Nursing care plans are an essential tool in the nursing process to create continuous and individualized care. Nursing care plans help nurses clarify care goals and prioritize interventions for both short and long-term goals of care. As part of the nursing process, the care plan is created after the nurse has identified a nursing diagnosis. A nursing diagnosis supports the care plan and outlines appropriate interventions. Nursing diagnoses should align with a NANDA-I nursing diagnosis, creating consistency in nursing diagnosis terminology and facilitating effective communication.1 Overall, a care plan is an essential tool for communication between nurses and other care team members so that high-quality, continuous, evidence-based care is provided.
In this article:
- What is a Nursing Care Plan?
- Why Use Nursing Care Plans?
- Types of Nursing Care Plans
- The Nursing Process
- How To Write a Nursing Care Plan
- Nursing Care Plan Considerations
- Creating SMART Goals
- Examples of Collaborative SMART Goals
- Nursing Interventions
- Tips for Effective Care Planning
- Care Plan Examples
What is a Nursing Care Plan?
Nursing care plans are an essential tool within the nursing process to organize high-quality patient care. Nursing care plans are often called the “plan of care” and provide directions to nurses and the interprofessional team. Care plans are often described as the roadmap of patient care.2 They can be used to prioritize care and to plan interventions.
Why Use Nursing Care Plans?
Listed below are some of the benefits of using care plans in nursing practice.
1. Follows the client from admission to discharge
Care plans can be used to continually update care goals during an interaction. This includes care provided across settings, including community, acute, or residential settings.
2. Helps nurses plan interventions and revise care
Care plans provide structure to interventions, allowing the nurse to assess the intervention’s outcome and potentially revise care based on the result of those interventions.
3. Measures outcomes of interventions
Care goals and interventions related to those goals are clearly laid out in the plan of care. In addition, the care plan provides a roadmap to determine if the interventions provided have addressed the care goals.
4. Communication and continuity between nurses
The plan of care is a document that assists nurses in providing continuous and consistent care, working toward shared goals.
5. Coordinates other disciplines
The care plan may include input or interventions other interdisciplinary team members provide. A care plan communicates priorities between interprofessional team members to coordinate on common goals.
6. Engage with the patient/patient-centered care
Whenever possible, the patient should be involved in creating their plan of care. Nursing care plans are best used collaboratively with patients and families to account for a patient’s preferences, values, culture, and lifestyle.2
7. Documentation purposes
Care plans are an opportunity for nurses to demonstrate that safe and ethical care was provided in accordance with professional regulations. Documentation may be used for communication, quality improvement, research, or legal proceedings.
Types of Nursing Care Plans
There is some variation in how care plans are used in practice. The structure and format of a care plan depends on the purpose of the care plan and the care setting.
Formal vs. Informal Care Planning
Generally, informal care plans are not formally documented. Informal care plans might include the goals that the nurse has for their shift. These goals will be modified depending on the day’s priorities or changes in the patient’s condition.
Formal care plans are documented as part of the patient record used to coordinate, prioritize, and maintain continuity of care. While formal care plans are also modifiable depending on new priorities or the outcomes of interventions, they are often related to the longer-term goals of the patient. The formal care plan might include goals to meet before discharge from the hospital or the service. Both formal and informal care plans are used within the framework of the nursing process.
Standardized vs. Individualized Care Planning
Care plans can be either standardized or individualized for the individual patient. Many care settings will use standardized care plans for specific patient conditions to ensure consistent care is delivered. One example of a standardized care plan is the post-operative care pathway used in post-surgical units. These post-operative care plans outline expected goals for each post-operative day. However, standardized care plans should be tailored when possible to the needs of the individual patient.
In contrast, individualized care plans are created for individual patient needs. Individual care plans should include input from the patient whenever possible to create personalized goals and support patient adherence. When creating an individualized care plan, consider the patient’s health status, history, and motivational factors and inquire about what matters most to them.
The Nursing Process
Care plans enter the nursing process at the planning stage but are influenced by all other steps. The steps of the nursing process can be remembered with the acronym ADPIE.3
Here is a breakdown of the nursing process:
1. Assessment: Assessing the client’s needs, gathering data
In the assessment phase of the nursing process, the nurse collects and analyzes objective and subjective data. Then, the nurse uses their nursing knowledge and critical thinking skills to decide if further assessments are necessary to identify a nursing diagnosis.
