nursing care plan paper example

Nursing Care Plans Explained: Types, Tutorial & Examples

Nursing care plans are written tools that outline nursing diagnoses , interventions, and goals. Care plans are especially useful for student nurses as they learn to utilize the nursing process. By creating a nursing care plan based on a patient’s assessment, the nurse learns how to prioritize, plan goals and interventions, and evaluate outcomes related to specific disease processes. Care plans are essential for communication between nurses and other care team members in order to provide high-quality, continuous, evidence-based care.

In this article:

• What is a Nursing Care Plan?
• Why Use Nursing Care Plans?
• Types of Nursing Care Plans
• Nursing Care Plan Considerations
• Creating SMART Goals
• Nursing Interventions
• Tips for Effective Care Planning
• Nursing Care Plan Examples

Nursing care plans are a structured framework for delivering patient care. Nursing care plans are often called the “plan of care” and provide directions to nurses and the interprofessional team. Care plans are often described as the roadmap of patient care 2 , as they help nurses plan, prioritize, rationalize, and evaluate interventions.

Listed below are some of the benefits of using care plans in nursing practice.

1. Follows the client from admission to discharge . Care plans are continually updated depending on the patient’s status, goals, and outcomes and follow the patient across facility transfers and to different care settings.

2. Helps nurses plan interventions and revise care . Care plans provide structure to interventions, allowing the nurse to assess the intervention’s outcome and potentially revise care based on the outcome.

3. Evaluates interventions . Care plans include a combination of short and long-term goals that are specific, measurable, and timely. The nurse can evaluate if interventions are effective by evaluating goal progression.

4. Communication and continuity between nurses . The plan of care is a document that assists nurses in providing continuous and consistent care, working toward shared goals.

5. Coordinates other disciplines . The care plan may include input or interventions other interdisciplinary team members provide. A care plan communicates priorities between interprofessional team members to coordinate on common goals.

6. Engage with the patient/patient-centered care . Whenever possible, the patient should be involved in creating their plan of care. Nursing care plans are best used collaboratively with patients and families to account for a patient’s preferences, values, culture, and lifestyle. 2

7. Documentation purposes . Care plans are an opportunity for nurses to demonstrate that safe and ethical care was provided in accordance with professional regulations. Documentation may be used for communication, quality improvement, research, or legal proceedings.

8. Offers a framework for consistent care. A nursing diagnosis supports the care plan and outlines appropriate interventions. Nursing diagnoses should align with a NANDA-I nursing diagnosis, creating consistency in nursing diagnosis terminology and facilitating effective communication. 1

9. Prevents future health hazards. Some care plans may include nursing diagnoses the patient is at risk for, like falls or infection. Care plan interventions and goals can be created to prevent complications.

There is some variation in how care plans are used in practice. The structure and format of a care plan depend on the purpose of the care plan and the care setting.

Formal vs. Informal Care Planning

Generally, informal care plans are not formally documented. Informal care plans might include the nurse’s goals for their shift. These goals can be modified depending on the day’s priorities or changes in the patient’s condition.

Formal care plans are documented as part of the patient record used to coordinate, prioritize, and maintain continuity of care. While formal care plans are also modifiable depending on new priorities or the outcomes of interventions, they are often related to the longer-term goals of the patient. The formal care plan might include goals to meet before discharge from the hospital or the service. Both formal and informal care plans are used within the framework of the nursing process.

Standardized vs. Individualized Care Planning

Care plans can be either standardized or individualized for the patient. Many care settings will use standardized care plans for specific patient conditions to deliver consistent care. One example of a standardized care plan is the post-operative care pathway used in post-surgical units. These post-operative care plans outline expected goals for each post-operative day. However, standardized care plans should be tailored when possible to the needs of the individual patient.

In contrast, individualized care plans are created for individual patient needs. Individualized care plans should include input from the patient whenever possible to create personalized goals and support patient adherence. When creating an individualized care plan, consider the patient’s health status, history, and motivational factors and inquire about what matters most to them.

The Nursing Process

Care plans enter the nursing process at the planning stage but are influenced by all other steps. The steps of the nursing process can be remembered with the acronym ADPIE. 3

• Implementation/Interventions

Here is a breakdown of the nursing process:

1. Assessment: Assessing the client’s needs, gathering data In the assessment phase of the nursing process, the nurse collects and analyzes objective and subjective data . Then, the nurse uses their nursing knowledge and critical thinking skills to decide if further assessments are necessary to identify a nursing diagnosis.

2. Diagnosis: What’s going on? Crafting a nursing diagnosis Based on data collected during the assessment phase, the nurse crafts a nursing diagnosis that can be used to direct care planning. 4 The nurse should assign a nursing diagnosis using the standardized terminology laid out by NANDA-I. A nursing diagnosis is a clinical judgment that describes actual or potential health problems or opportunities for health improvement of a patient, family, or community.

3. Planning: Time to create goals In step three of the nursing process, the nurse, ideally in collaboration with the patient, creates goals of care based on the nursing diagnosis. A care plan, including interventions and expected outcomes, is created to achieve these goals.

4. Implementation: Time to act In the implementation phase of the nursing process, the nurse takes actions and performs the interventions described in the care plan to achieve the goals of care. The nurse uses their knowledge, experience, and critical thinking to decide which interventions are a priority. Often, interventions are based on orders from the physician.

5. Evaluate: What are the outcomes? In the evaluation phase of the nursing process, the nurse reassesses the patient to determine if the intervention has the desired outcome. Next, the nurse should evaluate if the goals of care have been met or require more time. If the intervention does not have the desired effect, the nurse should consider if the care plan needs revision or if the goals of care need to be updated.

Nursing Process Example

Here is an example of how the steps of the nursing process fit together. 

The nurse assesses the client who was in a motor vehicle accident. The client reports a pain level of 9/10 in their right shoulder. Through an x-ray, the client is determined to have a dislocated shoulder, and the nursing diagnosis of acute pain is applied. The nurse begins planning treatment and goals to reduce pain and instill comfort. The nurse administers IV pain medication as ordered and supports the right arm with pillows. The nurse evaluates the effectiveness of interventions by asking the client to rate their pain on a scale of 0-10. Depending on the outcome, the nurse may determine that the intervention was successful or requires revision.

How To Write a Nursing Care Plan

With experience, nursing care plans become second nature as part of nursing practice. Since nursing care planning can be formal or informal, a nursing care plan may look very different depending on the care context and the patient’s needs. While informal care plans may not be written in the patient chart, writing effective formal care plans takes practice. Formal care plans are important for communicating significant changes in the patient’s condition to the care team.

Care plans will appear differently depending on each electronic health record, computer platform, setting (home health, doctor’s office, etc.), and nursing specialty (case management, PACU, etc.). Regardless, the nursing process stays the same. One way to improve the skill of care plan writing is to read examples of high-quality care plans. Nurses can also ask experienced colleagues for feedback on their care plans. Some care settings will have templates of expected formal care plans. 

Overall, the care plan should flow seamlessly as part of the nursing process, taking into account relevant nursing diagnoses, expected outcomes, and the effectiveness of the planned interventions. If necessary, goals are revised, and the care plan is repeated until goals are met or are no longer applicable.

While rationales are not included in traditional nursing care plans, they are used in student care plans. When learning to write care plans, adding the rationale behind the diagnosis and interventions can be helpful. Students can explain the pathophysiology behind their assessment and why their intervention is necessary to guide their understanding.

Consider the hierarchy of needs.

