Nursing care plans are not intended to be the bane of your nursing school journey. I promise. They certainly can be anxiety inducing, but I promise they are a great learning tool for nursing students as well as a helpful guideline for practicing nurses.
If you are struggling to create nursing care plans or simply want another perspective, then follow this step-by-step guide on how to create a nursing care plan.
In order to create a nursing care plan, it is important to understand the nursing process and how to use a nursing diagnosis handbook so make sure you brush up on those topics if you have not already.
Recommended: The Nursing Process & How To Use A Nursing Diagnosis Handbook
First things first, what even is a nursing care plan?!
Well, the answer is in its name. It is a plan of care that is tailored to the specific needs of a patient. Nursing care plans are a way for nurses to plan nursing interventions to improve existing issues and prevent other issues from arising.
This care plan is utilized by all the nurses that care for the patient and the care plan is continually modified as the patient’s status changes.
What is included in a nursing care plan?
Nursing care plans consist of the following:
- Nursing diagnoses addressing actual and potential problems
- Goals/outcome for the patient’s problems
- Nursing interventions that guide the care the nurse provides for the patient
- Evaluation of implemented care plan
Here’s a video that covers the highlights of the info in this post if you would rather watch a video. 🙂
Step One- Assessment
As with the nursing process, our process of creating a nursing care plan begins with assessment. During your clinical rotation you will complete a head-to-toe assessment on the patient that you are caring for.
As a nursing student you are still perfecting your assessment skills, so it is ok to recruit a preceptor or nursing instructor to help you identify and classify certain abnormal findings. It is also important to keep in mind that the holistic nursing assessment is more than just the physical assessment; be sure to account for the psychological, sociological, developmental, spiritual, and cultural aspects of the patient as well.
You will want to keep a good record of all the abnormal findings as these will be integral in your care plan (it is the information that you will base the entirety of your care plan on). Gather as much information as you can about your patient.
Once you have gathered and organized all your information, or “evidence”, you will move on to the next step.
Step Two- Diagnosis
As you are likely very aware, as nurses we do not give medical diagnoses; we are not medical doctors. We cannot give a diagnosis of “heart failure” or “cancer”.
As nurses we utilize what are referred to as nursing diagnoses.
There are three parts of a nursing diagnosis:
- Problem
- Etiology
- Signs & symptoms
I will go into detail on each of these individually shortly.
In order to choose nursing diagnoses for our patients we must refer to the list of NANDA-I approved nursing diagnoses. You can find these in the nursing diagnosis handbook that your nursing school likely required you to purchase.
Using the assessment information, you will find an appropriate diagnosis for your patient.
For instance, if your patient has congestive heart failure (CHF) you may find the following symptoms:
- Lung sounds: crackles x5
- Productive cough- sputum is frothy
- Oxygen @ 3L via nasal cannula- 98% oxygen saturation
- Dyspnea upon exertion
- Pitting edema +3 to BLE
- Cap refill >3 seconds
- Faintly palpable pedal pulses
- Medications: Lasix 40 mg daily, sliding scale insulin before meals, metoprolol 75 mg daily
- Medical history- CHF, hypertension, stents x2, diabetes mellitus, kidney disease, reoccurring stasis ulcers, prostatectomy, rotator cuff surgery
Problem
When we refer to our nursing diagnosis handbook, we can use symptoms and medical diagnoses the patient presents with to guide our decision of which diagnoses to choose for our patient. In our example, it appears the patient is having problems with excess fluid, so we will want to be on the look out for a diagnosis that fits that bill.
I am choosing to look under CHF to see if any listed diagnoses seem appropriate for the patient in our example.
Let us take a look at a few of the diagnoses that are listed to determine if they are appropriate for our patient.
Constipation r/t decreased activity intolerance: When we assessed our patient, we found the patient’s abdomen was soft and non-distended. Bowel sounds were active x4. Patient stated his last bowel movement was during the previous shift and has been going daily since being admitted to the hospital. At this point this is not an appropriate diagnosis for our patient.
Excess Fluid Volume r/t impaired excretion of sodium and water: If we refer to our assessment data, we can see that it is pretty clear that the patient has an excess amount of fluid that is not being excreted properly. He has crackles in all lung fields, frothy sputum expectoration, pitting edema +3 to BLE, etc.
As you can see, not all of the diagnoses that are listed under CHF apply to our patient. We rely on our assessment data to guide our decision of which diagnosis to choose; do not pick a diagnosis simply because it is listed. It has to be appropriate for your patient.