2. Diagnosis: What’s going on? Crafting a nursing diagnosis
Based on data collected during the assessment phase, the nurse crafts a nursing diagnosis that can be used to direct care planning.4 The nurse should assign a nursing diagnosis using the standardized terminology laid out by NANDA-I. A nursing diagnosis is a clinical judgment that describes actual or potential health problems or opportunities for health improvement of a patient, family, or community.
3. Planning: Time to create goals
In step three of the nursing process, the nurse, ideally in collaboration with the patient, creates goals of care based on the nursing diagnosis. A care plan, including expected outcomes, is created to achieve these goals. A nursing care plan is essential for this phase of the nursing process because it directs interventions and how outcomes will be measured.
4. Implementation: Time to act
In the implementation phase of the nursing process, the nurse implements the interventions described in the care plan to achieve the goals of care. The nurse uses their knowledge, experience, and critical thinking to decide what interventions are a priority. Often, interventions are based on orders from the physician.
5. Evaluate: What are the outcomes?
In the evaluation phase of the nursing process, the nurse reassesses the patient to determine if the intervention has the desired outcome. Next, the nurse should evaluate if the goals of care have been met or require more time. If the intervention does not have the desired effect, the nurse should consider if the care plan needs revision or if the goals of care need to be updated.
Nursing Process Example
Here is an example of how the steps of the nursing process fit together.
The nurse assesses the client who was in a motor vehicle accident. The client reports a pain level of 9/10 in their right shoulder. Through an x-ray, the client is determined to have a dislocated shoulder, and the nursing diagnosis of acute pain is applied. The nurse begins planning treatment and goals to reduce pain and instill comfort. The nurse administers IV pain medication as ordered and supports the right arm with pillows. The nurse evaluates the effectiveness of interventions by asking the client to rate their pain on a scale of 0-10. Depending on the outcome, the nurse may determine that the intervention was successful or requires revision.
How To Write a Nursing Care Plan
With experience, nursing care plans become second nature as part of nursing practice. Since nursing care planning can be formal or informal, a nursing care plan may look very different depending on the care context and the patient’s needs. While informal care plans may not be written in the patient chart, writing effective formal care plans takes practice. Formal care plans are important for communicating significant changes in the patient’s condition to the care team.
Care plans will appear differently depending on each electronic health record, computer platform, setting (home health, doctor’s office, etc.), and nursing specialty (case management, PACU, etc.). Regardless, the nursing process stays the same. One way to improve the skill of care plan writing is to read examples of high-quality care plans. Nurses can also ask experienced colleagues for feedback on their care plans. Some care settings will have templates of expected formal care plans.
Overall, the care plan should flow seamlessly as part of the nursing process, taking into account relevant nursing diagnoses, expected outcomes, and the effectiveness of the planned interventions. If necessary, goals are revised, and the care plan is repeated until goals are met or are no longer applicable.
While rationales are not included in traditional nursing care plans, they are used in student care plans. When learning to write care plans, adding the rationale behind the diagnosis and interventions can be helpful. Students can explain the pathophysiology behind their assessment and why their intervention is necessary to guide their understanding.
Nursing Care Plan Considerations
Consider the hierarchy of needs.
In any care setting, there are often competing priorities that nurses must handle. When deciding on how to prioritize care needs for patients, a useful framework to organize care is Maslow’s hierarchy of needs.5 The highest priority needs are at the bottom of the pyramid and include physiological needs such as air, nutrition, and sleep. The nurse must prioritize physical needs over those closer to the top of the pyramid, such as the need for a sense of connection.
Creating SMART Goals
S.M.A.R.T. goals are specific, measurable, attainable, realistic, and time-bound. SMART goals are helpful in care planning because they increase the likelihood that the goal created will be practical and achievable. Conversely, goals that are too vague or not realistic are less likely to be achieved, which can discourage the goal-setter.
Specific goals are not overly broad. A shared goal of “walking more” is not specific. However, “Walk three laps of the unit 3 times a day” is specific.
Related to being specific, there should be some way to measure whether the goal has been met or is at least progressing. There should be a benchmark that signals that the goal has been met. Benchmarks could be behavioral, physical, or expressed by the patient.
