Creating Nursing Care Plans: The Definitive Guide
As a nurse, you need to retain a lot of medical information to accurately apply what you know to patients in need. This is why writing nursing care plans is one of the most essential parts of the nursing process.
Nursing care plans help you communicate patient care and track their progress towards achieving recovery.
Since they’re a daily part of real-world nursing, perfecting them in nursing school will set you up for success in the future. How you use them depends on where you’re at in your career and schooling.
We have everything you need in this post to understand, write, and implement top-notch nursing care plans.
Your Most Pressing Questions About Nursing Care Plans
What is a Nursing Care Plan?
Nursing care plans are essentially a roadmap for nurses to follow when going through patient care. It’s a collection of essential patient information in a chart-like document.
A nursing care plan will provide the details of the patient’s condition, explain the goals and interventions of care, and outline expected outcomes in a way everyone can understand.
What is the Purpose of Creating a Nursing Care Plan?
The overall purpose of a nursing care plan is to ensure that the patient receives and understands the best possible treatment and gets the most out of their health plan.
For instance, if you have a patient with a broken femur, you need to outline in your care plan:
- How the fracture occurred.
- How their health history affects treatment and care.
- Which tests were ran on the patient.
- Which treatments they will receive.
- Goals for leg movement.
- Evaluation of treatment responses.
You should also base patients’ care plans on evidence-based practice, so it can help guide medical decisions.
Types of Nursing Care Plans
There are generally four types of nursing care plans that will depend on your workplace, specialty, and patient needs:
Informal
Informal nursing care plans aren’t typically written down anywhere, and are usually just shared verbally between your patient and their loved ones.
They can be made up on the fly when treating very simple and familiar ailments.
For example, if a patient is experiencing a minor skin rash, their informal care plan will be not to scratch it.
Formal
A formal nursing care plan requires more time and effort and has much more weight.
Compared to informal care plans, they involve more detailed assessments of the patient’s condition, along with treatment recommendations and additional tests.
Formal nursing care plans can also become part of the legal record if any legal issues come up in the future.
Standardized
Standardized nursing care plans follow a specific template that allows nurses to quickly create charts that meet regulatory requirements.
These templates are typically provided by the facility or insurance companies. Standardized care plans outline general approaches to treating patients with similar conditions.
For example, if a patient needs a stitch on their forehead, you would likely give them a standardized treatment plan for minor head cuts.
Individualized
An individualized nursing care plan describes how patients will be treated specifically to their circumstances.
They’re specific to the individual’s needs – i.e., the patient with the forehead cut actually got a bacterial infection from impact. Therefore, they’ll need individualized care for the infection.
The Main Components of a Nursing Care Plan
Your care plan should contain all the information necessary to provide safe, quality care to a patient. The main components of a nursing care plan are:
- Patient health assessment (physical, emotional, cognitive, etc.)
- Medical history (past, family, social, etc.)
- Diagnosis
- Expected outcomes (long and short-term)
- Nursing interventions and their rationale
- Implementation
- Evaluation (and any revision(s))
Learn about the components of the nursing process here along with your care plans.
How to Use a Nursing Care Plan
Nurses use care plans as reminders when they go into rounds with other nurses. In addition, patients’ loved ones can use them as guides for home care after discharge, and patients can use them as tools for managing their own health at home.
Overall, nursing care plans help keep everyone on the same page.
Nursing Care Plans in Nursing School & Clinicals vs. on the Job
Nursing care plans are standard in nursing schools and almost every medical facility because they help nurses understand and learn how to perform their job with patients safely and effectively.
You’ll likely find yourself writing several care plans in nursing school as a foundation for learning and postgraduate practice as a nurse.
For practice nursing care plans, you’ll be given a list of fake patients in school, and real patients during clinicals. These patients will all need different diagnoses and types of care.
In clinicals, you’ll create these plans as part of your rotations. The nursing care plans you write during clinicals may not be the best, but it’s an excellent opportunity to perfect them.
When you’re on the job after graduation, your employer may require you to develop care plans as a core job responsibility.
