how to write an evaluation for nursing care plan

Nursing Care Plans Explained: Types, Tutorial & Examples

Nursing care plans are written tools that outline nursing diagnoses , interventions, and goals. Care plans are especially useful for student nurses as they learn to utilize the nursing process. By creating a nursing care plan based on a patient’s assessment, the nurse learns how to prioritize, plan goals and interventions, and evaluate outcomes related to specific disease processes. Care plans are essential for communication between nurses and other care team members in order to provide high-quality, continuous, evidence-based care.

In this article:

• What is a Nursing Care Plan?
• Why Use Nursing Care Plans?
• Types of Nursing Care Plans
• Nursing Care Plan Considerations
• Creating SMART Goals
• Nursing Interventions
• Tips for Effective Care Planning
• Nursing Care Plan Examples

Nursing care plans are a structured framework for delivering 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 , as they help nurses plan, prioritize, rationalize, and evaluate interventions.

Listed below are some of the benefits of using care plans in nursing practice.

1. Follows the client from admission to discharge . Care plans are continually updated depending on the patient’s status, goals, and outcomes and follow the patient across facility transfers and to different care 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 outcome.

3. Evaluates interventions . Care plans include a combination of short and long-term goals that are specific, measurable, and timely. The nurse can evaluate if interventions are effective by evaluating goal progression.

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.

8. Offers a framework for consistent care. 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

9. Prevents future health hazards. Some care plans may include nursing diagnoses the patient is at risk for, like falls or infection. Care plan interventions and goals can be created to prevent complications.

There is some variation in how care plans are used in practice. The structure and format of a care plan depend 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 nurse’s goals for their shift. These goals can 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 patient. Many care settings will use standardized care plans for specific patient conditions to deliver consistent care. 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. Individualized 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

• Implementation/Interventions

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 interventions and expected outcomes, is created to achieve these goals.

4. Implementation: Time to act In the implementation phase of the nursing process, the nurse takes actions and performs the interventions described in the care plan to achieve the goals of care. The nurse uses their knowledge, experience, and critical thinking to decide which 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.

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 including 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.

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 Specific goals are not overly broad. A shared goal of “walking more” is not specific. However, “Walk three laps of the unit three times a day” is specific.

Measurable 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. 

Attainable 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. 

Realistic 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.

Time-bound  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 shorter than 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 may 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.

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, reviewing 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.

Below you’ll find a list of over 400 care plans. All our care plans are written and reviewed by registered nurses.

• Atrial Fibrillation
• Bradycardia
• Cardiomyopathy
• Chest Pain (Angina)
• Coronary Artery Disease
• Heart Failure
• Hypertension
• Hypotension
• Myocardial Infarction
• Pulmonary Embolism
• Tachycardia
• Tetralogy of Fallot

Endocrine & Metabolic

• Diabetes Mellitus
• Diabetic Foot Ulcer
• Diabetic Ketoacidosis
• Hyperglycemia
• Hyperlipidemia
• Hypocalcemia & Hypercalcemia
• Hypoglycemia
• Hypokalemia & Hyperkalemia
• Hyponatremia & Hypernatremia
• Hypothyroidism
• Malnutrition
• Metabolic Acidosis
• Metabolic Alkalosis
• Syndrome of inappropriate antidiuretic hormone (SIADH)

Gastrointestinal

• Abdominal Pain
• Appendicitis
• Bowel Perforation
• Clostridioides Difficile
• Colon Cancer
• Colostomy & Ileostomy
• Crohn’s Disease
• Diverticulitis
• Gastrointestinal Bleed
• Liver Cirrhosis
• Nausea & Vomiting
• Pancreatic Cancer
• Pancreatitis
• Paralytic Ileus
• Peritonitis
• Small Bowel Obstruction
• Ulcerative Colitis

Genitourinary

• Acute Kidney Injury
• Benign Prostatic Hyperplasia (BPH)
• Chronic Kidney Disease
• End Stage Renal Disease (ESRD)
• Kidney Stones
• Pyelonephritis
• Urinary Tract Infection

Hematologic & Lymphatic

• Anaphylaxis
• Blood Transfusion
• Deep Vein Thrombosis
• Low Hemoglobin
• Neutropenia
• Peripheral Vascular Disease
• Sickle Cell Anemia
• Thrombocytopenia

Infectious Diseases

• Human Immunodeficiency Virus (HIV)
• Methicillin-resistant Staphylococcus aureus (MRSA)
• Respiratory syncytial virus (RSV)
• Tuberculosis

Integumentary

• Pressure Ulcers
• Wound Care & Infection

Maternal & Newborn

• Breastfeeding
• Hyperemesis Gravidarum
• Labor and Delivery
• Placenta Previa
• Postpartum Hemorrhage
• Preeclampsia
• 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)
• Psychosocial
• Post-traumatic stress disorder (PTSD)
• Schizophrenia
• Substance Abuse

Musculoskeletal

• Compartment Syndrome
• Hip Fracture
• Knee Replacement Surgery
• Myasthenia Gravis
• Osteoarthritis
• Osteomyelitis
• Osteoporosis
• Rhabdomyolysis
• Rheumatoid Arthritis
• Spinal Cord Injury

Neurological

• Cerebral Palsy
• Diabetic Neuropathy
• Encephalopathy
• Headache & Migraine
• Multiple Sclerosis
• Parkinson’s Disease
• Peripheral Neuropathy
• Stroke (CVA)
• Transient Ischemic Attack (TIA)
• Traumatic Brain Injury

Respiratory

• Acute Respiratory Failure
• Acute respiratory distress syndrome (ARDS)
• Chest Tube Insertion
• Chronic obstructive pulmonary disease (COPD)
• Cystic Fibrosis
• Pleural Effusion
• Pneumothorax
• Pulmonary Edema
• Tracheostomy

Other Care Plans

Anything that didn’t match a specific category you’ll find here:

• Alcohol Withdrawal Syndrome
• Breast Cancer
• Chemotherapy
• 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, Books@Ovid 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, Books@Ovid 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

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• Clinical Orthopedic Residency (OCS)
• Orthopaedic Manual Physical Therapy Fellowship (OMPT)
• Continuing Professional Education (CPE)
• Doctor of Physical Therapy (DPT)
• Non-Degree Physical Therapy Online Courses
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How to Write a Care Plan: A Guide for Nurses

Care plans are a way to strategically approach and streamline the nursing process. They also enable effective communication in a nursing team. This guide will help you understand the fundamentals of nursing care plans and how to create them, step by step. We’ll also outline best practices to keep in mind and provide you with a nursing care plan sample that you can download and print.

Table of Contents

What Is a Nursing Care Plan?

What are the components of a care plan, care plan fundamentals, sample nursing care plan.

A nursing care plan documents the process of identifying a patient’s needs and facilitating holistic care, typically according to a five-step framework. A care plan ensures collaboration among nurses, patients, and other healthcare providers. ((M. Vera., “Nursing Care Plans (NCP): Ultimate Guide and Database”, July 5, 2021: https://nurseslabs.com/nursing-care-plans/ )) ((Medical Dictionary for the Health Professions and Nursing, Farlex, “nursing care plan”, 2012: https://medical-dictionary.thefreedictionary.com/nursing+care+plan )) ((Health Navigator, “Care planning”, April 6, 2021: https://www.healthnavigator.org.nz/clinicians/c/care-planning/ )) ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/ ))

Key Reasons to Have a Care Plan

The purpose of a nursing care plan is to document the patient’s needs and wants, as well as the nursing interventions (or implementations) planned to meet these needs. As part of the patient’s health record, the care plan is used to establish continuity of care. ((C. Björvell et al., “Development of an audit instrument for nursing care plans in the patient record,” Quality in Health Care , March 1, 2000: https://qualitysafety.bmj.com/content/qhc/9/1/6.full.pdf )) These are the main reasons to write a care plan:

• Patient-centered care 

A care plan helps nurses and other care team members organize aspects of patient care according to a timeline. It’s also a tool for them to think critically and holistically in a way that supports the patient’s physical, psychological, social, and spiritual care. Sometimes a patient should be assigned to a nurse with specific skills and experience; a care plan makes that process easier. For patients, having clear goals to achieve will make them more involved in their treatment and recovery. ((Health Navigator, “Care planning”, April 6, 2021: https://www.healthnavigator.org.nz/clinicians/c/care-planning/ ))

• Nursing team collaboration

Writing a care plan allows a team of nurses (as well as physicians, assistants, and other care providers) to access the same information, share opinions, and collaborate to provide the best possible care for the patient. 

• Documentation and compliance

A well-written care plan allows nurses to measure the effectiveness of care and to record evidence that the care was given. This is important both to maximize care efficiency and to provide documentation for healthcare providers.

Care plans are structured as a five-step framework: assessment, diagnosis, outcomes and planning, implementation, and evaluation. ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/ ))

Step 1: Assessment

The first step of writing a care plan requires critical thinking skills and data collection. Different healthcare organizations use different formats for the assessment phase. In general, the data you will collect here is both subjective (e.g., verbal statements) and objective (e.g., height and weight, intake/output). The source of the subjective data could be the patients or their caretakers, family members, or friends.

Nurses can gather data about the patient’s vital signs, physical complaints, visible body conditions, medical history, and current neurological functioning. Digital health records may help in the assessment process by populating some of this information automatically from previous records.

Step 2: Diagnosis

Using the collected data, you will develop a nursing diagnosis—which the North American Nursing Diagnosis Association (NANDA) defines as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.” ((NANDA, “Glossary of Terms”: https://nanda.org/publications-resources/resources/glossary-of-terms/ )) 

A nursing diagnosis sets the basis for choosing nursing actions to achieve specific outcomes. A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid ((Saul McLeod, “Maslow’s Hierarchy of Needs,” Simply Psychology , Dec. 29, 2020: https://www.simplypsychology.org/maslow.html )) (which identifies and ranks human needs) and helps prioritize treatments. For example, physiological needs (such as food, water, and sleep) are more fundamental to survival than love and belonging, self-esteem, and self-actualization, so they have the priority when it comes to nursing actions. ((Chiung-Yu Shih et al, “The association of sociodemographic factors and needs of haemodialysis patients according to Maslow’s hierarchy of needs,” Journal of Clinical Nursing , July 30, 2018: https://pubmed.ncbi.nlm.nih.gov/29777561/ ))

Based on the diagnosis, you’ll set goals (Step 3) to resolve the patient’s problems through nursing implementations (Step 4).

Step 3: Outcomes and Planning

After the diagnosis is the planning stage. Here, you will prepare SMART goals (more detail on this later) based on evidence-based practice (EBP) guidelines. You will consider the patient’s overall condition, along with their diagnosis and other relevant information, as you set goals for them to achieve desired and realistic health outcomes for the short and long term. 

Step 4: Implementation

Once you’ve set goals for the patient, it’s time to implement the actions that will support the patient in achieving these goals. The implementation stage consists of performing the nursing interventions outlined in the care plan. As a nurse, you will either follow doctors’ orders for nursing interventions or develop them yourself using evidence-based practice guidelines.

Interventions are classified into the following seven domains: family, behavioral, physiological, complex physiological, community, safety, and health system interventions. There are several basic interventions that you need to implement during each shift: pain assessment, changing the resting position, listening, cluster care, preventing falls, and fluid consumption.

Step 5: Evaluation

In the final step of a care plan, the health professional (who can be either a doctor or a nurse) will evaluate whether the desired outcome has been met. You will then adjust the care plan based on this information.

In a simple but useful way, Nurse.org explains the core questions your care plan should answer: what, why, and how. ((Mariam Yazdi, “4 Steps to Writing a Nursing Care Plan,” Nurse.org, March 23, 2018: https://nurse.org/articles/nursing-care-plan-how-to/ )) A nursing care plan should include:

• The What : What does the patient suffer from? What do they risk suffering from?
• The Why : Why does your patient suffer from this? Why do they risk suffering from this?
• The How : How can you make this better?

Successful care plans use the fundamental principles of critical thinking, client-centered techniques, goal-oriented strategies, evidence-based practice (EBP) recommendations, and nursing intuition. ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/ ))

SMART Goals

In the planning phase of writing a care plan, it’s important that you use goal-oriented strategies. A SMART goals template can help in this process:

• Specific : Your goals for the patient must be well-defined and unambiguous. 
• Measurable : You need to set certain metrics to measure the patient’s progress toward these goals.
• Achievable : Their goal should be possible to achieve.
• Realistic : Their goals must be within reach and relevant to the overall care plan.
• Time-bound : The patient’s goals should have a clear starting time and end date (which can be flexible). 

Effective Communication

Unless your care plan is communicated effectively to all relevant stakeholders, it will only be a plan. Remember that the purpose of a nursing care plan is not to be a static document, but to guide the entire nursing process and enable teamwork, with the goal of improving care. Writing skills are crucially important for nurses—you’ll need to be as accurate and current as possible in your descriptions. For effective communication, keep in mind the following best practices when writing a care plan:

• Write down everything immediately so you don’t forget the details.
• Write clearly and concisely, using terms that your team will understand.
• Include dates and times.

Although you will learn communication skills in an undergraduate or graduate nursing program , you will also develop them over time and with practical experience. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/ ))

Shareable and Easy to Access

Care plans also need to be easy to share with the relevant stakeholders—patients, doctors, other members of the nursing team, insurance companies, etc. The documentation format will vary according to hospital policy , but, in general, care plans are created in electronic format and integrated into the electronic health record (EHR) for easy access to everyone. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/ ))

Finally, you will need to update your care plans often with the latest information. That implies checking in with patients frequently and recording data about how the patient is progressing toward their goals, which will be important in the evaluation stage of the care plan. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/ ))

Despite the overall general objective, nursing care plans written by students are not the same as those created by registered nurses in clinical settings. The student version is much longer, has a greater level of detail, and is exhaustively thorough. On the other hand, nurses often assume some basic concepts and note some of the steps in the care plan only mentally. ((M. Vera., “Nursing Care Plans (NCP): Ultimate Guide and Database”, July 5, 2021: https://nurseslabs.com/nursing-care-plans/ ))

For example, in the interventions section, a student would write: “vital signs recorded every four hours: blood pressure, heart rate, three- or five-lead electrocardiograms, functional oxygen saturation, respiratory rate, and skin temperature,” while an experienced registered nurse might just write “Q4 vital signs.”

Why this difference? As a student or recent graduate, including all the information in your care plan will help you solidify your training. While writing care plans in school can be a very time-consuming task, mastering this information in nursing school will improve your competency and confidence. Most of the information that you’ll have to look up while you’re still in school will become second nature in the future. Here’s what a care plan written by a student looks like:

• Assessment : “heart rate 100 bpm, dyspnea, restlessness, guarding behavior.”
• Diagnosis : “impaired gas exchange RT collection of mucus in airway.”
• Outcomes and planning : “patient must maintain optimal gas exchange.”
• Implementations : “assess respiration; encourage breathing and position changes.”
• Rationale : “respiration will indicate the level of lung involvement, as the patient will adjust their breathing to facilitate gas exchange; these will improve ventilation and allow for chest expansion.”
• Evaluation : “the patient maintained good gas exchange, normal respiratory rate.”

Note that student care plans often have an additional column—rationale—where students note the scientific explanation for the implementations they chose. To help you get started with a care plan writing practice, we’ve created a printable nursing care plan, which you can use to practice writing all the steps outlined in this article.

Wrapping Up: Writing an Effective Nursing Care Plan

To be successful, a nursing plan needs effective communication, goal-oriented tasks, accessibility and shareability, and evidence-based practice. 

When it meets these qualities and is supported by the nurse’s intuition, critical thinking, and a general focus on the patient, a nursing care plan becomes a go-to resource for nurses to record and access all the information they need. A care plan is your roadmap for effective nursing care, and a collaboration tool that improves the entire healthcare process.

While all nursing programs teach the basics of writing a care plan, your communication, goal setting, and critical thinking skills will be shaped by the program you attend. 

For example, one of the benefits of writing care plans is that it will allow you to develop professionalism , along with important values like accountability, respect, and integrity. Key results of professionalism include better overall care, improved team communication, and a more positive work environment. ((Nursco, “Professionalism in Nursing – 5 Tips for Nurses,” July 13, 2018: https://www.nursco.com/professionalism-nursing-5-tips-nurses/ )) 

That’s why it’s important that you choose the right program for your needs—one that will help you develop communication and critical thinking skills, as well as professionalism, to be ready for the day-to-day nursing life. 

The University of St. Augustine for Health Sciences (USAHS) offers a Master of Science in Nursing degree (MSN), a Doctor of Nursing Practice degree (DNP), and Post-Graduate Nursing Certificates designed for working nurses. Our degrees are offered online, with optional on-campus immersions.* Role specialties include Family Nurse Practitioner (FNP), Nurse Educator ,** and Nurse Executive . The MSN has several options to accelerate your time to degree completion. Earn your advanced nursing degree while keeping your work and life in balance.

*The FNP role specialty includes two required hands-on clinical intensives as part of the curriculum.

**The Nurse Educator role specialty is not available for the DNP program.

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4.8 Evaluation

Open Resources for Nursing (Open RN)

Evaluation is the sixth step of the nursing process (and the sixth Standard of Practice by the American Nurses Association). This standard is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.” [1] Both the client status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed. [2]

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a client’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a client, discusses the care plan with others on the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans should be updated as higher priority goals emerge. The results of the evaluation must be documented in the client’s medical record. Evaluation is outside the scope of practice for LPN/VNs, but they may assist in collecting reassessment data for the RN to evaluate.