Goals might take work to meet, but attainable goals are within reach. Goals that are too difficult or require multiple steps to reach are more likely to discourage rather than encourage.
An achievable goal is also realistic. Attainable goals are possible to meet, while realistic goals take into consideration the context and potential barriers to meeting the goal.
Setting a time limit on the goal grounds the goal in reality and allows for measurement. The chosen period should depend on the goal’s size and should support progress and focus.
Examples of Collaborative SMART Goals
Here are two examples of how SMART goals can be used in care planning:
Goal: “The client will rate their pain three or less on a scale of 0-10 by discharge.”
- Specific: The goal includes an exact number on the pain scale acceptable to the patient.
- Measurable: The goal can be tracked over time and measured on the pain scale.
- Attainable: This depends on the specific patient context, but for the example, we will assume this is an achievable goal for the patient.
- Realistic: Similarly, this goal must be realistic, which will depend on the patient’s pain tolerance.
- Time-bound: In the inpatient setting, ‘by discharge’ is an appropriate time frame.
Goal: The patient will demonstrate independently using a glucometer to check their blood sugar and how to self-administer necessary insulin after three diabetes education sessions.
- Specific: The goal includes specific behaviors and outcomes of the education sessions.
- Measurable: The nurse can assess if the goal is complete by asking the patient to demonstrate their skills.
- Attainable: The patient has the motor and cognitive ability to learn these skills.
- Realistic: Enough time has been given for practice and education so that the patient feels comfortable and confident.
- Time-bound: This goal is set to be achieved after three education sessions. At the end of the third session, the nurse can assess if the goal has been met or if more support or time is needed to meet this goal.
Short vs. Long-Term Goals
When creating goals of care, it can be helpful to categorize goals into short-term or long-term goals. Short-term goals are commonly found in acute care settings, where care interactions are not as long as in the community. However, both long and short-term goals are used across care settings.
Short-term goals can be completed within a few hours or days. Although there is no precise cut-off for what makes a short-term care goal, short-term goals tend to focus on issues that need to be immediately addressed. An example of a short-term care goal is to improve the patient’s shortness of breath by identifying the cause and administering an intervention to relieve the shortness of breath.
In contrast, long-term goals are usually completed over weeks or months. Long-term care goals tend to be aimed at more chronic health challenges, prevention, and improvement. While important, they tend to be less urgent than short-term care goals. An example of a long-term care goal is the reduction of HbA1c over several months for a patient at risk for diabetes.
Once goals and a plan of care are established, the nurse will perform interventions. There are three main categories of nursing interventions.
Independent: Independent nursing interventions are within the nurse’s scope of practice and do not require the participation of another health professional, such as a physician, to carry out the intervention. Nurses can initiate, implement, and evaluate independent nursing interventions. An example of an independent nursing intervention is providing patient education.
Dependent: Dependent nursing interventions require the participation of another health professional to carry out the intervention. Dependent interventions are often ordered by physicians and then implemented by nurses. Collecting blood work that a physician has ordered is an example of a dependent nursing intervention.
Collaborative: Collaborative nursing interventions are carried out with other healthcare professionals through collaboration or consultation. Collaborating with a physical therapist on exercises to improve patient mobility is an example of a collaborative nursing intervention.
Tips for Effective Care Planning
1. Create goals with the patient when possible. The patient should be included in their care plan to ensure goals are congruent with their lifestyle, values, and preferences. This includes patient involvement in planning interventions and defining the intervention’s successful outcome. Including the patient in the care planning process will increase their motivation to actively participate in their care.
2. Revise goals if necessary. If the goal is not met within the original timeframe, the goal may need revision to ensure that it is achievable and realistic, or the timeframe may need to be extended.
3. Continue to assess and reassess the patient. It is essential to continually evaluate the patient’s status to ensure that the goals and interventions are still appropriate for their condition.
4. If a goal is not met, assess why. Interventions that are not working or care plan goals that are not met require revision. This may include revising the interventions, updating the goals of care, revising the patient diagnosis, assessing the client’s motivation or lack thereof, and furthering patient education.
