Nursing Care Plans Explained | (2023)

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Written by NurseJournal Staff Click to Read Full Biography Contributing Writer

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Updated March 23, 2023

Nursing Care Plans Explained | (13) Reviewed by

Reviewed by Brandy Gleason Click to Read Full Biography Contributing Reviewer

Brandy Gleason has nearly 20 years of nursing experience in bedside, supervisory, managerial, and senior leadership positions. She currently teaches in a prelicensure nursing program and coaches master's students through their final projects.Her ...

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What are nursing care plans and how do they improve nursing and patient health? Learn more, including how to develop nursing care plans.

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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.

  1. 1

    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.

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  2. 2

    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.

  3. 3

    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.

  4. 4


    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.

  5. 5

    (Video) Nursing Care Plan: Easy and Simple


    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:


  • Focus too much on medicine, taking a generalized approach to healing

  • Forget to document your assessment, diagnosis, expected outcomes, interventions, and rationale

  • Write sarcastic, rude, or offensive notes

  • Be afraid to ask for help or have someone look over your care plan

  • Be too broad with your documentation (it can cause confusion and misinterpretation)


  • Understand that not all medicine works for every patient; remember the individual patient's unique needs

  • Focus on evidenced-based practices that result in positive patient outcomes

  • Keep in mind that your care plan can be used in court if you ever find yourself in a legal case

  • Keep patient safety in the center of your documentation

  • Use your care plan as a tool to communicate your patients' needs and wants with your team members

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.

(Video) (a plea to nursing students) Nursing Care Plans and Why They Matter

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


What are the 4 main parts of a nursing care plan? ›

What Are the Components of a Care Plan?
  • Step 1: Assessment. The first step of writing a care plan requires critical thinking skills and data collection. ...
  • Step 2: Diagnosis. ...
  • Step 3: Outcomes and Planning. ...
  • Step 4: Implementation. ...
  • Step 5: Evaluation.

What are the 5 steps of nursing care plan? ›

The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.

What are the 6 components of nursing care plan? ›

A care plan includes the following components: assessment, diagnosis, expected outcomes, interventions, rationale and evaluation. According to UK nurse Helen Ballantyne, care plans are a critical aspect of nursing and they are meant to allow standardised, evidence-based holistic care.

How do you explain what a care plan is? ›

What is a care plan? A care plan is a form [1.48 MB] where you can summarize a person's health conditions, specific care needs, and current treatments. The care plan should outline what needs to be done to manage the care needs. It can help organize and prioritize caregiving activities.

What are 3 important elements of an effective care plan? ›

A care plan consists of three major components: The case details, the care team, and the set of problems, goals, and tasks for that care plan.

What are the two 2 types of nursing care plan? ›

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 three priorities of nursing care? ›

Nursing school curriculum teaches nurses to utilize many resources to establish priorities including:
  • Airway, breathing, and circulation (ABCs),
  • Maslow's hierarchy of needs (basic needs first, see Figure 1 below),
  • Nursing Process (see Figure 2 below),
  • Time-sensitive indicators that are relevant in the acute care setting.

What are the four phases of care? ›

Table 1
Phases of careEthical elements
1. Recognition of need (caring about)1. Attentiveness
2. Willingness to respond to (take care of) a need2. Responsibility
3. Direct action (care-giving)3. Competence
4. Reaction to the care process (of the care receiver)4. Responsiveness

What are the 6 C's nursing standard? ›

The 6 Cs – care, compassion, courage, communication, commitment, competence - are a central part of 'Compassion in Practice', which was first established by NHS England Chief Nursing Officer, Jane Cummings, in December 2017.

What are the 6 C's in nursing assignment? ›

So, the 6Cs are care, compassion, competence, communication, courage and commitment.

What are the 6 C's of nursing nursing times? ›

The values were care, compassion, competence, communication, courage and commitment, and became commonly referred to as the “6Cs of nursing”.