Ideally, when the planned interventions are implemented, the client will respond positively, and the expected outcomes are achieved. However, when interventions do not assist in progressing the client toward the expected outcomes, the nursing care plan must be revised to more effectively address the needs of the client These questions can be used as a guide when revising the nursing care plan:

• Did anything unanticipated occur?
• Has the client’s condition changed?
• Were the expected outcomes and their time frames realistic?
• Are the nursing diagnoses accurate for this client at this time?
• Are the planned interventions appropriately focused on supporting outcome attainment?
• What barriers were experienced as interventions were implemented?
• Does ongoing assessment data indicate the need to revise diagnoses, outcome criteria, planned interventions, or implementation strategies?
• Are different interventions required?

See Figure 4.15 [3]  for a comparison of the Evaluation phase of the nursing process to the NCSBN Clinical Judgment Model.

Putting It Together

See an example of the Evaluation phase in the following box.

Example of Evaluation

Refer to Scenario C in the “ Assessment ” section of this chapter and Appendix C . The nurse evaluates the client’s progress toward achieving the expected outcomes.

For the nursing diagnosis Excess Fluid Volume , the nurse evaluated four expected outcomes to determine if they were met during the time frames indicated:

• The client will report decreased dyspnea within the next 8 hours.
• The client will have clear lung sounds within the next 24 hours.
• The client will have decreased edema within the next 24 hours.
• The client’s weight will return to baseline by discharge.

Evaluation of the client condition on Day 1 included the following data: “ The client reported decreased shortness of breath, and there were no longer crackles in the lower bases of the lungs. Weight decreased by 1 kg, but 2+ edema continued in ankles and calves .” Based on this data, the nurse evaluated the expected outcomes as “ Partially Met ” and revised the care plan with two new interventions:

• Request prescription for TED hose from provider.
• Elevate client’s legs when sitting in chair.

For the second nursing diagnosis, Risk for Falls , the nurse evaluated the outcome criteria as “ Met ” based on the evaluation, “ The client verbalizes understanding and is appropriately calling for assistance when getting out of bed. No falls have occurred. ”

The nurse will continue to reassess the client’s progress according to the care plan during hospitalization and make revisions to the care plan as needed. Evaluation of the care plan is documented in the client’s medical record.

• American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
• American Nurses Association. (n.d.) The nursing process . https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/ ↵
• “ Evaluation Phase of the Nursing Process Compared to the NCSBN Clinical Judgment Model ” by Tami Davis is licensed by  CC BY 4.0 . ↵

Nursing Fundamentals 2e Copyright © by Open Resources for Nursing (Open RN) is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Nursing Care Plans Explained

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This page can help you understand nursing care plans, how they improve nursing team communication and patient care, and how to develop nursing care plans for your patients. Nursing care plans are individualized and ensure consistency for nursing care of the patient, document patient needs and potential risks, and help patients and nurses work collaboratively toward optimal outcomes.

What Is a Nursing Care Plan?

Nursing care plans are a vital part of the nursing process. They provide a centralized document of the patient’s condition, diagnosis, the nursing team’s goals for that patient, and measure of the patient’s progress. Nursing care plans are structured to capture all the important information for the nursing team in one place.

Because they centralize this information and updates, they ensure that everything important is documented and available to all team members. This also makes patient education easier, since all nursing staff members know and can reinforce what the patient needs to learn.

Without nursing care plans, communication can become disjointed, patient information might be scattered across different patient records and databases, or nursing staff might have to rely on verbal handoffs that the new nurse may mishear or even forget if they are dealing with multiple crises at once.

Developing a Nursing Care Plan

Nursing care plans include the initial patient assessment and diagnosis, the desired outcomes and how to achieve them, and an evaluation of the patient’s results. While the names of the individual parts may vary from organization to organization (for example, “implementation” in one plan might be called “intervention” in another), all nursing care plans include these fundamental components.

Many, but not all, nursing care plans include rationales, the reasons for an intervention, while others require them only if there is some reason not to provide the standard intervention.

Nursing plans should be holistic and take account of nonclinical needs where possible, such as preferences for chaplain services or other ways to support the patient’s mental well-being.

Patient Assessment

Patient assessment includes a thorough evaluation of subjective and objective symptoms and vital signs. Nurses are responsible for collecting and maintaining this data, although certified nursing assistants may help collect vital signs.

Nursing Diagnoses

A nursing diagnosis is created by a nurse based on the subjective and objective data collected during the patient assessment. This is separate from a medical diagnosis which must be provided by a physician or nurse practitioner. Nurses select standardized diagnoses approved by the North American Nursing Diagnosis Association (NANDA) that are relevant to the patient’s condition, symptoms, and risks.

Anticipated Outcomes/Goals

This section describes the goals for the patient, usually both short-term goals, such as reduction of pain or improvement in symptoms or vital signs, as well as long-term goals, such as recovery within a certain time frame. The goals are directly related to the nursing diagnosis.

Implementation

Implementation describes how the nursing team can work to achieve these goals. Specific nursing interventions are planned based on the goals. This section also documents what nursing-specific care the nursing team has performed for the patient.

This section describes how well the patient’s condition responded to the nursing interventions or, in other words, how the goals were or were not met. If the goals were not met, the nurse revises the plan. If the goals were met, the nurse may decide to add more goals and interventions.

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Nursing Care Plan Do’s and Don’ts

While nursing care plans are created to document the care you are providing for your patient, there are “Do’s and Don’ts” to writing an effective care plan. Here are a few:

Using a Nursing Care Plan

In addition to centralizing information, nursing care plans are one of the most effective tools for nurses to uphold the nursing code of ethics and to document that they did so in case of lawsuits or accusations of failure to adhere to care standards. This is one of the many reasons for all nurses and nursing assistants to understand and update each patient’s nursing care plan when necessary.

Unlike most electronic health records systems, nursing care plans are designed to address the patient’s holistic needs which helps provide a better patient experience. When all members of a care team have access to all the information about a patient’s needs and preference, everyone stays on the same page.

Many organizations have their own preferred formats for nursing care plans, but if you are looking for models to update your existing nursing care plan or implement a new one, you can find samples and templates from Craig Hospital and Nursing Home Help .

Page last reviewed July 26, 2021

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How to Write a Nursing Care Plan (Steps and Tips)

Knowing how to write a good nursing care plan is critical for nursing students and practicing nurses. Care plans act as a tool that helps nursing students and nurses strategically manage the nursing process to solve different problems affecting a patient. Nursing care plans also allow effective communication within a nursing team for collaborative or individual decision-making.

In this guide, we take you through the basics of nursing care plans and steps to create the best and give examples/illustrations to make it simpler. With the best practices we outline in this guide, you can write a nursing care plan without worrying that your end product will be subpar.

This guide is valuable to nursing students as it comprehensively addresses what matters. Besides, it is written by professional nurse researchers collaborating with top talents/brains in the nursing industry. It is also updated regularly to capture any new developments as far as nursing care planning is concerned.

What is a Nursing Care Plan?

A nursing care plan, abbreviated as NCP, refers to a document that details the relevant information about the history and diagnosis of the patient, their current or potential care needs, treatment goals, risks, treatment priorities, and evaluation plan.

Nursing care plans are usually updated depending on the patient's stay at a facility, preferably during and after every shift.

As a nursing student, you will be assigned to write a nursing care plan based on a scenario. For example, your preceptor could also ask you to write a care plan based on a real patient hospitalized in a clinical center where you are doing your internship or practicum.

The process of care planning begins during admission. As we have said above, it gets updated throughout the patient's stay depending on the changes they exhibit and report and based on evaluation of the achievement of the set goals. When you can plan and execute a patient-centered care plan, you have mastered the art of giving quality and excellent nursing services to your patient.

Let's peek at why nursing care plans are written with a view of their professional and academic importance.

Reasons for Writing Nursing Care Plans

You must note that there are different types of nursing care plans, either formal or informal. The formal nursing care plans are roughly documented or exist in the minds of the nurse. On the other hand, formal nursing care plans are either written on paper or computerized to guide the nursing process. Formal nursing care plans can also be standardized or individualized/patient-centered. While the standardized care plans focus on a specific population or group of patients, say those with cardiac arrest or osteoporosis, the individualized or patient-centered care plans are customized to the unique needs of a specific patient that cannot be addressed through a standardized care plan.

Given the understanding of the typologies of nursing care plans, let's now look at why we write them. Nursing care plans are written, or they exist for different reasons, including:

• To promote the use of evidence-based practices in nursing care to address different healthcare needs of the patients
• Holistically caring for patients in recognition of the nursing metaparadigm (health, people, environment, and nursing)
• Enabling nursing teal collaboration through information sharing and collaborative decision-making
• Measuring the effectiveness of care and documenting the nursing process for care efficiency and compliance
• Offering patient-centered or individualized care to improve outcomes
• Identifying the unique roles of nurses in attending to the needs of the patient without constant consultation with physicians
• Allowing for continuity of care by allowing nurses from different shifts to render quality interventions to patients optimizes care outcomes.
• Guide for delegating duties and assigning specific staff to a patient, especially in cases of specialized care.
• Defining a patient's goals helps involve them in decision-making regarding their care.

The Main Components of a Nursing Care Plan

A well-written nursing care plan must have specific components. The main components of a nursing care plan (NCP) are:

• Expected outcomes
• Interventions
• Evaluations

Let's elaborate on these five main components of a nursing care plan.

• Assessment. Assessments are akin to data collection. It entails a detail of the physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic, and environmental. Nursing assessments, combined with the results of medical findings and diagnostic studies, are documented in the client database and form the foundation for developing the client's care plan. The assessment is facilitated through observations for objective data and interviews with patients and their significant others or family for subjective data.
• Diagnosis. With a correct assessment, a nursing care plan details the clinical judgment that helps nurses determine the care plan or interventions for the specific patient.
• Expected outcomes. The outcomes entail the specific, measurable actions for a patient to be achieved within a specific time. The outcomes can be short, medium and long-term depending on the patient's condition.
• Interventions. This entails planning for actions to be taken to achieve the set goals of the patients and expected outcomes, including the rationale behind them. The rationale is evidence-based practices drawn from clinical guidelines, standard operating procedures, evidence-based guidelines, and best practices.
• Evaluations. This section of a nursing care plan entails a set of steps to determine the effectiveness of a nursing intervention or nursing interventions to assess whether the expected outcomes have been met.

What makes a good nursing care plan?

A good nursing care plan contains information about the patient's diagnosis, immediate and changing care needs, treatment goals, specific nursing interventions, and an evaluation plan to determine the effectiveness of care. Such a nursing care plan document can only be achieved through observing certain care plan fundamentals.

• The care plan must answer the questions of what, why, and how.
• A successful care plan uses the fundamental aspects of critical thinking to come up with a patient-centered approach to care
• Follows evidence-based practice guidelines when developing interventions or explaining the rationale for actions
• Has SMART goals for the patients
• Allows for effective communication
• Sharable and easily accessible. If written, it should be legible to everyone else. If you are typing it, use a readable font and good formatting.
• Up to date. It entails the latest information about the patient and changes in their conditions.

Steps for Writing a Nursing Care Plan

You will be assigned a patient scenario or case study as a student. These can be actual case studies from real cases happening on hospital floors or cases created to facilitate teaching and learning. As a professional nurse, you will write the case study based on your patient's condition. Given the understanding of the five main components of a nursing care plan, we also say that nursing care plans follow a five-step framework.

1. Assessment

The first step of writing a nursing care plan is to practice critical thinking skills and perform data collection. During this phase, you collect subjective and objective data. The source of subjective data is an interview with the caretakers, family members, or friends of the patient and the patient. The objective data are observed or measured by you, such as weight, height, heart rate, and respiratory rates. In this section of your nursing care plan, you will include the following:

• Verbal statements from the patient and those accompanying them
• Vital signs (heart rate, blood pressure, respiration, temperature, oxygen saturation)
• Physical complaints (headache, vomiting, nausea, pain, swelling)
• Body conditions (head-to-toe assessments)
• Medical history
• Physical features (height and weight)
• Concerns, perceptions, and feelings of the patient
• Lab findings
• Diagnostic tests (EKG, X-ray, echocardiogram, etc.)

2. Diagnosis

The success of this section depends on the accuracy of the data collected from the first part. Next, you need to select a nursing diagnosis that fits the goals and objectives of hospitalization. The diagnosis step entails analyzing the data from the first step or assessment. Writing good nursing diagnoses is a step in the right direction toward choosing nursing strategies targeting specific desired outcomes.

According to NANDA , nursing diagnosis is a clinical judgment about the human response to life processes or conditions. It also refers to vulnerability to that response by an individual, group, community, or family.

When writing a nursing diagnosis, it is essential to formulate it based on Maslow's Hierarchy of Needs Pyramid so that you can prioritize treatments and interventions. For instance, you need to prioritize the basic physiological needs before the higher needs, such as self-actualization and self-esteem. The rationale for first addressing the physiological/safety needs is that they form the foundations for nursing processes (care and intervention planning).

A good diagnosis identifies a problem (current health problem and the nursing interventions required), the risk factors or etiology (reasons for the problem/condition), and the characteristics of the problem (signs and symptoms).

Nursing diagnoses can be categorized into:

• Problem-focused diagnoses . The problems that present during the assessment of the patient. This is the actual diagnosis based on signs and symptoms. It could include shortness of breath, anxiety, acute pain, impaired skin integrity, etc.
• Risk nursing diagnoses . These are clinical judgments that a problem does not exist. However, the presence of risk factors predisposes the patient to the problem unless specific interventions are taken. Examples can include the risk of falls as evidenced by weak bones, the risk of injury as evidenced by altered mobility, the risk of infection as evidenced by immunosuppression, etc.
• Health Promotion or wellness diagnosis is a clinical judgment about the desire and motivation to increase well-being or reach one's health potential.
• Syndrome diagnoses . The clinical judgment concerns and combination of risk nursing diagnoses or problems that can occur due to specific events. Examples include chronic pain syndrome, frail elderly syndrome, etc.

You can read more from Nightingale College concerning nursing diagnosis .

Note that the nursing diagnoses will change as the client progresses through various stages of illness or maladaptation to resolve the problem or to the conclusion of a condition. Therefore, every decision must be time-bound, given that decisions might change as additional information is gathered.

When writing a student nursing care plan, you must provide a rationale for a specific diagnosis. This means including in-text citations from peer-reviewed nursing journal articles.

3. Outcomes

After writing the diagnosis section, you need to develop SMART (specific, measurable, achievable, relevant, and time-bound) goals based on evidence-based practice (EBP) guidelines and client-centered. To do this, you must consider the patient's overall condition, relevant information, and diagnosis.

The goals and desired outcomes describe what you expect to achieve by implementing specific nursing interventions or actions based on the diagnoses. The goals direct the intervention planning process and serve to evaluate the client's progress. When writing the goals, consider the medical diagnosis made by ad advanced healthcare practitioner or physician. It could include COPD, chronic kidney disease, heart failure, diabetes mellitus, diabetes ketoacidosis, obesity, thyroidectomy, hyper/hypothyroidism, cancer, Alzheimer's disease, endocarditis, eating disorders, acid-based balance disorders, fluid/electrolyte imbalance, etc.

The goals of the patient and expected outcomes can be short-term or long-term. Short-term goals immediately focus on the shift in behavior, mainly within a few hours or days. Long-term goals are objectives to be met over a long period, months or weeks.

When writing the goals and desired outcomes, you must include the subject, verb, conditions or modified, and criterion. Usually, they are written in the future tense.

Let's explore the four components:

• Subject. This refers to the client, any part of the client, or some attribute of the client. It could be vitals (temperature, urinary output, blood pressure)
• Verb. This specifies the specific action that the client will perform.
• Conditions or modifiers. These are the "what, where, when, and how?" added to the verb to explain the situations under which behavior is performed.
• Criterion . These are indicators of the standard by which a performance is measured and evaluated or the level at which the patient can comfortably and efficiently perform a given behavior or action.

Examples of goals and outcomes

• The patient will demonstrate adequate cardiac output as evidenced by vital signs within acceptable limits, no symptoms of heart failure, and absence of dysrhythmias.
• The client will identify individual nutritional needs within 36 hours
• The client will ambulate using a cane within 24 hours of surgery

4.  Nursing Interventions

Planning for nursing interventions or strategies is also called the implementation stage. You will be performing various nursing interventions, including following doctor's orders. Every intervention should be developed using evidence-based practice guidelines.

Interventions are classified into seven domains: family, physiological, community, complex physiological, safety, health system, and behavioral interventions. They can be implemented during shifts. Some interventions include pain assessment, listening, preventing falls, administering fluids, etc.

Nursing interventions refer to a set of activities or actions undertaken by a nurse in response to the diagnosis to achieve expected outcomes and meet a patient's goals.

The interventions majorly focus on eliminating or reducing the etiology of the nursing diagnosis. There are different types of nursing interventions:

• Independent nursing interventions . These are activities that the nurses can initiate based on their licensing, clinical judgment, and skills. They include ongoing assessments, emotional support, empathy, providing comfort, patient education, and referrals to other healthcare professionals.
• Dependent nursing interventions . These are activities undertaken through orders from physicians or supervisors. These can be orders to give specific medications, perform diagnostic tests, treatments, diets, or activities.
• Collaborative nursing interventions . Nurses undertake these actions in collaboration with other healthcare team members such as dietitians, physicians, social workers, and therapists.

