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Plan for Your Hospital

How to Develop a
Nursing Care Plan for
Your Hospital
By Cheryl McKay, PhD, RN, Nurse on March
Executive Accountable Care 3, 2020

Care plans are part of the core curriculum in

most nursing schools. Yet, new hospital
nurses often complain that despite all the
hype and time spent learning how to make a
nursing care plan, they never do it again after
graduation. As a nursing leader, you might
not have written one for a while, either. Why
should you start now?

Care plans help nurses focus on patients in a

holistic, big-picture way so they can deliver
evidence-based, patient-centered care. Care
plans also help hospitals ensure continuity of
care across nursing shifts, promote inter-
professional collaboration by getting
everyone on the same page, and meet
documentation requirements for insurers and
governing bodies.

Even if your hospital requires care plans,

unless it’s a strict requirement, there’s a good
chance your nurses aren’t preparing one for
every single patient because they’re too busy.
Depending on the unit, they might only treat
people for a couple of days before they’re
overwhelmed with redundant paperwork.
Considering that most of the information in a
nursing care plan is already required in
multiple sections of each patient’s electronic
health record (EHR), nurses might not see the
point in drafting an o!cial plan of care.

Unless care plans are required, nurses

probably won’t make them. And unless care
plans are useful, writing them will be
perceived as more “busywork” — the bane of
every nurse’s existence.

What are the benefits of a nursing care plan

for hospitals? How can you ensure that care
plans are a useful tool that nurses will want to
have at their disposal?

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Why Your Hospital Needs a Nursing

Care Plan
Care plans are used to teach nursing students
how to individualize patient care, think
critically about what’s needed to achieve the
desired outcomes, and work towards those
outcomes through the nursing process.
Experienced nurses already know how to do
that, without documenting it and often
without even realizing they’re doing it. Still, a
formal nursing care plan can be a valuable
tool for e"ective communication in nursing.

Long-term care providers such as nursing

homes, mental health facilities, and home
health nurses typically use formal care plans,
and they are often required to do so by
governing bodies like the Joint Commission.
Yet, in hospitals, care plans often fall by the
wayside.

For hospitals that successfully implement

care plans, there are many benefits,
including:

Continuity of care: Nursing care plans

ensure that nurses from di"erent shifts or
floors have the same patient data, are
aware of the patient’s nursing diagnoses,
share their observations with one another,
and collaborate towards the same goals.

Inter-professional collaboration: Nurses

are the heart of the care team, but they’re
not the only members. Physicians, social
workers, nursing assistants, physical
therapists, and other care providers also
need to understand the patient’s health
problems, goals, and progress. A nursing
care plan puts all this information in one
place, providing a clear roadmap to the
desired outcomes.

Patient-centered care: Care plans help to

ensure that patients receive evidence-
based, holistic care. Nursing diagnoses are
standardized to ensure quality care, but
nursing interventions are tailored to meet
the physical, psychological, and social
needs of the individual patient.

Engaged patients: Setting achievable

goals for and with patients helps to guide
and measure nursing care. Goals also help
motivate patients to become more
involved in their recovery, because they
can understand exactly what they need to
do to achieve the desired outcomes.

Compliance: The care plan serves as proof

of receipt and helps payers determine how
much they should reimburse for care.

What Is a Nursing Care Plan?

A nursing care plan is the written
manifestation of the nursing process, which
the American Nurses Association defines as
“the common thread uniting di"erent types
of nurses who work in varied areas … the
essential core of practice for the registered
nurse to deliver holistic, patient-focused
care.”

The nursing process includes five key steps:

1. Assessment: Collecting and analyzing data

to gain a holistic understanding of the
patient’s needs and risk factors.

2. Diagnosis: Using data, patient feedback,

and clinical judgment to form the nursing
diagnoses.

3. Outcomes/Planning: Setting short-term

and long-term goals based on the nurse’s
assessment and diagnosis, ideally with
input from the patient. Determining
nursing interventions to meet those goals.

4. Implementation: Implementing nursing

care according to the care plan, based on
the patient’s health conditions and the
nursing diagnosis. Documenting care the
nurse performs.

5. Evaluation: Monitoring (and documenting)

the patient’s status and progress towards
goals, and modifying the care plan as
needed.

A nursing care plan is formal documentation

of this process, and most care plans are
organized into four columns that closely
mirror the steps of the nursing process. Care
plans include:

1. Nursing diagnoses

2. Desired outcomes/goals

3. Nursing interventions

4. Evaluation

NurseLabs notes that some healthcare

providers use only three columns, combining
“desired outcomes/goals” and “evaluation”
into the same column, whereas other
providers use five columns, including one for
“assessment cues.” Care plans for nursing
students typically include another column for
“rationale/scientific explanation,” where they
are asked to explain the reasoning behind
their proposed nursing interventions.

In case you haven’t seen one in a while,

here’s what a nursing care plan looks like:

SampleNursingCarePlanFormat(3Columns)

Client:JonStark
CarePlanby:W.Smith,RN
Dateinitiated:12-29-2018

NURSINGDIAGNOSIS OUTCOMES&EVALUATION INTERVENTIONS

ActivityintoleranceRTexhaustion Noreportsofdyspnea 1.Provideaquietenvironmentand

associatedwithinterruptioninusual
sleeppatternbecauseofdiscomfort.
excessivecoughing,anddyspnea
limitvisitorsduringacutephaseas
Vitalsignswithinnormalrange indicated.
2.Paceactivityforpatientswith
reducedactivity.

3.Assistpatienttoassume
comfortablepositionforrestand
sleep.

