Nursing Care Plan Including Diagnosis and Intervention

1. How to Write a Nursing Care Plan
How to Write a Nursing Care Plan
Nursing Care Plan Components
A nursing care plan has several key components including,
• Nursing diagnosis
• Expected outcome
• Nursing interventions and rationales
• Evaluation
Each of the five main components is essential to the overall nursing process and care plan. A
properly written care plan must include these sections otherwise, it won’t make sense!
• Nursing diagnosis - A clinical judgment that helps nurses determine the plan of care for
their patients
• Expected outcome - The measurable action for a patient to be achieved in a specific time
frame.
• Nursing interventions and rationales - Actions to be taken to achieve expected
outcomes and reasoning behind them.
• Evaluation - Determines the effectiveness of the nursing interventions and determines if
expected outcomes are met within the time set.
How to Write a Nursing Care Plan
Determine the patient's most significant issues prior to composing the nursing care plan.
Consider both medical and psychosocial difficulties. At times, a patient's psychosocial concerns
may be more pressing or even hold up his or her discharge than the patient's actual medical
problems.
After compiling a list of the patient's issues and the corresponding nursing diagnosis, you must
determine which are the most significant. In general, this is done by contemplating the ABCs
(Airway, Breathing, Circulation). However, these won't ALWAYS be the most significant or
even pertinent for your patient.
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.
This information can come from,

2. • Verbal statements from the patient and family
• Vital signs
o Blood pressure
o Heart rate
o Respirations
o Temperature
o Oxygen Saturation
• Physical complaints
o Pain
o Headache
o Nausea
o Vomiting
• Body conditions
o Head-to-toe assessment findings
• Medical history
• Height and weight
• Intake and output
• Patient feelings, concerns, perceptions
• Laboratory data
• Diagnostic testing
o Echocardiogram
o X-Ray
o EKG
Step 2: Diagnosis
Using the information and data gathered in Step 1, the nursing diagnosis that best suits the
patient, his or her hospitalization goals and objectives is selected.
North American Nursing Diagnosis Association (NANDA) defines nursing diagnosis as "a
clinical judgment about the human response to health conditions/life processes, or a vulnerability
for that response, by an individual, family, group, or community."
The nursing diagnosis is founded on Maslow's Hierarchy of Needs and assists with treatment
prioritization. The next stage involves determining the goals for resolving the patient's problems
through nursing interventions based on the nursing diagnosis selected.
There are 4 types of nursing diagnoses.
1. Problem-focused - Patient problem present during a nursing assessment is known as a
problem-focused diagnosis
2. Risk - Risk factors require intervention from the nurse and healthcare team prior to a real
problem developing
3. Health promotion - Improve the overall well-being of an individual, family, or
community

3. 4. Syndrome - A cluster of nursing diagnoses that occur in a pattern or can all be addressed
through the same or similar nursing interventions
After determining which type of the four diagnoses you will use, start building out the nursing
diagnosis statement.
The three main components of a nursing diagnosis are:
1. Problem and its definition - Patient’s current health problem and the nursing
interventions needed to care for the patient.
2. Etiology or risk factors - Possible reasons for the problem or the conditions in which it
developed
3. Defining characteristics or risk factors - Signs and symptoms that allow for applying a
specific diagnostic label/used in the place of defining characteristics for risk nursing
diagnosis
Examples:
PROBLEM-FOCUSED DIAGNOSIS
Problem-Focused Diagnosis related to ______________________ (Related Factors) as
evidenced by _________________________ (Defining Characteristics).
RISK DIAGNOSIS
The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as
evidenced by __________________________ (Risk Factors).
Step 3: Outcomes and Planning
After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-
based practices. SMART is an acronym that stands for,
• Specific
• Measurable
• Achievable
• Relevant
• Time-Bound
It is essential to take into account the patient's medical diagnosis, overall condition, and all
collected data. A physician or other advanced healthcare professional makes a medical diagnosis.
It is essential to remember that a medical diagnosis does not change if the patient's condition
improves, and it remains a permanent part of the patient's medical history.
Examples of medical diagnosis include,

4. • Chronic Lung Disease (CLD)
• Alzheimer’s Disease
• Endocarditis
• Plagiocephaly
• Congenital Torticollis
• Chronic Kidney Disease (CKD)
During this period, you will also consider the patient's goals and short- and long-term outcomes.
These objectives must be achievable and desired by the patient. For instance, if a goal is for the
patient to seek counseling for alcoholism during hospitalization, but the patient is currently
detoxifying and experiencing mental distress, this goal may not be achievable.
Step 4: Implementation
Now that the objectives have been established, you must take the necessary steps to assist the
patient in achieving them. While some actions will produce immediate results (e.g.,
administering a suppository to a patient with constipation to induce a digestive movement),
others may not be observed until later in the hospitalization.
The implementation phase means performing the nursing interventions outlined in the care plan.
Interventions are classified into seven categories:
• Family
• Behavioral
• Physiological
• Complex physiological
• Community
• Safety
• Health system interventions
Some interventions will be patient or diagnosis-specific, but there are several that are completed
each shift for every patient:
• Pain assessment
• Position changes
• Fall prevention
• Providing cluster care
• Infection control
Step 5: Evaluation
The fifth and final step of the nursing care plan is the evaluation phase. This is when you
evaluate if the desired outcome has been met during the shift. There are three possible outcomes,
• Met
• Ongoing

5. • Not Met
On the basis of the evaluation, it can be determined whether the objectives and interventions
need to be modified. Ideally, all nursing care plans, including objectives, should be met prior to
discharge. This is not always true, particularly when a patient is being discharged to hospice,
home care, or a long-term care facility. Initially, you will discover that the majority of care plans
will have ongoing objectives that may be met within a few days or weeks. It depends on the
patient's condition and the desired outcomes.
Consider selecting objectives that the patient is capable of achieving. This will not only help the
patient feel as though they are making progress, but it will also relieve the nurse by allowing
them to monitor the patient's overall progress.
Nursing Care Plan Fundamentals
Nursing care plans contain information about a patient’s diagnosis, goals of treatment, specific
nursing interventions, and an evaluation plan. The nursing plan is constantly updated with
changes and new subjective and objective data.
Key aspects of the care plan include,
• Assessment
• Diagnosis
• Outcome and Planning
• Implementation
• Evaluation
Through subjective and objective data, constantly assessing your patient’s physical and mental
well-being, and the goals of the patient/family/healthcare team, a nursing care plan can be a
helpful and powerful tool.