For our example, we will choose “excess fluid volume”.
I want to briefly touch on “risk for” diagnoses. These diagnoses are important to keep in mind, but often nursing instructors will only allow students to include one “risk for” diagnosis in their care plan.
These types of diagnoses are not problems that the patient is currently experiencing but problems they are at risk of developing. For example, a patient who is not getting out of bed and who has limited mobility could be given the diagnosis “Risk for impaired skin integrity”.
These diagnoses are not typically the priority in terms of nursing care plans, but you address them the same way as you would an “actual” nursing diagnosis.
Etiology
Now that we have the “problem” piece of our nursing diagnosis, we can shift our attention to the “related/to” portion of the nursing diagnosis.
The r/t portion of the nursing diagnosis is often referred to as the etiology. This basically means “Why is this problem happening? What is the mechanism that is driving this issue to occur?”
We must focus on the pathophysiology that is occurring in the patient. It is important to note that we cannot simply say “The excess fluid is related to the patient’s heart failure”. While this is true, we must describe this in terms of pathophysiology.
For instance, “The excess fluid is related to decreased cardiac output, backflow of fluid into the lungs”. You are basically taking the medical diagnosis (in this example, heart failure) and describing the mechanism of the disease process that is causing the problem to occur.
Signs & Symptoms
The last part of our nursing diagnosis is the “as evidenced by” portion. This is the easiest part as it is simply fill in the blank. The information that you will include in this section is the “evidence” that supports your claim that the patient is experiencing the problem you are stating they have.
In our example, we are claiming that our patient is experiencing excess fluid volume. In order to support that claim, we must describe the signs and symptoms that show he has fluid retention. It is important to note that it is appropriate to include lab values and medications in this section, as well.
Look at the assessment data that I listed above and take a moment to think about which of those pieces of information support the nursing diagnosis of fluid retention.
Almost all of them, huh?
Not so good news for the patient but great news for us because that signifies that we have strong evidence to support our diagnosis.
Now that we have the last piece of the puzzle, let us put it all together.
Excess fluid volume r/t decreased cardiac output, backflow of fluid into the lungs, AEB crackles x5, productive cough, +3 pitting edema to BLE, faint pedal pulses, Lasix 40 mg daily, dyspnea upon exertion
We did it! We created a nursing diagnosis that is tailored to the specific presentation of our individual patient. Now it is time to figure out how we are going to help this patient resolve or improve these issues.
Step three- Planning
This is the part where, as a nursing student, you will showcase to your nursing instructor that you know how to take care of a patient who is experiencing a certain problem. This is an incredible learning tool as you will plan how to take care of a patient in the comfort of your own home. You will list out all the actions that you would take to help this patient, often without implementing any of said tasks. Take advantage of this precious learning time. You are creating critical thinking skills that will be of great use to your patients in the future!
During this planning stage you will assemble a list of nursing interventions as well as identify goals for your patient.
Goals
The best way to remember how to create a goal for your patient is to define the opposite of the problem they are currently experiencing. If your patient is experiencing pain, then your goal is, intuitively, to make their pain go away! Or at least dramatically decrease it. We would be able to identify that we met our goal if our patient states “my pain is a 2” on a scale from 0-10, patient is not grimacing, etc.
We could further define our patient outcomes by stating
- The patient will be able to tolerate activities of daily living without complaining of pain greater than 3 (on a scale of 0-10)
- The patient will be able to sleep 6-8 hours at night without waking up frequently with complains of pain
Pain is a pretty easy example to illustrate but let us focus on our patient and the problems he is experiencing.
If our patient is experiencing excess fluid volume, then what should our goal be for him?
Fluid balance
How are we going to know that he has reached this goal of fluid balance? Well he will have a decrease in the amount of fluid he is retaining so we would hope to assess the following:
- Lung sounds clear x5
- No edema in BLE
- Palpable pedal pulses
If we put all that together we have our goal: Fluid balance AEB lung sounds clear x5, no edema in BLE, and palpable pedal pulses
Patient outcomes for this goal could be:
- The patient will remain free of edema by the end of the week
- The patient will remain free of crackles in the lungs by the end of the week
- The patient will be able to complete activities of daily living without experiencing dyspnea by the end of the week.
It is important to note that the goals should follow the SMART guidelines (Specific, Measurable, Attainable, Realistic, and Timed).
