[hen-ui-text variant=”b4″]This page can help you understand nursing care plans, how they improve nursing team communication and patient care, and how to develop nursing care plans for your patients. Nursing care plans are individualized and ensure consistency for nursing care of the patient, document patient needs and potential risks, and help patients and nurses work collaboratively toward optimal outcomes.[/hen-ui-text][hen-ui-heading variant=”h2″]What Is a Nursing Care Plan?[/hen-ui-heading][hen-ui-text variant=”b4″]Nursing care plans are a vital part of the nursing process. They provide a centralized document of the patient’s condition, diagnosis, the nursing team’s goals for that patient, and measure of the patient’s progress. Nursing care plans are structured to capture all the important information for the nursing team in one place.[/hen-ui-text][hen-ui-text variant=”b4″]Because they centralize this information and updates, they ensure that everything important is documented and available to all team members. This also makes [hen-ui-link href=”/articles/tips-to-improve-patient-education/”]patient education[/hen-ui-link] easier, since all nursing staff members know and can reinforce what the patient needs to learn.[/hen-ui-text][hen-ui-text variant=”b4″]Without nursing care plans, communication can become disjointed, patient information might be scattered across different patient records and databases, or nursing staff might have to rely on verbal handoffs that the new nurse may mishear or even forget if they are dealing with multiple crises at once.[/hen-ui-text][hen-ui-heading variant=”h2″]Developing a Nursing Care Plan[/hen-ui-heading][hen-ui-text variant=”b4″]Nursing care plans include the initial patient assessment and diagnosis, the desired outcomes and how to achieve them, and an evaluation of the patient’s results. While the names of the individual parts may vary from organization to organization (for example, “implementation” in one plan might be called “intervention” in another), all nursing care plans include these fundamental components.[/hen-ui-text][hen-ui-text variant=”b4″]Many, but not all, nursing care plans include rationales, the reasons for an intervention, while others require them only if there is some reason not to provide the standard intervention.[/hen-ui-text][hen-ui-text variant=”b4″]Nursing plans should be holistic and take account of nonclinical needs where possible, such as preferences for chaplain services or other ways to support the patient’s mental well-being.[/hen-ui-text][hen-ui-list variant=”ordered” bullet-style=”check”] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h4″]Patient Assessment[/hen-ui-heading] [hen-ui-text variant=”b4″]Patient assessment includes a thorough evaluation of subjective and objective symptoms and vital signs. Nurses are responsible for collecting and maintaining this data, although certified nursing assistants may help collect vital signs.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h4″]Nursing Diagnoses[/hen-ui-heading] [hen-ui-text variant=”b4″]A nursing diagnosis is created by a nurse based on the subjective and objective data collected during the patient assessment. This is separate from a medical diagnosis which must be provided by a physician or nurse practitioner. Nurses select standardized diagnoses approved by the North American Nursing Diagnosis Association (NANDA) that are relevant to the patient’s condition, symptoms, and risks.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h4″]Anticipated Outcomes/Goals[/hen-ui-heading] [hen-ui-text variant=”b4″]This section describes the goals for the patient, usually both short-term goals, such as reduction of pain or improvement in symptoms or vital signs, as well as long-term goals, such as recovery within a certain time frame. The goals are directly related to the nursing diagnosis.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h4″]Implementation[/hen-ui-heading] [hen-ui-text variant=”b4″]Implementation describes how the nursing team can work to achieve these goals. Specific nursing interventions are planned based on the goals. This section also documents what nursing-specific care the nursing team has performed for the patient.