When selecting a nursing intervention, it should be evidence-based, safe, appropriate for the client's age, health, and condition, and achievable. Every nursing intervention is followed with rationales, which are specific explanations about why a nursing intervention is the most appropriate given the diagnosis and the goals. When giving the rationales, you are expected to refer to your pathophysiological and psychological principles as a student. This means including in-text citations from peer-reviewed journals or clinical practice guidelines to support the choice of a specific intervention.

Nursing interventions are based on your identified needs during data collection or assessment. The timelines for the outcomes should reflect the anticipated length of stay and the individualized nurse-client expectations. You can create a mind map when conceptualizing the needs of the patient/client. The tool helps visualize the link between symptoms and interventions. It is why you will sometimes be asked by an instructor to do a NANDA concept or mind map before writing a nursing care plan assignment.

When writing a nursing strategy or intervention, you should be very specific. You should begin with an action verb that indicates what you are expected to do. You should also include qualifiers expressing how, when, where, time, amount, and frequency of the planned activity. For example:

• "Assist as needed with self-care activities each morning."
• "Record respiratory and pulse rates before, during, and after ambulating."
• "instruct the family in post-discharge care."

5. Evaluation and Documentation

This is the last step of the nursing care plan. As nursing care is provided, you will undertake ongoing assessments to evaluate the client's response to therapy and achieve the expected outcomes.

You should document the response to interventions, which is pretty much what evaluation is about. You can then adjust the care plan based on the information.

Evaluation helps identify the effectiveness of the nursing care plan. It also helps determine if the nursing processes were effective or if there is a need to terminate, continue, or change them.

When evaluating outcomes, you must label them as met, ongoing, or not. You can then decide whether the goals of the intervention need to be altered.

In most cases, all the goals are expected to be met by the time of discharge. However, you must prepare for that transition if a patient is discharged to a long-term care facility, nursing home, or hospice.

If everything is okay, you should document the nursing care plan (NCP) per the hospital's policy or standard operating procedure.

Nursing Care Plan Template for Nursing Students

Your instructor will give you a case study or patient scenario to write a nursing care plan. Some instructors also allow you to develop a nursing case study and write an appropriate nursing care plan. You can also use a real case from your shadowing, internship, or practicum experience. Whichever the case, you can use the template below if none is given. You should organize the nursing care plan into columns for easier entry and organization.

Your introduction should briefly revisit the case study. If requested, expound on the etiology of the medical diagnosis in the background section. The next section is your nursing care plan with columns of assessment, diagnosis, goals and outcomes, interventions, and evaluation, making it 5 columns . Some instructors only want three columns for nursing diagnosis, outcomes and evaluation, and interventions, while others insist on four columns for nursing diagnosis, goals and outcomes, interventions, and evaluation. Below is an example of the nursing care plan section:

The next section can include discharge planning, medication management, rest and activities, diet planning, ongoing care, sleeping, and follow-up.

Finally, write a conclusion that summarizes the entire nursing care plan and include a list of the references you used when writing the nursing care plan.

Sample Nursing Care Plan for Schizophrenia

Nursing Diagnosis : Ineffective coping skills and risk for hematologic side effects of Clozapine

Goals and expected outcomes

• To remain stable on medication and to transition into a less restrictive environment.
• Adequate rest and nutritional intake
• Establish communication and build trust, and encourage patients to participate in the therapeutic community.
• Increase ability to communicate with others.
• Symptom management; decrease in hallucination, delusions, and other psychotic features such as self-talk
• Increase self-esteem
• Subjective and Objective reduction of psychotic symptoms (an irrational behavior)
• Adhere to recommended therapy, including medications, psychotherapy, and lab appointments for hematology.

Nursing Interventions

• Assist the patient in identifying strengths and coping abilities ( nursing interventions) . Strength-based approaches help better recover schizophrenic patients (Xie, 2013). Emphasis on strength is a positive coping mechanism proven to buffer the impact of negative symptoms and promote rehabilitation of patients with schizophrenia (Tian et al., 2019). ( rationale)
• Meet monthly with the clinical team. Interprofessional teams help in the effective management of psychotic disorders such as schizophrenia. Psychiatrists and pharmacists can help improve the patient's status (Farinde, 2013).
• Obtain weekly Vital Signs. Interprofessional teams help in the effective management of psychotic disorders such as schizophrenia. Psychiatrists and pharmacists can help improve the patient's status (Farinde, 2013).
• Encourage all medications as prescribed. Adherence to pharmacological treatment helps alleviate the psychotic symptoms of schizophrenia, v. Non-adherence could lead to deterioration of the symptoms (El-Mallakh & Findlay, 2015).
• Provide opportunities for self-reflection, self-care, positive self-image, and effective communication. Encouraging healthy habits among schizophrenic patients helps optimize functioning, such as drug adherence, maintenance of sleep, reduced stress levels, self-care maintenance, and anxiety (Tian et al., 2019).
• Encourage outings and identify opportunities to reduce anxiety -enjoy music, poetry, and creative writing, and connect with a church spiritual group. Empathy helps the patient perceive the caregivers as caring and makes them feel accepted. It also helps the patients maintain positive coping mechanisms (Peixoto, Mour'o, & Serpa Junior, 2016).
• Monitor lab results (WBC and ANC) and report significant changes per Clozapine guidelines. Patients taking Clozapine must be monitored frequently as they are more predisposed to serious blood dyscrasias. In addition, discontinuing WBC monitoring after 6 months of starting the drug could lead to mortality and accidents (Kar, Barreto & Chandavarkar, 2016).
• Monitor for hematologic side effects: Neutropenia, leukopenia, agranulocytosis, and thrombocytopenia (secondary to bone marrow suppression caused by Clozapine). Clozapine has serious side effects such as seizures, cardiomyopathy, myocarditis, cardiomyopathy, neutropenia, ad agranulocytosis (Dixon & Dada, 2014).
• Instruct patient to report any side effects, illness, s/s of infection, fatigue, or bruising without apparent cause. Constant monitoring of psychotic symptoms helps change treatment (Holder, 2014). For instance, it can help determine if the antipsychotic medication is not working and include evidence-based psychosocial interventions (Stroup & Marder, 2015).
• Monitor anticholinergic effects; dry mouth, difficulty urinating, constipation.
• Monitor for reduction/increase of psychotic symptoms
• Discourage caffeine. Caffeine interacts with Clozapine and can lead to toxicosis. It increases the plasma concentrations of Clozapine (De Berardis et al., 2019). Caffeine inhibits the metabolism of Clozapine through the inhibition of CYP1A2 (Delacr�taz et al., 2018)
• The patient will have reduced symptoms, adhere to medication, and show improvement.
• The patient will control his feelings, perceptions, and thought processes.
• Social increasing ease of communication since starting Clozaril (date). The patient will easily interact with caregivers, family, and other patients.
• The patient will acknowledge the importance of medication in lowering suspicion.
• Self-talk has diminished since admission. The patient will also exhibit high self-esteem levels.
• The patient will have reduced anxiety and violent behavior and have remission.

Brekke, I. J., Puntervoll, L. H., Pedersen, P. B., Kellett, J., & Brabrand, M. (2019). The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review. PloS one , 14 (1), e0210875. https://doi.org/10.1371/journal.pone.0210875

De Berardis, D., Rapini, G., Olivieri, L., Di Nicola, D., Tomasetti, C., Valchera, A., ... & Serafini, G. (2018). Safety of antipsychotics for the treatment of schizophrenia: a focus on the adverse effects of Clozapine. Therapeutic advances in drug safety, 9(5), 237-256.

Delacr'taz, A., Vandenberghe, F., Glatard, A., Levier, A., Dubath, C., Ansermot, N.,  Eap, C. B. (2018). Association Between Plasma Caffeine and Other Methylxanthines and Metabolic Parameters in a Psychiatric Population Treated with Psychotropic Drugs Inducing Metabolic Disturbances. Frontiers in psychiatry , 9 , 573. https://doi.org/10.3389/fpsyt.2018.00573

Dixon, M., & Dada, C. (2014). How clozapine patients can be monitored safely and effectively.  The Pharmaceutical Journal, 6 (5), 131.

El-Mallakh, P., & Findlay, J. (2015). Strategies to improve medication adherence in patients with schizophrenia: the role of support services. Neuropsychiatric disease and treatment, 11 , 10771090. https://doi.org/10.2147/NDT.S56107

Farinde, A. (2013). Interprofessional Management of Psychotic Disorders and Psychotropic Medication Polypharmacy.  Health and Interprofessional Practice, 1 (4), 4.

Holder, D., S. (2014). Schizophrenia. American Family Physician, 90 (11), 775-782.

Kar, N., Barreto, S., & Chandavarkar, R. (2016). Clozapine Monitoring in Clinical Practice: Beyond the Mandatory Requirement. Clinical psychopharmacology and neuroscience: the official scientific journal of the Korean College of Neuropsychopharmacology, 14 (4), 323�329. https://doi.org/10.9758/cpn.2016.14.4.323

Lantta, T., H�t�nen, H. M., Kontio, R., Zhang, S., & V�lim�ki, M. (2016). Risk assessment for aggressive behavior in schizophrenia.  The Cochrane database of systematic reviews, 2016 (10). https://doi.org/ 10.1002/14651858.CD012397

Peixoto, M. M., Mour�o, A. C. D. N., & Serpa Junior, O. D. D. (2016). Coming to terms with the other's perspective: empathy in the relation between psychiatrists and persons diagnosed with schizophrenia.  Ciencia & saude coletiva, 21 (3), 881-890.

Stroup, T. S., & Marder, S. (2015). Pharmacotherapy for schizophrenia: Acute and maintenance phase treatment.  UpToDate .

Tian, C. H., Feng, X. J., Yue, M., Li, S. L., Jing, S. Y., & Qiu, Z. Y. (2019). Positive Coping and Resilience as Mediators between Negative Symptoms and Disability among Patients with Schizophrenia . Frontiers in psychiatry, 10 , 641.

Xie, H. (2013). Strengths-based approach for mental health recovery. Iranian journal of psychiatry and behavioral sciences, 7 (2), 5�10.

Writing the best nursing care plan can sound easy on paper, but the process is demanding and tiresome. If you are a nursing student who wants to delegate writing nursing care plans to someone who can help you do so accurately, affordably, and reliably, you can trust our care plan writers.

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Nursing Care Plan (+ Template)

Table of contents, what is a nursing care plan .

A nursing care plan is a written document detailing the nursing interventions that will be done to meet a client’s needs and health goals. It serves as a guide for personalized care of the client and facilitates communication in the healthcare team. 

What is a nursing intervention? 

Nursing interventions are actions in a care plan, such as patient education or treatments. They are formed using patient feedback, evidence-based sources, and the nursing process. 

How to write a nursing care plan 

How to prepare a nursing care plan using the 5-step nursing process (adpie):.

Following the nursing diagnoses that were formed based on a thorough assessment (history, physical assessment, focused assessment), a clear plan of care goals, interventions, and desired outcomes is defined. 

Nursing tip: Gather information in a logical and informed way to provide the best care possible. 

Nursing tip: To address each intervention to assess quality in patient care, goals need to be SMART: 

• M easurable
• A ttainable

Discuss with your client which health goals they would like to achieve. 

Nursing care plan template & examples

Once the client’s goals are established, nursing interventions (NIC) and standard nursing outcomes (NOC) can be used to guide patient care. 

They can, for example, be presented in the nursing care plan in a column-based format: 

Examples of goals could be: 

• Stage 1 pressure ulcer will resolve
• Client demonstrates insulin injection procedure
• Client reports pain level < 4 with ambulation

Examples of fitting nursing interventions could be: 

• Reposition client every 2 hours
• Request diabetes education consult
• Administer pain medication 1 hour before physical therapy

Examples of possible outcomes could be: 

• Reduced redness in lower back area
• Client demonstrates self-injection techniques
• Client ambulates 100 feet twice a day

Nursing intervention examples (practice questions)

Which nursing intervention is placed in the plan of care for a client diagnosed with osteoarthritis.

Answer options:

• Apply a cold compress to the affected joint for 15–20 minutes
• Encourage high-impact exercise like jogging
• Administer IV antibiotics as prescribed
• Start a weight-lifting program for strength

Correct answer:

• Applying a cold compress to the affected joint for 15–20 minutes.

Explanation: 

Cold compresses can help reduce inflammation and relieve pain in osteoarthritis. High-impact exercise and lifting weights can worsen the condition, and antibiotics are not used for osteoarthritis, as it’s not caused by an infection.

A client is diagnosed with hypervolemia. Which is the priority nursing intervention?

• Encourage fluid intake hourly
• Monitor weight and strict I & O
• Administer bronchodilators
• Initiate cardiac monitoring

      2. Monitor weight and intake and output carefully.

In hypervolemia, fluid overload is a concern. Monitoring weight and intake and output allows for accurate assessment and helps guide treatment. More fluid intake would exacerbate the problem, and bronchodilators are not directly related to fluid volume management. Cardiac monitoring is not required as no cardiac problem is identified.

A client has completed a bone marrow biopsy. Which nursing intervention is the priority action post-procedure?

• Elevate the extremity where the biopsy was taken
• Administer a dose of intravenous antibiotics
• Apply pressure to the biopsy site
• Use heating pad at site on low setting

      3. Apply pressure to the biopsy site.

Applying pressure to the biopsy site helps prevent hemorrhage and facilitates clot formation. Elevating the extremity and administering antibiotics are not generally the priority interventions post-bone marrow biopsy. Ice packs, not heat, can be used for short periods of time for tenderness.

Which nursing intervention is essential in caring for a client diagnosed with compartment syndrome?

• Apply ice to the affected extremity.
• Elevate the affected limb above heart level.
• Loosen or remove the tight bandage or cast.
• Alert the Rapid Response Team.

       3. Loosen or remove the tight bandage or cast.

Compartment syndrome is caused by increased pressure within a muscle compartment, which can compromise circulation to the area. If a tight bandage or cast is contributing to the pressure, it should be loosened or removed to alleviate the pressure. The other answers could potentially worsen the condition. The Rapid Response Team is notified for imminent deterioration, which this client is not manifesting

The nurse cares for a client diagnosed with pyelonephritis. Which nursing intervention does the nurse include in the plan of care?

• Encourage fluid restriction.
• Administer prescribed antibiotics.
• Apply a heating pad to the lower back.
• Instruct client to keep blood glucose lower.

      2. Administer prescribed antibiotics.

Pyelonephritis is a bacterial infection of the kidneys that usually requires antibiotic treatment for resolution. Fluid restriction is generally not recommended; in fact, increased fluids may be encouraged. A heating pad may provide temporary relief but doesn’t treat the underlying infection. If the client does have diabetes mellitus, it does increase the risk for pyelonephritis, but no mention of this is given. 

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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, what is the purpose of creating a nursing care plan.

• What Are the Types of Nursing Care Plans?
• Which Components Go Into a Nursing Care Plan?
• How Do You Use a Nursing Care Plan?

How Do You Write a Nursing Care Plan?

• What Are SimpleNursing’s Nursing Care Plans?

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.

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 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.

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.)
• 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.

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
• 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:

Nursing Care Plan for Diabetes

Nursing care plan for hypertension, nursing care plan for uti, nursing care plan for decreased cardiac output, nursing care plan for activity intolerance, nursing care plan for excess fluid volume, nursing care plan for impaired gas exchange, nursing care plan for impaired skin integrity, nursing care plan for acute pain nursing diagnosis & care plan, 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.

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The Ultimate Guide to Nursing Care Plans

What is a nursing care plan, types of nursing care plans.

• Nursing Care Plan Components

How to Write a Nursing Care Plan

Sample nursing care plans.

If you aspire to become a nurse, you'll want to familiarize yourself with what nursing care plans (NCPs) are all about. Nursing care plans provide a means of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes.

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A nursing care plan contains relevant information about a patient’s diagnosis, the goals of treatment, the specific nursing orders (including what observations are needed and what actions must be performed), and an evaluation plan. 

Over the course of the patient’s stay, the plan is updated with any changes and new information as it presents itself. In fact, most hospitals require nurses to update the care plan during and after each shift. 

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What is the Purpose of a Nursing Care Plan?

Nursing care plans help define nursing guidelines and some treatment guidelines (as ordered) for a specific patient.

Essentially, it is a plan of action. It helps guide nurses throughout their shift in caring for the patient. It also allows nurses to provide attentive and focused care. 

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There are four main types of nursing care plans. 

• Informal - A care plan that exists in the nurse’s mind and is actions the nurse wishes to accomplish during their shift.
• Formal - This is a written or computerized plan that organizes and coordinates the patient’s care information and plan. 
• Standardized - Nursing care for groups of patients with everyday needs.
• Individualized - A care plan tailored to the specific needs of the patient. 

What are the Components of a Nursing Care Plan?

Nursing care plans follow a five-step process: 

• Expected outcomes
• Interventions
• Rationale and Evaluation

>> Related: The Nursing Process Explained

When writing a nursing care plan, you first have to determine what type of care plan you are interested in. If it is for your own use throughout the shift, then an informal one may be beneficial; however, if it is for the patient’s chart and required during your shift then an individualized care plan is the way to go. 

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Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and objective nursing data . This information can come from, 

• Verbal statements from patient and family
• Vital signs
• Physical complaints
• Body conditions
• Medical history
• Height and weight
• Intake and output

Step 2: Diagnosis

Using the information and data collected in Step 1, a nursing diagnosis is chosen that best fits the patient, the goals, and objectives for the patient’s hospitalization. 

According to North American Nursing Diagnosis Association (NANDA), defines a nursing diagnosis as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.”

