What EXACTLY is a care plan?

CRNBSN18 · Aug 5, 2012

Careplans are a little different in school than in the workplace. The ones you do in school are more detailed, because you need to learn what you are doing before you start filling out the "short form" versions. They are usually meant as more of a teaching method so you learn how to use labs, medications and medical diagnoses to apply nursing diagnoses. So, of course they take longer to fill out.
You will learn in school that there are doctor's diagnoses (such as sepsis, cancer, anemia, etc...), and nursing diagnoses. The careplan is filled out by the nurse who is admitting the patient, and every nurse who assumes care afterwords reviews, and if necessary, revises the care plan. This is meant to insure consistant care is given by all nurses.
For example, if I admit an elderly patient who has orthostatic hypotension (their blood pressure drops with they stand up), they would be in danger of falling. A nursing diagnosis might be "risk of injury due to falls related to hypotension". So, then I would apply the necessary interventions to try to prevent the injury. Such as "bed alarm in place", "call button within reach", etc... This would all be called out in the care plan. So when you took over care of the patient you would review the careplan, and initial it. This stays in the patient's chart.
There is an organization called NANDA North American Nursing Diagnosis Association. They put out a list of standard nursing diagnoses. This is the standard my school used and I would imagine a lot of other schools use as well.
Good luck in school, I hope this helps.

Oh man!! I can't thank you enough!! :-)

nurseprnRN, BSN, RN · Aug 5, 2012

"my patient is here for a gi infection. hmm... what is a good nursing dx? how about infection? oh, wait that's not in the book. so then you have to settle for risk for infection, which makes no sense, "risk for infection r/t infection as evidenced by pooping here brains out"'

no, and your problem is that you assume that nursing diagnosis is dependent on the medical one(s).this is wrongheaded, shortsighted, and unprofessional. no, the medical diagnosis isn't the nursing diagnosis. but it can be a defining characteristic; if you have looked in your nanda-i 2012-2014 you will see quite a few nursing diagnoses with one of the defining characteristics = "disease process."

this does not mean that there is a magic list of medical diagnoses from which you can derive nursing diagnoses. nothing is farther from the truth.

yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

for example, if i admit a 55-year-old with diabetes and heart disease, i recall what i know about dm pathophysiology. i'm pretty sure i will probably see a constellation of nursing diagnoses related to these effects, and i will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. i might find readiness to improve health status, or ineffective coping, or risk for falls, too. i might learn that the patient has sexual dysfunction. these, and many, many others, are all things you often see in diabetics who come in with complications. they are all things that nursing treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. but i can't put them in any individual's plan for nursing care until *i* assess for the symptoms that indicate them, the defining characteristics of each.

medical diagnoses are derived from medical assessments-- diagnostic imaging, laboratory studies, pathology analyses, and the like. this is not to say that nursing diagnosis doesn't use the same information, so read on.

nursing diagnoses are derived from nursing assessments, not medical ones. so to make a nursing diagnosis, a nursing assessment has to occur. for that, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.

medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "activity intolerance related to (because the patient has) congestive heart failure/duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." however, your faculty will then ask you how you know. this is the dread (and often misunderstood) "as evidenced by."

in the case of activity intolerance, how have you been able to make that diagnosis? you will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to spo2 85% with turning in bed."

so, you don't think of a diagnosis for your patient and then go searching for supporting data. you collect data and then figure out a nursing diagnosis, same as the physician collects data and figures out a medical diagnosis.

i hope this is helpful to you who are just starting out in this wonderful profession. it's got a great body of knowledge waiting out there to help you do well for and by your patients, and you do need to understand its processes.

in the example quoted above, you might have a great many nursing diagnoses, depending on your nursing assessment. for example, depending on the individual patient, you might have: risk for electrolyte imbalance, deficient fluid volume, imbalanced nutrition, diarrhea, dysfunctional gi motility, incontinence, toileting self-care deficit, confusion, stress overload, ineffective coping, disturbed body image, noncompliance, risk for shock, impaired tissue integrity, impaired comfort, nausea, acute pain, ineffective self-health management, risk-prone health behavior, or others.

a professional nurse will look past the code brown (why does everyone always think of feces when they think of nursing, anyway? don't you get really tired of that?) and see what the patient in the bed is experiencing, things that contribute to his illness, what nursing can do to help...and all of those are completely independent of the medical diagnosis and the medical plan of care. as a matter of fact, the nurse is unprofessional if all s/he does is look to the medical diagnosis for direction for his/her care. might as well be a cna if that's all you can do.

