A nursing care plan (NCP) is a systematic tool used to identify a patient’s current health needs and potential future risks. Care plans help nurses, patients, and other healthcare providers communicate effectively to achieve health outcomes. They are essential for maintaining the quality and consistency of patient care.

Care planning starts when a patient is admitted and is regularly updated as their condition changes and goals are met. Providing personalized care is a core part of good nursing practice.

Sometimes, information for the care plan might come from a relative, friend, or caregiver, especially for children or adults with difficulty communicating their needs.

Types of Nursing Care Plans
Care plans can be informal or formal.

• An informal care plan is a plan the nurse keeps in their mind.

• A formal care plan is a written or digital guide for organizing patient care.

Formal care plans are either standardized or individualized:

• Standardized care plans outline care for groups of patients with common issues.

• Individualized care plans are made for a specific patient’s unique needs that standard plans might not cover.

Standardized Care Plans
These are pre-made guides used by nurses and healthcare facilities to ensure patients with certain conditions get consistent care. They help meet minimum standards and save nurses time by providing common tasks already outlined.

Standardized plans are a starting point but aren’t specific to one patient’s unique needs and goals. They can be used as a base to build an individualized plan.

Individualized Care Plans
An individualized care plan means customizing a standard plan or creating a new one to fit a specific patient’s unique needs, goals, and what works best for them. This leads to more personal and complete care that better suits the patient’s situation, strengths, and goals.

Individualized plans can also make patients happier because they feel their care is designed for them.

Tips for making a care plan individualized:

• Do a full assessment of the patient’s health, history, and what they hope to achieve.

• Include the patient in planning. Ask about their health goals and what they prefer. This helps ensure the plan matches their wishes.

• Keep assessing and evaluating as the patient’s health and goals change. Update the plan as needed.

Objectives
The main aims of writing a nursing care plan are:

• Promote nursing care based on evidence and make healthcare settings comfortable.

• Support holistic care, covering the patient’s physical, mental, social, and spiritual health, along with managing and preventing illness.

• Help create programs like care pathways (team plans for specific conditions) and care bundles (best practices for certain diseases).

• Clearly identify goals and what outcomes are expected.

• Improve communication and documentation of care.

• Provide a way to measure nursing care.

Purposes of a Nursing Care Plan
Writing a nursing care plan is important for several reasons:

• Defines the nurse’s role. It highlights the nurse’s specific actions for patient well-being, not just following doctor’s orders.

• Guides individualized care. It acts as a roadmap for care and encourages nurses to think critically about tailoring interventions.

• Ensures continuity of care. Nurses on different shifts can use the plan to provide consistent care.

• Coordinates care. It helps all healthcare team members understand the patient’s needs and what actions to take.

• Documentation. It records observations, nursing actions, and patient teaching. Proper documentation proves care was given.

• Helps assign staff. It can guide assigning nurses with specific skills to patients who need them.

• Monitors progress. It helps track how the patient is doing and allows for adjustments to the plan.

• Guides reimbursement. Medical records, including care plans, are used by insurance to determine payment.

• Defines patient’s goals. It involves patients in their treatment, benefiting both them and the nurse.

Components
A nursing care plan (NCP) typically includes:

• Client health assessment: Information gathered about the patient’s health status (physical, emotional, social, etc.) from assessment techniques, medical records, and tests. This includes both subjective (what the patient says) and objective (what you observe or measure) data.

• Nursing diagnosis: A statement describing the patient’s health problem or concern based on assessment data.

• Expected client outcomes: Specific, measurable goals the nurse and patient hope to achieve through interventions. These can be short-term or long-term.

• Nursing interventions: Specific actions the nurse will take to address the nursing diagnosis and reach the expected outcomes. These should be based on best practices.

• Rationales: (Often for students) Explanations based on scientific principles for why a specific intervention was chosen.

• Evaluation: Plans for monitoring the patient’s progress and adjusting the care plan as needed.

Care Plan Formats
Nursing care plans are often organized into columns.

• Three-Column Format: Includes columns for Nursing Diagnosis, Outcomes and Evaluation, and Interventions.

• Four-Column Format: Includes columns for Nursing Diagnosis, Goals and Outcomes, Interventions, and Evaluation.

• Some formats may add a column for Assessment Cues or Rationales (especially for students).

Student Care Plans
Student care plans are generally more detailed than those used by practicing nurses. This is because they are a learning exercise.

Student care plans often include an extra column for “Rationale” or “Scientific Explanation” after the interventions. This column explains the scientific reason behind each chosen nursing action.

Writing a Nursing Care Plan
Here are the steps to create a care plan for a patient:

Step 1: Data Collection or Assessment
Gather all health information about the patient using assessment methods (physical exam, history, interview, records). Identify potential issues and related factors based on this data.

Step 2: Data Analysis and Organization
Look at the collected information. Group related pieces of data together to help figure out the patient’s needs and how to prioritize them.

Step 3: Formulating Your Nursing Diagnoses
Write clear statements describing the patient’s health problems that nursing care can help with.

See a complete guide on formulating nursing diagnoses for more details.

Step 4: Setting Priorities
Decide which nursing diagnoses or problems need attention first. Life-threatening issues are always high priority.

Consider factors like the patient’s values, what they feel is most important, available resources, and how urgent the problem is. Involve the patient in setting priorities.

Maslow’s Hierarchy of Needs can help prioritize: Basic physical and safety needs come before higher needs like belonging or self-esteem.

Step 5: Establishing Client Goals and Desired Outcomes
Work with the patient to set specific goals for each priority nursing diagnosis. Goals describe what the nurse and patient hope to achieve. Goals should be:

• Specific: Clearly stated.

• Measurable: Can be tracked.

• Attainable: Possible to achieve.

• Realistic: Possible with resources.

• Timely: Have a timeframe.

Goals should focus on what the patient will do or experience, not just what the nurse will do. Use clear, observable terms. Ensure goals are realistic and align with other treatments. Each goal should relate to one nursing diagnosis. Goals need to be important to the patient.

Goals can be:

• Short-term: Achieved quickly (hours/days).

• Long-term: Achieved over weeks/months (often for chronic issues or discharge planning).

Goals or outcome statements often include:

• Subject (the patient)

• Verb (the action)

• Conditions (how/when/where – optional)

• Criterion (standard of performance – optional)

Step 6: Selecting Nursing Interventions
Choose specific actions the nurse will perform to help the patient reach their goals. Interventions should target the cause of the problem or reduce risk factors.

Interventions can be:

• Independent: Actions the nurse can do based on their license and skill (e.g., teaching, providing comfort).

• Dependent: Actions done under a doctor’s order (e.g., giving medication).

• Collaborative: Actions done with other healthcare team members (e.g., working with a dietitian).

Interventions must be safe, appropriate, achievable with resources, align with the patient’s values, fit with other therapies, and be based on nursing knowledge.

Write interventions clearly, starting with an action verb. Include details on how, when, where, and how often. Use only approved abbreviations.

Refer to clinical practice guidelines (CPGs) for evidence-based interventions for specific conditions.

Step 7: Providing Rationale
(Mainly for students) Explain the scientific reason or principle behind why you chose a particular nursing intervention. This helps connect theory to practice.

Step 8: Evaluation
This is an ongoing process where you check the patient’s progress toward achieving their goals and assess if the care plan is working. The evaluation helps decide if interventions should be continued, changed, or stopped.

Step 9: Putting it on Paper
The finished care plan is documented in the patient’s medical record according to facility policy. It is a permanent record that other nurses will use. Different formats are used, often following the steps of the nursing process.