NURSING CARE PLANS

INTRODUCTION
When planning care, a nurse will usually have more interventions that are necessary to meet
a client’s expected outcomes. Some are discarded as inappropriate and others are adapted to
clients needs and abilities. As a result, the list of possible interventions narrowed down to
those suitable to clients. These interventions are then written down on the nursing care plans.

DEFINITION

The nursing care plan is a written guide that organizes information about a client’s care into a
meaningful whole. It includes the actions nurses must take to address the client’s nursing
diagnosis and meet the stated goal.

PURPOSE

1) A written care plan is designed to direct clinical care and to decrease the risk of
incomplete and incorrect or inaccurate results.
2) To allow any nurse to quickly identify the client’s nursing diagnosis, goal and outcomes
and nursing interventions that has to be started.
3) To identify and coordinate the resources used to deliver nursing care. If all equipment and
supplies needed for providing care is included in the care plan, the nurse’s time is used
more effectively in providing care.
4) To provide continuity care.
5) To document information exchanged by nurse- in -charge of shifts. Nurses focuses on their
reports on nursing care and treatment and clients outcomes as delineated as care plans.
This information will be discussed at the end of each shifts.
6) Helps to include the long term needs of the client. Incorporating goals of the care plan into
discharge planning is particularly important for a client who will be undergoing long term
rehabilitation in the community or who requires home care.
7) To provide individual and family participation in goal setting.
8) The expected outcome criteria used in the evaluation of care, helps the nurse with
objective statement which determine whether the goals of care have been achieved.
9) To serve as a guide for reimbursement from medical insurance companies, often called
third party reimbursement.
10) To provide a source of information for quality improvement and research.

IMPORTANT CONCEPTS THAT GUIDE A NURSING PLAN OF CARE:

  The plan of care is nursing centered
 The plan of care is a step by step process

The plan of care is nursing centered:

It is essential to identify the scope and depth of nursing practice. By focusing on the
treatment of human resources to actual and potential health problems, the nurse remains in
the nursing practice domain.

A step by step process is evidenced by the following:

 Sufficient data are collected to substantiate nursing diagnosis

 Outcome criteria must be identified for each goal. Nursing interventions must be
specifically designed to meet the identified goal.
 Each intervention should be supported by a scientific rationale.
 Evaluation must address whether each goal was completely met, partially met or not
at all met.

GUIDELINES FOR WRITING NURSING CARE PLAN

1) Date and sign the plan

2) Use the category headings:

- Nursing diagnosis
- Goals/outcome criteria
- Nursing orders
- Evaluation

3) Use standardized medical or English symbols and key words rather than complete
sentences to communicate your ideas.
4) Refer to procedure book or other sources of information rather than including all the steps
on a written care plan
5) Tailor the plan to the unique characteristics of the client by ensuring that the client’s
choices such as preferences about the time of care and the methods used are included. This
reinforces the client’s individuality and sense of control.
6)Ensure that the nursing care plan incorporates preventive and health maintenance aspect as
well restorative interventions.
7) Ensure that the nursing care plan contains orders for ongoing assessment of client.
8) Include collaborative and coordination activities in the plan.
9) Includes plans for the client’s discharge and home care needs.
TYPES OF NURSING CARE PLAN

As the nurses care for people in various health care facilities, there are a variety of nursing
care plan formats.

 STUDENT CARE PLANS:

Nursing students learn to write and use a nursing care plan as a part of their education. The
student care plan is essential for learning the problem solving technique, the nursing process,
skills or written communication and organizational skills needed for nursing care. Most
important, by using the nursing care plan, student can apply the knowledge gained from
nursing and medical literature and the class room to a practice situation.

The nursing diagnosis with the highest priority is the beginning point for nursing care plan and
is followed by another nursing diagnosis in order of assigned priority. It uses a 6 column
format like assessment, diagnosis, goals/outcome, implementation, scientific rationale and
evaluation column.

 INSTITUTIONAL CARE PLANS

Institutional care plans are concise documents that become part of the clients medical record.
Many hospitals use the Kardex nursing care plan. Kardex is the trade name for the card filling
system which contains

a) Basic demographic information about the person, such as the name, age, sex, medical
diagnosis, surgical procedures and physician’s name
b) Basic care information such assess type of bath, frequency of vital signs, allowable activity,
ordered treatments and so on. These are usually included on the outside of the card and
nursing care plan is usually placed inside.

Each institution has its own format for Kardex, but the basic information contained on it is
universal. One feature of an institutional care plan different from that of a student care plan
is the omission of scientific rationale.