ProudStudent · Aug 5, 2012

So, is it horrible that I'm dreading these things and my first semester as a nursing student doesn't start for a few more weeks?!?! LOL

BlueEyedGuy · Aug 5, 2012

"my patient is here for a gi infection. hmm... what is a good nursing dx? how about infection? oh, wait that's not in the book. so then you have to settle for risk for infection, which makes no sense, "risk for infection r/t infection as evidenced by pooping here brains out"'
no, and your problem is that you assume that nursing diagnosis is dependent on the medical one(s).this is wrongheaded, shortsighted, and unprofessional. no, the medical diagnosis isn't the nursing diagnosis. but it can be a defining characteristic; if you have looked in your nanda-i 2012-2014 you will see quite a few nursing diagnoses with one of the defining characteristics = "disease process."

this does not mean that there is a magic list of medical diagnoses from which you can derive nursing diagnoses. nothing is farther from the truth.

yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

for example, if i admit a 55-year-old with diabetes and heart disease, i recall what i know about dm pathophysiology. i'm pretty sure i will probably see a constellation of nursing diagnoses related to these effects, and i will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. i might find readiness to improve health status, or ineffective coping, or risk for falls, too. i might learn that the patient has sexual dysfunction. these, and many, many others, are all things you often see in diabetics who come in with complications. they are all things that nursing treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. but i can't put them in any individual's plan for nursing care until *i* assess for the symptoms that indicate them, the defining characteristics of each.

medical diagnoses are derived from medical assessments-- diagnostic imaging, laboratory studies, pathology analyses, and the like. this is not to say that nursing diagnosis doesn't use the same information, so read on.

nursing diagnoses are derived from nursing assessments, not medical ones. so to make a nursing diagnosis, a nursing assessment has to occur. for that, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.

medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "activity intolerance related to (because the patient has) congestive heart failure/duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." however, your faculty will then ask you how you know. this is the dread (and often misunderstood) "as evidenced by."

in the case of activity intolerance, how have you been able to make that diagnosis? you will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to spo2 85% with turning in bed."

so, you don't think of a diagnosis for your patient and then go searching for supporting data. you collect data and then figure out a nursing diagnosis, same as the physician collects data and figures out a medical diagnosis.

i hope this is helpful to you who are just starting out in this wonderful profession. it's got a great body of knowledge waiting out there to help you do well for and by your patients, and you do need to understand its processes.

in the example quoted above, you might have a great many nursing diagnoses, depending on your nursing assessment. for example, depending on the individual patient, you might have: risk for electrolyte imbalance, deficient fluid volume, imbalanced nutrition, diarrhea, dysfunctional gi motility, incontinence, toileting self-care deficit, confusion, stress overload, ineffective coping, disturbed body image, noncompliance, risk for shock, impaired tissue integrity, impaired comfort, nausea, acute pain, ineffective self-health management, risk-prone health behavior, or others.

a professional nurse will look past the code brown (why does everyone always think of feces when they think of nursing, anyway? don't you get really tired of that?) and see what the patient in the bed is experiencing, things that contribute to his illness, what nursing can do to help...and all of those are completely independent of the medical diagnosis and the medical plan of care. as a matter of fact, the nurse is unprofessional if all s/he does is look to the medical diagnosis for direction for his/her care. might as well be a cna if that's all you can do.

i don't actually disagree with you on the usage on nursing diagnoses. and that's actually a pretty good lessen you wrote on how to do it correctly.

i think you misinterpreted my gripe about nanda. i understand the patient's needs are multidimensional, and can/do use nursing diagnoses to address all the the patient's issues. however, sometimes there's something you want to address in your plan of care that doesn't fit well into the the predetemined nanda dx's.

itsnowornever, BSN, RN · Aug 6, 2012

Blue Eyed Guy---such as? If you give us examples of what you can't find then we can help you find it. There may be a puzzle piece you are missing to figuring it out.

Elladora · Aug 6, 2012

I had a clinical instructor that wanted us to take our Care Plans TO THE CELLULAR LEVEL. It was horrible. To this day I have yet to say "Hello Patient! I am here to treat your bad cells..."

Side note, she got fired at the end of our clinicals for being a bit of a nightmare.

llg, PhD, RN · Aug 6, 2012

Side note, she got fired at the end of our clinicals for being a bit of a nightmare.

I am happy to read that.

BillRoth2 · Aug 6, 2012

For me a care plan is based at Gordon's functional health patterns, 11 of them. I usually use at least two NANDA nursing diagnosis for each pattern. This personalizes the care plan for an individual patient or client. Of course you have to include the patient's medications and interactions along with their life situations to make it all work. I know this sounds vague but this is how I approach it. I hope this helps you.

CRNBSN18 · Aug 6, 2012

Got my care plan book in today-- I didn't expect it to be so big!

Kier721 · Aug 6, 2012

Got my care plan book in today-- I didn't expect it to be so big!

What book did you buy if you don't mind me asking? I've been trying to find one..just don't know where to start.

CRNBSN18 · Aug 6, 2012

What book did you buy if you don't mind me asking? I've been trying to find one..just don't know where to start.

I mentioned it earlier in the thread.. I think it's by ulrich and canale. It even comes with evolve resources, like you can go on the website and print out care plans etc. It was like $30 on amazon new

CRNBSN18 · Aug 6, 2012

What book did you buy if you don't mind me asking? I've been trying to find one..just don't know where to start.

Oh! And it is laid out pretty simple from

What I have viewed so far. It looks like it will be easy to navigate through.

Just looked on my bookshelf: it's ulrich & canale's care planning guides: prioritization, delegation, and critical thinking 7th edition.