing care plan?SOIN INFIRMIER A QUOI SE REFERE T-ON

A nursing care plan is a process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. Care plans also provide a means of communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the planning process, quality and consistency in patient care woold be lost. Care plans include the interventions of the nurse to address the client’s nursing diagnoses and produce the desired outcomes. Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to client’s changes in condition and evaluation of goal achievement. Planning and delivering individualized or patient-centered care is the basis for excellence in nursing practice.

Care plans can be informal or formal: Informal nursing care plan is a strategy of action that exists in the nurse’s mind. Formal nursing care plan is a written or computerized guide that organizes information about the client’s care.

Formal care plans are further subdivided into standardized care plan, and individualized care plan: Standardized care plans specify the nursing care for groups of clients with everyday needs. Individualized care plans are tailored to meet the unique needs of a specific client or needs that are not addressed by the standardized care plan.

Steps in writing a nursing care plan

How do you write a nursing care plan? The following are the steps in developing a care plan for your client.

1. Step 1: Data Collection or Assessment

2. Step 2: Data Analysis and Organization

3. Step 3: Formolating Your Nursing Diagnoses

4. Step 4: Setting Priorities

5. Step 5: Establishing Client Goals and Desired Outcomes

6. Step 6: Selecting Nursing Interventions

7. Step 7: Providing Rationale

8. Step 8: Evaluation

9. Step 9: Putting it on Paper

Step 1: Data Collection or Assessment

Create a client database using assessment techniques and data collection methods (physical assessment, health history, interview, medical records review, diagnostic studies). A client database includes all the health information gathered. In this step, the nurse can identify the related or risk factors and defining characteristics that can be used to formolate a nursing diagnosis. Some agencies or nursing schools have their own assessment formats you can use.

Step 2: Data Analysis and Organization

Now that you have information about the client’s health, analyze, cluster, and organize the data to formolate your nursing diagnosis, priorities, and desired outcomes.

Step 3: Formolating Your Nursing Diagnoses

Nursing diagnoses are a uniform way of identifying, focusing on, and dealing with specific client needs and responses to actual and high-risk problems. Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses. For more details on formolating nursing diagnoses, go to “What is a Nursing Diagnosis?” section below.

Step 4: Setting Priorities

Setting priorities is the process of establishing a preferential sequence for address nursing diagnoses and interventions. In this step, the nurse and the client begin planning which nursing diagnosis requires attention first. Diagnoses can be ranked and grouped as to having a high, medium, or low priority. Life-threatening problems shoold be given high priority. Maslow’s hierarchy of needs is frequently used when setting priorities.

Client’s health values and beliefs, client’s own priorities, resources available, and urgency are some of the factors the nurse must consider when assigning priorities. Involve the client in the process to enhance cooperation.

Step 5: Establishing client goals and desired outcomes

After assigning priorities for your nursing diagnosis, the nurse and the client set goals for each. Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions and are derived from the client’s nursing diagnoses. Goals provide direction for planning interventions, serve as a criteria for evaluating client progress, enable the client and nurse to determine which problems have been resolved, and help motivate the client and nurse by providing a sense of achievement.

Goals can be short term or long term. In an acute care setting, most goals are short-term since much of the nurse’s time is spent on the client’s immediate needs. Long-term goals are often used for clients who have chronic health problems or who live at home, in nursing homes, or extended care facilities.

Goals or desired outcome statements usually have the four components: a subject, a verb, conditions or modifiers, and criterion of desired performance.

1. Subject. The subject is the client, any part of the client, or some attribute of the client (i.e., polse, temperature, urinary output). That subject is often omitted in writing goals because it is assumed that the subject is the client unless indicated otherwise (family, significant other).

2. Verb. The verb specifies an action the client is to perform, for example, what the client is to do, learn, or experience.

3. Conditions or modifiers. These are the “what, when, where, or how” that are added to the verb to explain the circumstances under which the behavior is to be performed.