A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid and helps prioritize treatments. Based on the nursing diagnosis chosen, the goals to resolve the patient’s problems through nursing implementations are determined in the next step. 

Step 3: Outcomes and Planning

After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-based practices. SMART goals stands for Specific, Measurable, Achievable, Relevant, and Time-Bound . It is important to consider the patient’s medical diagnosis, overall condition, and all of the data collected. 

It is also during this time you will consider goals for the patient and outcomes for the short and long term. These goals must be realistic and desired by the patient. For example, if a goal is for the patient to seek counseling for alcohol dependency during the hospitalization but the patient is currently detoxing and having mental distress - this might not be a realistic goal. 

Step 4: Implementation

Now that the goals have been set, you must put the actions into effect to help the patient achieve the goals. While some of the actions will show immediate results (ex. giving a patient with constipation a suppository to elicit a bowel movement) others might not be seen until later on in the hospitalization. 

The implementation phase means performing the nursing interventions outlined in the care plan. Interventions are classified into seven categories: 

• Physiological
• Complex physiological
• Health system interventions

Some interventions will be patient or diagnosis-specific, but there are several that are completed each shift for every patient:

• Pain assessment
• Position changes
• Fall prevention
• Providing cluster care
• Infection control

Step 5: Evaluation 

The fifth and final step of the nursing care plan is the evaluation phase. This is when you evaluate if the desired outcome has been met during the shift. There are three possible outcomes, 

Based on the evaluation, it can determine if the goals and interventions need to be altered. 

Nursing Diagnosis:  Ineffective breathing pattern related to right pulmonary agenesis as evidenced by high carbon dioxide levels and absent breath sounds on right side of the chest. 

Assessment: 

• Vital signs: Monitor the patient’s heart rate, respiratory rate and SpO2 levels. Signs of respiratory distress include tachypnea, dyspnea and an SpO2 <95%. 
• Breathing patterns: If the patient shows signs of respiratory distress, it should alarm the nurse, and interventions should take place. Signs of respiratory distress include nasal flaring, accessory muscles, grunting, shortness of breath, and retractions.
• CO2 lab values: When the body has an ineffective breathing pattern, inadequate gas exchange will take place. During this, the body retains CO2 and can enter into a stage of respiratory acidosis. Monitor for respiratory acidosis with blood gas lab values.
• Skin assessment: A person experiencing respiratory distress may experience pallor, cyanotic, and/or mottled skin.

SMART Goal: The patient will maintain a SpO2 level of >95%, RR of 30 to 55 breaths per minute, and heart rate of 80 to 140 beats per minute until the end of the shift. 

Interventions: 

• Check manual heart rate and respiratory rate every four hours. 
• Check patient is on continuous SpO2 monitor with pulse oximetry on the same extremity throughout shift. 
• Obtain blood gases as ordered.
• Monitor for signs and symptoms of increased work of breathing and respiratory distress. 
• The patient is observed and/or documented to have SpO2, HR, and RR all within normal limits by end of the shift.
• The patient is documented to have received blood gas results that contain a CO2 value that is within the normal range.
• The patient is observed and documented to not experience any symptoms of respiratory distress throughout the shift. 

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Nursing care plan faqs, how do you write a nursing care plan.

• Writing a nursing care plan takes time and practice. It is something you will learn during nursing school and will continue to use throughout your nursing career. First, you must complete an assessment of your patient to determine the nursing diagnosis and include relevant patient information. Next, utilize a NANDA-approved diagnosis and determine expected and projected outcomes for the patient. Finally, implement the interventions and determine if the outcome was met. 

What is the purpose of the nursing care plan?

• Nursing care plans provide a means of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes.

What are the 5 main components of a care plan?

• There are five main components to a nursing care plan including; assessment, diagnosis, expected outcomes, interventions, and rationale/evaluation. 

What is included in a nursing care plan?

• Nursing care plans include relevant information about the patient’s assessment, goals of treatment, interventions that need to occur, and observations. These observations may include subjective and objective data.

*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.

Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

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How To Write a Nursing Diagnosis

Last updated on January 26th, 2024 at 05:05 pm

There are different models that can be used to create a nursing care plan, and one of the most commonly used models is the ADPIE , which stands for: Assessment, Diagnosis, Planning, Interventions, and Evaluation. This article will guide you to create an accurate nursing care plan based on these five crucial steps.

Step 1: Assessment

It is important to note that all the data that you will put in the Assessment section of your nursing care plan are precise, brief, and are all able to support your nursing diagnosis.

Step 2: Diagnosis

Here’s an example:

Evidence: “as evidenced by productive cough, shortness of breath, oxygen saturation at 91% on room air”

Step 3: Planning

Step 4: intervention.

This step involves the nursing actions and rationale, or the reason for doing each nursing intervention. The nursing interventions include what and when to assess and monitor in terms of patient’s vital signs and diagnostics, the nursing actions required (e.g. medication, suctioning, oxygen therapy, dressing changes) fluid and dietary requirements, mobility, as well as patient education and support. Each nursing intervention should be precise and should be backed up by a factual rationale to briefly explain why such intervention or action is needed. For example:

Step 5: Evaluation

Evaluation is the final step in the nursing care plan where in you can set parameters to check if the desired outcomes and goals are fully met, partially met, or unmet. This shows whether the nursing actions are effective, need modifications, or require to be stopped and changed. If a goal is partially met or unmet, then it is crucial to re-visit the nursing diagnosis, re-think about the goals, and change some of the nursing interventions. Here’s an example:

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How to write a Nursing Care Plan step by step

Why are care plans necessary?

The short answer is: “Proper Preparation Prevents Poor Performance!” The formal answer is: Care plans are an important tool used to plan and provide personalized care to your patients through the implementation of the Nursing Process (ADPIE). They help you be more deliberate in the nursing care you provide.

Click here to follow along with our Free Care Plan Builder!

Our patient is a 54 y/o female with a primary diagnosis of Congestive Heart Failure (CHF). She presented to the emergency room complaining of shortness of breath on exertion.

• In the assessment, we identify the issue we are addressing. In this case, we are concerned by the patient’s cardiac condition due to their CHF diagnosis. So we go ahead and select the “Cardiac” button.

• For the diagnosis, we refine a bit more the type of cardiac issue we are addressing. We know that for patients suffering from congestive heart failure, cardiac output is often affected. We therefore proceed by selecting the “Cardiac Output Alteration” button.

• To complete the nursing diagnosis, we identify the expected outcome of the nursing diagnosis once we have implemented the proper interventions. We want the patient’s condition to improve so they can resume their usual activities of daily living without distress. So we select the “Improve” button to continue.

• After identifying an expected outcome, we have to make a plan on how to reach our goal of improving the patient’s cardiac out alteration. Our plan will comprise of interventions that provide Cardiac Care within our scope of practice. Let’s proceed by selecting the “Cardiac Care” button followed by “Cardiac Rehabilitation.”

• After assessing, diagnosing and planning, we now get to implement our interventions! We will do so by tapping the appropriate buttons and entering examples of actions we are/will take while providing the respective rationales.

• Patients with heart failure can develop cardiac arrhythmias and hemodynamic alterations that impair circulation and oxygenation exchange. Poor circulation and poor oxygenation can lead to organ damage
• Medications such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), aldosterone antagonists, beta-blockers, calcium channel blockers (CCBs), digitalis drugs, diuretics, inotropic agents, nitrates, and vasodilators are often used in the treatment and management of congestive heart failure
• Congestive heart failure reduces the kidney’s ability to excrete sodium resulting in fluid retention. A low sodium diet such as the DASH diet will help reduce the build up of fluid in the body and help minimize complications
• CHF patients may develop life threatening deteriorations such as myocardial infarctions, ventricular fibrillation and pulmonary edema
• In this last step of the Nursing Process, we evaluate our plan of care to see if it worked or needs some alterations. Fortunately for our patient, we made the appropriate diagnosis, created a personalized plan of care and intervened using evidence based actions. Our patient’s condition improved and she is now ready to be discharged pending final clearance form the provider. We will conclude by selecting the “Improved” button.

The Clinical Care Classification System is an evidence based tool for creating care plans based on the Nursing Process: Assess, Diagnose, Plan, Implement & Evaluate. Using the Nursing Process helps nurses be more deliberate in providing comprehensive care to their patients. You can use the NurseBrain Care Planner tool for free at https://nursebrain.app/careplan . Click here to download this sample patient and care plan.

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5 Steps to Writing a (kick ass) Nursing Care Plan (plus 5 examples) | NURSING.com

What are you struggling with in nursing school?

NURSING.com is the BEST place to learn nursing. With over 2,000+ clear, concise, and visual lessons, there is something for you!

How can I put this lightly?  The sooner you come to love nursing care plans, the easier your career as a nurse will be.

The relationship that most nurses have with care plans goes something like this:

• What the hell is a care plan?
• This seems easy!
• Agh! Why do they keep telling me my diagnosis is wrong?
• Screw it! I’ll just Google and copy some random care plan.
• I’ll never do these again once a graduate.
• Finally! I graduated . . . goodbye care plans.

"The sooner you come to love nursing care plans, the easier your career as a nurse will be."

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But allow me to present an alternate reality to you.  There is an evolution that occurs in new grad nurses (I’ve seen it over and over again).  They come out of school bright-eyed and excited to care for “real” patients.  They are “so glad” that they never have to do another care plan . . . This (stuff) get’s real.  They discover how hard being a nurse is . . .

After about 6 months they begin to get the hang of things . . . by a year . . . they’re really getting their own legs as a nurse.  They walk into a room and can assess the situation fully.  They can determine how a shift will go within a couple of minutes.  They have a sixth sense about them . . . a nurses sense.

Care Plan Database

We’ve created an enormous database of care plans for you to reference in nursing school. Check them out below.

View the Care Plans

What Has Happened?

The new nurse has developed “ critical thinking ” without even knowing it.  They are working through nursing care plans while considering a million different variables right on the spot . . . without even realizing it!

Those pesky little care plans are being developed, adjusted, evaluated . . . patient after patient, shift after shift.

And the nurse doesn’t even realize it.

So they continue to talk about how pointless care plans are and tell students: “ You’ll never do those in REAL life .” . . . little do they know, they’ve worked through multiple care plans during that shift .

I mean . . . think about it.

I arrive for a shift and hear about a patient who has some blanchable redness on the coccyx. BOOM!!!

The care plan is done . . . “ risk for impaired skin integrity ” . . .never technically entered my mind, but I’m already planning out the shift . . . how will I keep the skin dry, how often will I turn the patient, are they eating enough, do I need to get some barrier cream for them . . . see what I’m saying?

5 Steps to Writing a Nursing Care Plan

At NURSING.com, we want you to find a bit of excitement and comfort when writing care plans . . . little tip: they aren’t going away!  So, here are the 5 steps:

• Collect Information
• Think About How

Step 1 – Collect Information

• Your head-to-toe assessment
• Conversations with patients and loved ones
• Observations (lab values, vital signs)
• Report (or your report sheet)
• Chart review and notes
• Discussions with health care team members

Step 2 – Analyze

• Look at all information
• What are areas in which this patient has trouble and therefore needs to progress in?
• Think about the ways you could see the patient improving and how you would know they were improving
• Write down the general issues, how you’d help them progress in that area, and how’d you’d know they were progressing

(Tip – don’t worry about writing it in perfect NANDA-I, NIC or NOC terminology… just write it down in as you think of it)

Step 3 – Think About How

• How did you know he was in pain? Did he tell you? Did you observe it? Was he getting pain medications?
• Write an S or an O next to them
• A recent surgery, trauma, or disease process?
• Write all of your reasons (again in layman's terms) under the problem(s) you’ve identified
• What would you do to make this better? (Interventions)
• How would you know it got better? (Evaluation)

Step 4 – Translate

• Take your textbooks (NANDA-I, NIC, NOC, or whatever you may be using)
• Look up the official terms for the problem(s) and write them down
• Look up outcomes and interventions that may align with what you wrote down

Step 5 – Transcribe

• Get your nursing care plan template out
• Put the pieces together (problem + related to factor(s) + defining characteristics/”hows”)
• Use your S’s and O’s to place your subjective and objective data
• Write out your interventions and outcomes/evaluation
• Put your feet up – you’re done!

How to Write a Care Plan in 10 Minutes

5 Nursing Care Plan Examples

Sometimes all you need are a few examples to help you learn how to do a difficult task and to get the brain juices flowing.  Here are 5 care plans that I personally wrote during nursing school.

MEDICAL DIAGNOSIS: Pneumonia

MEDICAL DIAGNOSIS: Aspiration Pneumonia

MEDICAL DIAGNOSIS: Amputation

MEDICAL DIAGNOSIS: Appendicitis

Additional Resources

We’ve created with tons of other resources on the topic of Critical Thinking and Nursing Care Plans:

Blog Posts:

• Critical Thinking and Nursing Care Plans Go Together Like Chicken and Waffles
• Coming up with a Nursing Diagnosis Shouldn’t Give You HTN
• 7 Nursing Interventions You Should be Using Every Shift
• 2 Examples of Using Critical Thinking to Care for a Patient
• 4 “Real World” Examples of Using Clinical Judgement
• How to Come Up With a Nursing Care Plan . . . Plan
• Writing a Nursing Care Plan in Less Than 10 Minutes
• Nursing Care Plans and Why They Matter
• Critical Thinking on the Floor (real life examples)
• What is Critical Thinking and Why Should I Care

Newborn Assessment

4 steps to master critical thinking in nursing school.

Chances are you’ve heard about   critical thinking over and over from your nursing instructors,   read about it in textbooks, and seen it on tests.

Has anyone actually shown you how to use critical thinking in a nursing setting? I break it down into 4 simple steps on how you can master critical thinking.

This will not only serve you well in nursing school but also in your career as a nurse. We can all fall into the ruts of assuming things prior to taking in all the available information even as practicing nurses.

If you apply these 4 steps to master critical thinking without prior judgment it will make you a better nurse and keep your patients safe.

OMG! Please Don’t Make Me Take Report from Him . . . (plus Nursing Report Sheet Download) | NURSING.com

Patient positioning pictures cheat sheet for nursing students | nursing.com, similar blog posts.

Critical Thinking and Nursing Care Plans Go Together Like Chicken and Waffles | NURSING.com

How To Write the Perfect Nursing Care Plan with Examples

Stress Overload Nursing Diagnosis and Care Plan | NURSING.com

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Nursing Care Plans | Free Care Plan Examples for a Registered Nurses (RN) & Students

Nursing care plan overview & introduction: what is a care plan in nursing.

A nursing care plan is a part of the nursing process which outlines the plan of action that will be implemented during a patients’ medical care. LPNs (Licensed Practical Nurses) and Registered Nurses ( RNs) often complete a care plan after a detailed assessment has been performed on the patients’ current medical condition and prior medical history. The nurse can then take action with the patient by fulfilling the care plan’s goals and objectives.

On this page, you will get some free sample care plans that you can use as examples to understand more about how they help nurses treat people. If you want to view our care plan database, make sure to visit our free care plans section.

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When I was in nursing school I bought some books to help me with nursing care plans. Care plans take practice but once you catch on they are a piece of cake. Here are the books I recommend on using to help you with your nursing care plans. I believe they are the best books for nursing care plans. The first one is called “ Nursing Care Planning Made Incredibly Easy! ” It is like one of those “made for dummies” books. Here is a picture of it and you can find it on Amazon.com for less than $25.

Another great book is called “ Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span “. This book is excellent because it is universal for all areas in nursing for developing your care plans. This book is awesome for developing your care plans and is used by many nursing students.

*See disclosure at the end of this article.

Care plans are occasionally used by other medical staff, such as doctors, Respiratory therapists, physical therapists, and more. However, they are most often used and associated with the field of nursing.

Thinking about going to Nursing School?

Are you contemplating  going to nursing school, or are you actually in nursing school right now?  Nursing school can be challenging, especially if you do not know what to expect. Here is a great guide by S. L. Page BSN, RN called “ How to Pass Nursing School “. This book gives you detailed information about how to pass nursing school from beginning to end. S.L. Page, the creator of this website, complied all the information students what to know about nursing school into one easy to read guide. She gives in depth information on how to succeed in nursing school.

S.L. Page graduated from nursing school with honors and passed the NCLEX-RN on her first try. In this eBook, she reveals the strategies she used to help her succeed.

Here is what the book looks like:

Why Should Nurses Use Care Plans? Aren’t Care plans a Waste of Time?

In addition, care plans can be easily revised to provide new outcomes or treatment plans if a patient’s condition changes. This flexibility helps the nurse maintain focus during potentially stressful situations. Since the patient’s information will be conveniently located within the care plan, this will save time and reduce the risk of misinformation or mistakes.

Care plans are also helpful during a patient’s discharge process. Nurses can review the care plan to see if the patient met the nursing outcome during their treatment, and can base the patient’s later discharge care based on those outcomes.

Video About Nursing Care Plans

Why Do Nursing Students Use Care Plans?

Nursing school professors often require nursing students to complete many care plans throughout their college career. The reason is simple: Care plans are important. Nursing students should thoroughly learn about care plans for the following reasons:

• It Instills critical thinking and analytical skills related to nursing. This will help future nurses evaluate and treat patients more efficiently.
• By completing care plans, it helps the nursing student successfully pass their board’s test (NCLEX), HESI tests, and acquire their licensing.
• Since care plans are used in the nursing profession and in nursing care, it is vital that all nurses know how to complete them.

What’s the Difference Between Care Plans in Nursing School vs. Care Plans on the Job?