In any care setting, there are often competing priorities that nurses must handle. When deciding on how to prioritize care needs for patients, a useful framework to organize care is Maslow’s hierarchy of needs. 5 The highest priority needs are at the bottom of the pyramid including physiological needs such as air, nutrition, and sleep. The nurse must prioritize physical needs over those closer to the top of the pyramid, such as the need for a sense of connection.

S.M.A.R.T. goals are specific, measurable, attainable, realistic, and time-bound. SMART goals are helpful in care planning because they increase the likelihood that the goal created will be practical and achievable. Conversely, goals that are too vague or not realistic are less likely to be achieved, which can discourage the goal-setter.

Specific Specific goals are not overly broad. A shared goal of “walking more” is not specific. However, “Walk three laps of the unit three times a day” is specific.

Measurable Related to being specific, there should be some way to measure whether the goal has been met or is at least progressing. There should be a benchmark that signals that the goal has been met. Benchmarks could be behavioral, physical, or expressed by the patient. 

Attainable Goals might take work to meet, but attainable goals are within reach. Goals that are too difficult or require multiple steps to reach are more likely to discourage rather than encourage. 

Realistic An achievable goal is also realistic. Attainable goals are possible to meet, while realistic goals take into consideration the context and potential barriers to meeting the goal.

Time-bound  Setting a time limit on the goal grounds the goal in reality and allows for measurement. The chosen period should depend on the goal’s size and should support progress and focus.

Examples of Collaborative SMART Goals

Here are two examples of how SMART goals can be used in care planning: 

Goal: “The client will rate their pain three or less on a scale of 0-10 by discharge.”

• Specific: The goal includes an exact number on the pain scale acceptable to the patient.
• Measurable: The goal can be tracked over time and measured on the pain scale.
• Attainable: This depends on the specific patient context, but for the example, we will assume this is an achievable goal for the patient.
• Realistic: Similarly, this goal must be realistic, which will depend on the patient’s pain tolerance.
• Time-bound: In the inpatient setting, ‘by discharge’ is an appropriate time frame.

Goal: The patient will demonstrate independently using a glucometer to check their blood sugar and how to self-administer necessary insulin after three diabetes education sessions. 

• Specific: The goal includes specific behaviors and outcomes of the education sessions.
• Measurable: The nurse can assess if the goal is complete by asking the patient to demonstrate their skills. 
• Attainable: The patient has the motor and cognitive ability to learn these skills. 
• Realistic: Enough time has been given for practice and education so that the patient feels comfortable and confident. 
• Time-bound: This goal is set to be achieved after three education sessions. At the end of the third session, the nurse can assess if the goal has been met or if more support or time is needed to meet this goal.

Short vs. Long-Term Goals

When creating goals of care, it can be helpful to categorize goals into short-term or long-term goals. Short-term goals are commonly found in acute care settings, where care interactions are shorter than in the community. However, both long and short-term goals are used across care settings. 

Short-term goals can be completed within a few hours or days. Although there is no precise cut-off for what makes a short-term care goal, short-term goals tend to focus on issues that need to be immediately addressed. An example of a short-term care goal is to improve the patient’s shortness of breath by identifying the cause and administering an intervention to relieve the shortness of breath.

In contrast, long-term goals are usually completed over weeks or months. Long-term care goals tend to be aimed at more chronic health challenges, prevention, and improvement. While important, they may be less urgent than short-term care goals. An example of a long-term care goal is the reduction of HbA1c over several months for a patient at risk for diabetes.

Once goals and a plan of care are established, the nurse will perform interventions. There are three main categories of nursing interventions :

Independent: Independent nursing interventions are within the nurse’s scope of practice and do not require the participation of another health professional, such as a physician, to carry out the intervention. Nurses can initiate, implement, and evaluate independent nursing interventions. An example of an independent nursing intervention is providing patient education. 

Dependent: Dependent nursing interventions require the participation of another health professional to carry out the intervention. Dependent interventions are often ordered by physicians and then implemented by nurses. Collecting blood work that a physician has ordered is an example of a dependent nursing intervention.

Collaborative: Collaborative nursing interventions are carried out with other healthcare professionals through collaboration or consultation. Collaborating with a physical therapist on exercises to improve patient mobility is an example of a collaborative nursing intervention.

1. Create goals with the patient when possible. The patient should be included in their care plan to ensure goals are congruent with their lifestyle, values, and preferences. This includes patient involvement in planning interventions and defining the intervention’s successful outcome. Including the patient in the care planning process will increase their motivation to actively participate in their care. 

2. Revise goals if necessary. If the goal is not met within the original timeframe, the goal may need revision to ensure that it is achievable and realistic, or the timeframe may need to be extended.

3. Continue to assess and reassess the patient. It is essential to continually evaluate the patient’s status to ensure that the goals and interventions are still appropriate for their condition. 

4. If a goal is not met, assess why. Interventions that are not working or care plan goals that are not met require revision. This may include revising the interventions, updating the goals of care, reviewing the patient diagnosis, assessing the client’s motivation or lack thereof, and furthering patient education. 

5. Ensure that progress towards a goal is recognized even if a goal is not met . In some situations, the goal’s timeline may need to be extended for a goal to be met. Consider that a goal may be ‘met’ even if the outcome is not what was intended.

Below you’ll find a list of over 400 care plans. All our care plans are written and reviewed by registered nurses.

• Atrial Fibrillation
• Bradycardia
• Cardiomyopathy
• Chest Pain (Angina)
• Coronary Artery Disease
• Heart Failure
• Hypertension
• Hypotension
• Myocardial Infarction
• Pulmonary Embolism
• Tachycardia
• Tetralogy of Fallot

Endocrine & Metabolic

• Diabetes Mellitus
• Diabetic Foot Ulcer
• Diabetic Ketoacidosis
• Hyperglycemia
• Hyperlipidemia
• Hypocalcemia & Hypercalcemia
• Hypoglycemia
• Hypokalemia & Hyperkalemia
• Hyponatremia & Hypernatremia
• Hypothyroidism
• Malnutrition
• Metabolic Acidosis
• Metabolic Alkalosis
• Syndrome of inappropriate antidiuretic hormone (SIADH)

Gastrointestinal

• Abdominal Pain
• Appendicitis
• Bowel Perforation
• Clostridioides Difficile
• Colon Cancer
• Colostomy & Ileostomy
• Crohn’s Disease
• Diverticulitis
• Gastrointestinal Bleed
• Liver Cirrhosis
• Nausea & Vomiting
• Pancreatic Cancer
• Pancreatitis
• Paralytic Ileus
• Peritonitis
• Small Bowel Obstruction
• Ulcerative Colitis

Genitourinary

• Acute Kidney Injury
• Benign Prostatic Hyperplasia (BPH)
• Chronic Kidney Disease
• End Stage Renal Disease (ESRD)
• Kidney Stones
• Pyelonephritis
• Urinary Tract Infection

Hematologic & Lymphatic

• Anaphylaxis
• Blood Transfusion
• Deep Vein Thrombosis
• Low Hemoglobin
• Neutropenia
• Peripheral Vascular Disease
• Sickle Cell Anemia
• Thrombocytopenia

Infectious Diseases

• Human Immunodeficiency Virus (HIV)
• Methicillin-resistant Staphylococcus aureus (MRSA)
• Respiratory syncytial virus (RSV)
• Tuberculosis

Integumentary

• Pressure Ulcers
• Wound Care & Infection

Maternal & Newborn

• Breastfeeding
• Hyperemesis Gravidarum
• Labor and Delivery
• Placenta Previa
• Postpartum Hemorrhage
• Preeclampsia
• Preterm Labor