5. Ensure that progress towards a goal is recognized even if a goal is not met. In some situations, the goal’s timeline may need to be extended for a goal to be met. Consider that a goal may be ‘met’ even if the outcome is not what was intended.
Care Plan Examples
Below you’ll find a list of over 400 care plans. All our care plans are written and reviewed by registered nurses.
- Atrial Fibrillation
- Chest Pain (Angina)
- Coronary Artery Disease
- Heart Failure
- Myocardial Infarction
- Pulmonary Embolism
- Tetralogy of Fallot
Endocrine & Metabolic
- Diabetes Mellitus
- Diabetic Foot Ulcer
- Diabetic Ketoacidosis
- Hypocalcemia & Hypercalcemia
- Hypokalemia & Hyperkalemia
- Hyponatremia & Hypernatremia
- Metabolic Acidosis
- Metabolic Alkalosis
- Syndrome of inappropriate antidiuretic hormone (SIADH)
- Abdominal Pain
- Bowel Perforation
- Clostridioides Difficile
- Colon Cancer
- Colostomy & Ileostomy
- Crohn’s Disease
- Gastrointestinal Bleed
- Liver Cirrhosis
- Nausea & Vomiting
- Pancreatic Cancer
- Paralytic Ileus
- Small Bowel Obstruction
- Ulcerative Colitis
- Acute Kidney Injury
- Benign Prostatic Hyperplasia (BPH)
- Chronic Kidney Disease
- End Stage Renal Disease (ESRD)
- Kidney Stones
- Urinary Tract Infection
Hematologic & Lymphatic
- Blood Transfusion
- Deep Vein Thrombosis
- Low Hemoglobin
- Peripheral Vascular Disease
- Sickle Cell Anemia
- Human Immunodeficiency Virus (HIV)
- Methicillin-resistant Staphylococcus aureus (MRSA)
- Respiratory syncytial virus (RSV)
Maternal & Newborn
- Hyperemesis Gravidarum
- Labor and Delivery
- Placenta Previa
- Postpartum Hemorrhage
- Preterm Labor
Mental Health & Psychiatric
- Attention deficit hyperactivity disorder (ADHD)
- Altered Mental Status
- Antisocial Personality Disorder
- Bipolar Disorder
- Major Depression
- Mental Health
- Obsessive-Compulsive Disorder (OCD)
- Post-traumatic stress disorder (PTSD)
- Substance Abuse
- Compartment Syndrome
- Hip Fracture
- Knee Replacement Surgery
- Myasthenia Gravis
- Rheumatoid Arthritis
- Spinal Cord Injury
- Cerebral Palsy
- Diabetic Neuropathy
- Headache & Migraine
- Multiple Sclerosis
- Parkinson’s Disease
- Peripheral Neuropathy
- Stroke (CVA)
- Transient Ischemic Attack (TIA)
- Traumatic Brain Injury
- Acute Respiratory Failure
- Acute respiratory distress syndrome (ARDS)
- Chest Tube Insertion
- Chronic obstructive pulmonary disease (COPD)
- Cystic Fibrosis
- Pleural Effusion
- Pulmonary Edema
Other Care Plans
Anything that didn’t match a specific category you’ll find here:
- Alcohol Withdrawal Syndrome
- Breast Cancer
- Community Health
- End-of-Life (Hospice) Care
- Hearing Loss
- Sleep Apnea
- NANDA International. Our Story. Accessed January 7, 2023. https://nanda.org/who-we-are/our-story/
- Capriotti T, eBook Nursing Collection – Worldwide, [email protected] Purchased eBooks. Nursing Care Planning Made Incredibly Easy! Third. Wolters Kluwer; 2018. https://go.exlibris.link/P281xmcS
- Toney-Butler T, Thayer J. Nursing Process. Published 2022. https://www.ncbi.nlm.nih.gov/books/NBK499937/
- Carpenito LJ, [email protected] Purchased eBooks. Handbook of Nursing Diagnosis. 15th ed. Wolters Kluwer; 2017.
- Hayre-Kwan S, Quinn B, Chu T, Orr P, Snoke J. Nursing and Maslow’s Hierarchy; A Health Care Pyramid Approach to Safety and Security During a Global Pandemic. Nurse Lead. 2021;19(6):590-595. doi:10.1016/j.mnl.2021.08.013