These real-world nursing care plans are also important for dealing with legal liabilities. For instance, if a patient’s UTI worsens after visiting your hospital, and your care plan includes regular antibiotic use, you might not be held liable for said UTI.
How Do You Write a Nursing Care Plan?
As a nurse, you’ll write care plans during and after a patient’s visit. You can also revise them based on changes in the patient’s condition, or new information about their health status.
Make sure that everyone is involved in the patient’s care and free to contribute their thoughts and opinions on what should be included in the care plan.
Overall, you need to write your care plan comprehensively, informally, and informally.
Here’s a step-by-step breakdown of how to write a nursing care plan with a sample patient: Casey Clarke.
Step 1: Assess the Patient
In the assessment, you must gather all relevant info on the patient’s current medical condition and other factors that may impact the patient’s health. This info will be used to determine the type of care most effectively for this patient.
What to include in the nursing assessment:
- Initial complaint(s)
- Name and date of birth
- Address and contact information
- Past medical history
- Allergies
- Current medications (including prescription and over-the-counter medications)
- Medication side effects
- Vitals
- Mental status
In our example with Casey Clarke:
- Experiencing severe itchy red bumps on arms and shoulders.
- DoB – May 21st, 1997
- 123 Frederic St. Chicago, IL | 312-555-1234
- Has a past history of occasional migraines
- No known allergies
- Currently prescribed sumatriptan with no side effects
- All normal vitals
- Mentally competent
Step 2: Sort Out a Diagnosis
The patient diagnosis will be your guide throughout your stay at the hospital and will inform your care plan. As a nurse, it’s up to you to make sure that the patient’s diagnosis is accurate.
In your nursing diagnosis, list all the symptoms the patient has experienced before and during their stay, and how long they’ve had them. You should write your patient diagnosis in a clear, professional tone with correct medical terminology.
With our example, you find that Casey is showing signs of mosquito bite allergies. Even though she said she had no known allergies, this is something important to add to her history.
Step 3: Plan Patient Goals and Desired Outcomes
Patient goals in a nursing care plan should be obtainable and lead to their recovery. Consider intermediate, short-term goals vs. terminal, long-term goals.
Desired outcomes are also important when establishing goals in a care plan. The desired outcome needs to be clearly defined so that the nurse can know what they need to do to help achieve that outcome.
When establishing Desired Outcomes in a nursing care plan, use verbs like “will” and “must” instead of phrases like “should.”
In patient Casey’s case, main goals include consistently using medicated ointment and antihistamines while avoiding itching. The desired outcomes are reduced swelling, itching, and bumps.
Step 4: Compile an Evaluation
The patient evaluation should outline ongoing results of all your hard work. In this section of the care plan, you’ll explain how the patient’s condition has changed since the beginning of their visit.
To write an evaluation, you must consider your goal when treating this patient. Do they still have symptoms? Are they better? Has their condition improved? Why? Make sure to include mistakes, missteps, and successes so that others can learn from them.
In Casey’s evaluation, you can include that she did not experience anaphylaxis (thankfully), and responded well to medicated ointments. She’ll need to use benzocaine until symptoms subside, which will be reported by her.
Step 5: Write it All Out
All in all, it’s a lot of information, and you’ll need to organize it in a way that’s easily understandable to you and other nursing personnel.
Review all the information you have collected from your patient and family members regarding what they want from this experience. You’ll also want to identify gaps in your knowledge or understanding of the situation and ensure you’ve addressed those gaps before finalizing your nursing care plan.
Nursing Care Plan Template
Check out this template you can use to write an organized, concise care plan:
SimpleNursing Nursing Care Plans
These care plans include all of the important components with standard treatments:
Prepare for Your Nursing Career with the Right Tools
Nursing care plans are crucial to the day-to-day of your school, and in the future in a nursing role. So along with learning how to put together these care plans, you’ll need comprehensive resources to pass courses.
SimpleNursing includes study guides, quizzes, video rationales, and much more to ace your classes.
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