Care Plans In Nursing School:

• Very detailed and comprehensive. This is done so the nurse can become familiar with care plan development, processes, and outcomes, and terminology.
• Often completed on a blank sheet of paper, and each part of the care plan must be completed manually (typed or hand written). This often requires an extensive amount of time and research to complete.
• Often requires a NANDA Nursing Diagnosis book to help guide you when selecting a nursing diagnosis.

Care Plans on the Job:

• Less detailed–Nurses are generally not required to list as many interventions, outcomes, or other values. Instead of having a comprehensive nursing diagnosis statement, it is usually a “focus” that you need to have.
• Care plans are often created on pre-made templates that are “diagnosis-specific” for your patient. These templates often include small boxes or fields you can click or check. This greatly reduces the time it takes to complete.
• Care plans are often completed and stored electronically in many medical settings. However, they are also sometimes printed on templates.

How to Create a Nursing Care Plan: The Process of Developing a Care Plan

If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, keep reading to learn the basics of how to complete a care plan in nursing school.

• The first process in completing a care plan is the patient assessment. A nurse should review the patient’s medical history, diagnosis, lab values, medications, and familiarize themselves with the patient. This information is critical to creating an effective and accurate care plan.
• The nurse should then create a main focus for the patient’s treatment. Nurses often use the “A, B, C’s” (airway, breathing, and circulation) during this focus.  Your focus should come from the NANDA Nursing Diagnosis text.
• The nurse should then locate the focus in the NANDA book to help develop the “related to” and “as evidenced by” part of the nursing diagnosis statement.
• The nurse should select some outcomes and interventions based on the nursing diagnosis. At least 3 outcomes should be selected for the patient. Outcomes need to be measurable, patient specific, and have a definite time-frame.
• Intervention should also be measurable, patient-specific, and have parameters. The intervention should correlate with the outcomes. Often times, it is easier to develop the outcomes before the interventions.
• Review the care plan to make sure all of the information is correct.
• Implement the care plan into the nursing actions to provide care for the patient.
• Re-evaluate the care plan as treatment continues. Make any revisions if necessary if the patient’s condition improves or worsens.

What Do Care Plans Look Like in Nursing School?

The care plans given in nursing school are often on a blank sheet of paper with grid-lines for each focus, treatment, and outcome. Nursing students must then manually complete each field using a very comprehensive set of terms and goals. Sometimes, nursing students are intimidated by the care plan process, and often feel overwhelmed when faced with their first care plan. However, they should keep in mind that many nursing students feel this way, and they will become much easier to complete over time.

It is important to note that often times, nursing care plans can have a slightly different appearance. The exact design or appearance of the care plan can vary from school to school. In addition, many hospitals or medical centers adopt their own unique care plan versions. So each basic care plan design can be totally different from another.

An example picture of a basic blank care plan can be found below:

*Disclosure: The items recommended in this article are recommendations based on our own honest personal opinion and experience. We are an affiliate with Amazon.com, and when you buy the products recommended by us, you help support this site.

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Nursing Care Plans from A to Z: a Complete Guide for Registered Nurses

Posted on: Mar 9, 2022;

Nursing care plans are one of the most valuable tools nurses have at their disposal. They aid RNs in strategically outlining the best course of care for patients and enable quality communication within the healthcare team. Thus, writing and using a nursing care plan is one of the nursing skills that nursing students and experienced professionals have to cultivate consistently. 

Much attention is devoted to mastering this aspect of the nursing process in nursing school, so nursing care plans are an integral part of any nursing school curriculum. And the need to write care plans continues after graduation because a critical part of nursing practice relies on efficiently written and implemented care plans. 

This guide will walk you through everything you need to know about nursing care plans. Stick around to find the best practices for making a care plan , how to write it , and how to use this instrument to deliver quality care. 

What Is a Nursing Care Plan?

The nursing care plan (NCP) is a process through which the nurse identifies, documents, and keeps track of a parent’s state or condition, needs, and risks . The elaboration of the care plan starts when the patient is admitted to the medical facility. The NCP is continuously updated throughout the patient’s stay based on their condition and response to treatment. Typically, creating a nursing care plan follows a five-step framework. 

The nursing care planning process ensures that the quality of patient care is always up to the highest standards. It sets the groundwork for patient-centered care and is a sign of excellence in nursing practice .

Nursing care plans have a few significant objectives. First off, they aim to encourage evidence-based nursing care . Accounting for the fact that psychological, social, and spiritual health are as potent as physical health, nursing care plans advocate for holistic care to manage and prevent diseases. Other aims of this practice include:

• Identifying achievable goals for the nursing team.
• Spelling out desired care outcomes .
• Measuring nursing care . 

What Are The Types of Nursing Care Plans?

Nursing care plans are either informal or formal. The informal care plans are courses of action in response to a patient’s state that the nurse has thought of but hasn’t yet documented or formalized. 

A formal nursing care plan is the written version of the plan. It details the patient’s care information, information about the nursing interventions, the patient’s state, response to nursing interventions, and more. 

Standardized care plans are formal nursing care plans in which the RN specifies the care they offer to a group of clients with everyday needs. 

Individualized care plans are formal nursing care plans tailored to the needs of a particular patient. They are specific and unique to each patient’s condition or requirements. 

Student Nursing Care Plans vs. Professional Nursing Care Plans

Student nursing care plans and the care plans written by professional registered nurses have the same overall goal: to guide the process of nursing care . However, there are some important differences between them. 

Care plans formulated by aspiring RNs in nursing schools are significantly longer . They are written with greater detail and contain more thorough information. It is more time-consuming to devise student nursing care plans. Still, it’s a good training exercise. It solidifies the students’ knowledge and ensures they grasp and apply essential nursing concepts. 

Nursing care plans written by Registered Nurses in clinical settings are generally more concise . Unlike students, working professionals don’t have to write down every nursing judgment and decision-making step. Additionally, the clinical setting version of nursing plans does not include the rationale – an extra column in which nursing students have to present the scientific explanations for the chosen interventions. 

What Are the Main Reasons to Have a Care Plan?

There are many advantages to writing and implementing nursing care plans. They may be tedious to create, but they benefit nurses, patients, and the entire healthcare system in the long run. These are some of the reasons why care plans play such a vital part in patient care: 

• Nursing care plans are a roadmap to quality patient-centered care . Care plans help structure and organize patient care. When elaborating them, the nurse employs critical and holistic thinking, leading to better patient outcomes. 
• Nursing care plans ensure the continuity of care . Nurse care plans need to be written or computerized, and so they become a part of a patient’s health record. Consequently, nurses have access to the same patient information. Despite working different shifts, all RNs caring for a patient will be aware of the diagnosis, prior nursing interventions, and their coworkers’ observations and insights. This means that nurses work towards the same goal, which leads to better patient results. 
• Nursing care plans ensure collaboration with other members of the healthcare team . In addition to their fellow RNs, nurses also have to collaborate with physicians, assistants, social workers, physical therapists, and other health team members. Nursing plans put all the information in one place and make it easily accessible for all members of this interprofessional team. Thus, everyone is aware of the desired outcomes and can work towards them. 
• Nursing care plans keep patients engaged . An important part of formulating nursing care plans is setting goals for and with patients. This step motivates patients to be more involved in their recovery, makes them more compliant to treatment, and ensures better outcomes. 
• Nursing care plans can serve as evidence of given care . These are documents through which nurses document their interventions, thus acting as a record in case of lawsuits or accusations that they failed to adhere to nursing standards. They maximize the efficiency of the nurses while also shielding them from potential problems. 
• Nursing care plans act as guides for reimbursement . Insurance companies use medical records to determine the amount they will pay concerning the care the patient received. 

What Are the Components of a Nursing Care Plan?

Nursing care plans are essentially the written outcome of the nursing process. For this reason, the structure of a nursing care plan closely follows the five steps of the nursing process : assessment, diagnosis, planning, implementation, evaluation. 

More precisely, nursing care plans usually follow this template: 

• Nursing diagnosis
• Desired outcomes/goals
• Nursing interventions (or implementations)

Let’s look at each step more closely. 

Before everything else, a care plan must include a nursing diagnosis . To formulate a nursing diagnosis, you need to conduct a thorough assessment of the patient’s health, consisting of objective or subjective data. 

Learn everything you need to know about nursing diagnoses in our complete guide on the subject . 

After establishing a nursing diagnosis, the next step in your care plan is outlining desired outcomes and goals . The goals may be long-term or short-term, but all of them ought to be realistic and achievable. 

Following that, you need to start documenting the nursing interventions you carry out. 

The last component of the nursing plan is evaluation . This step covers the information about the outcomes of the nursing interventions. 

How to Write a Nursing Plan?

Developing a nursing plan may seem daunting at first. But it doesn’t have to be. Now that you’re familiar with the components, all you have to do is follow the step-by-step guide that we included below. 

Conduct patient assessment. 

When you start creating a nursing plan, you first gather information about the patient’s state using specific nursing assessment techniques and other data collection methods. This may include conducting a head-to-toe physical assessment, taking vitals, reviewing the patient’s health history and medical records, asking questions directly to the patient or their family, performing diagnosis studies. It is essential to be thorough and careful in gathering health data. 

Analyze and catalog all the information you got in the previous step. 

By now, you have large chunks of information about your patient’s state, their history, the health risks they encounter, and more. You need to structure it and pick the relevant details. Based on that, formulate a nursing diagnosis, which will help set your priorities and determine some desired outcomes. 

Formulate your nursing diagnosis. 

All the data you collected will help you in the diagnosing process. You should write the nursing diagnosis in line with the NANDA-I format, the internationally recognized way to identify and catalog RN diagnoses. Prioritizing will play a vital role in creating a nursing diagnosis. For this, Maslow’s hierarchy of needs will prove a helpful tool. Once you have indicated a diagnosis, you can set goals and pinpoint the desired nursing outcomes. 

Find everything you need to know about writing a nursing diagnosis in our complete guide on the subject. 

Set SMART patient goals.

After writing a diagnosis, you must set goals for the direction of care. This is essentially the planning stage, where you outline what you hope to achieve once the nursing process is implemented. These goals will pave the path for planning nursing interventions. Later on, they will be the standards by which you evaluate the patient’s health progress. 

It’s crucial to keep the goals clear, realistic, and specific. A good strategy for setting goals as part of the nursing plan is by employing the SMART technique: 

S pecific – Make sure the nursing goals you choose are unambiguous and well-defined. 

M easurable – Set specific metrics to determine/measure the efficacy of your actions and the patient’s progress.

A chievable – The nursing goals must be realistic and possible to achieve.

R ealistic – They need to be appropriate in relation to the overarching care plan.

T ime-bound – Deadlines can help you keep better track of your interventions and how efficient they are. These can be flexible. 

Goals can also be short-term or long-term . For the most part, as a nurse, you will devise short-term goals because you are mostly focused on the patient’s immediate (or near future) needs or concerns. Long-term nursing goals are mostly used by nurses working in home healthcare , nursing homes, or with patients suffering from chronic health problems. 

Choose appropriate nursing interventions

Nursing interventions are the actions a nurse takes to achieve patient goals and reach the desired outcomes. The interventions focus on reducing the causes of the nursing diagnosis or decreasing the risk factors. You may follow the doctor’s guidelines – dependent nursing interventions – to choose the appropriate interventions. Also, you can develop nursing interventions yourself, drawing from evidence-based practice – independent nursing interventions . Another type of nursing intervention is collaborative , which refers to the actions or activities you carry out in collaboration with other healthcare team members. 

There are seven categories of nursing interventions : family, behavioral, physiological, complex physiological, community, safety, and health system interventions. Some of the most common nursing interventions you can expect to perform during each shift include: assessing pain, giving medications, checking vital signs at specific intervals, changing the resting position, initiating fall precautions, or educating the patient.

After identifying the appropriate interventions, you will perform them in the implementation phase of the nursing process. 

Provide rationale for the chosen nursing interventions

This additional step is only included in student nursing care plans . Writing down the rationale in the student care plan serves as an exercise for students to ensure that they are fully aware of why a specific nursing intervention was the best course of action. 

Perform evaluation

Evaluation is the final step of the nursing care plan. In this phase, the nurse will analyze whether the care goals have been met and whether or not the nursing plan was effective. Importantly, evaluation is an ongoing process . Based on its conclusions, you can continue, change, or cancel nursing interventions. 

Tips and Tricks for Writing Efficient Nursing Care Plans

Keep your writing skills sharp. .

More than just an important document, a nursing care plan is a guide to efficient nursing care and interdepartmental collaboration. That’s why you need to be efficient in writing it. As much as possible, try to write everything down immediately not to miss or forget any details. Write clearly and concisely, but make sure you and the other members of the team understand the terms or abbreviations you use. Include dates and times. 

Always keep the plan up to date.

Make sure your care plans are constantly updated with the latest information. You should always document the changes in a patient’s state, the updates in the nursing interventions, or other developments that may occur in the process of care. 

Keep the plans accessible and easily shareable.

An essential characteristic of care plans is that they must be easily shareable with relevant stakeholders. These may include patients, other doctors or nurses, or insurance companies. The format for the nursing care plans may differ from one medical institution to another. Still, for the most part, they are electronic and become part of the electronic health record (EHR). Thus, they can be easily accessed by everyone. 

Nursing Care Plan Examples

As a nurse, you’ll have to write nursing plans for a wide variety of conditions: from hypertension, infection, decreased cardiac output, impaired skin integrity, acute pain to constipation, anxiety, diabetes, dehydration, and many more. To better illustrate how to write nursing care plans, we have assembled some examples. Bear in mind that the template of the nursing plan may differ from one institution to another. 

Are you Ready to Start Writing Efficient Nursing Care Plans?

Writing efficient, goal-oriented, easily-accessible, clear, and evidence-based nursing care plans is pivotal for any Registered Nurse.

In order to develop nursing care plans that encompass all these qualities, you need to be knowledgeable, display critical thinking, engage in teamwork, and focus on offering patient-centric care. If you follow these guidelines, the care plans you write will help elevate your professional status and the entire healthcare process.

We’re here to make your journey a little easier. Enroll in Nightingale College’s BSN program or advance your education with an online RN-to-BSN and discover that writing nursing care plans doesn’t have to be a daunting process.

Acute Pain Nursing Care Plan and Management

Feeling the sharp, stabbing pain of an acute injury or illness is a sensation that no one wants to experience. As nurses, it’s our job to help ease the suffering of our patients and provide the best possible care for those in pain. Creating a comprehensive care plan for acute pain nursing diagnosis can help relieve our patients’ discomfort and get them on the road to recovery. Whether it’s administering medication , providing emotional support, or teaching patients about pain management techniques, this care plan guide will help you utilize those tools on how to manage acute pain

Let’s take a closer look at how we can effectively care for patients experiencing acute pain. Use this guide to formulate your nursing care plans and nursing interventions for patients experiencing acute pain.

Table of Contents

What is acute pain, causes of pain, signs and symptoms, goals and outcomes, nursing diagnosis, related care plans, using the pqrst pain assessment mnemonic, determine factors that causes acute pain, determine patient’s response to pain, initiating nonpharmacologic pain management, provide pharmacologic pain management, recommended resources, references and sources.

The International Association for the Study of Pain (IASP) defined pain as “ an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage .” Another great and influential definition of pain is from Margo McCaffery, a nurse expert on pain, who defined it as “ pain is whatever the person says it is and exists whenever the person says it does .” The unpleasant feeling of pain is highly subjective in nature that may be experienced by the patient.

“Pain is whatever the person says it is and exists whenever the person says it does.” Margo McCaffery – Pain Management Nurse Pioneer

Acute pain is pain, as defined above, that has a duration of less than 3 months and relief can be anticipated or predicted. In contrast, chronic pain is has a duration of more than 3 months without an anticipated or predictable end. The physiological signs of acute pain emerge from the body’s response to pain as a stressor. Acute pain provides a protective purpose to make the person informed and knowledgeable about the presence of an injury or illness. The unexpected onset of acute pain reminds the patient to seek support, assistance, and relief.

Other factors such as the patient’s cultural background, emotions, and psychological or spiritual discomfort may contribute to acute pain. In older patients, assessment of pain can be challenging due to cognitive impairment and sensory-perceptual deficits. Assessment and management of the nursing diagnosis of acute pain are the main focus of this care plan.

Here are the common causes of pain:

• Tissue damage or break in tissue integrity such as in surgery , injury, fractures, and other conditions that breakdown or damage the body’s tissues.
• Inflammation is a normal immune response to injury or infection can also cause pain.
• Nerve damage or irritation that is commonly caused by sciatica, herniated disc, or infections such as shingles ( postherpetic neuralgia )
• Psychological conditions such as stress, depression , anxiety can all contribute to pain.

The following are the common manifestations that defines the characteristics of acute pain. Use these subjective and objective data to help guide you through the nursing assessment . Alternatively, you can check out the assessment guide for acute pain in the subsequent sections.

• Self-report of intensity using standardized pain intensity scales (e.g., Wong-Baker FACES scale, visual analog scale, numeric rating scale)
• Self-report of pain characteristics (e.g., aching, burning, electric shock, pins, and needles, shooting, sore/tender, stabbing, throbbing) using standardized pain scales (e.g., McGill Pain Questionnaire, Brief Pain Inventory)
• Guarding behavior or protecting the body part
• Facial mask of pain (e.g., grimaces)
• Expression of pain (e.g., restlessness, crying, moaning)
• Profuse sweating
• Alteration in BP , HR, RR
• Dilation of the pupils
• Proxy reporting pain and behavior/activity changes (e.g., family members , caregivers )

The following are the common nursing care planning goals and expected outcomes for Acute Pain:

• Patient demonstrates the use of appropriate diversional activities and relaxation skills.
• Patient describes satisfactory pain control at a level (for example, less than 3 to 4 on a rating scale of 0 to 10)
• Patient displays improved well-being such as baseline levels for pulse, BP , respirations, and relaxed muscle tone or body posture.
• Patient uses pharmacological and nonpharmacological pain-relief strategies.
• Patient displays improvement in mood, coping.