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item] [hen-ui-list-item][hen-ui-flex direction=”column” gap=”xxs”] [hen-ui-heading variant=”h4″]Evaluation[/hen-ui-heading] [hen-ui-text variant=”b4″]This section describes how well the patient’s condition responded to the nursing interventions or, in other words, how the goals were or were not met. If the goals were not met, the nurse revises the plan. If the goals were met, the nurse may decide to add more goals and interventions.[/hen-ui-text] [/hen-ui-flex][/hen-ui-list-item][/hen-ui-list][hen-ui-flex gap=”xl” align=”left” direction=”column”][hen-ui-flex gap=”xs” align=”left” direction=”column”][hen-ui-heading variant=”h2″]Popular Online RN-to-BSN Programs[/hen-ui-heading][hen-ui-text variant=”b4″ color=”subtext”]Learn about start dates, transferring credits, availability of financial aid, and more by contacting the universities below.[/hen-ui-text][/hen-ui-flex][hen-ui-dynamic-experience placement=”belowTheFold” /][/hen-ui-flex][hen-ui-heading variant=”h2″]Nursing Care Plan Do’s and Don’ts[/hen-ui-heading][hen-ui-text variant=”b4″]While nursing care plans are created to document the care you are providing for your patient, there are “Do’s and Don’ts” to writing an effective care plan. Here are a few:[/hen-ui-text][hen-ui-grid columns-md=”2″ gap=”sm”] [hen-ui-card variant=”background-white” border=”stroke” padding=”lg”] [hen-ui-card-content] [hen-ui-heading variant=”h3″]Don’t[/hen-ui-heading][hen-ui-list variant=”unordered” bullet-style=”bullet”] [hen-ui-list-item][hen-ui-text variant=”b4″]Focus too much on medicine, taking a generalized approach to healing[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Forget to document your assessment, diagnosis, expected outcomes, interventions, and rationale[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Write sarcastic, rude, or offensive notes[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Be afraid to ask for help or have someone look over your care plan[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Be too broad with your documentation (it can cause confusion and misinterpretation)[/hen-ui-text][/hen-ui-list-item][/hen-ui-list] [/hen-ui-card-content][/hen-ui-card][hen-ui-card variant=”background-white” border=”stroke” padding=”lg”] [hen-ui-card-content] [hen-ui-heading variant=”h3″]Do[/hen-ui-heading][hen-ui-list variant=”unordered” bullet-style=”bullet”] [hen-ui-list-item][hen-ui-text variant=”b4″]Understand that not all medicine works for every patient; remember the individual patient’s unique needs[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Focus on evidenced-based practices that result in positive patient outcomes[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Keep in mind that your care plan can be used in court if you ever find yourself in a legal case[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Keep patient safety in the center of your documentation[/hen-ui-text][/hen-ui-list-item] [hen-ui-list-item][hen-ui-text variant=”b4″]Use your care plan as a tool to communicate your patients’ needs and wants with your team members[/hen-ui-text][/hen-ui-list-item][/hen-ui-list] [/hen-ui-card-content][/hen-ui-card][/hen-ui-grid][hen-ui-heading variant=”h2″]Using a Nursing Care Plan[/hen-ui-heading][hen-ui-text variant=”b4″]In addition to centralizing information, nursing care plans are one of the most effective tools for nurses to uphold the [hen-ui-link href=”/resources//nursing-code-of-ethics/”]nursing code of ethics[/hen-ui-link] and to document that they did so in case of lawsuits or accusations of failure to adhere to care standards. This is one of the many reasons for all nurses and nursing assistants to understand and update each patient’s nursing care plan when necessary.[/hen-ui-text][hen-ui-text variant=”b4″]Unlike most electronic health records systems, nursing care plans are designed to address the patient’s holistic needs which helps provide a better patient experience. When all members of a care team have access to all the information about a patient’s needs and preference, everyone stays on the same page.[/hen-ui-text][hen-ui-text variant=”b4″]Many organizations have their own preferred formats for nursing care plans, but if you are looking for models to update your existing nursing care plan or implement a new one, you can find samples and templates from [hen-ui-link href=”https://craighospital.org/uploads/CarePlanGuide.NurseStudent.pdf”]Craig Hospital[/hen-ui-link] and [hen-ui-link href=”https://nursinghomehelp.org/educational/care-plan-examples/”]Nursing Home Help[/hen-ui-link].[/hen-ui-text][hen-ui-text variant=”b4″ tag=”em”]Page last reviewed July 26, 2021[/hen-ui-text]