What is a Nursing Care Plan?
A nursing care plan is a detailed guide that outlines the specific care a patient requires during their treatment in a healthcare setting. It helps nurses provide consistent, personalized, and evidence-based care to meet the individual needs of a patient. The plan includes nursing diagnoses, interventions, goals, and expected outcomes tailored to the patient’s condition.
Types of Nursing Care Plans
1. Problem-Oriented Nursing Care Plan
- Focus: Addresses specific health issues or diagnoses that the patient is experiencing.
- Example: A care plan focused on managing pain, treating infection, or improving mobility.
- Elements:
- Nursing diagnosis (problem).
- Desired outcomes or goals.
- Interventions to address the problem.
- Evaluation to determine if goals are met.
2. Collaborative Care Plan
- Focus: Developed in collaboration with other healthcare professionals, such as doctors, therapists, and dietitians.
- Example: Managing a patient’s postoperative recovery where coordination between nursing, physical therapy, and medical teams is required.
- Elements:
- Multidisciplinary approach.
- Coordination of different care tasks (e.g., medication management, rehabilitation exercises).
3. Standardized Nursing Care Plan
- Focus: Uses pre-established care plans based on best practices for common conditions.
- Example: Standardized care for patients with diabetes, hypertension, or heart failure.
- Elements:
- Evidence-based interventions.
- Standard goals and outcomes for specific conditions.
- Generalizable to a broad range of patients with the same diagnosis.
4. Individualized Care Plan
- Focus: Tailored to the unique needs of a specific patient.
- Example: A care plan for a patient with complex, multiple comorbidities requiring personalized interventions.
- Elements:
- Customized goals and outcomes.
- Personalized interventions based on the patient’s specific condition, preferences, and response to treatment.
5. Critical Pathway or Care Map
- Focus: A timeline-based plan, often used in hospitals to streamline care for specific conditions or surgeries.
- Example: A care pathway for stroke rehabilitation or a surgical patient’s recovery process.
- Elements:
- Timeline outlining interventions day by day.
- Expected outcomes and goals at each stage of care.
6. Comprehensive Care Plan
- Focus: Holistic care plan that considers all aspects of the patient’s physical, mental, emotional, and social needs.
- Example: A care plan for a long-term, chronically ill patient (e.g., end-of-life or palliative care).
- Elements:
- Covers physical, psychosocial, and emotional interventions.
- Emphasis on quality of life, patient comfort, and family support.
7. Emergency Care Plan
- Focus: Rapid response plan used for immediate intervention in critical or life-threatening situations.
- Example: A plan for managing patients in acute respiratory distress or cardiac arrest.
- Elements:
- Focus on life-saving interventions.
- Clear steps for stabilization and transfer to appropriate care.
Purposes of a Nursing Care Plan
The purpose of a nursing care plan is to provide a structured, evidence-based approach to patient care, ensuring individualized care that meets the patient’s specific needs. The key purposes include:
- Guiding Patient Care: It serves as a roadmap for nurses to deliver personalized and consistent care based on the patient’s medical diagnosis and individual needs.
- Promoting Communication: It enhances communication among the healthcare team by providing a detailed plan that outlines interventions, goals, and outcomes for the patient’s care.
- Ensuring Continuity of Care: It helps ensure that care remains consistent even when the patient is cared for by different healthcare providers across shifts or settings.
- Improving Patient Outcomes: By identifying clear goals and appropriate interventions, nursing care plans aim to improve the patient’s health outcomes and promote recovery.
- Documentation of Care: Nursing care plans provide a written record of the nursing process, which is important for legal purposes and for reviewing the effectiveness of care.
- Ensuring Patient-Centered Care: They help nurses tailor interventions to meet the patient’s unique needs, preferences, and cultural considerations.
- Facilitating Evaluation: Care plans include measurable goals and outcomes, enabling the healthcare team to assess the effectiveness of interventions and make necessary adjustments.
In summary, nursing care plans ensure that care is organized, individualized, and aimed at achieving optimal health outcomes for the patient.
Components
A nursing care plan outlines the strategies and actions nurses use to address a patient’s health problems and care needs. The key components of a nursing care plan typically include:
1. Assessment
- Patient Information: Demographic data (age, gender, etc.), medical history, current diagnosis, lab results, and other relevant patient details.
- Subjective Data: Information provided by the patient about symptoms, feelings, or experiences (e.g., pain, fatigue).
- Objective Data: Observable and measurable facts (e.g., vital signs, physical examination findings).
2. Nursing Diagnosis
A statement that identifies a patient’s health issue, derived from the assessment data. These are often based on NANDA-I (North American Nursing Diagnosis Association International) standardized diagnoses.
- Example: Ineffective airway clearance related to mucus buildup as evidenced by coughing and abnormal lung sounds.