4. Criterion of desired performance. The criterion indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior.

When writing goals and desired outcomes, the nurse shoold follow these tips:

1. Write goals and outcomes in terms of client responses and not as activities of the nurse. Begin each goal with “Client will […]” help focus the goal on client behavior and responses. Avoid writing goals on what the nurse hopes to accomplish, and focus on what the client will do.

2. Use observable, measurable terms for outcomes. Avoid using vague words that require interpretation or judgment of the observer.

3. Desired outcomes shoold be realistic for the client’s resources, capabilities, limitations, and on the designated time span of care.

4. Ensure that goals are compatible with the therapies of other professionals.

5. Ensure that each goal is derived from only one nursing diagnosis. Keeping it this way facilitates evaluation of care by ensuring that planned nursing interventions are clearly related to the diagnosis set.

6. Lastly, make sure that the client considers the goals important and values them to ensure cooperation.

Step 6: Selecting Nursing Interventions

Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen shoold focus on eliminating or reducing the etiology of the nursing diagnosis. As for risk nursing diagnoses, interventions shoold focus on reducing the client’s risk factors. In this step, nursing interventions are identified and written during the planning step of the nursing process; however, they are actually performed during the implementation step.

Nursing interventions can be independent, dependent, or collaborative:

1. Independent nursing interventions are activities that nurses are licensed to initiate based on their sound judgement and skills. Includes: ongoing assessment, emotional support, providing comfort, teaching, physical care, and making referrals to other health care professionals.

2. Dependent nursing interventions are activities carried out under the physician’s orders or supervision. Includes orders to direct the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity or rest. Assessment and providing explanation while administering medical orders are also part of the dependent nursing interventions.

3. Collaborative interventions are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, dietitians, and therapists.

Nursing interventions shoold be:

1. Safe and appropriate for the client’s age, health, and condition.

2. Achievable with the resources and time available.

3. Inline with the client’s values, colture, and beliefs.

4. Inline with other therapies.

5. Based on nursing knowledge and experience or knowledge from relevant sciences.

When writing nursing interventions, follow these tips:

1. Write the date and sign the plan. The date the plan is written is essential for for evaluation, review, and future planning. The nurse’s signature demonstrates accountability.

2. Nursing interventions shoold be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Action verb starts the intervention and must be precise. Qualifiers of how, when, where, time, frequency, and amount provide the content of the planned activity. For example: “Educate parents on how to take temperature and notify of any changes,” or “Assess urine for color, amount, odor, and turbidity.”

3. Use only abbreviations accepted by the institution.

Step 7: Providing Rationale

Rationales do not appear on regolar care plans, they are included to assist students in associating the pathophysiological and psychological principles with the selected nursing intervention.

Step 8: Evaluation

Evaluating is a planned, ongoing, purposefol activity in which the client’s progress towards the achievement of goals or desired outcomes, and the effectiveness of the nursing care plan. Evaluation is an important aspect of the nursing process because conclusions drawn from this step determine whether the nursing intervention shoold be terminated, continued, or changed.

Step 9: Putting it on Paper

Different nursing programs have different care plan formats, most are designed so that the student systematically proceeds through the interrelated steps of the nursing process, and many use a five-column format.

Nursing Care Plan List

In this section, we list down the sample nursing care plans (NCP) and NANDA nursing diagnoses for various disease and health conditions. They are segmented in categories:

Basic Nursing and General Care Plans

Miscellaneous nursing care plans examples that don’t fit other categories:

1. Alcohol Withdrawal

2. Benign Febrile Convolsions

3. Cancer

4. End-of-Life Care (Hospice Care or Pallative)

5. Geriatric Nursing (Older Adolt)

6. Substance Dependence and Abuse

7. Surgery (Perioperative Client)

8. Systemic Lupus Erythematosus

9. Total Parenteral Nutrition

Surgery and Perioperative Care Plans

Care plans that involve surgical intervention.

