NURS 08- MCN (WELL)

MODULE 1 (NURSING CARE PLAN)

Transcriber: Abbygail Roderos
NURSING CARE PLAN PURPOSE OF NURSING CARE PLAN

- Writing the best nursing care plan requires a step-by-step approach The following are the purposes and importance of writing a nursing care
to complete the parts needed for a care plan correctly. This tutorial plan:
has the ultimate database and list of nursing care plans (NCP) and
NANDA nursing diagnosis samples for our student nurses and - Defines nurse’s role. It helps to identify the unique role of nurses in
professional nurses to use — all for free! A care plan’s components, attending to clients’ overall health and well-being without having to
examples, objectives, and purposes are included with a detailed rely entirely on a physician’s orders or interventions.
guide on writing an excellent nursing care plan or a template for - Provides direction for individualized care of the client. It allows the
your unit. nurse to think critically about each client and develop interventions
directly tailored to the individual.
WHAT IS NURSING CARE PLAN? - Continuity of care. Nurses from different shifts or departments can
use the data to render the same quality and type of interventions to
- A nursing care plan (NCP) is a formal process that correctly care for clients, therefore allowing clients to receive the most benefit
identifies existing needs and recognizes potential needs or risks. from treatment.
Care plans provide communication among nurses, their patients, - Documentation. It should accurately outline which observations to
and other healthcare providers to achieve health care outcomes. make, what nursing actions to carry out, and what instructions the
Without the nursing care planning process, the quality and client or family members require. If nursing care is not documented
consistency of patient care would be lost. correctly in the care plan, there is no evidence the care was
provided.
- Nursing care planning begins when the client is admitted to the - Serves as a guide for assigning a specific staff to a specific client.
agency and is continuously updated throughout in response to the There are instances when a client’s care needs to be assigned to
client’s changes in condition and evaluation of goal achievement. staff with particular and precise skills.
Planning and delivering individualized or patient-centered care is - Serves as a guide for reimbursement. The insurance companies
the basis for excellence in nursing practice. use the medical record to determine what they will pay concerning
the hospital care received by the client.
TYPES OF NURSING CARE PLAN - Defines client’s goals. It benefits nurses and clients by involving
them in their treatment and care.
- Care plans can be informal or formal: An informal nursing care plan
is a strategy of action that exists in the nurse‘s mind. A formal COMPONENTS
nursing care plan is a written or computerized guide that organizes
the client’s care information. Formal care plans are further - A nursing care plan (NCP) usually includes nursing diagnoses,
subdivided into standardized care plans and individualized care client problems, expected outcomes, and nursing interventions and
plans: Standardized care plans specify the nursing care for groups rationales. These components are elaborated below:
of clients with everyday needs. Individualized care plans are tailored
to meet the unique needs of a specific client or needs that are not 1. Client health assessment, medical results, and diagnostic reports
addressed by the standardized care plan. are the first steps to be able to design a care plan. In particular,
client assessment is related to the following areas and abilities:
OBJECTIVES: physical, emotional, sexual, psychosocial, cultural,
spiritual/transpersonal, cognitive, functional, age-related, economic,
The following are the goals and objectives of writing a nursing care plan: and environmental. Information in this area can be subjective and
objective.
- Promote evidence-based nursing care and render pleasant and 2. Expected client outcomes are outlined. These may be long and
familiar conditions in hospitals or health centers. short-term.
- Support holistic care which involves the whole person, including 3. Nursing interventions are documented in the care plan.
physical, psychological, social, and spiritual, with the management 4. Rationale for interventions to be evidence-based care.
and prevention of the disease. 5. Evaluation. This documents the outcome of nursing interventions.
- Establish programs such as care pathways and care bundles. Care
pathways involve a team effort to reach a consensus regarding CARE PLAN FORMATS
standards of care and expected outcomes. In contrast, care bundles
are related to best practices concerning care given for a specific - Nursing care plan formats are usually categorized or organized into
disease. four columns: (1) nursing diagnoses, (2) desired outcomes and
- Identify and distinguish goals and expected outcomes. goals, (3) nursing interventions, and (4) evaluation. Some agencies
- Review communication and documentation of the care plan. use a three-column plan wherein goals and evaluation are in the
- Measure nursing care. same column. Other agencies have a five-column plan that includes
a column for assessment cues.
 NURSING CARE PLAN FORMAT (3 COLUMNS) 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 formulate a nursing diagnosis. Some agencies or nursing
schools have specific 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 formulate your nursing diagnosis,
priorities, and desired outcomes.