Mental Health & Psychiatric

• Attention deficit hyperactivity disorder (ADHD)
• Altered Mental Status
• Antisocial Personality Disorder
• Bipolar Disorder
• Major Depression
• Mental Health
• Obsessive-Compulsive Disorder (OCD)
• Psychosocial
• Post-traumatic stress disorder (PTSD)
• Schizophrenia
• Substance Abuse

Musculoskeletal

• Compartment Syndrome
• Hip Fracture
• Knee Replacement Surgery
• Myasthenia Gravis
• Osteoarthritis
• Osteomyelitis
• Osteoporosis
• Rhabdomyolysis
• Rheumatoid Arthritis
• Spinal Cord Injury

Neurological

• Cerebral Palsy
• Diabetic Neuropathy
• Encephalopathy
• Headache & Migraine
• Multiple Sclerosis
• Parkinson’s Disease
• Peripheral Neuropathy
• Stroke (CVA)
• Transient Ischemic Attack (TIA)
• Traumatic Brain Injury

Respiratory

• Acute Respiratory Failure
• Acute respiratory distress syndrome (ARDS)
• Chest Tube Insertion
• Chronic obstructive pulmonary disease (COPD)
• Cystic Fibrosis
• Pleural Effusion
• Pneumothorax
• Pulmonary Edema
• Tracheostomy

Other Care Plans

Anything that didn’t match a specific category you’ll find here:

• Alcohol Withdrawal Syndrome
• Breast Cancer
• Chemotherapy
• Community Health
• End-of-Life (Hospice) Care
• Hearing Loss
• Sleep Apnea
• NANDA International. Our Story. Accessed January 7, 2023. https://nanda.org/who-we-are/our-story/
• Capriotti T, eBook Nursing Collection – Worldwide, Books@Ovid Purchased eBooks. Nursing Care Planning Made Incredibly Easy! Third. Wolters Kluwer; 2018. https://go.exlibris.link/P281xmcS
• Toney-Butler T, Thayer J. Nursing Process. Published 2022. https://www.ncbi.nlm.nih.gov/books/NBK499937/
• Carpenito LJ, Books@Ovid Purchased eBooks. Handbook of Nursing Diagnosis. 15th ed. Wolters Kluwer; 2017.
• Hayre-Kwan S, Quinn B, Chu T, Orr P, Snoke J. Nursing and Maslow’s Hierarchy; A Health Care Pyramid Approach to Safety and Security During a Global Pandemic. Nurse Lead. 2021;19(6):590-595. doi:10.1016/j.mnl.2021.08.013

How to Write a Nursing Care Plan (Steps and Tips)

Knowing how to write a good nursing care plan is critical for nursing students and practicing nurses. Care plans act as a tool that helps nursing students and nurses strategically manage the nursing process to solve different problems affecting a patient. Nursing care plans also allow effective communication within a nursing team for collaborative or individual decision-making.

In this guide, we take you through the basics of nursing care plans and steps to create the best and give examples/illustrations to make it simpler. With the best practices we outline in this guide, you can write a nursing care plan without worrying that your end product will be subpar.

This guide is valuable to nursing students as it comprehensively addresses what matters. Besides, it is written by professional nurse researchers collaborating with top talents/brains in the nursing industry. It is also updated regularly to capture any new developments as far as nursing care planning is concerned.

What is a Nursing Care Plan?

A nursing care plan, abbreviated as NCP, refers to a document that details the relevant information about the history and diagnosis of the patient, their current or potential care needs, treatment goals, risks, treatment priorities, and evaluation plan.

Nursing care plans are usually updated depending on the patient's stay at a facility, preferably during and after every shift.

As a nursing student, you will be assigned to write a nursing care plan based on a scenario. For example, your preceptor could also ask you to write a care plan based on a real patient hospitalized in a clinical center where you are doing your internship or practicum.

The process of care planning begins during admission. As we have said above, it gets updated throughout the patient's stay depending on the changes they exhibit and report and based on evaluation of the achievement of the set goals. When you can plan and execute a patient-centered care plan, you have mastered the art of giving quality and excellent nursing services to your patient.

Let's peek at why nursing care plans are written with a view of their professional and academic importance.

Reasons for Writing Nursing Care Plans

You must note that there are different types of nursing care plans, either formal or informal. The formal nursing care plans are roughly documented or exist in the minds of the nurse. On the other hand, formal nursing care plans are either written on paper or computerized to guide the nursing process. Formal nursing care plans can also be standardized or individualized/patient-centered. While the standardized care plans focus on a specific population or group of patients, say those with cardiac arrest or osteoporosis, the individualized or patient-centered care plans are customized to the unique needs of a specific patient that cannot be addressed through a standardized care plan.

Given the understanding of the typologies of nursing care plans, let's now look at why we write them. Nursing care plans are written, or they exist for different reasons, including:

• To promote the use of evidence-based practices in nursing care to address different healthcare needs of the patients
• Holistically caring for patients in recognition of the nursing metaparadigm (health, people, environment, and nursing)
• Enabling nursing teal collaboration through information sharing and collaborative decision-making
• Measuring the effectiveness of care and documenting the nursing process for care efficiency and compliance
• Offering patient-centered or individualized care to improve outcomes
• Identifying the unique roles of nurses in attending to the needs of the patient without constant consultation with physicians
• Allowing for continuity of care by allowing nurses from different shifts to render quality interventions to patients optimizes care outcomes.
• Guide for delegating duties and assigning specific staff to a patient, especially in cases of specialized care.
• Defining a patient's goals helps involve them in decision-making regarding their care.

The Main Components of a Nursing Care Plan

A well-written nursing care plan must have specific components. The main components of a nursing care plan (NCP) are:

• Expected outcomes
• Interventions
• Evaluations

Let's elaborate on these five main components of a nursing care plan.

• Assessment. Assessments are akin to data collection. It entails a detail of the physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic, and environmental. Nursing assessments, combined with the results of medical findings and diagnostic studies, are documented in the client database and form the foundation for developing the client's care plan. The assessment is facilitated through observations for objective data and interviews with patients and their significant others or family for subjective data.
• Diagnosis. With a correct assessment, a nursing care plan details the clinical judgment that helps nurses determine the care plan or interventions for the specific patient.
• Expected outcomes. The outcomes entail the specific, measurable actions for a patient to be achieved within a specific time. The outcomes can be short, medium and long-term depending on the patient's condition.
• Interventions. This entails planning for actions to be taken to achieve the set goals of the patients and expected outcomes, including the rationale behind them. The rationale is evidence-based practices drawn from clinical guidelines, standard operating procedures, evidence-based guidelines, and best practices.
• Evaluations. This section of a nursing care plan entails a set of steps to determine the effectiveness of a nursing intervention or nursing interventions to assess whether the expected outcomes have been met.

What makes a good nursing care plan?

A good nursing care plan contains information about the patient's diagnosis, immediate and changing care needs, treatment goals, specific nursing interventions, and an evaluation plan to determine the effectiveness of care. Such a nursing care plan document can only be achieved through observing certain care plan fundamentals.

• The care plan must answer the questions of what, why, and how.
• A successful care plan uses the fundamental aspects of critical thinking to come up with a patient-centered approach to care
• Follows evidence-based practice guidelines when developing interventions or explaining the rationale for actions
• Has SMART goals for the patients
• Allows for effective communication
• Sharable and easily accessible. If written, it should be legible to everyone else. If you are typing it, use a readable font and good formatting.
• Up to date. It entails the latest information about the patient and changes in their conditions.

