Nursing Care Plans

NURSING CARE PLANS

NURSING PROCESS

• Learning Outcomes:

  • Identify the steps of the Nursing Process

  • Identify the purpose of a nursing care plan

  • Demonstrate beginning ability to write a nursing care plan for a given scenario

STEPS IN THE NURSING PROCESS

• Assessment: Collecting comprehensive data pertinent to the patient's health or situation.

• Diagnosis (Nursing): Analyzing the assessment data to determine the diagnosis or issues.

• Planning: Developing a plan that prescribes strategies to attain expected, measurable outcomes.

• Implementation: Implementing the identified plan.

• Evaluation: Checking the effectiveness of the plan and the degree to which goals have been achieved.

NURSING CARE PLAN

• A nursing care plan is:

  • The Nursing Process in action.

  • A documented guideline of patient care.

  • A communication tool between nurses and other healthcare professionals, ensuring continuity of care.

  • Designed to decrease the risk of incomplete, incorrect, or inaccurate care.

NURSING CARE PLAN TEMPLATE

• Components of a Nursing Care Plan:

  • Nursing Diagnosis (Written in NANDA format)

  • Must ensure the diagnosis is SMART:

    • Specific

    • Measurable

    • Achievable

    • Realistic

    • Timely

  • Patient Goal: Specific to patient needs.

  • Nursing Interventions:

  • Rationale for Interventions:

  • Evaluation of Goal:

  • Must include a definitive statement regarding goal attainment (met/partially met/not met).

  • Include references from relevant clinical documentation.

NURSING DIAGNOSIS

• NANDA-I Classification & Format:

  • Prioritized Patient-Centered Goals

  • Can be short-term or long-term; case studies focus on short-term.

  • SMART Elements included.

• Nursing Diagnosis Characteristics:

  • Must be evidence-based, safe, and within the nurse's scope of practice.

  • Must be compatible with medical orders.

• Scientific Rationale:

  • Valid scientific references must be included for each intervention.

• Evaluation:

  • Involves an analysis of the patient’s response to each intervention.

  • Must include dates, times, and initials of the evaluating nurse.

  • Include a definitive statement about goal achievement.

COMPARISON BETWEEN MEDICAL AND NURSING DIAGNOSIS

• Medical Diagnosis: Defines the patient’s disease or condition.

• Nursing Diagnosis: Defines the patient’s actual or potential response to their disease or condition that the nurse can manage.

  • Example: Risk for infection related to compound fractured tibia as evidenced by wound erythema, fever, and pain.

  • Example: Nausea related to appendicitis as evidenced by pallor, sweating, and the patient reporting they are about to vomit.

PRACTICE EXERCISE

• Task: Write a nursing diagnosis for patients with the following medical diagnoses:

  • Patient 1: Medical diagnosis: myocardial infarction

  • Patient 2: Medical diagnosis: pharyngitis

  • Patient 3: Medical diagnosis: orthostatic hypotension

  • Format: Nursing diagnosis (related to medical diagnosis) as evidenced by (assessment findings).

WORKING NURSING CARE PLAN

• Patient Case Study - Kate Smith:

  • Demographics:

  • Name: Kate Smith

  • Age: 45

  • Gender: Female

  • Ethnicity: American

  • Medical History: Diagnosed with Irritable Bowel Syndrome (IBS) 5 years ago and mild depression.

  • Current Medications: Mebeverine for IBS, Sertraline for depression.

  • Reason for Admission: Severe constipation (only one bowel movement in the past 7 days, hard and painful).

  • Symptoms: Feeling bloated and abdominal discomfort.

  • Vital Signs:

  • BP: 130/85 mmHg

  • HR: 78 beats/min

  • RR: 16 breaths/min

  • Temp: 36.8°C

  • Abdominal Examination Findings:

  • Distended abdomen with tenderness on palpation (especially in lower quadrants), hypoactive bowel sounds, no palpable masses.

NURSING DIAGNOSIS FOR KATE

• Nursing Diagnosis: Constipation related to irritable bowel syndrome as evidenced by inability to pass a bowel motion for 7 days with bloating and pain while passing a hard stool.

PATIENT-CENTERED GOALS

• Goals provide direction for individualized nursing interventions.

• Goals set standards for determining the effectiveness of interventions.

• Evidence indicates that patient involvement in goal setting enhances outcomes.