 COMPUTERISED NURSING CARE PLANS

The use of the computer and the need to efficiently organize the nurse’s time have resulted in
standardized care plans, which have prewritten plans created for a specific nursing diagnosis
or clinical problem(eg: immobility, abdominal surgery or post partum care) After completing a
nursing assessment, the nurse determines whether a standardized care plan should be used
for that particular client. Even if a care plan is generally appropriate for a client, the nurse
must add or delete information on the standardized form to individualise it for the client’s
needs. Failure to do so can result in incomplete and inaccurate task.

ADVANTAGES

1) Legible
2) Reduction in the number of time needed to develop and update the plan.
3) Access to plans developed by expert clinicians
4) Ability to collect information about groups of patients for research
5) Assist in documentation for third party reimbursement

DISADVANTAGES
1) Requires critical analysis of a preexisting plan to ensure that it is appropriate and current
2) It is critical that all pertinent information be collected and entered into the system.

 STANDARDISED NURSING CARE PLANS

Printed care plans known as standardized care plans, are developed commercially or by an
individual health care facility. These care plans are typed, preprinted duplicated and made
available to the appropriate units in the health care facility. The format is designed to leave
space for the nurse to individualize the care plan by filling the specific related factors
associated with nursing diagnosis, adding deadlines to the outcome and clarifying the
interventions with additional details. Ex: The direct nursing care for people with specific
medical diagnosis like myocardial infarction or with certain nursing diagnosis such as pain or
anxiety or who are undergoing special procedures such as cardiac catheterization.

ADVANTAGES

a) Reduced amount of time for writing

b) Well researched tool developed experienced

c) Particularly helpful to nurses who may be asked to work in an unfamiliar area.

DISADVANTAGES

a) Nurses may use these care plans without individualizing them for a particular person
b) Many of the nursing diagnosis, outcomes and interventions may not be applicable.
c) These may tend to be long
d) Frustrated by the amount of time, it takes simply to read them, some nurses have not
found them to be useful.
  CARE PLANS FOR COMMUNITY BASED SETTINGS

Planning care for clients in community based settings; for example, clinics, community centers
or client’s homes, involves using the same principle of nursing practice. However in these
settings, the nurse must complete a more comprehensive community, home and family
assessment. In this setting, the client/family unit is equal in partnership with health care
professionals. Ultimately, the client/family must be able to independently provide the
majority of health care.

Nurse designs a plan:

1. To educate the client or family about the necessary care techniques.

2. To teach the client/ family hoe to integrate care within the family activities.
3. To allow client/family to assume a greater percentage of care in gradual increments.
4. To include nurses’ and clients’/families’ evaluation of expected outcome.

 CRITICAL PATHWAYS
Critical pathways allow staff from all disciplines such as medicine,nursing, pharmacy and
social work to develop integrated care plans for a projected length of stay or number of visits
for clients with a specific case type.
For ex: a pathway for a surgical procedure such as a colon resection will recommend on a day-
by-day basis the client’s activities, consults, procedures and discharge planning activities and
educational topics. A critical pathway ensures better continuity of care because it maps out
clearly the responsibility of each health care disciplines.

 CONCEPT MAPS
It is often not realistic to have a written columnar plan developed for each nursing diagnosis,
and also columnar plan do not contain a means to show the association between different
nursing diagnosis and different nursing interventions. A concept map is a tool that assist
learners in developing a self appraisal of their own individual thinking process.
Basically it is a diagram of client’s problems and interventions that shows their relationships
to one another. The use of a concept map promotes critical thinking and helps student nurses
To organize complex client data, process complex relationships and achieve a holistics view
of client’s situations.

STEPS IN WRITING CONCEPT MAPS:

1) Before caring for an assigned client, gather the clinical assessment database from the
client’s medical record, including health history, physical assessment data, laboratory and
diagnostic data,medication history and treatment plan.
2) Review information on the client’s health problems, treatment and medications in course
textbooks, pharmacology books etc.
3) Review on the nursing unit any standardized care plans, critical pathways, clinical
protocols or client education materials appropriate for client care preparation.
4) Prepare the map by first developing a skeleton diagram of the client’s major medical
diagnosis in the middle of the map, then add associated nursing diagnosis around it.
5) Identify and group clinical assessment data, treatments, medications and medical history
data relate to the nursing diagnosis.
6) Analyze relationship among the nursing diagnoses. Draw lines between nursing diagnoses
to initiate relationships.
7) Finally list nursing interventions to attain the outcomes for each nursing diagnoses.