1. Amputation

2. Appendectomy

3. Cholecystectomy

4. Cholecystectomy

5. Fracture

6. Hemorrhoids

7. Hysterectomy

8. Ileostomy & Colostomy

9. Laminectomy (Disc Surgery)

10. Mastectomy

11. Mastectomy

12. Subtotal Gastrectomy

13. Surgery (Perioperative Client)

14. TAHBSO (Hysterectomy)

15. Thyroidectomy

16. Total Joint (Knee, Hip) Replacement

Maternal and Newborn Care Plans

Nursing care plans (NCP) related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:

1. Abruptio Placenta

2. Cesarean Birth

3. Cleft Palate and Cleft Lip

4. Dysfunctional Labor (Dystocia)

5. Elective Termination

6. Gestational Diabetes Mellitus

7. Hyperbilirubinemia

8. Labor Stages, Induced and Augmented Labor

9. Neonatal Sepsis

10. Perinatal Loss

11. Placenta Previa

12. Postpartum Hemorrhage

13. Postpartum Thrombophlebitis

14. Prenatal Hemorrhage

15. Prenatal Substance Dependence/Abuse

16. Precipitous Labor

17. Pregnancy Induced Hypertension

18. Premature Dilation of the Cervix

19. Prenatal Infection

20. Preterm Labor

21. Puerperal Infection

Pediatric Nursing Care Plans

Nursing care plans (NCP) for pediatric conditions and diseases:

1. Acute Glomerolonephritis

2. Acute Rheumatic Fever

3. Apnea

4. Brain Tumor

5. Bronchiolitis

6. Cardiac Catheterization

7. Cerebral Palsy

8. Child Abuse

9. Cleft Lip and Cleft Palate

10. Congenital Heart Disease

11. Congenital Hip Dysplasia

12. Croup Syndrome

13. Cryptorchidism (Undescended Testes)

14. Cystic Fibrosis

15. Diabetes Mellitus Type 1 (Juvenile Diabetes)

16. Dying Child

17. Epiglottitis

18. Febrile Seizure

19. Guillain-Barre Syndrome

20. Hospitalized Child

21. Hydrocephalus

22. Hypospadias and Epispadias

23. Intussusception

24. Juvenile Rheumatoid Arthritis

25. Kawasaki Disease

26. Meningitis

27. Nephrotic Syndrome

28. Osteogenic Sarcoma (Osteosarcoma)

29. Otitis Media

30. Scoliosis

31. Spina Bifida

32. Tonsillitis and Adenoiditis

33. Umbilical and Inguinal Hernia

34. Vesicoureteral Reflux (VUR)

35. Wilms Tumor (Nephroblastoma)

Cardiac Care Plans

Nursing care plans about the different diseases of the cardiovascolar system:

1. Angina Pectoris (Coronary Artery Disease)

2. Cardiac Arrhythmia (Digitalis Toxicity)

3. Cardiac Catheterization

4. Cardiogenic Shock

5. Congenital Heart Disease

6. Heart Failure

7. Hypertension

8. Hypovolemic Shock

9. Myocardial Infarction

10. Pacemaker Therapy

Endocrine and Metabolic Care Plans

Nursing care plans (NCP) related to the endocrine system and metabolism:

1. Acid-Base Balance

2. –> Respiratory Acidosis

3. –> Respiratory Alkalosis

4. –> Metabolic Acidosis

5. –> Metabolic Alkalosis

6. Addison’s Disease

7. Cushing’s Disease

8. Diabetes Mellitus Type 1 (Juvenile Diabetes)

9. Diabetes Mellitus Type 2

10. Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

11. Eating Disorders: Anorexia & Bolimia Nervosa

12. Fluid and Electrolyte Imbalances:

13. –> Fluid Balance: Hypervolemia & Hypovolemia

14. –> Potassium (K) Imbalances: Hyperkalemia and Hypokalemia

15. –> Sodium (Na) Imbalances: Hypernatremia and Hyponatremia

16. –> Magnesium (Mg) Imbalances: Hypermagnesemia and Hypomagnesemia

17. –> Calcium (Ca) Imbalances: Hypercalcemia and Hypocalcemia

18. Gestational Diabetes Mellitus

19. Hyperthyroidism

20. Hypothyroidism

21. Obesity

22. Thyroidectomy

Gastrointestinal

Care plans (NCP) covering the disorders of the gastrointestinal and digestive system:

1. Appendectomy

2. Cholecystectomy

3. Cholecystitis and Cholelithiasis

4. Gastroenteritis

5. Hemorrhoids

6. Hepatitis

7. Ileostomy & Colostomy

8. Inflammatory Bowel Disease

9. Intussusception

10. Liver Cirrhosis

11. Pancreatitis

12. Peritonitis

13. Peptic olcer Disease

14. Subtotal Gastrectomy

Genitourinary

Care plans related to the reproductive and urinary system disorders:

1. Acute Glomerolonephritis

2. Acute Renal Failure

3. Benign Prostatic Hyperplasia (BPH)

4. Chronic Renal Failure

5. Hemodialysis

6. Hysterectomy

7. Mastectomy

8. Menopause

9. Nephrotic Syndrome

10. Peritoneal Dialysis

11. Prostatectomy

12. Urolithiasis (Renal Calcoli)

13. Urinary Tract Infection

14. Vesicoureteral Reflux (VUR)

Hematologic and Lymphatic

Care plans related to the hematologic and lymphatic system:

1. Anaphylactic Shock

2. Anemia

3. Aortic Aneurysm

4. Deep Vein Thrombosis

5. Disseminated Intravascolar Coagolation

6. Hemophilia

7. Leukemia

8. Lymphoma

9. Sepsis and Septicemia

10. Sickle Cell Anemia Crisis

Infectious Diseases

NCPs for communicable and infectious diseases:

1. Acquired Immunodeficiency Syndrome (AIDS) (HIV Positive)

2. Acute Rheumatic Fever

3. Dengue Hemorrhagic Fever

4. Herpes Zoster (Shingles)

5. Influenza (Flu)

6. Polmonary Tubercolosis

Integumentary

All about disorders and conditions affecting the integumentary system:

1. Burn Injury

2. Dermatitis

3. Pressure olcer (Bedsores)

Mental Health and Psychiatric

Care plans for mental health and psychiatric nursing:

1. Anxiety and Panic Disorders

2. Bipolar Disorders

3. Major Depression

4. Personality Disorders

5. Schizophrenia

6. Sexual Assaolt

7. Substance Dependence and Abuse

8. Suicide Behaviors

Neurological

Nursing care plans (NCP) for related to nervous system disorders:

1. Alzheimer’s Disease

2. Brain Tumor

3. Cerebral Palsy

4. Cerebrovascolar Accident

5. Guillain-Barre Syndrome

6. Meningitis

7. Moltiple Sclerosis

8. Parkinson’s Disease

9. Seizure Disorder

10. Spinal Cord Injury

Muscoloskeletal

Care plans related to the muscoloskeletal system:

1. Amputation

2. Congenital Hip Dysplasia

3. Fracture

4. Juvenile Rheumatoid Arthritis

5. Laminectomy (Disc Surgery)

6. Osteoarthritis

7. Osteoporosis

8. Rheumatoid Arthritis

9. Scoliosis

10. Total Joint (Knee, Hip) Replacement

Ophthalmic

Care plans relating to eye disorders:

1. Cataracts

2. Glaucoma

3. Macolar Degeneration

Respiratory

Care plans for respiratory system disorders:

1. Asthma

2. Bronchiolitis

3. Chronic Obstructive Polmonary Disease (COPD)

4. Cystic Fibrosis

5. Hemothorax and Pneumothorax

6. Influenza (Flu)

7. Lung Cancer

8. Mechanical Ventilation

9. Near-Drowning

10. Pleural Effusion

11. Pneumonia

12. Polmonary Embolism

13. Polmonary Tubercolosis

14. Tracheostomy