School of Nursing

Northern Collaborative Baccalaureate Nursing Program

Principles of Creating the Nursing Care Plan

1. The care plan is based on your assessment – therefore a thorough assessment is
essential
2. The care plan is an expression of the priorities you have identified from your
assessment, to improve or maintain the client’s condition
3. The care plan is a living document; it changes as the identified priorities are addressed
and the assessment changes
a. The care plan is used to communicate the goals and individualized interventions
for the client, to other nurses working with the client
b. The care plan is limited to the period of care and for the use of people providing
the care; it is inappropriate to create a care plan for another nursing unit, for
Home Care, or for another institution – the nurses assessing and caring for the
client in those places during those times will create their own care plan based on
their own assessment
c. The care plan is a NURSING care plan – while it may be shared with family to
ensure they understand the rationale for the interventions, or to help them learn
how to help the client, it is inappropriate to create a NURSING care plan for the
parents to adhere to in their home after the client is discharged
4. The nursing diagnosis is best expressed in a two or three part statement:
a. Dehydration related to….., as evidenced by (or as manifested by)……..
b. Potential for dehydration, related to……..
c. By expressing what the identified problem is related to, and what evidence from
your assessment informs your identification of the problem, you will more easily
be able to determine priorities, appropriate goals and evidence-informed
interventions
5. An actual nursing diagnosis is a statement of something that is already occurring:
a. Dehydration related to….., as evidenced by…… indicates that the client is already
dehydrated, which is obvious from your assessment data
6. A potential (or risk of) nursing diagnosis is a statement of something that you know may
occur, given your knowledge of the trajectory of the client’s condition combined with
your knowledge of the client’s condition gained in the course of your assessment
a. Potential for (or risk for) dehydration related to……..indicates that the client is
not currently dehydrated but the nature of the client’s condition combined with
an assessment finding that the client is refusing fluids or is NPO, means that

1
 dehydration may occur in the absence of nursing interventions to ensure fluid
balance
7. Goals should be S.M.A.R.T.:
a. Specific (to the assessed priority)
b. Measurable
c. Attainable
d. Realistic
e. Time limited (should be accomplished within a realistic time frame – this may be
a shift, a set of shifts, or by discharge, but not after discharge)
8. Interventions should be evidence-informed:
a. This ensures that clients receive research-based care, rather than each individual
nurse deciding to do what is comfortable for him/her, or simply doing something
that “sounds good” or “has always been done”
b. It provides you with rationale when the client or family member asks “why is this
being done?”
9. Monitoring vital signs is objective assessment data; it is not a nursing intervention – it is
assessment and evaluation.
10. Evaluation is done with each client assessment, each shift, at the time frame you
expected your goal to be accomplished, etc.
a. Evaluation is essentially “reassessment”
b. Evaluation is ongoing, and informs the changing care plan
11. The writing of detailed nursing care plans by students is intended to assist the
instructor in assessing the student’s ability to assess, plan, intervene, and evaluate
clients with a variety of health problems
a. The instructor uses the detailed care plan to assess the student’s ability to
integrate theory and practice
b. The instructor uses the detailed care plan to assess the student’s ability to use
evidence-informed practice
c. The instructor uses the detailed care plan to assess the student’s critical thinking
d. The instructor uses deficits in the care plan to assist the student in learning and
understanding