 TEACHING PLANS
Teaching is a specialized form of nursing care plans. Individually developed teaching plans
may be hand written or computer generated for individuals with complex teaching needs. The
nurse modifies standard teaching plan as needed and uses the form to document the
outcome of teaching.

 PRACTICE GUIDELINES
Practice guidelines are also called protocols; specify nursing management of broad clinical
issues like maintenance of skin integrity, phases of hospitalization such as post operative care,
or interdependent clinical issues-for ex: management of a person receiving a certain type of
potent medication such as cardiac medication given intravenously in ICU.
When the standardized care plan or individually developed care plan contains information
about a variety of nursing diagnosis, the practice guide lines typically address one issue,
problem or nursing diagnoses. These are usually developed by experts and reviewed by a
group of nurses for validity.

ADVANTAGES
 Clearly specify well researched and agreed upon management of certain problems.
 Saves time

DISADVANTAGES
 The temptation to follow uncritically the interventions without individualizing them for
a particular person.
 No prepared plan of care, no matter what its format, replaces the judgments and critical
thinking of patient.

 CASE MANAGEMENT CARE PLANS

It is a method of delivering care that has evolved from the emphasis on decreasing the length
of stay in hospitals and focus on achieving timely client outcome. I t is designed to organize
care to achieve certain specific outcome with in a time frame permitted by the
reimbursement system.
 This plan is developed collaborately by nurses, physicians and other health care
professionals. It includes nursing diagnoses, outcomes, deadlines, nursing interventions and
physician interventions.
ADVANTAGES:
 Easy to identify appropriate steps in achieving the outcomes
 Resources are used more effectively
 Nurses are given more authority
DISADVANTAGES
 A great deal of planning is needed
 In some instances it is very difficult to gain the cooperation of physicians

HEALTH GOALS IMPLEMENTATION

INTRODUCTION
Implementation is the step of nursing process, where nurse provides care to patients. The
nurse initiates and complete actions necessary for achieving the goals and expected outcome
of nursing care.In theory, implementation of nursing care follows the planning component of
nursing process. However in practice, implementation may begin immediately after the
assessment when nurse identifies urgent need of the client in situations like cardiac arrest.
DEFINITION
I. Implementation refers to the action phase of the nursing process in which nursing care is
provided. It is the actual initiation of the plan and recording of nursing actions with the
purpose to provide technical and therapeutic nursing care required to help the client to
achieve an optimal level of health.
Shebeer Basheer P.
II. An autonomous action based on scientific rationale that is executed to benefit the client
in a predicted way related to nursing diagnosis and stated.
-Blue check and Mcloskey 1985
PURPOSES
 The primary focus of the implementation component is the provision of individualised
safe nursing care with a multy focal approach.
 Expansion of nursing knowledge about connection between nursing diagnoses,
treatment and outcome.
 Development of nursing and health care system
 To teach decision making to nursing students
 Determination of cost of services provided by the nurses
 Planning for resources needed in all types of nursing service practice settings
 Assist the patient to achieve valued health outcome

CRITICAL THINKING IN IMPLEMENTATION

When nurses use the nursing process, they make two types of decisions.
1) During the diagnostic process, the nurse forms conclusions, makes decisions and draws
inferences about the client’s assessment data and healyh care needs.
2) The nurse uses a methodological systematic, research based approach to plan and select
appropriate nursing intervention for a specific client as part of clinical decision making.

6 FACTORS TO BE CONSIDERED WHEN CHOOSING INTERVENTIONS

a) Desired or expected client outcome: The nurse identifies for each client the outcome that
can be reasonably expected and attained as a result of nursing intervention
b) Characteristics of nursing diagnoses: An intervention should be directed towards altering
the etiological or related factors of a client’s nursing diagnoses.For a risk nursing diagnosis
interventions are aimed at altering or eliminating risk factors for the diagnosis.
c) Evidence base for intervention: An evidence base includes the research or proven practice
guide lines that indicate the effectiveness of using an intervention with certain type of
clients.
d) Feasibility for performing an intervention: A single intervention can interact with other
interventions delivered by the nurse or members of health care team. The nurse must
consider how a proposed intervention will affect other planned interventions.
e) Acceptability to the client: An intervention must be acceptable to a client and family.
When choosing intervention, the nurse explains how the client is to participate, what
intervention involves and how the client might be affected.
f) Capability of the nurse: A nurse must be competent to perform the intervention. She
must have the knowledge of scientific rationale for the intervention; possess necessary
psychomotor and interpersonal skills.

