Nursing Care Plans

Writing a care plan in 9 steps

1. 1

   Assess the patient

   Collect subjective and objective data through interview, physical assessment, labs and chart review. Complete, accurate data is the foundation of every later step.

2. 2

   Analyze and cluster the data

   Group related cues, compare them with normal findings, and identify patterns that point to actual or potential problems.

3. 3

   Formulate nursing diagnoses

   Write the problem statement using a recognized diagnostic label plus related factors and evidence (problem related to cause as evidenced by signs).

4. 4

   Set priorities

   Rank diagnoses as high, medium or low using ABCs, Maslow's hierarchy and the patient's own stated priorities. Life-threatening problems come first.

5. 5

   Establish goals and outcomes

   Write SMART, patient-centered outcomes: specific, measurable, attainable, realistic and time-bound (short-term and long-term).

6. 6

   Select nursing interventions

   Choose independent, dependent and collaborative actions that are safe, evidence-based and matched to the outcome.

7. 7

   Provide rationales

   State the scientific reason each intervention works. Rationales are what turn a task list into clinical reasoning.

8. 8

   Evaluate the plan

   Compare the patient's actual response with the expected outcome: met, partially met or not met — then continue, revise or discontinue.

9. 9

   Document and communicate

   Record the plan and the patient's response in the health record so the whole team works from the same information.