 Step 3: Formulating Your Nursing Diagnoses

- NANDA 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
NURSING CARE PLAN FORMAT (4 COLUMNS) that can be prevented or resolved by independent nursing
intervention are termed nursing diagnoses. We’ve detailed the steps
on how to formulate your nursing diagnoses in this guide: Nursing
Diagnosis (NDx): Complete Guide and List

 Step 4: Setting Priorities

- Setting priorities deals with establishing a preferential sequence for
addressing 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
having a high, medium, or low priority. Life-threatening problems
should be given high priority.

- A nursing diagnosis encompasses Maslow’s Hierarchy of Needs

and helps to prioritize and plan care based on patient-centered
outcomes. In 1943, Abraham Maslow developed a hierarchy based
on basic fundamental needs innate to all individuals. Basic
STUDENT CARE PLANS physiological needs/goals must be met before higher needs/goals
can be achieved, such as self-esteem and self-actualization.
Physiological and safety needs provide the basis for implementing
- Student care plans are more lengthy and detailed than care plans
nursing care and nursing interventions. Thus, they are at the base
used by working nurses because they are a learning activity for the
of Maslow’s pyramid, laying the foundation for physical and
students.
emotional health.
NURSING CARE PLAN FORMAT (5 COLUMN FORMAT)
MASLOW’S HIERARCHY OF NEEDS

 Basic Physiological Needs: Nutrition (water and food), elimination

(Toileting), airway (suction)-breathing (oxygen)-circulation (pulse,
cardiac monitor, blood pressure) (ABCs), sleep, sex, shelter, and
exercise.
 Safety and Security: Injury prevention (side rails, call lights, hand
hygiene, isolation, suicide precautions, fall precautions, car seats,
helmets, seat belts), fostering a climate of trust and safety
(therapeutic relationship), patient education (modifiable risk factors
for stroke, heart disease).
 Love and Belonging: Foster supportive relationships, methods to
avoid social isolation (bullying), employ active listening techniques,
therapeutic communication, and sexual intimacy.
 Self-Esteem: Acceptance in the community, workforce, personal
- Care plans by student nurses are usually required to be handwritten achievement, sense of control or empowerment, accepting one’s
and have an additional column for “Rationale” or “Scientific physical appearance or body habitus.
Explanation” after the nursing interventions column. Rationales are  Self-Actualization: Empowering environment, spiritual growth, ability
scientific principles that explain the reasons for selecting a particular to recognize the point of view of others, reaching one’s maximum
nursing intervention. potential.
-
WRITING A NURSING CARE PLAN

How do you write a nursing care plan (NCP)? Just follow the steps below
to develop a care plan for your client.

 Step 1: Data Collection or Assessment

- The first step in writing a nursing care plan is to create a client
database using assessment techniques and data collection
 desired result.
 Attainable or Action-Oriented. Goals should be flexible but remain
possible.
 Realistic or Results-Oriented. This is important to look forward to
effective and successful outcomes by keeping in mind the available
resources at hand.
 Timely or Time-Oriented. Every goal needs a designated time
parameter, a deadline to focus on, and something to work toward.

- Hogston (2011) suggests using the REEPIG standards to ensure

that care is of the highest standards. By this means, nursing care
plans should be:

 Realistic. Given available resources.

 Explicitly stated. Be clear in precisely what must be done so there is
no room for misinterpretation of instructions.
 Evidence-based. That there is research that supports what is being
- The client’s health values and beliefs, priorities, resources available, proposed.
and urgency are factors the nurse must consider when assigning
 Prioritized. The most urgent problems being dealt with first.
priorities. Involve the client in the process to enhance cooperation.
 Involve. Involve both the patient and other members of the
multidisciplinary team who are going to be involved in implementing
 Step 5: Establishing Client Goals and Desired Outcomes
the care.
- After assigning priorities for your nursing diagnosis, the nurse and
the client set goals for each determined priority. Goals or desired  Goal centered. That the care planned will meet and achieve the
outcomes describe what the nurse hopes to achieve by goal set.
implementing the nursing interventions derived from the client’s
nursing diagnoses. Goals provide direction for planning SHORT TERM AND LONG TERM GOALS
interventions, serve as criteria for evaluating client progress, enable
the client and nurse to determine which problems have been - Goals and expected outcomes must be measurable and client-
resolved, and help motivate the client and nurse by providing a centered. Goals are constructed by focusing on problem prevention,
sense of achievement. resolution, and rehabilitation. Goals can be short-term or long-term.
Most goals are short-term in an acute care setting 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 live at home, nursing homes, or in extended-care facilities.

- Short-term goal. A statement distinguishing a shift in behavior that

can be completed immediately, usually within a few hours or days.
- Long-term goal. Indicates an objective to be completed over a
longer period, usually over weeks or months.
- Discharge planning. Involves naming long-term goals, therefore
promoting continued restorative care and problem resolution
through home health, physical therapy, or various other referral
sources.

