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:

• Assessment
• Diagnosis
• Expected outcomes
• Interventions
• Evaluations

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

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.

1. The care plan must answer the questions of what, why, and how.
2. A successful care plan uses the fundamental aspects of critical thinking to come up with a patient-centered approach to care
3. Follows evidence-based practice guidelines when developing interventions or explaining the rationale for actions
4. Has SMART goals for the patients
5. Allows for effective communication
6. 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.
7. 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:

1. 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.
2. 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.
3. Health Promotion or wellness diagnosis is a clinical judgment about the desire and motivation to increase well-being or reach one's health potential.
4. 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.

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