By: Maria Goretik, SST, M.

Kes
 A nursing care plan (NCP) is a formal
process that includes correctly identifying
existing needs, as well as recognizing
potential needs or risks.
Care plans also provide a means of
communication among nurses, their
patients, and other healthcare providers to
achieve health care outcomes.
 Purposes of a Nursing Care Plan
• Defines nurse’s role. It helps to identify the unique role of
nurses in attending the overall health and well-being of
clients without having to rely entirely on a physician’s
orders or interventions.
• Provides direction for individualized care of the client. It
allows the nurse to think critically about each client and to
develop interventions that are directly tailored to the
individual.
• Continuity of care. Nurses from different shifts or different
floors can use the data to render the same quality and type
of interventions to care for clients, therefore allowing
clients to receive the most benefit from treatment.
• Documentation. It should accurately outline which
observations to make, what nursing actions to carry out,
and what instructions the client or family members
require. If nursing care is not documented correctly in the
care plan, there is no evidence the care was provided.
• Serves as guide for assigning a specific staff to a specific
client. There are instances when client’s care needs to be
assigned to a staff with particular and precise skills.
• Serves as guide for reimbursement. The medical record is
used by the insurance companies to determine what they
will pay in relation to the hospital care received by the
client.
• Defines client’s goals. It does not only benefit nurses but
also the clients by involving them in their own treatment
and care.
Nursing Process
• Data Collection
• The best sources of information about the
client are the client and family. You also
consult other members of the healthcare team
for their information and analysis of the client.
• In addition, you learn information from the
client’s previous and present health records,
laboratory reports, and reference topics
dealing with the client’s medical diagnosis or
condition.
• Subjective Data
• Subjective data consist of the client’s opinions or
feelings about what is happening.
• Only the client can tell you that he or she is afraid
or has pain.
• Sometimes the client communicates through body
language: gestures, facial expressions, and body
posture.
• Both spoken and written words and body language
tell you the client’s opinions and feelings.
• Objective Data
• Objective data include all the measurable and observable
pieces of information about the client and his or her overall
state of health.
• As a nurse, you measure the client’s vital signs, height,
weight, and urine volume. You use specific descriptions about
the size and color of a wound.
• Measurements of body structure and function that involve
extent, rate, rhythm, amount, and size are usually made with
instruments—such as a stethoscope or sphygmomanometer—
or are the results of laboratory tests or radiologic diagnostic
tools.
• Laboratory tests also measure the chemical makeup of the
blood and urine.
DATA ANALYSIS
• Recognizing Patterns or Clusters
Some data are similar or have a pattern or connection
and are identified as symptoms. These symptoms
can be grouped together in clusters for further
analysis. 
• Identifying Strengths and Problems
While assessing the client, look for strengths the
client has that he or she can use in coping with
problems. Through careful analysis of data clusters,
you may identify actual or potential problems.
• Purposes of the Nursing Diagnosis
•    Identifies nursing priorities
•    Directs nursing interventions to meet
the client’s high-priority needs
•    Provides a common language and
forms a basis for communication and
understanding between nursing
professionals and the healthcare team
• The three-part nursing diagnostic statement
consists of the following components:
•    Problem: general label (e.g., airway
clearance, ineffective)
•    Etiology: specific, related factors such as
excessive mucus or foreign body obstruction
•    Signs and symptoms: specific, defining
characteristics, such as shortness of breath on
exertion or abnormal lung sounds (crackles,
wheezes, rhonchi), or ineffective cough
• PLANNING CARE
• After identifying the nursing diagnoses, you
begin planning nursing care.
• Planning is the development of goals to
prevent, reduce, or eliminate problems and
to identify nursing interventions that will
assist clients in meeting these goals.
• Setting priorities, establishing expected
outcomes, and selecting nursing
interventions result in a plan of nursing care
• Writing a Nursing Care Plan
• The nursing care plan is the formal guideline for
directing the nursing staff to provide client care
• The nursing care plan usually includes nursing
diagnoses or client problems (according to
priorities), expected outcomes (short- and long-
term objectives or goals), and nursing orders
(activities nurses carry out to help the client
achieve goals).
• Nurses develop the care plan shortly after a
client is admitted to the facility. 
• Nursing evaluation is the measurement
of the effectiveness of assessing,
diagnosing, planning, and
implementing. Evaluation includes the
following steps:
•    Analyzing the client’s responses
•    Identifying factors that contributed to
the success or failure of the care plan
•    Planning for future nursing care