Subjective (S):
Objective (O):
NANDA Nursing Diagnosis and Problem Etiology:
Ranking of Nursing Diagnosis:
Rationale for Ranking the Nursing Diagnosis:
Goal:
Outcomes:
Interventions (Orders) and Rationale
Evaluation:
Reference List:
Frequently Asked Questions About Nursing Care Plans
What is a nursing care plan (NCP)?
A nursing care plan is a written document that outlines the nursing care to be provided to a patient. It includes the patient’s health status, goals, interventions, and outcomes.
Why are nursing care plans important?
Nursing care plans help nurses organize and prioritize patient care, ensure continuity of care among healthcare providers, promote patient safety, and facilitate communication among the healthcare team.
What components are included in a nursing care plan?
A nursing care plan typically includes assessment data, nursing diagnoses, goals, interventions, and evaluation of outcomes.
How are nursing diagnoses determined?
Nursing diagnoses are determined through a comprehensive assessment of the patient’s health status, including physical, psychological, social, and environmental factors.
What are SMART goals in nursing care plans?
SMART goals are Specific, Measurable, Achievable, Relevant, and Time-bound goals that guide the nursing interventions and help evaluate the effectiveness of care.
How often should nursing care plans be updated?
Nursing care plans should be updated regularly, usually during each shift or whenever there is a significant change in the patient’s condition.
Who is involved in developing a nursing care plan?
Nurses primarily develop nursing care plans, but they collaborate with other healthcare team members, including physicians, therapists, and social workers, as needed.
What is the role of the patient in the nursing care planning process?
Patients are active participants in the nursing care planning process. Their input regarding preferences, goals, and concerns is crucial for developing a patient-centered care plan.
How are nursing care plans evaluated?
Nursing care plans are evaluated by assessing whether the patient’s goals have been met, the effectiveness of interventions, and any changes in the patient’s condition or needs.
Can nursing care plans be standardized?
While certain aspects of nursing care plans can be standardized, such as commonly used interventions for specific diagnoses, individualized care plans tailored to each patient’s unique needs are generally preferred for optimal outcomes.