What Is a Nursing Care Plan?

What Is a Nursing Care Plan?

A nursing care plan is the written representation of the nursing process, as defined by the American Nurses Association – “the common thread uniting different types of nurses who work in varied areas … the essential core of practice for the registered nurse to deliver holistic, patient-focused care.”

The nursing process consists of five major steps:

  • Assessment is gathering and analyzing data in order to acquire a comprehensive picture of the patient’s needs and risk factors.
  • Diagnosis: Forming nursing diagnoses based on data, patient feedback, and clinical judgment.
  • Outcomes/Planning: Establishing short- and long-term goals based on the nurse’s examination and diagnosis, ideally with patient engagement. Choosing nursing interventions to achieve such objectives.
  • Implementation entails carrying out nursing care in accordance with the care plan, which is based on the patient’s health status and the nursing diagnosis. Documenting the care provided by the nurse.
  • Monitoring (and documenting) the patient’s state and progress toward goals, as well as changing the treatment plan as necessary.

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A nursing care plan is official record of this procedure, and most care plans are divided into four columns that roughly reflect the nursing process’s steps. Care plans include the following:

  • Diagnoses in nursing
  • Expected outcomes/goals
  • Interventions by nurses
  • Evaluation

Writing a Nursing Care Plan

To develop a care plan, follow the nursing process:

  1. Assessment
  2. Diagnosis
  3. Outcomes/Planning
  4. Implementation
  5. Evaluation

1. Examine the patient.

The nurse begins by evaluating all relevant data, which may include (but is not limited to): medical history, lab results, vital signs, head-to-toe assessment data, interactions with the patient and loved ones, observations from other members, and demographic information. This information is used by the nurse to evaluate the patients:

  • Needs in terms of physical, emotional, psychological, and spiritual well-being
  • Areas for development
  • Risk elements

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Examples of assessment include:

  • Assessing and treating clients with pain
  • Assessing and treating clients with ADHD
  • Assessing and treating clients with anxiety disorder

2. Identify and list nursing diagnoses

Following a comprehensive examination, the nurse finds nursing diagnoses, which are health problems (or prospective health problems) that nurses can manage without the assistance of a physician. Nursing diagnoses include, for example, acute pain, fever, sleeplessness, and a danger of falling. The North American Nursing Diagnostic Association (NANDA) maintains an official nursing diagnosis list that includes definitions, characteristics, and commonly used interventions for each diagnosis.

3. Set goals for and with the patient

What are the goals, and how will the patient get there? The nurse responds to these questions based on the examination, nursing diagnosis, and patient input. Together, the nurse and patient establish reasonable goals that can be met with nursing interventions and (in some situations) patient effort. Short-term goals (e.g., alleviate acute pain following surgery) or long-term goals (e.g., lower the patient’s A1C with better diabetes care) The nurse then selects goals based on their importance, urgency, and patient feedback. Maslow’s hierarchy of needs can also be used by nurses to assist prioritize patient goals.

4. Carry out nursing interventions

Nursing interventions are acts made by nurses to meet patient goals and achieve desired outcomes, such as administering drugs, educating the patient, checking vital signs every couple of hours, beginning fall precautions, or measuring the patient’s pain levels at regular intervals. This is also where the nurse logs care as interventions are performed, including dependent nursing interventions required by physicians.

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5. Evaluate progress and modify the care plans accordingly

Finally, the nurse regularly observes and assesses the patient and the nursing care plan to answer the question: Are the nursing interventions assisting the patient in achieving their objectives and intended outcomes, and should those interventions be adjusted, discontinued, or continued?

Nursing care plan examples

Nursing care plan for pain – acute pain diagnosis

An acute pain nursing diagnosis is a painful sensory and emotional experience that is associated with or defined in terms of actual or probable tissue injury (International Association for the Study of Pain). It might happen after a surgery, an injury, or during labor and delivery.

It can be a rapid or gradual onset of any severity, ranging from mild to severe, and can last from a few seconds to 6 months.

The nursing interventions for acute pain listed below can assist a nurse in providing efficient and effective care to a patient suffering from Acute Pain.

Acute Pain related Nursing Diagnosis

Acute Pain – Nursing Care Plan 1

Nursing Diagnosis: Acute Pain related to hip fracture secondary to fall, as shown by pain score of 10, guarding sign on the affected limb, restlessness, and irritability

Desired Outcome: The client will report a pain score of 0.

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Interventions Rationales
Examine the patient’s vital signs. Patient is asked to rate his or her pain on a scale of 0 to 10, and to express the pain he or she is feeling. To compile a set of baseline observations for the patient. The 10-point pain scale is an internationally recognized, accurate, and useful pain rating measure.
Administer analgesic pain relievers as directed. To reduce the patient’s pain.
Request that the patient re-rate his or her acute pain 30 to 60 minutes after receiving the analgesic. To evaluate the efficiency of a treatment.
More analgesics should be administered at the recommended/prescribed intervals. To provide pain relief and patient comfort while minimizing the risk of overdosing.
Relocate the patient in his or her most comfortable/favored position. Encourage deep breathing exercises and pursed lip breathing. To improve patient comfort and alleviate anxiety/restlessness.
If the patient’s medical practitioner requests it, refer them to a pain expert. To allow the patient to receive further information and expert pain management care if necessary.

Acute Pain Nursing Care Plan 2

Nursing Diagnosis: Deficient Knowledge related to acute pain management as evidenced by patient’s verbalization of “I want to know more how to relieve my pain.”