Steps for Writing a Nursing Care Plan

You will be assigned a patient scenario or case study as a student. These can be actual case studies from real cases happening on hospital floors or cases created to facilitate teaching and learning. As a professional nurse, you will write the case study based on your patient's condition. Given the understanding of the five main components of a nursing care plan, we also say that nursing care plans follow a five-step framework.

1. Assessment

The first step of writing a nursing care plan is to practice critical thinking skills and perform data collection. During this phase, you collect subjective and objective data. The source of subjective data is an interview with the caretakers, family members, or friends of the patient and the patient. The objective data are observed or measured by you, such as weight, height, heart rate, and respiratory rates. In this section of your nursing care plan, you will include the following:

• Verbal statements from the patient and those accompanying them
• Vital signs (heart rate, blood pressure, respiration, temperature, oxygen saturation)
• Physical complaints (headache, vomiting, nausea, pain, swelling)
• Body conditions (head-to-toe assessments)
• Medical history
• Physical features (height and weight)
• Concerns, perceptions, and feelings of the patient
• Lab findings
• Diagnostic tests (EKG, X-ray, echocardiogram, etc.)

2. Diagnosis

The success of this section depends on the accuracy of the data collected from the first part. Next, you need to select a nursing diagnosis that fits the goals and objectives of hospitalization. The diagnosis step entails analyzing the data from the first step or assessment. Writing good nursing diagnoses is a step in the right direction toward choosing nursing strategies targeting specific desired outcomes.

According to NANDA , nursing diagnosis is a clinical judgment about the human response to life processes or conditions. It also refers to vulnerability to that response by an individual, group, community, or family.

When writing a nursing diagnosis, it is essential to formulate it based on Maslow's Hierarchy of Needs Pyramid so that you can prioritize treatments and interventions. For instance, you need to prioritize the basic physiological needs before the higher needs, such as self-actualization and self-esteem. The rationale for first addressing the physiological/safety needs is that they form the foundations for nursing processes (care and intervention planning).

A good diagnosis identifies a problem (current health problem and the nursing interventions required), the risk factors or etiology (reasons for the problem/condition), and the characteristics of the problem (signs and symptoms).

Nursing diagnoses can be categorized into:

• Problem-focused diagnoses . The problems that present during the assessment of the patient. This is the actual diagnosis based on signs and symptoms. It could include shortness of breath, anxiety, acute pain, impaired skin integrity, etc.
• Risk nursing diagnoses . These are clinical judgments that a problem does not exist. However, the presence of risk factors predisposes the patient to the problem unless specific interventions are taken. Examples can include the risk of falls as evidenced by weak bones, the risk of injury as evidenced by altered mobility, the risk of infection as evidenced by immunosuppression, etc.
• Health Promotion or wellness diagnosis is a clinical judgment about the desire and motivation to increase well-being or reach one's health potential.
• Syndrome diagnoses . The clinical judgment concerns and combination of risk nursing diagnoses or problems that can occur due to specific events. Examples include chronic pain syndrome, frail elderly syndrome, etc.

You can read more from Nightingale College concerning nursing diagnosis .

Note that the nursing diagnoses will change as the client progresses through various stages of illness or maladaptation to resolve the problem or to the conclusion of a condition. Therefore, every decision must be time-bound, given that decisions might change as additional information is gathered.

When writing a student nursing care plan, you must provide a rationale for a specific diagnosis. This means including in-text citations from peer-reviewed nursing journal articles.

3. Outcomes

After writing the diagnosis section, you need to develop SMART (specific, measurable, achievable, relevant, and time-bound) goals based on evidence-based practice (EBP) guidelines and client-centered. To do this, you must consider the patient's overall condition, relevant information, and diagnosis.

The goals and desired outcomes describe what you expect to achieve by implementing specific nursing interventions or actions based on the diagnoses. The goals direct the intervention planning process and serve to evaluate the client's progress. When writing the goals, consider the medical diagnosis made by ad advanced healthcare practitioner or physician. It could include COPD, chronic kidney disease, heart failure, diabetes mellitus, diabetes ketoacidosis, obesity, thyroidectomy, hyper/hypothyroidism, cancer, Alzheimer's disease, endocarditis, eating disorders, acid-based balance disorders, fluid/electrolyte imbalance, etc.

The goals of the patient and expected outcomes can be short-term or long-term. Short-term goals immediately focus on the shift in behavior, mainly within a few hours or days. Long-term goals are objectives to be met over a long period, months or weeks.

When writing the goals and desired outcomes, you must include the subject, verb, conditions or modified, and criterion. Usually, they are written in the future tense.

Let's explore the four components:

• Subject. This refers to the client, any part of the client, or some attribute of the client. It could be vitals (temperature, urinary output, blood pressure)
• Verb. This specifies the specific action that the client will perform.
• Conditions or modifiers. These are the "what, where, when, and how?" added to the verb to explain the situations under which behavior is performed.
• Criterion . These are indicators of the standard by which a performance is measured and evaluated or the level at which the patient can comfortably and efficiently perform a given behavior or action.

Examples of goals and outcomes

• The patient will demonstrate adequate cardiac output as evidenced by vital signs within acceptable limits, no symptoms of heart failure, and absence of dysrhythmias.
• The client will identify individual nutritional needs within 36 hours
• The client will ambulate using a cane within 24 hours of surgery

4.  Nursing Interventions

Planning for nursing interventions or strategies is also called the implementation stage. You will be performing various nursing interventions, including following doctor's orders. Every intervention should be developed using evidence-based practice guidelines.

Interventions are classified into seven domains: family, physiological, community, complex physiological, safety, health system, and behavioral interventions. They can be implemented during shifts. Some interventions include pain assessment, listening, preventing falls, administering fluids, etc.

Nursing interventions refer to a set of activities or actions undertaken by a nurse in response to the diagnosis to achieve expected outcomes and meet a patient's goals.

The interventions majorly focus on eliminating or reducing the etiology of the nursing diagnosis. There are different types of nursing interventions:

• Independent nursing interventions . These are activities that the nurses can initiate based on their licensing, clinical judgment, and skills. They include ongoing assessments, emotional support, empathy, providing comfort, patient education, and referrals to other healthcare professionals.
• Dependent nursing interventions . These are activities undertaken through orders from physicians or supervisors. These can be orders to give specific medications, perform diagnostic tests, treatments, diets, or activities.
• Collaborative nursing interventions . Nurses undertake these actions in collaboration with other healthcare team members such as dietitians, physicians, social workers, and therapists.

When selecting a nursing intervention, it should be evidence-based, safe, appropriate for the client's age, health, and condition, and achievable. Every nursing intervention is followed with rationales, which are specific explanations about why a nursing intervention is the most appropriate given the diagnosis and the goals. When giving the rationales, you are expected to refer to your pathophysiological and psychological principles as a student. This means including in-text citations from peer-reviewed journals or clinical practice guidelines to support the choice of a specific intervention.

Nursing interventions are based on your identified needs during data collection or assessment. The timelines for the outcomes should reflect the anticipated length of stay and the individualized nurse-client expectations. You can create a mind map when conceptualizing the needs of the patient/client. The tool helps visualize the link between symptoms and interventions. It is why you will sometimes be asked by an instructor to do a NANDA concept or mind map before writing a nursing care plan assignment.

When writing a nursing strategy or intervention, you should be very specific. You should begin with an action verb that indicates what you are expected to do. You should also include qualifiers expressing how, when, where, time, amount, and frequency of the planned activity. For example:

• "Assist as needed with self-care activities each morning."
• "Record respiratory and pulse rates before, during, and after ambulating."
• "instruct the family in post-discharge care."

5. Evaluation and Documentation

This is the last step of the nursing care plan. As nursing care is provided, you will undertake ongoing assessments to evaluate the client's response to therapy and achieve the expected outcomes.