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with acute pain based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities. However, if you still find value in utilizing nursing diagnosis labels, here are some examples to consider:

• Acute Pain related to tissue injury from surgical incision AEB patient reporting a pain level of 8 on a 1-10 scale, facial grimacing, and guarding the surgical site.
• Acute Pain related to inflammation and swelling secondary to sprained ankle AEB patient’s verbal report of pain, observed limping, and inability to bear weight on the affected leg.
• Acute Pain related to musculoskeletal injury (e.g., fracture , sprain) as evidenced by patient describing pain as sharp or throbbing, limited range of motion, and swelling at the injury site.
• Acute Pain related to inflammation (e.g., appendicitis , pancreatitis ) as evidenced by patient reporting localized abdominal pain, pain intensity increasing with movement , and presence of nausea or vomiting .
• Acute Pain related to mucosal irritation and inflammation in the urinary tract (e.g., urinary tract infection ) as evidenced by patient reporting burning sensation during urination , frequent need to urinate, and abdominal discomfort.
• Acute Pain related to cervical dilation and uterine contractions during labor as evidenced by patient reporting contraction pains, expressing distress during contractions, and utilizing pain relief techniques.

Diseases, medical conditions, and related nursing care plans for Acute Pain nursing diagnosis:

• Surgery (Perioperative Client)
• Brain Tumor
• Hypertension
• Tonsillitis
• Click here for more sample nursing care plans for the acute pain nursing diagnosis .

Nursing assessment and rationales

Proper nursing assessment of acute pain is imperative for the development of an effective pain management plan. Nurses play a crucial role in the assessment of pain, use these techniques on how to comprehensively assess acute pain:

Perform pain assessment

1. Perform a comprehensive assessment of pain. Determine the location, characteristics, onset, duration, frequency, quality, and severity of pain via assessment. The patient experiencing pain is the most reliable source of information about their pain. Their self-report on pain is the gold standard in pain assessment as they can describe the location, intensity, and duration. Thus, assessment of pain by conducting an interview helps the nurse in planning optimal pain management strategies.

Alternatively, you can use the nursing mnemonic “PQRST” to guide you during pain assessment:

• Provoking Factors : “What makes your pain better or worse?”
• Quality (characteristic): “Tell me what it’s exactly like. Is it a sharp pain, throbbing pain, dull pain, stabbing, etc?”
• Region (location): “Show me where your pain is.”
• Severity : Ask your pain to rate pain by using different pain rating methods (e.g., Pain scale of 1-10, Wong-Baker Faces Scale).
• Temporal (onset, duration, frequency): “Does it occur all the time or does it come and go?”

2. Assess the location of the pain by asking to point to the site that is discomforting. Using charts or drawings of the body can help the patient, and the nurse determines specific pain locations. For clients with a limited vocabulary, asking to pinpoint the location helps in clarifying your pain assessment – this is especially important when assessing pain in children.

See also : Pain Perplex: 5 Things Nurses Need to Understand About Pain Management

3. Perform history assessment of pain Additionally, the nurse should ask the following questions during pain assessment to determine its history: (1) effectiveness of previous pain treatment or management; (2) what medications were taken and when; (3) other medications being taken; (4) allergies or known side effects to medications.

4. Determine the client’s perception of pain. In taking a pain history, provide an opportunity for the client to express in their own words how they view the pain and the situation to gain an understanding of what the pain means to the client. You can ask, “What does having this pain mean to you?”, “Can you describe specifically how this pain is affecting you?”.

5. Pain should be screened every time vital signs are evaluated. Many health facilities set pain assessment as the “fifth vital sign” and should be added to routine vital signs assessment.

6. Pain assessments must be initiated by the nurse. Pain responses are unique for each person, and some clients may be reluctant to report or voice out their pain unless asked about it.

7. Use the Wong-Baker FACES Rating Scale to determine pain intensity. Some clients (e.g., children, language constraints) may not relate to numerical pain scales and may need to use the Wong-Baker Faces Rating Scale. Pain assessment tools help translate the patient’s subjective experience of pain into objective numbers or descriptors.

 8. Investigate signs and symptoms related to pain. An accurate assessment of pain is crucial in providing an individualized plan of care. Bringing attention to associated signs and symptoms may help the nurse in evaluating the pain. In some instances, the existence of pain is disregarded by the patient.

9. Determine the patient’s anticipation for pain relief . Some patients may be satisfied when pain is no longer intense; others will demand complete elimination of pain. This influences the perceptions of the effectiveness of the treatment modality and their eagerness to engage in further treatments.

10. Assess the patient’s willingness or ability to explore a range of techniques to control pain. Some patients may be hesitant to try the effectiveness of nonpharmacological methods and may be willing to try traditional pharmacological methods (i.e., the use of analgesics). A combination of both therapies may be more effective, and the nurse has the duty to inform the patient of the different methods to manage pain.

11. Determine factors that alleviate pain. Ask clients to describe anything they have done to alleviate the pain. These may include, for example, meditation, deep breathing exercises, praying, etc. Information on these alleviating activities can be integrated into planning for optimal pain management.

12. Evaluate the patient’s response to pain and management strategies. It is essential to assist patients to express as factually as possible (i.e., without the effect of mood, emotion, or anxiety ) the effect of pain relief measures. Inconsistencies between behavior or appearance and what the patient says about pain relief (or lack of it) may reflect other methods the patient is using to cope with the pain rather than pain relief itself.

13. Provide ample time and effort regarding the patient’s report of their pain experience. Patients may be reluctant to report their pain as they may perceive staff to be very busy and have competing demands on their time from other nurses, doctors, and patients (Manias et al., 2002). Interruptions during pain management can prevent nurses from assessing and managing the patient’s pain experience.

14. Evaluate what the pain suggests to the patient. The meaning of pain will directly determine the patient’s response. Some patients, especially the dying , may consider that the “act of suffering” meets a spiritual need.

Nursing interventions for acute pain

Nurses are not to judge whether the acute pain is real or not. As a nurse, we should spend more time treating patients. The following are the therapeutic nursing interventions for your acute pain nursing diagnosis:

1. Provide measures to relieve pain before it becomes severe. It is preferable to provide an analgesic before the onset of pain or before it becomes severe when a larger dose may be required. An example would be preemptive analgesia, which is administering analgesics before surgery to decrease or relieve pain after surgery . The preemptive approach is also useful before painful procedures like wound dressing changes, physical therapy, postural drainage , etc.

2. Acknowledge and accept the client’s pain. Nurses have the duty to ask their clients about their pain and believe their reports of pain. Challenging or undermining their pain reports results in an unhealthy therapeutic relationship that may hinder pain management and deteriorate rapport.

3. Provide nonpharmacologic pain management. Nonpharmacologic methods in pain management may include physical, cognitive-behavioral strategies, and lifestyle pain management. See methods below: 

3.1. Provide cognitive-behavioral therapy (CBT) for pain management. These methods are used to provide comfort by altering psychological responses to pain. Cognitive-behavioral interventions include:

• Distraction. This technique involves heightening one’s concentration upon non-painful stimuli to decrease one’s awareness and experience of pain. Drawing the person away from the pain lessens the perception of pain. Examples include reading, watching TV, playing video games, and guided imagery.
• Eliciting the Relaxation Response. Stress correlates to an increase in pain perception by increasing muscle tension and activating the SNS. Eliciting a relaxation response decreases the effects of stress on pain. Examples include directed meditation, music therapy, and deep breathing .
• Guided imagery. Involves the use of mental pictures or guiding the patient to imagine an event to distract from the pain.
• Repatterning Unhelpful Thinking . Involves patients with strong self-doubts or unrealistic expectations that may exacerbate pain and result in failure in pain management.
• Other CBT techniques include Reiki, spiritually directed approaches, emotional counseling, hypnosis, biofeedback, meditation, and relaxation techniques.

3.2. Provide cutaneous stimulation or physical interventions Cutaneous stimulation provides effective pain relief, albeit temporary. The way it works is by distracting the client away from painful sensations through tactile stimuli. Cutaneous stimulation techniques include:

• Massage . When appropriate, massaging the affected area interrupts the pain transmission, increases endorphin levels, and decreases tissue edema . Massage aids in relaxation and decreases muscle tension by increasing superficial circulation to the area. Massage should not be done in areas of skin breakdown, suspected clots, or infections.
• Heat and cold applications. Cold works by reducing pain, inflammation, and muscle spasticity by decreasing the release of pain-inducing chemicals and slowing the conduction of pain impulses. Cold is best when applied within the first 24 hours of injury while heat is used to treat the chronic phase of an injury by improving blood flow to the area and through reduction of pain reflexes.
• Acupressure . An ancient Chinese healing system of acupuncture wherein the therapist applies finger pressure points that correspond to many of the points used in acupuncture.
• Contralateral stimulation . Involves stimulating the skin in an area opposite to the painful area. This technique is used when the painful area cannot be touched.
• Transcutaneous Electrical Nerve Stimulation (TENS). Is the application of low-voltage electrical stimulation directly over the identified pain areas or along with the areas that innervate pain.
• Immobilization . Restriction of movement of a painful body part is another nonpharmacologic pain management. To do this, you need splints or supportive devices to hold joints in the position optimal for function. Note that prolonged immobilization can result in muscle atrophy, joint contracture, and cardiovascular problems. Check with the agency protocol.
• Other cutaneous stimulation interventions include therapeutic exercises (tai-chi, yoga, low-intensity exercises, ROM exercises), and acupuncture.

4. Provide pharmacologic pain management as ordered. Pain management using pharmacologic methods involves using opioids (narcotics), nonopioids ( NSAIDs ), and co analgesic drugs. The World Health Organization (WHO) published guidelines on the logical usage of analgesics to treat cancer using a three-step ladder approach – also known as the analgesic ladder . The analgesic ladder focuses on aligning the proper analgesics with the intensity of pain.

• Step 1: For mild pain (1 to 3 pain rating), the WHO analgesic ladder suggests the use of nonopioid analgesics with or without coanalgesics. If pain persists or increases despite providing full doses, then proceed to the next step.
• Step 2: For moderate pain (4 to 6 pain rating), opioid, or a combination of opioid and nonopioid is administered with or without conanalgesics.
• Step 3: For severe pain (7 to 10), the opioid is administered and titrated in ATC scheduled doses until the pain is relieved.

4.1. Administer nonopioids including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen , as ordered.  NSAIDs work in peripheral tissues. Some block the synthesis of prostaglandins, which stimulate nociceptors. They are effective in managing mild to moderate pain. All NSAIDs have anti-inflammatory (except for acetaminophen), analgesic, and antipyretic effects. They work by inhibiting the enzyme cyclooxygenase (COX), a chemical activated during tissue damage, resulting in decreased synthesis of prostaglandins. NSAIDs also have a ceiling effect. Once the maximum analgesic benefit is achieved, additional amounts of the same drug will not produce more analgesia and may risk the patient for toxicity. Common side effects of NSAIDs include heartburn or indigestion. There is also a possibility of forming a small stomach ulcer due to platelet aggregation. To prevent these side effects, clients should be taught to take NSAIDs with food and a full glass of water. Common NSAIDs include:

• Aspirin. It can prolong bleeding time and should be stopped a week before a client undergoes any surgical procedure. Should never be given to children below 12 years of age due to the possibility of Reye’s syndrome. May cause excessive anticoagulation if the client is taking warfarin .
• Acetaminophen (Tylenol). May have serious hepatotoxic side effects and possible renal toxicity with high dosages or with long-term use. Limit acetaminophen usage to 3 grams per day.
• Celecoxib (Celebrex). Is a COX-2 inhibitor that has fewer GI side effects than COX-1 NSAIDs.

For the full list, please visit: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Related Agents

4.2. Administer opioids as ordered. Opioids are indicated for severe pain and can be administered orally, IV, PCA systems, or epidurally.

• Opioids for moderate pain. These include codeine , hydrocodone , and tramadol (Ultram) which are combinations of nonopioid and opioid.
• Opioids for severe pain. These include morphine , hydromorphone , oxycodone, methadone , and fentanyl . Most of these are controlled substances due to potential misuse. These drugs are indicated for severe pain, or when other medications fail to control pain.

For the full list, please visit: Narcotics, Narcotic Antagonists, and Antimigraine Agents

4.3. Administer coanalgesics (adjuvants), as ordered.  Coanalgesics are medications that are not classified as pain medication but have properties that may reduce pain alone or in combination with other analgesics. They may also relieve other discomforts, increase the effectiveness of pain medications, or reduce the pain medication’s side effects. Commonly used coanalgesics include: 

• Antidepressants . Is a common coanalgesic that helps in increasing pain relief, improving mood, and reducing excitability.
• Local Anes t hetics . These drugs block the transmission of pain signals and are used for pain in specific areas of nerve distribution.
• Other coanalgesics. Include anxiolytics, sedatives, and antispasmodics to relieve other discomforts. Stimulants, laxatives, and antiemetics are other coanalgesics that reduce the side effects of analgesics.

5. Manage acute pain using a multimodal approach.  A multimodal approach is based on using two or more distinct methods or drugs to enhance pain relief (rather than resorting to opioid use or other pain management strategies alone). Different combinations of analgesic medications, adjuvants, and procedures can act on different sites and pathways in an additive or synergistic fashion. Combining medications and techniques allows the lowest effective dose of each drug to be administered, resulting in reduced side effects. 

6. Administer analgesia before painful procedures whenever possible. Doing so will help prevent pain caused by relatively painful procedures (e.g., wound care , venipunctures, chest tube removal, endotracheal suctioning, etc.).

7. Perform nursing care during the peak effect of analgesics.  Oral analgesics typically peak in 60 minutes, and intravenous analgesics in 20 minutes. Performing nursing tasks during the peak effect of analgesics optimizes client comfort and compliance in care. 

8. Evaluate the effectiveness of analgesics as ordered and observe for any signs and symptoms of side effects. The patient’s effectiveness of pain medications must be evaluated individually since they are absorbed and metabolized differently.

For more interventions related to pain, please visit Chronic Pain Nursing Care Plan

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care  Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health   Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ! Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Recommended resources to further your study for this acute pain nursing care plan .

• Hartrick, C. T. (2004). Multimodal postoperative pain management .   American Journal of Health-System Pharmacy ,  61 (suppl_1), S4-S10.
• Herr, K., Titler, M. G., Schilling, M. L., Marsh, J. L., Xie, X., Ardery, G., … & Everett, L. Q. (2004). Evidence-based assessment of acute pain in older adults: current nursing practices and perceived barriers.   The Clinical journal of pain ,  20 (5), 331-340.
• Hsieh, L. L. C., Kuo, C. H., Lee, L. H., Yen, A. M. F., Chien, K. L., & Chen, T. H. H. (2006). Treatment of low back pain by acupressure and physical therapy: randomized controlled trial .  Bmj ,  332 (7543), 696-700.
• Khan, K. A., & Weisman, S. J. (2007). Nonpharmacologic pain management strategies in the pediatric emergency department .  Clinical Pediatric Emergency Medicine ,  8 (4), 240-247.
• Loeser, J. D., & Treede, R. D. (2008). The Kyoto protocol of IASP basic pain terminology ☆.   Pain ,  137 (3), 473-477.
• Loggia, M. L., Juneau, M., & Bushnell, M. C. (2011). Autonomic responses to heat pain: Heart rate, skin conductance, and their relation to verbal ratings and stimulus intensity .  PAIN® ,  152 (3), 592-598.
• Manias, E., Botti, M., & Bucknall, T. (2002). Observation of pain assessment and management− the complexities of clinical practice .  Journal of clinical nursing ,  11 (6), 724-733.
• McCaffery, M. (1990). Nursing approaches to nonpharmacological pain control .  International Journal of nursing studies ,  27 (1), 1-5.
• Reid, C., & Davies, A. (2004). The World Health Organization three-step analgesic ladder comes of age .
• Urden, L. D., Stacy, K. M., & Lough, M. E. (2006).  Thelan’s critical care nursing: diagnosis and management  (pp. 918-966). Maryland Heights, MO: Mosby.
• Treede, R. D. (2018). The International Association for the Study of Pain definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes.   Pain reports ,  3 (2).
• Pasero, C., & McCaffery, M. (1999).  Pain: clinical manual  (Vol. 9). St. Louis: Mosby.
• Urba, S. G. (1996). Nonpharmacologic pain management in terminal care .  Clinics in geriatric medicine ,  12 (2), 301-311.
• Vargas-Schaffer, G. (2010). Is the WHO analgesic ladder still valid?: Twenty-four years of experience.   Canadian Family Physician ,  56 (6), 514-517.
• Voscopoulos, C., & Lema, M. (2010). When does acute pain become chronic?.  British journal of anaesthesia ,  105 (suppl_1), i69-i85.

9 thoughts on “Acute Pain Nursing Care Plan and Management”

Thanks so much I’ve learnt alot

This is very helpful. Thank you.

Thank you. This is very helpful guidance for student nurses like myself. Keep up the great work.

I learned a lot and very helpful ☺️. Thank you.