• Goals can be short-term or long-term, based on patient needs.

GOALS MUST BE:

• Specific: Clearly define what is to be achieved.

• Measurable: Capable of quantification.

• Achievable: Realistic given patient capabilities and available resources.

• Realistic: Possible for the patient to achieve.

• Timed: Establish a time limit for goal achievement and evaluation.

NURSING INTERVENTIONS

• Actions aimed at helping the patient reach health goals.

• Must be:

  • Evidence-based

  • Safe & within the nurse’s scope of practice

  • Compatible with medical orders.

• Types of Nursing Interventions:

  • Nurse-initiated interventions

  • Collaborative interventions

  • Providing direct care, assisting in ADLs (Activities of Daily Living), counseling, teaching, delegating, supervising, and evaluating.

RATIONALE FOR INTERVENTIONS

• Rationale explains the scientific reasoning behind interventions and the anticipated patient response.

• Must be supported by current sources and evidence.

EVALUATION OF GOAL ATTAINMENT

• The purpose of nursing care is to resolve health problems, prevent potential issues, and maintain health.

• Evaluation requires analyzing patient responses to interventions to determine effectiveness.

• Evaluation statements:

  • Must be dated, timed, and signed.

  • One overarching goal statement must be included.

  • Outcomes: Goal met, partially met, or not met.

NURSING CARE PLAN EXAMPLE FOR KATE

• Nursing Diagnosis: Constipation related to irritable bowel syndrome as evidenced by inability to pass a bowel motion for 7 days.

• Patient-Centered Goal: The patient will experience improvement in constipation by passing a soft stool (type 3 or 4 on Bristol stool chart) within 12 hours.

• Nursing Interventions:

  • Administer laxatives as prescribed (details to be included).

  • Increase daily fluid intake to 2 liters of water.

  • Encourage natural laxatives such as Kiwi Crush (160–200ml daily or as prescribed).

  • Encourage mobilization around the ward at least 3 times a day.

  • Refer to the dietician for dietary fiber assessment.

• Rational for Interventions:

  • Laxatives effectively manage constipation by improving stool frequency and texture (Brenner et al., 2022).

  • Increasing fluid intake is crucial for softening stools and promoting ease of passage through the colon (Watt, 2021).

  • Kiwifruit is high in dietary fiber and can help with digestive comfort (Richardson et al., 2018).

  • Increased physical activity aids in bowel transit time (Okusaga et al., 2020).

  • Dietary fiber contributes to fecal bulk (Singh et al., 2022).

EVALUATION OF OUTCOMES FOR KATE

• Evaluation notes:

  • 15/08/25, 1430: Molaxole 2 sachets were administered, leading to soft bowel motion within 12 hours.

  • 15/08/25, 1430: Patient consumed 1.5 liters of water, resulting in a soft bowel motion.

  • 15/08/25, 1430: Patient reported consuming 200ml of Kiwi Crush with noting of normal bowel movement.

  • 15/08/25, 1430: Patient mobilized more than 3 times, resulting in regular bowel movement.

  • 15/08/25: Dietician referral sent; patient includes high fiber foods in meal orders.

  • Definitive Goal Statement: The patient experienced improvement in constipation, passing a soft stool (type 3) within 12 hours, thus the goal was met.

ADDITIONAL NURSING DIAGNOSIS

• Ongoing Concerns: Despite resolution of constipation, further nursing care plan indicated for sleep disturbances, reported due to perimenopause.

REFERENCES

• Bashir, A., & Sizar, O. (2024). Laxatives. In StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK537246/

• Brenner, D. M., et al. (2022). Treatment strategies for chronic constipation. The American Journal of Gastroenterology.

• Douglas, C., & Crisp, J. (2021). Nursing Fundamentals. Elsevier Australia.

• Okusaga, O., et al. (2020). Effectiveness of early mobilization versus laxative use. Australian Journal of Advanced Nursing.

• Richardson, D. P., et al. (2018). Nutritional attributes of kiwifruit. European Journal of Nutrition.

• Singh, P., et al. (2022). The role of food in treating bowel disorders. The American Journal of Gastroenterology.

• Toney-Butler, T. J., & Thayer, J. M. (2023). Nursing Process. In StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/

• Watt, E. (2021). Maintaining continence: Bowel. In Crisp, J. (2021). Potter & Perry’s Fundamentals of Nursing.