You should document the response to interventions, which is pretty much what evaluation is about. You can then adjust the care plan based on the information.

Evaluation helps identify the effectiveness of the nursing care plan. It also helps determine if the nursing processes were effective or if there is a need to terminate, continue, or change them.

When evaluating outcomes, you must label them as met, ongoing, or not. You can then decide whether the goals of the intervention need to be altered.

In most cases, all the goals are expected to be met by the time of discharge. However, you must prepare for that transition if a patient is discharged to a long-term care facility, nursing home, or hospice.

If everything is okay, you should document the nursing care plan (NCP) per the hospital's policy or standard operating procedure.

Nursing Care Plan Template for Nursing Students

Your instructor will give you a case study or patient scenario to write a nursing care plan. Some instructors also allow you to develop a nursing case study and write an appropriate nursing care plan. You can also use a real case from your shadowing, internship, or practicum experience. Whichever the case, you can use the template below if none is given. You should organize the nursing care plan into columns for easier entry and organization.

Your introduction should briefly revisit the case study. If requested, expound on the etiology of the medical diagnosis in the background section. The next section is your nursing care plan with columns of assessment, diagnosis, goals and outcomes, interventions, and evaluation, making it 5 columns . Some instructors only want three columns for nursing diagnosis, outcomes and evaluation, and interventions, while others insist on four columns for nursing diagnosis, goals and outcomes, interventions, and evaluation. Below is an example of the nursing care plan section:

The next section can include discharge planning, medication management, rest and activities, diet planning, ongoing care, sleeping, and follow-up.

Finally, write a conclusion that summarizes the entire nursing care plan and include a list of the references you used when writing the nursing care plan.

Sample Nursing Care Plan for Schizophrenia

Nursing Diagnosis : Ineffective coping skills and risk for hematologic side effects of Clozapine

Goals and expected outcomes

• To remain stable on medication and to transition into a less restrictive environment.
• Adequate rest and nutritional intake
• Establish communication and build trust, and encourage patients to participate in the therapeutic community.
• Increase ability to communicate with others.
• Symptom management; decrease in hallucination, delusions, and other psychotic features such as self-talk
• Increase self-esteem
• Subjective and Objective reduction of psychotic symptoms (an irrational behavior)
• Adhere to recommended therapy, including medications, psychotherapy, and lab appointments for hematology.

Nursing Interventions

• Assist the patient in identifying strengths and coping abilities ( nursing interventions) . Strength-based approaches help better recover schizophrenic patients (Xie, 2013). Emphasis on strength is a positive coping mechanism proven to buffer the impact of negative symptoms and promote rehabilitation of patients with schizophrenia (Tian et al., 2019). ( rationale)
• Meet monthly with the clinical team. Interprofessional teams help in the effective management of psychotic disorders such as schizophrenia. Psychiatrists and pharmacists can help improve the patient's status (Farinde, 2013).
• Obtain weekly Vital Signs. Interprofessional teams help in the effective management of psychotic disorders such as schizophrenia. Psychiatrists and pharmacists can help improve the patient's status (Farinde, 2013).
• Encourage all medications as prescribed. Adherence to pharmacological treatment helps alleviate the psychotic symptoms of schizophrenia, v. Non-adherence could lead to deterioration of the symptoms (El-Mallakh & Findlay, 2015).
• Provide opportunities for self-reflection, self-care, positive self-image, and effective communication. Encouraging healthy habits among schizophrenic patients helps optimize functioning, such as drug adherence, maintenance of sleep, reduced stress levels, self-care maintenance, and anxiety (Tian et al., 2019).
• Encourage outings and identify opportunities to reduce anxiety -enjoy music, poetry, and creative writing, and connect with a church spiritual group. Empathy helps the patient perceive the caregivers as caring and makes them feel accepted. It also helps the patients maintain positive coping mechanisms (Peixoto, Mour'o, & Serpa Junior, 2016).
• Monitor lab results (WBC and ANC) and report significant changes per Clozapine guidelines. Patients taking Clozapine must be monitored frequently as they are more predisposed to serious blood dyscrasias. In addition, discontinuing WBC monitoring after 6 months of starting the drug could lead to mortality and accidents (Kar, Barreto & Chandavarkar, 2016).
• Monitor for hematologic side effects: Neutropenia, leukopenia, agranulocytosis, and thrombocytopenia (secondary to bone marrow suppression caused by Clozapine). Clozapine has serious side effects such as seizures, cardiomyopathy, myocarditis, cardiomyopathy, neutropenia, ad agranulocytosis (Dixon & Dada, 2014).
• Instruct patient to report any side effects, illness, s/s of infection, fatigue, or bruising without apparent cause. Constant monitoring of psychotic symptoms helps change treatment (Holder, 2014). For instance, it can help determine if the antipsychotic medication is not working and include evidence-based psychosocial interventions (Stroup & Marder, 2015).
• Monitor anticholinergic effects; dry mouth, difficulty urinating, constipation.
• Monitor for reduction/increase of psychotic symptoms
• Discourage caffeine. Caffeine interacts with Clozapine and can lead to toxicosis. It increases the plasma concentrations of Clozapine (De Berardis et al., 2019). Caffeine inhibits the metabolism of Clozapine through the inhibition of CYP1A2 (Delacr�taz et al., 2018)
• The patient will have reduced symptoms, adhere to medication, and show improvement.
• The patient will control his feelings, perceptions, and thought processes.
• Social increasing ease of communication since starting Clozaril (date). The patient will easily interact with caregivers, family, and other patients.
• The patient will acknowledge the importance of medication in lowering suspicion.
• Self-talk has diminished since admission. The patient will also exhibit high self-esteem levels.
• The patient will have reduced anxiety and violent behavior and have remission.

Brekke, I. J., Puntervoll, L. H., Pedersen, P. B., Kellett, J., & Brabrand, M. (2019). The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review. PloS one , 14 (1), e0210875. https://doi.org/10.1371/journal.pone.0210875

De Berardis, D., Rapini, G., Olivieri, L., Di Nicola, D., Tomasetti, C., Valchera, A., ... & Serafini, G. (2018). Safety of antipsychotics for the treatment of schizophrenia: a focus on the adverse effects of Clozapine. Therapeutic advances in drug safety, 9(5), 237-256.

Delacr'taz, A., Vandenberghe, F., Glatard, A., Levier, A., Dubath, C., Ansermot, N.,  Eap, C. B. (2018). Association Between Plasma Caffeine and Other Methylxanthines and Metabolic Parameters in a Psychiatric Population Treated with Psychotropic Drugs Inducing Metabolic Disturbances. Frontiers in psychiatry , 9 , 573. https://doi.org/10.3389/fpsyt.2018.00573

Dixon, M., & Dada, C. (2014). How clozapine patients can be monitored safely and effectively.  The Pharmaceutical Journal, 6 (5), 131.

El-Mallakh, P., & Findlay, J. (2015). Strategies to improve medication adherence in patients with schizophrenia: the role of support services. Neuropsychiatric disease and treatment, 11 , 10771090. https://doi.org/10.2147/NDT.S56107

Farinde, A. (2013). Interprofessional Management of Psychotic Disorders and Psychotropic Medication Polypharmacy.  Health and Interprofessional Practice, 1 (4), 4.

Holder, D., S. (2014). Schizophrenia. American Family Physician, 90 (11), 775-782.

