Nursing care plan

A nursing care plan outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified by nursing assessment

Nursing assessment

Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status.-Stage one of the nursing process:...

. The creation of the plan is an intermediate stage of the nursing process

Nursing process

The nursing process is a modified scientific method. Nursing practise was first described as a four stage nursing process by Ida Jean Orlando in 1958,. It should not be confused with nursing theories or Health informatics...

. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.

Characteristics of the nursing care plan

1. Its focus is holistic, and is based on the clinical judgment of the nurse, using assessment data collected from a nursing framework.
2. It is based upon identifiable nursing diagnoses (actual, risk or health promotion) - clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes.
3. It focuses on client-specific nursing outcomes that are realistic for the care recipient
4. It includes nursing interventions which are focused on the etiologic or risk factors of the identified nursing diagnoses.
5. It is a product of a deliberate systematic process.
6. It relates to the future.

Elements of the nursing care plan

The nursing care plan consists of a nursing diagnosis

Nursing diagnosis

A nursing diagnosis may be part of the nursing process and is a clinical judgement about individual, family, or community experiences/responses to actual or potential health problems/life processes...

 with defining characteristics (subjective and objective data that support the diagnosis), related factors or risk factors, expected outcomes/goals, and nursing interventions.

See also

• NANDA
  NANDA
  NANDA International is a professional organization of nurses standardized nursing terminology that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses...
  
  
• Nursing Interventions Classification
  Nursing Interventions Classification
  The Nursing Interventions Classification is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associate with the creation of a nursing care plan. The NIC consists of a standardized list which contains 433...
  
  
• Nursing Outcomes Classification
  Nursing Outcomes Classification
  The Nursing Outcomes Classification is a classification system which describes patient outcomes sensitive to nursing intervention. The NOC is a system to evaluate the effects of nursing care as a part of the nursing process...
  
  
• Omaha System
  Omaha System
  The Omaha System is a standardized health care terminology consisting of an assessment component , an intervention component , and an outcomes component...