COMPONENTS OF GOALS AND DESIRED OUTCOMES

- Goals or desired outcome statements usually have four

components: a subject, a verb, conditions or modifiers, and a
criterion of desired performance.

- One overall goal is determined for each nursing diagnosis. The

terms goal, outcome, and expected outcome are often used
interchangeably.

- According to Hamilton and Price (2013), goals should be SMART. - Subject. The subject is the client, any part of the client, or some
SMART goals analysis strategy stands for – Specific, Measurable, attribute of the client (i.e., pulse, temperature, urinary output). That
Attainable, Realistic, and Time-Bound goals. subject is often omitted in writing goals because it is assumed that
the subject is the client unless indicated otherwise (family,
 Specific. It should be clear, significant, and sensible for a goal to be significant other).
effective. - Verb. The verb specifies an action the client is to perform, for
 Measurable or Meaningful. Making sure a goal is measurable example, what the client is to do, learn, or experience.
makes it easier to monitor progress and know when it reaches the - Conditions or modifiers. These are the “what, when, where, or how”
 that are added to the verb to explain the circumstances under which social workers, dietitians, and therapists. These actions are
the behavior is to be performed. developed in consultation with other health care professionals to
- Criterion of desired performance. The criterion indicates the gain their professional viewpoint.
standard by which a performance is evaluated or the level at which
the client will perform the specified behavior. These are optional. Nursing interventions should be:

When writing goals and desired outcomes, the nurse should follow these - Safe and appropriate for the client’s age, health, and condition.
tips: - Achievable with the resources and time available.
- Inline with the client’s values, culture, and beliefs.
1. Write goals and outcomes in terms of client responses and not as - Inline with other therapies.
activities of the nurse. Begin each goal with “Client will […]” help - Based on nursing knowledge and experience or knowledge from
focus the goal on client behavior and responses. relevant sciences.
2. Avoid writing goals on what the nurse hopes to accomplish, and
focus on what the client will do. When writing nursing interventions, follow these tips:
3. Use observable, measurable terms for outcomes. Avoid using
vague words that require interpretation or judgment of the observer. 1. Write the date and sign the plan. The date the plan is written is
4. Desired outcomes should be realistic for the client’s resources, essential for evaluation, review, and future planning. The nurse’s
capabilities, limitations, and on the designated time span of care. signature demonstrates accountability.
5. Ensure that goals are compatible with the therapies of other 2. Nursing interventions should be specific and clearly stated,
professionals. beginning with an action verb indicating what the nurse is expected
6. Ensure that each goal is derived from only one nursing diagnosis. to do. Action verb starts the intervention and must be precise.
Keeping it this way facilitates evaluation of care by ensuring that Qualifiers of how, when, where, time, frequency, and amount
planned nursing interventions are clearly related to the diagnosis provide the content of the planned activity. For example: “Educate
set. parents on how to take temperature and notify of any changes,” or
7. Lastly, make sure that the client considers the goals important and “Assess urine for color, amount, odor, and turbidity.”
values them to ensure cooperation. 3. Use only abbreviations accepted by the institution.

 Step 6: Selecting Nursing Interventions  Step 7: Providing Rationale

- Nursing interventions are activities or actions that a nurse performs - Rationales, also known as scientific explanations, explain why the
to achieve client goals. Interventions chosen should focus on nursing intervention was chosen for the NCP.
eliminating or reducing the etiology of the nursing diagnosis. As for
risk nursing diagnoses, interventions should 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.

TYPES OF NURSING INTERVENTIONS

Nursing interventions can be independent, dependent, or collaborative:

- Independent nursing interventions are activities that nurse are

licensed to initiate based on their sound judgment and skills.
Includes: ongoing assessment, emotional support, providing
comfort, teaching, physical care, and making referrals to other
health care professionals.
- 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. - Rationales do not appear in regular care plans. They are included to
- Collaborative interventions are actions that the nurse carries out in assist nursing students in associating the pathophysiological and
collaboration with other health team members, such as physicians,
 psychological principles with the selected nursing intervention.

 Step 8: Evaluation
- Evaluating is a planned, ongoing, purposeful activity in which the
client’s progress towards achieving goals or desired outcomes and
the effectiveness of the nursing care plan (NCP). Evaluation is an
essential aspect of the nursing process because conclusions drawn
from this step determine whether the nursing intervention should be
terminated, continued, or changed.

 Step 9: Putting it on Paper

- The client’s care plan is documented according to hospital policy
and becomes part of the client’s permanent medical record which
may be reviewed by the oncoming nurse. 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.