What should a good care plan look like? ›

Care and support plans include:
  • what's important to you.
  • what you can do yourself.
  • what equipment or care you need.
  • what your friends and family think.
  • who to contact if you have questions about your care.
  • your personal budget and direct payments (this is the weekly amount the council will spend on your care)

How do you create a good care plan? ›

8 Steps To Create a Care Plan
  1. 1) Defining the Patient's Goals. ...
  2. 2) Listing Barriers to a Patient's Goals. ...
  3. 3) Identify Symptoms the Patient Experiences. ...
  4. 4) List Interventions You'd Like to Make. ...
  5. 5) Documenting All Support the Patient is Receiving. ...
  6. 6) Identify Patient Allergies and Medications. ...
  7. 7) Decide Which Metrics to Track.
Jan 4, 2021

Can nurses write care plans? ›

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.

What is the main purpose of a care plan? ›

Care plans. If you're found to have care and support needs after your care needs assessment, you'll get a care plan. This sets out the help you can expect to meet your care needs.

Who is responsible for writing the care plan? ›

The Comprehensive Care Plan is a four-section written plan developed by the client's medical provider, the Care Coordination Team and the client to help the client achieve his or her treatment goals.

What is an example of a nursing diagnosis? ›

The nurse can conclude a nursing diagnosis based on these symptoms: impaired swallowing. Examples of nursing diagnosis: risk for impaired liver function; urinary retention; disturbed sleep pattern; decreased cardiac output. On the other hand, a medical diagnosis is made by a doctor or advanced health care practitioner.

What are the 3 C's of patient care? ›

Perspective: Consistency, Continuity, and Coordination—The 3Cs of Seamless Patient Care | Commonwealth Fund.

What notes do you write in a care plan? ›

When writing care notes, they should be concise and quick to the point. They shouldn't contain any type of jargon, abbreviations or acronyms. This could lead to confusion and misunderstandings when going through notes. Ensure that the notes are easy to read and understand for everyone involved in the client's care.

What items are in a care plan? ›

Some of them may overlap slightly, so adapt this as needed.
  • Basic Client Information. Medical information. ...
  • The Client's Needs. A clear description of the client's needs. ...
  • The Client's Goals. What the client's goals are. ...
  • The Client's Support and/or Care. ...
  • Details of Emergency Procedures. ...
  • A Record of When the Plan Was Created.

What are two nursing care priorities? ›

Because of the importance of recognizing clinical deterioration in a client, a nurse must always be attuned to the set of physiological needs that are important to maintain life and prevent death. These priorities of care are related to the ABCs – airway, breathing, and circulation – introduced above.

What are two core values in nursing? ›

Core values of nursing include altruism, autonomy, human dignity, integrity, honesty and social justice [3]. The core ethical values are generally shared within the global community, and they are a reflection of the human and spiritual approach to the nursing profession.

What is the first step in nursing care plan? ›

Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and objective data. Subjective data is what the patient tells us their symptoms are, including feelings, perceptions, and concerns. Objective data is observable and measurable.

What does the nurse use to formulate a nursing care plan? ›

A nursing care plan is a formal process that includes six components: assessment, diagnosis, expected outcomes, interventions, rationale, and evaluation.

What are the ABCs of prioritizing nursing? ›

First priority is the airway, next is breathing, then circulation. Keeping in mind that this is the guideline for prioritizing care, this will direct you to the correct option.

Which patient is the nurse's first priority? ›

The first-level priority problems are health issues that are life-threatening and require immediate attention. These are health problems associated with ABCs; airway, breathing, and circulation, such as establishing an airway, supporting breathing, and addressing sudden perfusion and cardiac issues.

What is the highest priority in nursing care? ›

The ABCs identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order.

What are the 3 types of care? ›

Three different types of care for serious illness: Supportive, palliative, and hospice.

What are the 3 levels of healthcare? ›

Primary care is the main doctor that treats your health, usually a general practitioner or internist. Secondary care refers to specialists. Tertiary care refers to highly specialized equipment and care.