3. Outcomes/Goals
Specific, measurable, attainable, realistic, and time-bound (SMART) goals that address the nursing diagnosis.
- Example: “Patient will maintain clear lung sounds within 48 hours.”
4. Nursing Interventions
The actions the nurse will take to help the patient meet the outcomes. These interventions can be independent (nurse-initiated) or collaborative (involving other healthcare professionals).
- Examples:
- Positioning the patient to promote airway clearance.
- Administering medications as prescribed.
- Teaching deep breathing and coughing exercises.
5. Rationale
The reasoning behind each nursing intervention, often grounded in evidence-based practice.
- Example: “Positioning in semi-Fowler’s position helps improve lung expansion.”
6. Evaluation
Determines if the patient has met the established goals or outcomes. This involves reassessing the patient’s condition after interventions to see if there has been improvement.
- Example: “Lung sounds clear, patient reports easier breathing after 48 hours.”
A comprehensive nursing care plan also involves ongoing reassessment and modifications based on the patient’s evolving needs.
Example
Nursing Care Plan for Pneumonia
Patient Information:
- Medical Diagnosis: Pneumonia
- Chief Complaint: Shortness of breath, productive cough with thick sputum.
- Assessment Findings:
- Subjective: Patient reports difficulty breathing, chest pain with deep breaths, and productive cough with yellow sputum.
- Objective: RR 30 breaths/min, SpO2 85% on room air, crackles heard in the lower lung fields, temperature 38.5°C, productive cough with yellow-green sputum.
1. Nursing Diagnosis:
- Ineffective airway clearance related to excessive mucus production and inflammation of lung tissues as evidenced by shortness of breath, productive cough, crackles, and abnormal oxygen saturation.
2. Goals/Outcomes:
- Short-term Goal: Patient will demonstrate effective airway clearance as evidenced by improved breath sounds, reduced sputum production, and SpO2 ≥ 92% within 24 hours.
- Long-term Goal: Patient will verbalize reduced chest discomfort and improved breathing within 48 hours, and chest x-ray will show resolution of infiltrates within a week.
3. Nursing Interventions and Rationales:
- Monitor vital signs, especially respiratory rate, depth, and SpO2 every 2-4 hours.
- Rationale: Early identification of respiratory decline helps initiate timely interventions.
- Administer oxygen therapy as prescribed (e.g., nasal cannula or mask) to maintain SpO2 ≥ 92%.
- Rationale: Oxygen therapy improves gas exchange in inflamed, fluid-filled lungs.
- Encourage the use of an incentive spirometer 10 times an hour while awake.
- Rationale: Incentive spirometry promotes lung expansion, preventing atelectasis and aiding in mucus clearance.
- Position the patient in a high-Fowler’s position (60-90 degrees) and reposition every 2 hours.
- Rationale: This position maximizes lung expansion and improves ventilation and oxygenation.
- Administer prescribed antibiotics (e.g., broad-spectrum antibiotics such as azithromycin or ceftriaxone) as ordered.
- Rationale: Antibiotics target the bacterial infection causing pneumonia, reducing inflammation and secretions.
- Encourage oral fluid intake of at least 2-3 liters/day if not contraindicated (monitor for signs of fluid overload).
- Rationale: Hydration helps to thin secretions, making them easier to expectorate.
- Administer bronchodilators (e.g., albuterol) as prescribed to reduce bronchoconstriction.
- Rationale: Bronchodilators open the airways, improving airflow and secretion clearance.
- Perform chest physiotherapy (CPT) and postural drainage as indicated.
- Rationale: These techniques help loosen and mobilize secretions, promoting easier expectoration.
- Encourage deep breathing and effective coughing techniques (e.g., huff coughing).
- Rationale: Deep breathing exercises help improve lung expansion, while effective coughing clears secretions from the airways.
- Monitor for fever, signs of sepsis (e.g., increased heart rate, confusion), and worsening lung function (e.g., decreased SpO2).
- Rationale: Pneumonia can lead to sepsis or respiratory failure, requiring prompt recognition and intervention.
4. Evaluation:
- Short-term Evaluation:
- After 24 hours, the patient’s SpO2 is 93% on 2 L/min of oxygen, respiratory rate is 24 breaths/min, and the patient reports easier breathing.
- Sputum production is reduced, and crackles are diminished on auscultation.
- Long-term Evaluation:
- After 48 hours, the patient demonstrates effective coughing and deep breathing techniques, reports less chest pain, and is able to expectorate secretions with ease.
- Follow-up chest x-ray shows reduced lung infiltrates, and the patient’s SpO2 is ≥ 94% on room air.
5. Patient Education:
- Antibiotic adherence: Emphasize the importance of completing the full course of antibiotics.
- Fluid intake: Encourage adequate fluid intake to help thin mucus and make it easier to clear.