Thanks so much I really appreciate it I learnt a lot

Thanks for sharing this amazing post! Remember that acute pain management should be individualized based on the patient’s unique circumstances. Regular reassessment and communication are key components of effective acute pain management. Always adhere to your healthcare facility’s policies and protocols when implementing pain management interventions.

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Nursing Care Plans: An Introduction

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What is a Nursing Care Plan?

A nursing care plan is a road map for the care of a patient and a necessary tool in following the nursing process. Understanding nursing care plans is an important part of any nursing school curriculum and definitely something you’ll need to know as a nursing student. 

In this guide, you’ll learn how to write and use a nursing care plan and why they’re important for maintaining quality patient care.

Why are Care Plans Important?

Care plans play a vital role in the treatment of a patient. They clearly define guidelines along with the nurse’s role in patient care and help them create and achieve a solid plan of action. This equips nurses to provide focused care—without overlooking important steps.

Nursing care plans also promote:

Collaboration

• A well-documented care plan ensures the patient’s entire care team (doctors, nurses, etc.) can access the same information, give input, and join forces to provide the best care possible.
• Care plans help nurses uphold the nursing code of ethics and provide a record that they did so in case of lawsuits or accusations that they failed to adhere to care standards.
• A care plan is a communication tool for patient care between nurses. When nurses change shifts they’re able to reference the patient’s care plan to ensure the same quality care and interventions are being executed.

Without nursing care plans, nursing staff might have to rely on verbal communication and patient information could become more easily scattered or lost, all of which could result in improper patient care .

How to Write a Nursing Care Plan

Nursing care plans follow a five-step process: assessment, diagnosis, outcomes, implementation, and evaluation.

Assess the patient.

The first step to writing a care plan is performing a patient assessment. This includes reviewing your patient’s medical history, diagnosis, lab values, and medications. This step is critical to creating an effective and accurate care plan for either short term or long term care.

Make a diagnosis.

Nursing diagnoses differs from a medical diagnosis in that it’s based on the patient’s response to an illness, rather than the illness itself. Simply put, a nursing diagnosis is focused on patient care rather than treatment.

According to NANDA (North American Nursing Diagnosis Association), a good nursing care plan should not only list each diagnosis but define it as well. For example, acid reflux should be described as: "Ineffective airway clearance related to gastroesophageal reflux as evidenced by retching, upper airway congestion, and persistent coughing.”

Set goals and outcomes.

Once you’ve completed an assessment and diagnosis, it’s time to write down goals and a desired health care outcomes for your patient. These describe what you hope to achieve in the short- and long-term future, provide direction for planning interventions, and serve as criteria for evaluating progress. Goals are documented in the patient’s care plan so that other nurses and health professionals caring for the patient have access to it.

Determine nursing interventions.

At this point in the care plan, you’ll list all planned nursing interventions and document any that you’ve performed. You’ll write down things such as client responses to care, pain scale responses, medications given and their dosages, vital signs, etc. This communicates what nursing orders were implemented, what still needs to be done, and if the patient is ready to be discharged.

Evaluate the plan.

Evaluation is necessary in a patient care plan to determine whether to continue, adjust, or terminate the plan of care. It measures the degree to which goals and outcomes are achieved and provides evidence for what factors positively or negatively impacted those goals.

How to Use a Nursing Care Plan

Registered nurses and nurse practitioners use these plans in the nursing process as a road map for providing care. They’re also a tool to help nurses think critically and holistically to support the patient’s needs—physically, socially, spiritually, and psychosocially. Only RNs can develop the care plan and make changes, although LPNs can contribute suggestions.

A nursing care plan begins as soon as a patient is admitted and is updated frequently as their condition changes or after an evaluation. It’s an ongoing process that requires detailed, accurate documentation that strictly adheres to the nursing code of ethics , as well as HIPAA rules and regulations .

Knowing how to write and implement a nursing care plan is one essential skill you’ll need as a nurse or nurse practitioner . With a degree in nursing , you’ll gain this valuable experience—and the tools to provide the best patient care possible.

Ready to Start Your Journey?

HEALTH & NURSING

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• Open access
• Published: 14 August 2024

Organizational characteristics of highly specialized units for people with dementia and severe challenging behavior

• Gerrie van Voorden 1 , 2 , 3 , 4 ,
• Raymond T. C. M. Koopmans 1 , 2 , 3 , 4 , 5 ,
• Mijke M. Strik-Lips 2 ,
• Martin Smalbrugge 6 , 7 ,
• Sytse U. Zuidema 8 , 9 ,
• Anne M. A. van den Brink 2 ,
• Anke Persoon 1 , 2 , 3 , 4 ,
• Richard C. Oude Voshaar 9 , 10 &
• Debby L. Gerritsen 1 , 2 , 3 , 4  

BMC Geriatrics volume  24 , Article number:  681 ( 2024 ) Cite this article

72 Accesses

Metrics details

People with dementia and severe challenging behavior in the Netherlands can be temporarily admitted to highly specialized units when their behavior is not manageable in regular dementia special care units (DSCUs). With scarce evidence available for the treatment of these patients, treatment in these units is in a pioneering phase. To gain more insight into these units, this study investigated organizational characteristics, i.e. admission and discharge characteristics, staffing, the physical environment, and the management of severe challenging behavior.

Three data collection methods were used: 1) a digital questionnaire to be completed by the unit manager, 2) an interview with the physician responsible for medical care and often another practitioner, and 3) an observation of the physical environment for which the OAZIS-dementia questionnaire was used. Descriptive analysis was used for quantitative data and thematic analysis for qualitative data, after which data was interpreted together. Thirteen units participated, with their sizes ranging from 10 to 28 places.

Patients were mainly admitted from regular DSCUs, home or mental health care, and discharged to regular DSCUs. A multidisciplinary team comprising at least an elderly care physician or geriatrician, psychologist, and nursing staff member and other therapists as needed provided the treatment. Nursing staff hours per patient considerably differed among units. Nursing staff played a central role in the treatment. Competences such as reflectiveness on one’s own behavior, and being able to cope with stressful situations were described as relevant for nursing staff. Investing in a stable nursing staff team was described as important. The units varied in whether their work-up was more intuitive or methodological. In the diagnostic phase, observation together with an extensive analysis of the patient’s biography was essential. The units used a broad variety of interventions, and all paid attention to sensory stimuli. In the observation of the physical environment, the safety scored well and domesticity relatively low.

Highly specialized units show strong heterogeneity in organizational characteristics and management, which can be understood in the light of the pioneering phase. Despite this, similarities were found in nursing staff roles, frequent multidisciplinary evaluation, and attention to sensory stimuli.

Peer Review reports

Challenging behavior in persons with dementia – also known as behavioral and psychological symptoms of dementia (BPSD) or neuropsychiatric symptoms [ 1 ] – is common in nursing homes, with a mean prevalence of 82% [ 2 ]. The burden of challenging behavior is high, being associated with a lower quality of life [ 3 , 4 , 5 ], and increased distress in caregivers [ 5 , 6 , 7 , 8 ]. Severe challenging behavior – especially aggression and agitation – is known to lead to admission to psychiatric services, specialist care units or long-term care [ 9 ]. Moreover, the costs of especially agitation at the end of life in dementia increases informal and formal health care costs by 30% [ 10 ]. A small proportion of people with dementia show very frequent or severe agitation with, a prevalence of 7.4% and 6.3%, respectively [ 11 , 12 ]. For very frequent physical aggression and very frequent vocalizations, a two-week prevalence of 2.2% and 11.5%, respectively, has been found in nursing home patients [ 13 ].

In the Netherlands, most people with dementia who cannot live on their own anymore live in a dementia special care unit (DSCU) [ 14 ]. Although DSCUs have varying characteristics, common elements are the psychogeriatric expertise of trained staff and activities that meet the needs of the people with dementia in a tailored environment [ 15 , 16 ]. In the Netherlands, DSCUs commonly have a multidisciplinary team available that comprises of an elderly care physician, a health care psychologist, and nursing staff – the majority regards certified nursing assistants—which can be extended with therapists, i.e. physiotherapist, occupational therapist, speech therapist and dietician, when indicated [ 17 , 18 , 19 ]. Table 1 describes the roles and education of the usual team members in further detail.

In the Netherlands, since approximately a decade, a small selection of people with severe challenging behavior can be temporarily admitted to highly specialized units when their behavior is not (regarded) manageable in a regular DSCU, such as behavior that causes serious safety problems, is very unpredictable or is very vocally disruptive. Several developments in health care have possibly contributed to the need for such units. First, the number of people with dementia is increasing whereas the number of nursing home places is not growing accordingly [ 24 , 25 ]. Second, nursing homes tend to have more people admitted with challenging behavior which also is more severe [ 26 , 27 ]. Third, admission possibilities in mental health care have been phased out in the Netherlands, leading to a decrease of 25.4% of admission days at wards in mental health care for people with delirium, dementia or other amnestic and cognitive disorders from 2012 to 2018 [ 28 ]. Fourth, it is believed that people with dementia and severe challenging behavior need expertise from both long-term care and mental health care [ 29 ]. Finally, the health care inspectorate has reported concerns about the quality of care for people with dementia and severe challenging behavior in the Netherlands [ 30 ]. These highly specialized units have been developed by long-term care organizations often in close cooperation with mental health care institutions.

However, at present little is known about these highly specialized units. For the aim of understanding whether these units contribute to a better quality of life and care for people with dementia and severe challenging behavior, it is needed to know what the organizational characteristics of these highly specialized units are. These insights can be used for further research into whether and why these units provide effective management of the challenging behavior. Elements of this knowledge about the management may eventually be proven useful in other settings. In Australia, a specialist residential dementia care program exists [ 31 ]. In one of these units, people with dementia and severe challenging behavior reside in an eight-place domestic-style residential cottage on average for twelve months, after which they are transferred to regular dementia care services [ 32 ]. Despite this example, little is known about this specific patient group, other similar care settings and the treatment applied there. Therefore, we studied these highly specialized units in the Netherlands to gain insights for clinical practice and further research.

Our aim was to describe the general characteristics of these units based on the following questions:

What are the organizational characteristics of these units regarding admission and discharge, staffing, and the physical environment?

What characterizes the management of severe challenging behavior on these units?

Sample and setting

Only units with temporarily admitted patients with dementia and severe challenging behavior in dementia were included. Units were identified and recruited by the six academic networks of long-term care [ 33 ]. At the start of this study, sixteen units were identified and invited to participate, fourteen of which gave consent. One of these units was closed at the start of the study, leaving thirteen units located throughout the Netherlands. Five units were part of a mental health care organization, and seven part of a long-term care organization, with two units in one organization (units 08 and 09), and one unit was a collaboration of both.

To answer the research questions, we used three data collection methods: 1) a digital questionnaire with mainly factual questions to be completed by the unit manager, 2) an interview about the treatment with the physician responsible for medical care, who was encouraged to invite another practitioner, and 3) an observation of the physical environment by the researcher. We chose these different methods to be able to answer our research questions, to provide for time for the unit manager to look up data, and to establish richer results for the topics competences of nursing staff, and physical environment. Data about these topics were integrated where applicable in the analysis [ 34 ]. Interviews and observations were scheduled on the same day and conducted at the workplace of the interviewees from May until August 2018.

Measurements

Digital questionnaire.

The digital questionnaire was self-developed with Lime Survey and sent to the unit managers [ 35 ]. The questionnaire comprised 43–48 mandatory, mainly fact-based questions at the unit level (see Table  2 ). Questions concerning the reasons for admission, competences and training of nursing staff, and work and education of the unit manager were open-ended. Twelve digital questionnaires were completed by the unit managers, and one by a baccalaureate-educated registered nurse in the unit due to time constraints of the unit manager. The patient administration had no exact data regarding residences before admission, number of compulsory admissions, discharge locations, and full-time equivalents of nursing staff (see Supplementary Materials 1–3), which were estimated by unit managers. Unit managers often had an educational background as baccalaureate-educated registered nurse after which they were trained in care management. They were on average 53.1 years old, and for 2.8 years involved.

We developed an interview guide that followed the patient journey which was inspired by the (clinical) experience from the authors and piloted. It comprised of topics such as first day of admission, characterization of treatment, training in the management of behavior, and experienced difficulties (for all topics and questions see the interview guide in Supplementary Material 4). The interviews were conducted by the first author (GV), who was not known to the interviewees. The principal interviewee – the physician(s) responsible for medical care – was requested to invite another professional, preferably a psychologist as they are usually involved in case of challenging behavior on regular DSCUs [ 19 ]. All interviews were audiotaped and transcribed verbatim, and a summary of the transcript was sent to the interviewees as a member check. Twelve interviews were held, lasting between 56 and 85 min. The interviewees comprise nine elderly care physicians, two geriatricians, and one geriatric psychiatrist. In seven units, the (health care) psychologist joined, in one unit the other physician responsible for medical care, and in one unit the nurse practitioner. Interviewees where on average 46.4 years old, and 19% of the interviewees were male. Saturation was reached after nine interviews, in the sense that no new themes were identified.

Observation of physical environment

The OAZIS-dementia [ 36 ] was used, which has been developed to assess long-term care environments in a Dutch setting [ 37 , 38 ]. The OAZIS-dementia has a good inter-rater reliability, with higher scores indicating a higher probability that the environment has positive effects on its residents [ 37 ]. It comprises 72 items to be rated on a five-point Likert scale, ranging from 1 ‘not at all’ to 5 ‘completely’ applicable. The instrument is divided into seven themes: 1) privacy and autonomy, 2) sensory stimulation, 3) view and nature, 4) facilities, 5) orientation and routing, 6) domesticity/small scale, and 7) safety. An example item from the theme facilities is: ‘there is enough space for the resident to receive visitors in his/her own room.’ In addition, we added items about the number of other rooms available and their function, e.g. the availability of a seclusion room. The OAZIS-dementia and general observation form was completed by GV. In two units, GV observed together with ML.

Quantitative data

The quantitative digital questionnaire responses and OAZIS-dementia scores were analyzed by the use of descriptive statistics. For each category in the OAZIS-dementia, the points reached were summed up and divided by the total number of items in this category. For the weighed final score, all items were summed up and divided by the total item number.

Qualitative data and data integration

Qualitative data from the digital questionnaire, interviews, and the observation of the physical environment was analyzed together. Investigator triangulation was realized by GV and ML jointly analyzing the interview transcripts supervised by DG, following the principles of thematic analysis [ 34 ]. GV and ML manually coded the first transcript separately by labeling meaningful fragments using open coding in a pragmatic way [ 39 , 40 ], discussing differences until they reached agreement. Atlas.ti version 8.3.16 was used for coding [ 41 ]. The other interviews were coded by ML or GV and discussed. Codes referred to facts as well as experiences and views, in line with the interview questions asked. First, GV and ML analyzed coded text fragments that related to management of severe challenging behavior, which led to the merging and splitting of codes, finalized by a visualization of relevant themes in management according to the interviewees. Furthermore, remaining codes were analyzed together with the open-ended questions from the digital questionnaire about the competences of nursing staff and the description of the general impression of the physical environment by GV, supervised by DG.

Quantitative and qualitative data were, after the above mentioned analyses, interpreted together in relation to the research questions.

Quality of interviews

GV reflected on the course of the interview, the agreement between the interviewees, the impression of the interviewees, the first impression of the added value of the interview, and whether there were moments of being suggestive after every interview [ 40 ]. GV wrote memos during data collection and analysis. GV and ML wrote memos during the interview analysis in a shared document. After six interviews, they decided to elaborate on the topics of non-pharmacological interventions, physical restraints and psychotropic drugs as they often lacked in-depth information concerning why these were applied in treatment. We followed the consolidated criteria for reporting qualitative research (COREQ) for the qualitative parts (see Supplementary Material 5 [ 42 ]).

Ethics statement

The study was conducted in accordance with the Declaration of Helsinki as well as the rules applicable in the Netherlands. The local Medical Ethics Review Committee, CMO region Arnhem-Nijmegen at the Radboud University Medical Center, stated that the Medical Research Involving Human Subjects Act (WMO) does not apply to this study and that an official approval of this study was not required (reference number 2018–4354). Informed consent was obtained from all participants, i.e. unit managers and interviewees, prior to data collection.

Organizational characteristics (research question 1)

Admission and discharge characteristics.

The majority of patients were admitted from regular DSCUs, home or a mental health care institution. Details of the admission and discharge characteristics per unit can be found in Supplementary Material 1. Before admission, the admission criteria were checked in terms of severe challenging behavior and (suspected) dementia. In three units, a maximum of two to three patients with physical aggression was allowed. Nine units exclusively treated patients with dementia, whereas three units also treated other older patients within the same or another sub-unit. Psychiatric comorbidity was not an exclusion criterion, except alcohol dependency in three units, and reflected the rule rather than the exception according to unit managers and interviewees. The proportion of compulsory admissions on a unit varied between 4 and 90% (median 20%) at the moment the digital questionnaire was completed. The mean age of patients ranged from 65 to 82 years. At admission, the vast majority of patients used many different types of psychotropic drugs, often without a good rationale, according to the interviewees. Some interviewees mentioned that the severe challenging behavior for which patients were admitted was not present after admission in a few cases, and suggested that another social and/or physical environment may explain this. The length of stay ranged from one to twelve months. The majority of patients were discharged to regular DSCUs, and the proportion of deaths ranged between 6 and 63% (median 19%) on average per unit per year.