How many phases should there be in a care plan? ›

provides an introduction to care and support planning, introduces the 4 steps of the approach and sets out what should happen at each step: prepare, discuss, document, and review. care' means to service users and demonstrates the pivotal role of effective, personalised care and support planning.

What makes a good nurse? ›

Kindness, fairness, caring, trustworthiness, emotional stability, empathy, and compassion are aspects of your personality that serve you well as a nurse. You exhibit strong communication skills. You communicate well with patients and colleagues — sometimes at their worst life moments.

What are the big C's in nursing? ›

Nurses operate on six core values which are commonly known as the 6 C's. These are Care, Compassion, Competence, Communication, Courage and Commitment. Nurses who operate on these values ensure that the job gets done in an effective and efficient manner and that patients are safe and treated well.

What are the 5c in nursing? ›

According to Roach (1993), who developed the Five Cs (Compassion, Competence, Confidence, Conscience and Commitment), knowledge, skills and experience make caring unique.

What do you write in a nursing care plan evaluation? ›

These questions can be used as a guide when revising the nursing care plan:
  1. Did anything unanticipated occur?
  2. Has the patient's condition changed?
  3. Were the expected outcomes and their time frames realistic?
  4. Are the nursing diagnoses accurate for this patient at this time?

What should a care plan look like? ›

Care and support plans include:
  • what's important to you.
  • what you can do yourself.
  • what equipment or care you need.
  • what your friends and family think.
  • who to contact if you have questions about your care.
  • your personal budget and direct payments (this is the weekly amount the council will spend on your care)

How do you read a care plan? ›

Regardless of what your preferences are, your care plan should include:
  1. What your assessed care needs are.
  2. What type of support you should receive.
  3. Your desired outcomes.
  4. Who should provide care.
  5. When care and support should be provided.
  6. Records of care provided.
  7. Your wishes and personal preferences.
  8. The costs of the services.
Oct 5, 2020

What are the 4 types of nursing assessments? ›

WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation.

What are examples of nursing diagnosis in nursing care plan? ›

After a thorough assessment, the nurse identifies nursing diagnoses — health problems (or potential health problems) that nurses can handle without physician intervention. For example, acute pain, fever, insomnia, and risk for falls are all nursing diagnoses.

What are the 6 C's of nursing interview questions? ›

Interviewee: Before your interview, you must ensure you understand the six Cs of nursing, which are: care, compassion, competence, communication, courage and commitment. It's not enough to say what they are – you need to share examples of when you've successfully exhibited all these traits.

How do I pass my nursing test? ›

  1. Time Management. To be successful in nursing school, you must manage your time appropriately. ...
  2. Get Organized. ...
  3. Use Mnemonics. ...
  4. Study Everyday. ...
  5. Complete Practice Questions. ...
  6. Participate in a Study Group. ...
  7. Focus on course objectives when studying. ...
  8. Know your learning style.

How do you answer a nursing weakness question? › suggests you state the professional weakness but emphasize the positive and add your solution for overcoming this shortcoming — because all weaknesses are opportunities for growth. Any time you mention a weakness, it's wise to mention what you're actively doing to overcome the hurdle.

How do you write a good care note? ›

When writing care notes, they should be concise and quick to the point. They shouldn't contain any type of jargon, abbreviations or acronyms. This could lead to confusion and misunderstandings when going through notes. Ensure that the notes are easy to read and understand for everyone involved in the client's care.

How often should you read a care plan? ›

It is legally required that care plans be reviewed at least once every twelve months.

What is an example of an episode of care? ›

A: An episode of care is a patient's entire treatment needed for an illness or “episode.” For example, if a patient has a heart attack, everything done to diagnose and treat that condition is all grouped together into one clinically-defined episode of care.

What is listed in a care plan? ›

A care plan is a document that records the care to be provided to an individual that includes the consideration of that person's unique abilities, physical, social and emotional needs, and cultural and spiritual preferences.


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