Nurseslabs

SampleNursingCarePlanFormat(4Columns)
Client:JonStark
CarePlanby:W.Smith,RN
Dateinitiated:12-29-2018

NURSINGDIAGNOSISGOALS&OUTCOMES INTERVENTIONS EVALUATION

After8hoursofnursing 1.Assesstherate,rhythm, After8hoursofnursing

Ineffectiveairway
clearanceRTtracheal intervention,thepatient anddepthofrespiration, intervention,thepatient
chestmovement,anduse wasabletomaintain
bronchialinflammation, willdisplay/maintainpatent
ofaccessorymuscles.
edemaformation. airwaywithbreathsounds patentairwaywithbreath
increasedsputum clearing;absenceof
dyspnea,cyanosis,as 2.Elevateheadofbed,
productionABcoughing,
evidencedbykeepinga changeposition
dyspnea,purulentsputum frequently.
patentairwayand clearingsecretions.
effectivelyclearing
secretions. 3.Suctionasindicated:
frequentcoughing,
adventitiousbreath
sounds,desaturation
relatedtoairway
secretions.

Nurseslabs

How to Write a Nursing Care Plan

To create a plan of care, nurses should follow
the nursing process:

1. Assessment

2. Diagnosis

3. Outcomes/Planning

4. Implementation

5. Evaluation

1. Assess the patient.

The nurse starts by reviewing all relevant
data, including (but certainly not limited to):
medical history, lab results, vital signs, head-
to-toe assessment data, conversations with
the patient and their loved ones, observations
from other care team members, and
demographic information. The nurse uses
this data to assess the patients:

Physical, emotional, psychosocial, and

spiritual needs

Areas for improvement

Risk factors

2. Identify and list nursing

diagnoses.
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. The North American Nursing
Diagnosis Association (NANDA) curates an
o!cial nursing diagnosis list, which includes
definitions, features, and commonly applied
interventions for each diagnosis.

3. Set goals for (and ideally with)

the patient.
What are the desired outcomes, and how will
the patient get there? The nurse answers
these questions based on the assessment,
nursing diagnosis, and feedback from the
patient. Together, the nurse and patient set
reasonable goals that can be achieved with
nursing interventions and (in some cases)
e"ort by the patient. Goals can be short-term
(e.g., resolve acute pain after surgery) or
long-term (e.g., lower the patient’s A1C with
better diabetes management). Then the nurse
prioritizes goals based on urgency,
importance, and patient feedback. Nurses
can also use Maslow’s hierarchy of needs to
help prioritize patient goals.

4. Implement nursing
interventions.
Nursing interventions are actions taken by the
nurse to achieve patient goals and get
desired outcomes — for example, giving
medications, educating the patient, checking
vital signs every couple hours, initiating fall
precautions, or assessing the patient’s pain
levels at certain intervals. This is also where
the nurse documents care as they perform
interventions, including dependent nursing
interventions ordered by physicians.

5. Evaluate progress and change

the care plan as needed.
Finally, the nurse monitors and evaluates the
patient and the nursing care plan on a regular
basis to answer the question: Are the nursing
interventions helping the patient reach their
goals and desired outcomes, and should
those interventions be changed, terminated,
or continued?

How to Implement Nursing Care

Plans in Your Hospital
For care plans to be useful, they need to
promote e"ective communication in nursing.
They need to be shareable, easy to access,
and always up to date. That means they need
to be electronic, and preferably integrated
into the EHR for cloud access and real-time
inter-professional collaboration.

Leading EHR providers have care plan

functionality built into their systems, with lists
of nursing diagnoses and interventions.
Finding these resources is not always
intuitive, but with a little help from IT, you can
build custom care plan forms that are part of
each patient’s record and each nurse’s
workflow. With the right integrations, you can
even automate parts of the care plan so
certain fields get automatically populated
with information. That means fewer fields for
nurses to fill out and regularly update.

Nurses are also more likely to comply with

care plan requirements if they don’t have to
track down an available computer first. If they
can access the care plan from secure mobile
devices, they can review and update care
plans at the patient bedside, refer to them
regularly to help guide patient care, and even
use them as a patient education tool.

Smartphone-wielding nurses can do more

than manage care plans on the go. They can
also use HIPAA-compliant clinical workflow
solutions that let them securely talk, text, or
have a group conference about the plan of
care.

Supported by technology and a secure

communication platform, a patient care plan
becomes a resource for nurses to get all the
information they need in one place, a
roadmap for recovery, and a collaboration
tool that helps ensure continuity of care.

Learn more about smartphone-based clinical

communications with EHR integration.

Cheryl
McKay, PhD,
RN, Nurse
Executive
Accountable
Care
Dr. Cheryl McKay is a
healthcare leader
with over 20 years of
executive experience
in directing quality
care for large
academic facilities,
smaller multi-site
inpatient and
outpatient centers, as
well as research,
quality, education,
and clinical divisions.
As a critical care
clinical specialist,
nurse executive, and
researcher, she has a
broad range of
experience in helping
clients successfully
manage technology
implementation and
advancement,
product
development,
marketing, and sales.

Tags: Nursing Diagnosis, Registered Nurse,

Nursing Students, Nursing Care, Nursing Care
Plan, Nurse Educator, Acute Pain, Nursing
Schools, Nursing Process, Plan Of Care, Care
Plans Include, American Nursing, Nursing
Diagnoses, Health Problems, Nursing
Interventions, Desired Outcomes, Nurse
Performs, evidence based, long term,
Continuity of care, Patient Care

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