Kar, N., Barreto, S., & Chandavarkar, R. (2016). Clozapine Monitoring in Clinical Practice: Beyond the Mandatory Requirement. Clinical psychopharmacology and neuroscience: the official scientific journal of the Korean College of Neuropsychopharmacology, 14 (4), 323�329. https://doi.org/10.9758/cpn.2016.14.4.323

Lantta, T., H�t�nen, H. M., Kontio, R., Zhang, S., & V�lim�ki, M. (2016). Risk assessment for aggressive behavior in schizophrenia.  The Cochrane database of systematic reviews, 2016 (10). https://doi.org/ 10.1002/14651858.CD012397

Peixoto, M. M., Mour�o, A. C. D. N., & Serpa Junior, O. D. D. (2016). Coming to terms with the other's perspective: empathy in the relation between psychiatrists and persons diagnosed with schizophrenia.  Ciencia & saude coletiva, 21 (3), 881-890.

Stroup, T. S., & Marder, S. (2015). Pharmacotherapy for schizophrenia: Acute and maintenance phase treatment.  UpToDate .

Tian, C. H., Feng, X. J., Yue, M., Li, S. L., Jing, S. Y., & Qiu, Z. Y. (2019). Positive Coping and Resilience as Mediators between Negative Symptoms and Disability among Patients with Schizophrenia . Frontiers in psychiatry, 10 , 641.

Xie, H. (2013). Strengths-based approach for mental health recovery. Iranian journal of psychiatry and behavioral sciences, 7 (2), 5�10.

Writing the best nursing care plan can sound easy on paper, but the process is demanding and tiresome. If you are a nursing student who wants to delegate writing nursing care plans to someone who can help you do so accurately, affordably, and reliably, you can trust our care plan writers.

We are a nursing writing service website that offers assistance with completing various nursing assignments. The writers are experienced in research and writing nursing papers online. To date, we have supported the dreams of many nursing students, saving them time and money and maintaining their mental health.

Do not miss a deadline because you are busy with a shift; we can take over and make great things happen. Our nursing care plans are original, 100% plagiarism-free, and submitted to your email within your selected deadline. We also allow you to communicate with your writer to make changes together, share perspectives, and exchange ideas.

We can help you write care plans for type 2 diabetes, risk for injury, acute kidney injury, pressure ulcer, pulmonary embolism, chest pain, hypoglycemia, dementia, PTSD, hyperlipidemia, UTI, asthma, CHF, atrial fibrillation, bipolar disorder, risk for fall, ineffective coping, anemia, seizure, constipation, and any other condition or diagnosis.

Do not hesitate to contact us if you need help.

Important NOTICE!

The information in this article and the website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.

Related Readings:

• Topics for nursing essays and research papers.
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How to Write a Nursing Care Plan

Nursing care plan components, nursing care plan fundamentals.

Knowing how to write a nursing care plan is essential for nursing students and nurses. Why? Because it gives you guidance on what the patient’s main nursing problem is, why the problem exists, and how to make it better or work towards a positive end goal. In this article, we'll dig into each component to show you exactly how to write a nursing care plan. 

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A nursing care plan has several key components including, 

• Nursing diagnosis
• Expected outcome
• Nursing interventions and rationales

Each of the five main components is essential to the overall nursing process and care plan. A properly written care plan must include these sections otherwise, it won’t make sense!

• Nursing diagnosis - A clinical judgment that helps nurses determine the plan of care for their patients
• Expected outcome - The measurable action for a patient to be achieved in a specific time frame. 
• Nursing interventions and rationales - Actions to be taken to achieve expected outcomes and reasoning behind them.
• Evaluation - Determines the effectiveness of the nursing interventions and determines if expected outcomes are met within the time set.

>> Related: What is the Nursing Process?

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Before writing a nursing care plan, determine the most significant problems affecting the patient. Think about medical problems but also psychosocial problems. At times, a patient's psychosocial concerns might be more pressing or even holding up discharge instead of the actual medical issues. 

After making a list of problems affecting the patient and corresponding nursing diagnosis, determine which are the most important. Generally, this is done by considering the ABCs (Airway, Breathing, Circulation). However, these will not ALWAYS be the most significant or even relevant for your patient. 

Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and objective nursing data . Subjective data is what the patient tells us their symptoms are, including feelings, perceptions, and concerns. Objective data is observable and measurable.

This information can come from, 

Verbal statements from the patient and family

Vital signs

Blood pressure

Respirations

Temperature

Oxygen Saturation

Physical complaints

Body conditions

Head-to-toe assessment findings

Medical history

Height and weight

Intake and output

Patient feelings, concerns, perceptions

Laboratory data

Diagnostic testing

Echocardiogram

Step 2: Diagnosis

Using the information and data collected in Step 1, a nursing diagnosis is chosen that best fits the patient, the goals, and the objectives for the patient’s hospitalization. 

According to North American Nursing Diagnosis Association (NANDA), defines a nursing diagnosis as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.”

A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid and helps prioritize treatments. Based on the nursing diagnosis chosen, the goals to resolve the patient’s problems through nursing implementations are determined in the next step. 

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There are 4 types of nursing diagnoses.  

Problem-focused - Patient problem present during a nursing assessment is known as a problem-focused diagnosis

Risk - Risk factors require intervention from the nurse and healthcare team prior to a real problem developing

Health promotion - Improve the overall well-being of an individual, family, or community

Syndrome - A cluster of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions

After determining which type of the four diagnoses you will use, start building out the nursing diagnosis statement. 

The three main components of a nursing diagnosis are:

Problem and its definition - Patient’s current health problem and the nursing interventions needed to care for the patient.

Etiology or risk factors - Possible reasons for the problem or the conditions in which it developed

Defining characteristics or risk factors - Signs and symptoms that allow for applying a specific diagnostic label/used in the place of defining characteristics for risk nursing diagnosis

PROBLEM-FOCUSED DIAGNOSIS

Problem-Focused Diagnosis related to ______________________ (Related Factors) as evidenced by _________________________ (Defining Characteristics).

RISK DIAGNOSIS

The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as evidenced by __________________________ (Risk Factors).

Step 3: Outcomes and Planning

After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-based practices. SMART is an acronym that stands for,

It is important to consider the patient’s medical diagnosis, overall condition, and all of the data collected. A medical diagnosis is made by a physician or advanced healthcare practitioner.  It’s important to remember that a medical diagnosis does not change if the condition is resolved, and it remains part of the patient’s health history forever. 

Examples of medical diagnosis include, 

Chronic Lung Disease (CLD)

Alzheimer’s Disease

Endocarditis

Plagiocephaly 

Congenital Torticollis 

Chronic Kidney Disease (CKD)

It is also during this time you will consider goals for the patient and outcomes for the short and long term. These goals must be realistic and desired by the patient. For example, if a goal is for the patient to seek counseling for alcohol dependency during the hospitalization but the patient is currently detoxing and having mental distress - this might not be a realistic goal. 

Step 4: Implementation

Now that the goals have been set, you must put the actions into effect to help the patient achieve the goals. While some of the actions will show immediate results (ex. giving a patient with constipation a suppository to elicit a bowel movement) others might not be seen until later on in the hospitalization. 

The implementation phase means performing the nursing interventions outlined in the care plan. Interventions are classified into seven categories: 

Physiological

Complex physiological

Health system interventions

Some interventions will be patient or diagnosis-specific, but there are several that are completed each shift for every patient:

Pain assessment

Position changes

Fall prevention

Providing cluster care

Infection control

Step 5: Evaluation 

The fifth and final step of the nursing care plan is the evaluation phase. This is when you evaluate if the desired outcome has been met during the shift. There are three possible outcomes, 

Based on the evaluation, it can determine if the goals and interventions need to be altered. Ideally, by the time of discharge, all nursing care plans, including goals should be met. Unfortunately, this is not always the case - especially if a patient is being discharged to hospice, home care, or a long-term care facility. Initially, you will find that most care plans will have ongoing goals that might be met within a few days or may take weeks. It depends on the status of the patient as well as the desired goals. 