Nursing Interventions
The nursing interventions “are like road maps directing the best ways to provide nursing care.” (Ackley and Ladwig 2014). These interventions will help us to reach the goals we have set for our patient.
This is the bread and butter of what nurses actually do. As a nursing student you will have to think about what tasks to perform for a patient who is experiencing a particular issue. However, once you are a nurse a lot of these tasks will become second nature to you, and you will perform them without even thinking about it. You will become great at deciding what nursing interventions to implement by practicing creating high quality nursing care plans. Nursing care plans really will help you be a better nurse in the long run!
So how do we decide which nursing interventions to plan for our patient?
Well once again we will refer to the nursing diagnosis handbook for clues on which nursing interventions to include. We want to choose nursing interventions that will help our patient reach optimal functioning.
In the case of our patient we will want to choose nursing interventions that are specific to his status, situation, and symptoms. Do not include nursing interventions just because they sound good; they need to actually pertain to your patient.
Your nursing instructors will decide how many interventions you need to list for each nursing diagnosis. When I was in nursing school, we were required to write 10 interventions per diagnosis.
The nursing interventions should start with “The nurse will” because these are actions that the nurse will be implementing.
The following are some nursing interventions that would be appropriate for our patient:
- The nurse will elevate the lower extremities with pillows whenever the patient is lying in bed.
- The nurse will administer Lasix 40 mg IV push daily at 0900.
- The nurse will assess the consistency, color, and odor of sputum that the patient coughs up.
If your nursing instructors require you to include a rationale for each intervention, then you will simply explain how each intervention will help the patient improve their symptoms.
For example, why would we want to elevate the patient’s lower extremities? Well, we know that the patient has +3 pitting edema in their BLE. This extra fluid can be encouraged to drain from the feet by elevating them on pillows because…gravity! SCIENCE!
Hehe all kidding aside, you can see how this intervention can be explained simply to justify implementing it. That is what you aim to do with a rationale.
Step Four- Implement and Evaluate
In nursing school, you may not actually get the chance to implement all the nursing interventions that you planned for your patient. However, you are still required to evaluate the goals you set for your patient.
When you evaluate your goals, you will label them as “met”, “partially met”, or “not met”.
In order to decide if your goals have been met you will assess your patient and determine if there have been any improvements in their condition.
In our example, if we reassess our patient and we find that all their symptoms were resolved (pitting edema, crackles in lungs, productive cough, pedal pulses, dyspnea upon exertion), then we can say that our goal was met.
If we reassess our patient and find that they have resolved their productive cough and crackles in their lungs, but the edema remains, then we would say the goal was partially met.
If we find that all of the symptoms are still present and there have been no improvements, then we would say that the goal was not met.
Although as nurses we want to see as much improvement in our patients as possible, in terms of your nursing care plan, it is ok your goals are not met yet.
However, if the issue lies in the care plan, then the nurse would need to reevaluate the nursing interventions as well as the goals set for the patient. If a patient experienced a significant decline during their hospital stay, then some goals that were originally set may not be attainable anymore.
This is why it is important to continue to evaluate the nursing care plan to ensure that it is appropriate and meets the specific need of the patient.
Step Five- Prioritize
So far, we have only created one nursing diagnosis for our patient. However, we know that our patients often have many issues related to a variety of comorbidities.
You may take care of a patient that you could create 5-10 nursing diagnoses for! In nursing school, it is likely that your instructors will want you to create around 3-5 nursing diagnoses for your patients. They will also want you to prioritize the diagnoses in order of importance
One way to guide your decision-making process of which diagnoses are most important is to refer to the Airway, Breathing, Circulation (ABC) approach.
An important note to make is that even if a “risk for” diagnosis includes a potential problem with the patient’s airway, it should not be prioritized over an actual problem with patient is having with their breathing.
Conclusion
Whew! I hope that was not too overwhelming. I know that nursing care plans can cause anxiety in nursing students because there is a bit of a learning curve and often times you fail a few care plans before you pass one.
However, I believe that if you follow the steps that I have laid out that you will find success in creating your care plans.
As always, if you have any questions just reach out to me and I would be happy to help.
Happy Nursing!
References:
“The Nursing Process: Using clinical reasoning skills to determine nursing diagnoses and plan care.” Nursing Diagnosis Handbook: an Evidence-Based Guide to Planning Care, by Betty J. Ackley and Gail B. Ladwig, Mosby Elsevier, 2014, pp. 8-8.