IMPLEMENTATION SKILLS
Nursing practice includes cognitive, interpersonal, psychomotor, ethical and legal skills. Each
type of skill is needed to implement nursing intervention.
1. Cognitive skills:
The necessary cognitive skills for implementing are problem solving, decision making, critical
thinking and creativity. They are crucial and safe to intelligent nursing care. The nurse must
know the rationale for therapeutic interventions; understand normal and abnormal
physiological and psychological responses.
2. Interpersonal skills:
These are essential for effective nursing action
 Ability to establish a trusting nurse patient relationship grounded in responsible caring
 Ability to communicate patient and family, good interpersonal communication is
critical for keeping clients informed, providing individualized teaching and effectively
supporting with challenging emotional needs.
 Ability to work collaboratively with members of the health care team to implement
the interdisciplinary plan of care.
3. Psychomotor skills
Psychomotor skills involve the integration of cognitive and motor activities.
 Ability to competently use the equipment and technique specified by the patient plan
of care
 Ability to perform nursing care safely, based on sound scientific rationale
 Ability to ask for assistance when working with unfamiliar equipments
4. Ethical and legal skills
 Commitment to successfully implement the plan of care within the scope of legal
practice
 Ability to participate as a trusted and effective patient advocate
 Consistent use of appropriate legal safeguards while implementing the care
 Demonstration of accountability for all actions performed

TYPES OF NURSING INTERVENTION

I. Direct care:
These are treatments performed through interaction with the client. Direct care
interactions include both the ‘laying of hands’ actions and those that are more supportive
and counseling in nature. The steps are:
a) Activities of daily living
b) Physical care techniques
c) Counseling
d) Teaching
e) Controlling adverse reactions
f) Preventive measures
II. Indirect care:
Indirect care intervention is a treatment performed away from the patient but on behalf
of the clients or group of clients. This includes:
a) Documentation
b) Delegation
c) Environmental management
d) Computer entry
e) Telephone consultation
f) Shift report
g) Specimen management

PHASES OF IMPLEMENTATION
1.PREPARATION PHASE:
It involves preparing for the actual implementation of the plan. This phase consist of 5 steps.
i. Knowledge of the plan: The nurse first becomes familiar with the established plan,
either by listening to the verbal report or by reading the written plan.
ii. Validation of the plan: The plan is validated with the client and other health team
members. By reviewing client’s records and using knowledge and experience, the
nurse determines whether the plan is still viable or whether it needs to be revised.
 iii. Knowledge and skills needed to implement the plan: If the nurse lacks specific
knowledge or skills she should receive assistance from other nurse.
iv. Preparation of the client: The nurse explains the actions, the purpose, expected
sensations, client’s responsibility and expected outcomes. Preparation of the client
also involves privacy, preparing the client physically if necessary such as positioning
and ensuring the protection of client’s sense of modesty.
v. Preparation of the environment: Prior to the implementation, the nurse prepares the
environment and obtains the resources necessary to carry out the plan.
2. IMPLEMENTATION PHASE:
On completion of the preparation phase, the nurse carries out the plan with the client. Skilful
and efficient implementation of the plan enhances the provisions of competent care. It should
be client focused ,outcome oriented, physically and psychologically safe.
3. POST IMPLEMENTATION:
It begins after completion of nursing intervention. It includes:
a) Closure:
It includes what actions took place. Clarifying doubt by answering questions, indicating follow
up with the client for evaluation and identifying client’s response.
b) Ensuring client’s safety:
Nurse leaves the client in a safe, comfortable environment. For ex. Raise side rails, call
buttons are placed within easy reach.
c) Care of the articles:
After the completion of the actions, articles should be taken to utility room and cared
properly.
d) Documentation:
Action implemented and client’s response should be documented.
e) Verbal communication:
To provide continuity and co-ordinated care, appropriate communication among health team
members is necessary.