Consider picking goals that are achievable and can be met by the patient. This will help the patient feel like they are making progress but also provide relief to the nurse because they can track the patient’s overall progress. 

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Nursing care plans contain information about a patient’s diagnosis, goals of treatment, specific nursing interventions, and an evaluation plan. The nursing plan is constantly updated with changes and new subjective and objective data. 

Key aspects of the care plan include,

Outcome and Planning

Implementation

Through subjective and objective data, constantly assessing your patient’s physical and mental well-being, and the goals of the patient/family/healthcare team, a nursing care plan can be a helpful and powerful tool.

*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.

Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

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How to Write a Care Plan: A Guide for Nurses

Care plans are a way to strategically approach and streamline the nursing process. They also enable effective communication in a nursing team. This guide will help you understand the fundamentals of nursing care plans and how to create them, step by step. We’ll also outline best practices to keep in mind and provide you with a nursing care plan sample that you can download and print.

Table of Contents

What Is a Nursing Care Plan?

What are the components of a care plan, care plan fundamentals, sample nursing care plan.

A nursing care plan documents the process of identifying a patient’s needs and facilitating holistic care, typically according to a five-step framework. A care plan ensures collaboration among nurses, patients, and other healthcare providers. ((M. Vera., “Nursing Care Plans (NCP): Ultimate Guide and Database”, July 5, 2021: https://nurseslabs.com/nursing-care-plans/ )) ((Medical Dictionary for the Health Professions and Nursing, Farlex, “nursing care plan”, 2012: https://medical-dictionary.thefreedictionary.com/nursing+care+plan )) ((Health Navigator, “Care planning”, April 6, 2021: https://www.healthnavigator.org.nz/clinicians/c/care-planning/ )) ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/ ))

Key Reasons to Have a Care Plan

The purpose of a nursing care plan is to document the patient’s needs and wants, as well as the nursing interventions (or implementations) planned to meet these needs. As part of the patient’s health record, the care plan is used to establish continuity of care. ((C. Björvell et al., “Development of an audit instrument for nursing care plans in the patient record,” Quality in Health Care , March 1, 2000: https://qualitysafety.bmj.com/content/qhc/9/1/6.full.pdf )) These are the main reasons to write a care plan:

• Patient-centered care 

A care plan helps nurses and other care team members organize aspects of patient care according to a timeline. It’s also a tool for them to think critically and holistically in a way that supports the patient’s physical, psychological, social, and spiritual care. Sometimes a patient should be assigned to a nurse with specific skills and experience; a care plan makes that process easier. For patients, having clear goals to achieve will make them more involved in their treatment and recovery. ((Health Navigator, “Care planning”, April 6, 2021: https://www.healthnavigator.org.nz/clinicians/c/care-planning/ ))

• Nursing team collaboration

Writing a care plan allows a team of nurses (as well as physicians, assistants, and other care providers) to access the same information, share opinions, and collaborate to provide the best possible care for the patient. 

• Documentation and compliance

A well-written care plan allows nurses to measure the effectiveness of care and to record evidence that the care was given. This is important both to maximize care efficiency and to provide documentation for healthcare providers.

Care plans are structured as a five-step framework: assessment, diagnosis, outcomes and planning, implementation, and evaluation. ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/ ))

Step 1: Assessment

The first step of writing a care plan requires critical thinking skills and data collection. Different healthcare organizations use different formats for the assessment phase. In general, the data you will collect here is both subjective (e.g., verbal statements) and objective (e.g., height and weight, intake/output). The source of the subjective data could be the patients or their caretakers, family members, or friends.

Nurses can gather data about the patient’s vital signs, physical complaints, visible body conditions, medical history, and current neurological functioning. Digital health records may help in the assessment process by populating some of this information automatically from previous records.

Step 2: Diagnosis

Using the collected data, you will develop a nursing diagnosis—which the North American Nursing Diagnosis Association (NANDA) defines as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.” ((NANDA, “Glossary of Terms”: https://nanda.org/publications-resources/resources/glossary-of-terms/ )) 

A nursing diagnosis sets the basis for choosing nursing actions to achieve specific outcomes. A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid ((Saul McLeod, “Maslow’s Hierarchy of Needs,” Simply Psychology , Dec. 29, 2020: https://www.simplypsychology.org/maslow.html )) (which identifies and ranks human needs) and helps prioritize treatments. For example, physiological needs (such as food, water, and sleep) are more fundamental to survival than love and belonging, self-esteem, and self-actualization, so they have the priority when it comes to nursing actions. ((Chiung-Yu Shih et al, “The association of sociodemographic factors and needs of haemodialysis patients according to Maslow’s hierarchy of needs,” Journal of Clinical Nursing , July 30, 2018: https://pubmed.ncbi.nlm.nih.gov/29777561/ ))

Based on the diagnosis, you’ll set goals (Step 3) to resolve the patient’s problems through nursing implementations (Step 4).

Step 3: Outcomes and Planning

After the diagnosis is the planning stage. Here, you will prepare SMART goals (more detail on this later) based on evidence-based practice (EBP) guidelines. You will consider the patient’s overall condition, along with their diagnosis and other relevant information, as you set goals for them to achieve desired and realistic health outcomes for the short and long term. 

Step 4: Implementation

Once you’ve set goals for the patient, it’s time to implement the actions that will support the patient in achieving these goals. The implementation stage consists of performing the nursing interventions outlined in the care plan. As a nurse, you will either follow doctors’ orders for nursing interventions or develop them yourself using evidence-based practice guidelines.

Interventions are classified into the following seven domains: family, behavioral, physiological, complex physiological, community, safety, and health system interventions. There are several basic interventions that you need to implement during each shift: pain assessment, changing the resting position, listening, cluster care, preventing falls, and fluid consumption.

Step 5: Evaluation

In the final step of a care plan, the health professional (who can be either a doctor or a nurse) will evaluate whether the desired outcome has been met. You will then adjust the care plan based on this information.

In a simple but useful way, Nurse.org explains the core questions your care plan should answer: what, why, and how. ((Mariam Yazdi, “4 Steps to Writing a Nursing Care Plan,” Nurse.org, March 23, 2018: https://nurse.org/articles/nursing-care-plan-how-to/ )) A nursing care plan should include:

• The What : What does the patient suffer from? What do they risk suffering from?
• The Why : Why does your patient suffer from this? Why do they risk suffering from this?
• The How : How can you make this better?

Successful care plans use the fundamental principles of critical thinking, client-centered techniques, goal-oriented strategies, evidence-based practice (EBP) recommendations, and nursing intuition. ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/ ))

SMART Goals

In the planning phase of writing a care plan, it’s important that you use goal-oriented strategies. A SMART goals template can help in this process:

• Specific : Your goals for the patient must be well-defined and unambiguous. 
• Measurable : You need to set certain metrics to measure the patient’s progress toward these goals.
• Achievable : Their goal should be possible to achieve.
• Realistic : Their goals must be within reach and relevant to the overall care plan.
• Time-bound : The patient’s goals should have a clear starting time and end date (which can be flexible). 

Effective Communication

Unless your care plan is communicated effectively to all relevant stakeholders, it will only be a plan. Remember that the purpose of a nursing care plan is not to be a static document, but to guide the entire nursing process and enable teamwork, with the goal of improving care. Writing skills are crucially important for nurses—you’ll need to be as accurate and current as possible in your descriptions. For effective communication, keep in mind the following best practices when writing a care plan:

• Write down everything immediately so you don’t forget the details.
• Write clearly and concisely, using terms that your team will understand.
• Include dates and times.