Desired Outcome: The patient will be able to demonstrate appropriate knowledge of his or her acute pain and how to manage it at the end of the health education session.

Interventions Rationales
Examine the patient’s readiness to learn, as well as any misconceptions or learning barriers (e.g. denial of diagnosis or poor lifestyle habits). To address the patient’s cognition and mental state in relation to pain management, as well as to assist the patient in overcoming learning barriers.
Describe his or her pain management strategy (e.g. medications, relaxation techniques, related physiotherapy or exercises). Avoid medical jargon and explain in plain English. To provide details about his or her pain management plan.
Explain to the patient the specifics of the medications indicated to manage acute pain (e.g., drug class, use, advantages, side effects, and risks).

Request that the patient demonstrate or repeat the self-administration details to you.

To completely explain each recommended drug to the patient, including the purpose, potential side effects, adverse occurrences, and self-administration instructions.
Educate the patient about non-pharmacological pain management approaches such as imaging, diversion, prescribed exercises, and relaxation. Reduce stress and provide appropriate pain management without relying too heavily on pharmaceuticals.

Acute Pain Nursing Care Plan 3

Nursing Diagnosis: Activity intolerance related to acute pain as evidenced by pain score of 8 to 10 out of 10, fatigue, disinterest in ADLs due to pain, verbalization of tiredness and generalized weakness

Desired Outcome: The patient will display increased activity levels and active engagement in necessary and desirable activities.

Interventions Rationales
Examine the patient’s everyday activities, as well as any actual or perceived limitations to physical exercise.

Inquire about any type of activity he or she used to perform or would want to attempt.

To establish a baseline of activity levels and mental state in patients suffering from acute pain, weariness, or exercise intolerance.
As tolerated, encourage gradual activity through self-care and exercise.

Explain why it’s important to cut down on sedentary activities like watching TV and using social media for lengthy periods of time.

Alternate periods of physical exercise with times of uninterrupted rest of 60-90 minutes.

To progressively raise the patient’s physical exercise tolerance.

Allowing the patient to pace activity against rest to avoid triggering acute pain.

Prior to exercise or physical activity, take analgesics as directed.

Instruct students in deep breathing exercises and relaxation techniques.

Make sure the room has enough ventilation.

To alleviate pain before to a workout session.

Allowing the patient to relax while resting and facilitating efficient stress management.

To ensure that the room receives adequate oxygenation.

As needed, refer the patient to the physiotherapy or occupational therapy team. To give more specific care for the patient in terms of assisting him/her in gaining confidence in increasing daily physical activity.

Acute Pain Nursing Care Plan 4

Nursing Diagnosis: Acute Pain related to infection secondary to pleurisy as evidenced by pain score of 10 out of 10, pain upon inhalation, shortness of breath

Desired Outcome: The patient’s pain level will be 0 out of 10.

 

Interventions Rationales
Examine the patient’s vital signs.

Ask the patient to rate his or her pain on a scale of 0 to 10 and to describe the agony he or she is feeling.

To compile a set of baseline observations for the patient.

The 10-point pain scale is an internationally recognized, accurate, and useful pain rating measure.

Administer analgesic pain relievers as directed.

Antibiotics should be taken as directed.

To alleviate the patient’s suffering.

To take care of the underlying infection.

Request that the patient re-rate his or her acute pain 30 minutes to an hour after receiving the painkiller. To determine the efficacy of a treatment.
More analgesics should be administered at the recommended/prescribed intervals. To provide pain relief and patient comfort while minimizing the risk of overdosing.
Raising the head of the bed and encouraging the patient to sit in a semi-position. Fowler’s

Encourage deep breathing exercises and pursed lip breathing.

To alleviate shortness of breath and promote lung expansion.

To improve patient comfort and alleviate anxiety/restlessness.

As needed, refer the patient to a pain specialist. To enable the patient to receive further information and expert pain management care as needed.

Acute Pain Nursing Care Plan 5

Nursing Diagnosis: Imbalanced Nutrition: Lower than the average Body Requirements as a result of decreased food intake as a result of acute discomfort, as demonstrated by weight loss, low muscular tone, and a lack of appetite.

Desired Outcome: The patient will maintain a weight within the normal BMI range by following healthy eating patterns and making healthy food selections.

 

Intervention Rationale
Make a daily weight chart as well as a food and fluid chart.

Discuss with the patient the patient’s short and long-term weight growth goals.

To efficiently monitor the patient’s daily dietary intake and weight-loss progress.
As directed, administer analgesics. To alleviate discomfort, as intense pain can lead to disinterest in eating and, eventually, a lack of sufficient nutrition.
Instruct the patient to avoid fizzy beverages and foods that produce gas. To alleviate stomach distention, which can aggravate acute discomfort.
Please refer the patient to a dietician. To give more specialized nutrition and diet care for the patient.

More application of nursing care plan include:

  • nursing care plan for hypertension
  • nursing care plan for infection
  • fluid volume deficit nursing care plan
  • nursing care plan for constipation
  • nursing care plan for copd
  • nursing care plan for anxiety
  • anxiety nursing care plan
  • nursing care plan for pneumonia
  •  impaired skin integrity nursing care plan
  • nursing care plan for dementia
  • nursing care plan for diabetes
  • nursing care plan for dehydration
  • nursing care plan for gi bleed
  • nursing care plan for dvt
  • fluid and electrolyte imbalance nursing care plan
  • nursing care plan for depression
  • self care plan

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