IMPLEMENTATION PROCESS
When carrying out the plan of care, nurses use specialized abilities to:
 Determine the patient’s new or continuing need for nursing assistance.
 Promote self care
 Assist the patient to achieve valued health outcomes.
1) REASSESSING THE CLIENT
Assessing is a continuous process that occurs each time a nurse interacts with a client. When
new data are gathered and a new need is identified, the nurse modifies the plan. During the
initial phase of implementation, the nurse reassess the client. The reassessment provides way
to determine whether the proposed nursing action is still appropriate for the client’s level of
wellness.
2) REVIEWING AND REVISING THE EXISTING CARE PLAN:
After reassessing a client, the nurse reviews the care plan, compares assessment data to
validate the stated nursing diagnoses and determines whether the nursing interventions
remain the most appropriate for the clinical situation.
If the client’s status has changed and the nursing diagnoses and related nursing
intervention are no longer appropriate, the nursing care plan needs to be modified.
Modification includes 4 steps:
 Data in assessment column are revised to reflect the client’s current status. New data
entered in care plan should be dated to inform other members of the health team.
 Nursing diagnoses are revised. Nursing diagnoses that are no longer relevant are
deleted, related factors are revised and new nursing diagnoses are added and dated.
 Specific interventions are revised to correspond to the new nursing diagnoses and
client’s goals.
 The nurse determines what method of evaluation will be used to determine if
outcomes are achieved.
3) ORGANISING RESOURCES AND CLIENT CAREDELIVERY
Successful implementation of plan of care requires a high degree of organization and
efficacy on today’s hectic health care environment.
a) Client: before beginning to perform interventions, the nurse should make the client as
physically and psychologically comfortable as possible. Adequate preparation allows
the client to obtain maximal benefit from each intervention.
b) Equipment: The nurse determines the needed item and their availability . Equipment
should be in the working order to ensure safe use. All necessary supplies should be
gathered and put in a convenient location.

c) Environment: The surrounding in which nursing activities occur should be safe and
conducive to the implementation of the therapy.
d) Personnel: Both patient and professional caregivers can be harmed when
interventions are attempted by the wrong person or by an insufficient number of
people .It is the nurses responsibility to determine whether to perform an intervention
or to delegate it to other member of the nursing team.

4) ANTICIPATING AND PREVENTING COMPLICATIONS

Risk to the client arises from both illness and treatment. Then nurse must identify these risks,
evaluate the relative benefit of the treatment versus risk and initiate the risk prevention
measures,. Scientific rationale for how certain interventions can prevent or minimize
complications help the nurse to evaluate the usefulness of preventive measures.
Determining need for assistance:
Before implementing care the nurse determines need for assistance and the type
required.Assistance may be needed in performing a procedure,comforting a client or
preparing a client for a procedure.
 5) PROMOTING SELFCARE: TEACHING,COUNCELLING AND ADVOCACY
The nurse assesses the patient’s ability to meet his or her needs independently. Balancing the
need to make each patient feel cared for and loved is an important component of the art of
nursing.
When routines of self care are included ,instruction should include the time of the
procedure ,the equipment used, the process and the level of patient involvement.

6)ASSISTING PATIENTTOMEET THE HEALTH OUTCOME

In this phase of implementation process, the nursing team carries out its order.The nursing
action planned to promote patient goal achievement and resolution of health problem should
be carefully executed.
NURSE’S ROLE IN IMPLEMENTAION.
The nurse assumes variety of roles while implementing the plan:
Practitioner role model
Educator leader or manager
Researcher
Advocate

ADVANCE NURSING PRACTICE

TOPIC PRESENTATION ON:

FORMULATION OF NURSING CARE PLANS AND

IMPLEMENTATION OF HEALTH GOALS
SUBMITTED TO:
MISS. PHABITHA PHILIP
LECTURER

SUBMITTED BY:
MRS. MERIN ACHANKUNJU
FIRST YEAR MSc NURSING

PRESENTED ON:
4/12/12

DR. M.V.SHETTY COLLEGE OF NURSING

RESEARCH STUDY:

Factors influencing best practice guide line implementation: Lesson learned from
administrators, nursing staff and project leaders.

AIM: This paper reports the perception of administrators , staff and project leaders about
factors influencing implementation of nursing best practice guidelines.

METHOD: 22 organisations in cluster of two to 5, implemented one of seven guidelines in

acute, community and long term care settings. The topics were client centered care, crises
intervention, healthy adolescent development, pain assessment, pressure ulcers, supporting
and strengthening families and therapeutic relationships.

FINDINGS:
Factors at individual, organizational and environmental levels were identified as influencing.

BIBLIOGRAPHY:
1. Potter AP, Perry AG, Fundamentals of nursing, 6th edition,Noida: Saunder’s imprint
Of Elsevier; 2005.Pp:325-351

2. Kozier B, Erb G, Berman A, Snyder S. “Fundamentals of nursing”, 7th ed,Delhi: Pearson

education publication; 2004. Pp: 315-327
 3. Basheer Shebeer P, Khan Yaseen S,” A concise text book of Advanced nursing practice”
Bangalore: Emmes Medical publishers; 2012. Pp:508-524

NET REFERENCE:
http://wikipedia.org/wiki/nursing interventions
http://nursing edu.org/edu/nursing implementation

JOURNALS:
Unique focus of nursing intervention. Nursing mirror, Nov.1994.Pp46-49