A multidisciplinary team comprising at least a physician responsible for medical care, a psychologist and a nursing staff member but often more professionals such as therapists treated the patients. One, two or three physicians were responsible for medical care (see Supplementary 2): eleven elderly care physicians, two geriatricians, and three (geriatric) psychiatrists. In six units, (geriatric) psychiatrists were permanently involved in the treatment. In four units, a psychiatrist was sometimes consulted. Psychiatrists were valued by the interviewees for their expertise regarding the prescription of psychotropic drugs and psychiatric diagnostics. In three units, neurologists were permanently involved for their expertise in diagnostic problems in neurodegenerative diseases. In all units, therapists such as physiotherapists, occupational therapists speech therapists and dieticians were involved by the physician when necessary. A few units had a music therapist or psychomotor therapist involved. One unit had therapists who had received extra training in sensory integration [ 43 ]. This unit also employed personnel who were so-called miMakkus clowns, which is a practice-based psychosocial intervention using clowning for people with advanced stage dementia with the goal to make contact where communication in the usual cognitive way is no longer possible [ 44 ].

In ten units, baccalaureate-educated registered nurses worked in relatively low numbers, but the vast majority comprised registered vocationally trained nurses, and certified nurse assistants with a median average age of 38 years. Most units had a vast majority of registered vocationally trained nurses ( n  = 5) or a vast majority of certified nurse assistants ( n  = 5). The availability of nursing staff hours per patient substantially differed among units, ranging from 2.9 to 6.2 nursing staff hours per 24 h per patient (median 3.9). The median average sick leave was 5% in the former year (without maternity leave). All but one unit had vacancies for nursing staff (details per unit can be found in Supplementary Material 3). A stable team was seen as important, and thus in some units nursing staff were employed for a minimum of 24–32 contract hours per week.

Nursing staff were seen as central in the treatment by the interviewees: “They [nursing staff members] also try things before agreements [about management] are made. They are often the ones who come up with new approaches. We also come up with them, but I think that the performing and also coming up with is a very big task of the [nursing staff] team” (unit 11). Competences that were seen as important in nursing staff by both unit managers and interviewees included being open to new approaches, flexibility, reflectiveness on one’s own behavior, being good at observing and describing behavior, and being able to cope with stressful situations such as aggression. The ability to provide personal care with a caring attitude together with being able to set boundaries and act upon the challenging behavior was seen as key: “On the one hand, you should be able to provide warm personal care and be creative, but you should also be able to be directive when necessary and sense when you should approach someone from below and when from above” (unit 03). At one unit, the staff were also trained in the principles of miMakkus for communication in alternative ways [ 44 ]. Most units provided training for nursing staff to manage with physical aggression. Some units started with peer consultation focusing on the experience of caring for patients with severe challenging behavior, led by the psychologist. It helped staff in being able to set boundaries and gaining confidence in their ability to search for and apply suitable interventions. The support of the nursing staff manager was seen as important. Attention to work balance, mental support and extra staff during times of crisis helped in preventing sick leave and being more open to new behavioral approaches, according to the interviewees.

Six units involved volunteers, whereas in the other units interviewees considered this impossible due to the severity of the patients’ behavior. Units with volunteers focused on recruiting volunteers who could manage severe challenging behavior, and strongly invested in their supervision.

• Physical environment

General impression

Unit sizes ranged from 10 to 28 one person rooms available. Three units had the possibility to walk all around the unit. Interviewees mentioned their experience that this could reduce agitation in some patients and was missed when not available. Three units had sub-units with very low visual stimuli and very few objects. One sub-unit had only very soft objects. Eight units had seclusion rooms and in eight units enclosure beds were available, namely a bed with a canopy with zippered panels attached to a height-adjustable bed [ 45 , 46 ]. Details of the general impression per unit can be found in Supplementary Material 6.

OAZIS-dementia

The theme of safety scored highest on average in terms of the probability that the environment has a positive effect on the safety of a patient, while the theme of domesticity scored lowest (Table  3 ). Other individual items that scored relatively low were reducing noise by spatial planning ( n  = 11), bath rooms not being visible from the general living room ( n  = 6), and bath rooms not being directly accessible from the patients’ room ( n  = 7). The unit with the lowest score (unit 10) had a low score on the view and nature, and invested little in domesticity. The unit with the highest score (unit 01) had invested in the physical environment of the unit with special attention to sensory stimulation.

Management (research question 2)

Units varied in the degree in which they used a more intuitive or methodological work-up. Two interviewed elderly care physicians described their work-up explicitly as intuitive, although this was nuanced in one interview by the psychologist. In three units, specific evidence-based methods and/or multi-disciplinary programs developed for regular DSCUs were used, such as the ABC method, and the multidisciplinary programs STA-OP! protocol and Grip on Challenging Behavior [ 47 , 48 , 49 ]. Three units had explicit wishes or plans for training in a multidisciplinary program.

Before admission

Prior to admission, it was considered critically whether treatment was needed. Units considered which interventions had been used to date, and often gave advice to prevent admission. In one unit, the interviewee mentioned they insisted on consultation in the current residence beforehand, thereby preventing about one-third of proposed admissions. This prior consultation was conducted by the physician responsible for medical care or the psychologist, sometimes together with a nursing staff member. In three units, there was close collaboration with an ambulant team within the organization that advised in home situations.

Diagnostics

Interviewees explained that they had a program of clinical investigation in the first week after admission, comprising an analysis of the medical history in conjunction with the (psychotropic) drug use, physical and psychiatric examination, laboratory examination, making a first plan for the behavioral approach with interventions for the nursing staff, and a hetero-anamnesis of the biography, often with attention to personality and coping style. Two interviewees mentioned that without a biography it was often difficult to treat these patients well: “Yes, that’s when you miss quite a part of the puzzle. This can make it very difficult to draw conclusions,. in which case you find yourself struggling to find the correct approach for quite some time” (unit 04). All units paid attention to sensitivity for sensory stimuli, although the intensity and expertise available differed among units. Tolerance of a certain level of challenging behavior was essential in this phase to enable effective observation: “If someone wants it [the challenging behavior] gone immediately, it changes your perspective. There’s a certain peace like: ‘okay, this is it, let’s see where we still can be of any help to someone’” (unit 05) . “A very enthusiastic team that is really able to let people be. I find that really important too. [A team] that does not react immediately but is able to let it run its course for a while and see what happens together” (unit 11). The multidisciplinary team interpreted the behavior and discussed treatment every week (every other week in one unit). To ensure a consistent approach by the nursing staff, attention to differences in the experience and interpretation of the behavior was seen as essential.

For most patients, the treatment comprised a combination of non-pharmacological interventions and psychotropic drugs. Although interviewees strived to taper off the psychotropic drugs, they did not always consider this to be possible. They were satisfied when they could reduce the number of different types of psychotropic drugs and prescribe psychotropic drugs with a better rationale. Overall, interviewees mentioned that guidelines held limited usefulness for the treatment in these units: “Almost everything we do is no longer evidence-based and that’s a huge problem.” “We all have mainly expert opinions, meaning the knowledge of people who know more about it” (unit 06). Interviewed psychiatrists described that they used the psychiatric guidelines more freely than usual: “For example, in severe disinhibited behavior—not sleeping any more, being very restless. You can also interpret this as manic and we treat it as manic, and we find we achieve good results. We try especially try to find which box to tick, because the guideline is not able [to provide for a proper label], which label fits best and try to treat for that” (unit 02). As a clinical evaluation instrument of the challenging behavior, four units completed the Neuropsychiatric Inventory (NPI-Q) and the Cohen-Mansfield Agitation Inventory (CMAI) at regular intervals [ 50 , 51 ]. In two units, these were used in the actual evaluation of the treatment. In one of these units, goals were identified and evaluated with a goal attainment score.

Overall, visual stimuli were minimized and few objects were available to prevent over-stimulation and harm. In three units, patients were first admitted to a sub-unit with very few stimuli, before being moved to a sub-unit with more stimuli when they showed less aggression. Enclosure beds were also used to reduce stimuli, but also for improving sleep during the night, reducing ongoing restlessness and preventing falls. Other examples of specific interventions in sensory stimuli were deep pressure through a weighted vest or a headphone.

Non-pharmacological interventions used varied among the units, and included video-interaction training, sensory integration therapy, music therapy, Snoezelen, psychomotor therapy, and principles of “powerless in daily living” (PDL) care, a type of emotion-oriented care for patients with an irreversible self-care deficit [ 52 ]. As previously mentioned, one unit also used the principles of miMakkus, one unit paid special attention to the role of sleeping disorders, and one stimulated a break with patterns in the family system by discouraging visits during the first two weeks after admission. In one unit, patients with therapy-resistant severe challenging behavior were sometimes treated with electroconvulsive therapy with relevant results, although the therapy had to be continued to sustain the results.

Discharge was regarded possible when the patient’s behavior was expected to be manageable in a regular DSCU. Discharge was often difficult due to the specific needs of the patients, while being stigmatized by the assumed psychiatric comorbidity of potential units was also a problem according to interviewees from units with a background in mental health care. Some interviewees mentioned that discharge seemed to be impossible for some patients, sometimes after a probation discharge: “I might say that we go on trying, but that’s actually not always the case. Because at a certain moment we simply don’t know any more, than it’s manageable for the unit.” “Exactly, sometimes it’s manageable for us, and then we say that this is the best possible. But we mean that it’s not manageable in a regular unit” (unit 05).

Some units strongly invested in discharge by inviting the nursing staff of the proposed unit for discharge to care for the patient together to explain behavioral guidance in practice. These units’ teams were also available for the new units after discharge.

The main finding of this study is that units are pioneering and have strong heterogeneity in the management of severe challenging behavior in dementia. This heterogeneity was demonstrated by the varying degree to which a more intuitive or methodological work-up was used, the broad variety of non-pharmacological interventions used, and the differences in nursing staff hours, nursing staff education levels, length of stay, and the physical environment. Despite these differences, there were similarities in emphasis on observation with an open attitude, the key role of nursing staff, frequent multidisciplinary meetings, and attention to sensory stimuli.

Although units varied in the degree to which they adopted a more intuitive or methodological work-up and the fact that a broad variety of non-pharmacological interventions was used, the ability – especially of the nursing staff members – to observe behavior was seen as key. These observations together with an analysis of the (non-)medical biography and personality were interpreted and discussed by management in the multidisciplinary team meetings. From literature, we know that pre-morbid personality may play a role in challenging behavior [ 53 ]. In a qualitative study in patients with extreme challenging behavior in regular DSCUs, sub-optimal interdisciplinary collaboration and communication was one of the factors that contributed to the experience of an impasse [ 54 ]. The frequent multidisciplinary meetings may have facilitated collaboration and communication, although from our own research about severe challenging behavior we also know that this needs to be facilitated by process conditions such as the organization’s support of the professionals, and clear agreements and defined roles [ 55 ].

All units paid attention to sensory stimuli that were thought to affect the behavior, although the methods to analyze this and their intensity varied among units. In some units, special adaptions to the physical environment were made. Challenging behavior may be due to sensory impairment and/or sensory processing abnormalities [ 56 , 57 ], which therefore require assessment and individualized sensory stimuli. Compulsory admissions were common, which means that the challenging behavior caused danger to oneself or others [ 58 ]. These and other possible coercive measurements in the form of physical restraining interventions such as enclosure beds and seclusion rooms were used to prevent harm or diminish sensory stimuli. However, further research into the effectiveness of interventions that are or may be physically restraining is necessary.

Role of nursing staff

The nursing hours per patient per 24 h substantially differed among units. The median average of 3.9 h per patient per day is similar to the current hours per resident per day in regular nursing home units in the United States [ 59 ]. Despite this, in five units the education level of nursing staff was higher than in regular DSCUs in the Netherlands, and all units hired nursing staff with specific competences. Nursing staff competences that were seen as relevant were an openness to new approaches, flexibility, reflectiveness, being able to observe behavior well with a certain tolerance towards challenging behavior, and being able to cope with stressful situations. Indeed, these are competences that are known to be important in regular dementia care [ 60 , 61 , 62 ]. Moreover, a consistent approach by the nursing team seems essential, which was facilitated discussing the interpretations of the behavior. A consistent approach by the nursing staff and an open attitude of those involved in the direct environment have also been found to be part of the successful treatment of severe challenging behavior [ 55 ].

Being open to new approaches, showing a certain tolerance towards the behavior, and coping with stressful situations possibly corresponds with the competence of the therapeutic use of self, which includes perseverance, situational awareness, and the ability to be present [ 61 ]. This therapeutic use of self probably requires a reflectiveness on one’s own behavior as a nursing staff member. Learning this is part of training as a registered nurse, but not as a nursing assistant [ 63 , 64 ]. The participating units fostered this reflectiveness on one’s own behavior by recruiting nursing staff, and some units offered training through peer consultation. This reflectiveness may also be valuable in and improved by the frequent multidisciplinary meetings.

Strengths and limitations

There are two main strengths of this study. First, the integration of different types of data collection offers rich insights into the organization of these units. Second, this study represents the organization and management of challenging behavior of highly specialized units in the Netherlands, with thirteen out of sixteen known units having participated.

There are some possible limitations to this study. First, the data were collected in 2018 when several of these pioneering units had recently started. Therefore, characteristics and management of behavior on these units may have developed, and insights may have changed from the experience of these pioneering units. Second, we found that most unit managers did not have complete data, which is a concern for better monitoring in the future. Moreover, this led to estimations by the unit managers and therefore led to less precise data. Third, we asked the physician responsible for medical care to invite another practitioner – such as the psychologist – whom he/she considered important in the treatment. Nurses and nursing assistants were not interviewed about the experiences and competences that they consider useful in their work, which may have led to selection bias towards the perspective of what is relevant for the physician. Moreover, nursing staff was considered as most important in the management of challenging behavior, meaning that their perspective is particularly relevant and that further research should include this. Fourth, interventions used in the management of challenging behavior may have remained unmentioned, whereby data saturation was not reached concerning this. Despite this, the main finding of heterogeneity in interventions persists together with the representativeness for the Netherlands. Fifth, the units differed in their experience and expertise, i.e. six units had opened less than two years prior to the study, which may have resulted in less in-depth interviews.

Conclusions and implications

We found that these pioneering units have strong heterogeneity in their organization and management of severe challenging behavior in people with dementia. This finding emphasizes the need for further research into what is effective in interventions, the (social) context such as the attitude of persons surrounding the patients, as well as the physical environment. The framework for complex interventions may prove useful to investigate this [ 65 ]. Furthermore, research into the necessity of these highly specialized units could shed light on what is needed on regular DSCUs to manage challenging behavior better and prevent transfers of patients. Recent research in patients admitted to some of these highly specialized units has shown that increasing severity of the challenging behavior, realization that the needs of the person with dementia cannot be met, and the burden of the nursing staff—often triggered by a life-threatening event—may lead to these admissions [ 66 ]. Combining this knowledge with information about organizational influences on both highly specialized units and DSCUs, such as already known influences, i.e. staff availability, staff training, the use of specific methods such as dementia care mapping, and influence of the physical environment [ 15 , 16 , 26 , 27 , 67 ], but also societal developments such as the tendency to live at home longer [ 68 ], could provide relevant insights for improving the quality of care on both DSCUs and highly specialized units. This also holds for insight into specific patient characteristics of patients admitted to highly specialized units such as dementia type, character and severity of the challenging behavior, and whether and why treatment is effective.

Although this study found a great variety in organization and management of severe challenging behavior, we think that three suggestions for practice can be formulated. First, nursing staff plays a key role in the management of the behavior. A stable, higher educated team with many contract hours per nursing staff member as well as a certain tolerance for severe challenging behavior to observe well was described as necessary. Second, investing in the physical environment seems to be of value. Safety, a low amount of visual and auditive stimuli, space and interventions to dose stimuli individually probably add to the wellbeing of patients on these units. Third, the involvement of expertise from mental health care was valued. These possible implications deserve further study.

Availability of data and materials

Data from the digital questionnaires are available in Supplementary Materials 1, 3 and 6. Data of the interviews are not publicly available to ensure the interviewees’ privacy, but are available on reasonable request from the corresponding author ([email protected]). Data from the observation of the physical environment are available on request from the corresponding author.

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Acknowledgements

We thank Paul van der Lee for some preparatory work. We thank the participating units for their contributions.

This work was supported by the Netherlands Organization for Health Research and Development (ZonMw) under grant number 839120009.

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Gerrie van Voorden, Raymond T. C. M. Koopmans, Anke Persoon & Debby L. Gerritsen

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Gerrie van Voorden, Raymond T. C. M. Koopmans, Mijke M. Strik-Lips, Anne M. A. van den Brink, Anke Persoon & Debby L. Gerritsen

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Alzheimer Center Groningen, Groningen, Netherlands

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GV: methodology, software, formal analysis, investigation, data curation, writing—original draft, writing—reviewing and editing, project administration. RK: conceptualization, methodology, writing—reviewing and editing, funding acquisition. ML: formal analysis, investigation, writing—reviewing and editing. MS: conceptualization, methodology, writing—reviewing and editing, funding acquisition. SZ: conceptualization, methodology, writing—reviewing and editing, funding acquisition. AB: methodology, writing—reviewing and editing. AP: conceptualization, methodology, writing—reviewing and editing, funding acquisition. ROV: methodology, writing—reviewing and editing. DG: conceptualization, methodology, formal analysis, investigation, writing—reviewing and editing, supervision, project administration, funding acquisition.

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van Voorden, G., Koopmans, R.T.C.M., Strik-Lips, M.M. et al. Organizational characteristics of highly specialized units for people with dementia and severe challenging behavior. BMC Geriatr 24 , 681 (2024). https://doi.org/10.1186/s12877-024-05257-x

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