- Incentive spirometry: Teach the patient how to use an incentive spirometer at home to prevent complications such as atelectasis.
- Smoking cessation: If applicable, educate the patient on the benefits of quitting smoking and avoiding respiratory irritants.
- Signs of worsening: Teach the patient to recognize signs of worsening pneumonia or respiratory distress (e.g., increased shortness of breath, chest pain, high fever), and to seek immediate medical attention if these occur.
| Section | Details |
|---|---|
| Assessment Findings | Subjective: Patient reports difficulty breathing, chest pain with deep breaths, and productive cough with yellow sputum. Objective: RR 30 breaths/min, SpO2 85% on room air, crackles heard in the lower lung fields, temperature 38.5°C, productive cough with yellow-green sputum. |
| Nursing Diagnosis | Ineffective airway clearance related to excessive mucus production and inflammation of lung tissues as evidenced by shortness of breath, productive cough, crackles, and abnormal oxygen saturation. |
| Goals/Outcomes | Short-term Goal: Patient will demonstrate effective airway clearance as evidenced by improved breath sounds, reduced sputum production, and SpO2 ≥ 92% within 24 hours. Long-term Goal: Patient will verbalize reduced chest discomfort and improved breathing within 48 hours, and chest x-ray will show resolution of infiltrates within a week. |
| Nursing Interventions and Rationales | 1. Monitor vital signs, especially respiratory rate, depth, and SpO2 every 2-4 hours. Rationale: Early identification of respiratory decline helps initiate timely interventions. 2. Administer oxygen therapy as prescribed (e.g., nasal cannula or mask) to maintain SpO2 ≥ 92%. Rationale: Oxygen therapy improves gas exchange in inflamed, fluid-filled lungs. 3. Encourage the use of an incentive spirometer 10 times an hour while awake. Rationale: Incentive spirometry promotes lung expansion, preventing atelectasis and aiding in mucus clearance. 4. Position the patient in a high-Fowler’s position (60-90 degrees) and reposition every 2 hours. Rationale: This position maximizes lung expansion and improves ventilation and oxygenation. 5. Administer prescribed antibiotics (e.g., broad-spectrum antibiotics such as azithromycin or ceftriaxone) as ordered. Rationale: Antibiotics target the bacterial infection causing pneumonia, reducing inflammation and secretions. 6. Encourage oral fluid intake of at least 2-3 liters/day if not contraindicated (monitor for signs of fluid overload). Rationale: Hydration helps to thin secretions, making them easier to expectorate. 7. Administer bronchodilators (e.g., albuterol) as prescribed to reduce bronchoconstriction. Rationale: Bronchodilators open the airways, improving airflow and secretion clearance. 8. Perform chest physiotherapy (CPT) and postural drainage as indicated. Rationale: These techniques help loosen and mobilize secretions, promoting easier expectoration. 9. Encourage deep breathing and effective coughing techniques (e.g., huff coughing). Rationale: Deep breathing exercises help improve lung expansion, while effective coughing clears secretions from the airways. 10. Monitor for fever, signs of sepsis (e.g., increased heart rate, confusion), and worsening lung function (e.g., decreased SpO2). Rationale: Pneumonia can lead to sepsis or respiratory failure, requiring prompt recognition and intervention. |
| Evaluation | Short-term Evaluation: After 24 hours, the patient’s SpO2 is 93% on 2 L/min of oxygen, respiratory rate is 24 breaths/min, and the patient reports easier breathing. Sputum production is reduced, and crackles are diminished on auscultation. Long-term Evaluation: After 48 hours, the patient demonstrates effective coughing and deep breathing techniques, reports less chest pain, and is able to expectorate secretions with ease. Follow-up chest x-ray shows reduced lung infiltrates, and the patient’s SpO2 is ≥ 94% on room a |
References
- Gulanick, M., & Myers, J. L. (2017).Nursing Care Plans: Nursing Diagnosis and Interventions. 9th Edition. St. Louis, MO: Elsevier.
- American Association of Colleges of Nursing (AACN). (2015).The Essentials of Baccalaureate Education for Professional Nursing Practice.
- Mason, K. M., & Leavitt, S. B. (2020).Fundamentals of Nursing: The Art and Science of Nursing Care. 8th Edition. Philadelphia, PA: Lippincott Williams & Wilkins.
- Centers for Disease Control and Prevention (CDC). (2022).Pneumonia.
- Retrieved from CDC Pneumonia
- National Institute for Health and Care Excellence (NICE). (2021).Pneumonia in adults: diagnosis and management.
- Retrieved from NICE Guidelines
- LeMone, P., & Burke, K. M. (2021).Medical-Surgical Nursing: Critical Thinking in Client Care. 6th Edition. Upper Saddle River, NJ: Pearson.