Although you will learn communication skills in an undergraduate or graduate nursing program , you will also develop them over time and with practical experience. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/ ))

Shareable and Easy to Access

Care plans also need to be easy to share with the relevant stakeholders—patients, doctors, other members of the nursing team, insurance companies, etc. The documentation format will vary according to hospital policy , but, in general, care plans are created in electronic format and integrated into the electronic health record (EHR) for easy access to everyone. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/ ))

Finally, you will need to update your care plans often with the latest information. That implies checking in with patients frequently and recording data about how the patient is progressing toward their goals, which will be important in the evaluation stage of the care plan. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/ ))

Despite the overall general objective, nursing care plans written by students are not the same as those created by registered nurses in clinical settings. The student version is much longer, has a greater level of detail, and is exhaustively thorough. On the other hand, nurses often assume some basic concepts and note some of the steps in the care plan only mentally. ((M. Vera., “Nursing Care Plans (NCP): Ultimate Guide and Database”, July 5, 2021: https://nurseslabs.com/nursing-care-plans/ ))

For example, in the interventions section, a student would write: “vital signs recorded every four hours: blood pressure, heart rate, three- or five-lead electrocardiograms, functional oxygen saturation, respiratory rate, and skin temperature,” while an experienced registered nurse might just write “Q4 vital signs.”

Why this difference? As a student or recent graduate, including all the information in your care plan will help you solidify your training. While writing care plans in school can be a very time-consuming task, mastering this information in nursing school will improve your competency and confidence. Most of the information that you’ll have to look up while you’re still in school will become second nature in the future. Here’s what a care plan written by a student looks like:

• Assessment : “heart rate 100 bpm, dyspnea, restlessness, guarding behavior.”
• Diagnosis : “impaired gas exchange RT collection of mucus in airway.”
• Outcomes and planning : “patient must maintain optimal gas exchange.”
• Implementations : “assess respiration; encourage breathing and position changes.”
• Rationale : “respiration will indicate the level of lung involvement, as the patient will adjust their breathing to facilitate gas exchange; these will improve ventilation and allow for chest expansion.”
• Evaluation : “the patient maintained good gas exchange, normal respiratory rate.”

Note that student care plans often have an additional column—rationale—where students note the scientific explanation for the implementations they chose. To help you get started with a care plan writing practice, we’ve created a printable nursing care plan, which you can use to practice writing all the steps outlined in this article.

Wrapping Up: Writing an Effective Nursing Care Plan

To be successful, a nursing plan needs effective communication, goal-oriented tasks, accessibility and shareability, and evidence-based practice. 

When it meets these qualities and is supported by the nurse’s intuition, critical thinking, and a general focus on the patient, a nursing care plan becomes a go-to resource for nurses to record and access all the information they need. A care plan is your roadmap for effective nursing care, and a collaboration tool that improves the entire healthcare process.

While all nursing programs teach the basics of writing a care plan, your communication, goal setting, and critical thinking skills will be shaped by the program you attend. 

For example, one of the benefits of writing care plans is that it will allow you to develop professionalism , along with important values like accountability, respect, and integrity. Key results of professionalism include better overall care, improved team communication, and a more positive work environment. ((Nursco, “Professionalism in Nursing – 5 Tips for Nurses,” July 13, 2018: https://www.nursco.com/professionalism-nursing-5-tips-nurses/ )) 

That’s why it’s important that you choose the right program for your needs—one that will help you develop communication and critical thinking skills, as well as professionalism, to be ready for the day-to-day nursing life. 

The University of St. Augustine for Health Sciences (USAHS) offers a Master of Science in Nursing degree (MSN), a Doctor of Nursing Practice degree (DNP), and Post-Graduate Nursing Certificates designed for working nurses. Our degrees are offered online, with optional on-campus immersions.* Role specialties include Family Nurse Practitioner (FNP), Nurse Educator ,** and Nurse Executive . The MSN has several options to accelerate your time to degree completion. Earn your advanced nursing degree while keeping your work and life in balance.

*The FNP role specialty includes two required hands-on clinical intensives as part of the curriculum.

**The Nurse Educator role specialty is not available for the DNP program.

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Nursing Care Plan (+ Template)

Table of contents, what is a nursing care plan .

A nursing care plan is a written document detailing the nursing interventions that will be done to meet a client’s needs and health goals. It serves as a guide for personalized care of the client and facilitates communication in the healthcare team. 

What is a nursing intervention? 

Nursing interventions are actions in a care plan, such as patient education or treatments. They are formed using patient feedback, evidence-based sources, and the nursing process. 

How to write a nursing care plan 

How to prepare a nursing care plan using the 5-step nursing process (adpie):.

Following the nursing diagnoses that were formed based on a thorough assessment (history, physical assessment, focused assessment), a clear plan of care goals, interventions, and desired outcomes is defined. 

Nursing tip: Gather information in a logical and informed way to provide the best care possible. 

Nursing tip: To address each intervention to assess quality in patient care, goals need to be SMART: 

• M easurable
• A ttainable

Discuss with your client which health goals they would like to achieve. 

Nursing care plan template & examples

Once the client’s goals are established, nursing interventions (NIC) and standard nursing outcomes (NOC) can be used to guide patient care. 

They can, for example, be presented in the nursing care plan in a column-based format: 

Examples of goals could be: 

• Stage 1 pressure ulcer will resolve
• Client demonstrates insulin injection procedure
• Client reports pain level < 4 with ambulation

Examples of fitting nursing interventions could be: 

• Reposition client every 2 hours
• Request diabetes education consult
• Administer pain medication 1 hour before physical therapy

Examples of possible outcomes could be: 

• Reduced redness in lower back area
• Client demonstrates self-injection techniques
• Client ambulates 100 feet twice a day

Nursing intervention examples (practice questions)

Which nursing intervention is placed in the plan of care for a client diagnosed with osteoarthritis.

Answer options:

• Apply a cold compress to the affected joint for 15–20 minutes
• Encourage high-impact exercise like jogging
• Administer IV antibiotics as prescribed
• Start a weight-lifting program for strength

Correct answer:

• Applying a cold compress to the affected joint for 15–20 minutes.

Explanation: 

Cold compresses can help reduce inflammation and relieve pain in osteoarthritis. High-impact exercise and lifting weights can worsen the condition, and antibiotics are not used for osteoarthritis, as it’s not caused by an infection.

A client is diagnosed with hypervolemia. Which is the priority nursing intervention?

• Encourage fluid intake hourly
• Monitor weight and strict I & O
• Administer bronchodilators
• Initiate cardiac monitoring

      2. Monitor weight and intake and output carefully.

In hypervolemia, fluid overload is a concern. Monitoring weight and intake and output allows for accurate assessment and helps guide treatment. More fluid intake would exacerbate the problem, and bronchodilators are not directly related to fluid volume management. Cardiac monitoring is not required as no cardiac problem is identified.

A client has completed a bone marrow biopsy. Which nursing intervention is the priority action post-procedure?

• Elevate the extremity where the biopsy was taken
• Administer a dose of intravenous antibiotics
• Apply pressure to the biopsy site
• Use heating pad at site on low setting

      3. Apply pressure to the biopsy site.

Applying pressure to the biopsy site helps prevent hemorrhage and facilitates clot formation. Elevating the extremity and administering antibiotics are not generally the priority interventions post-bone marrow biopsy. Ice packs, not heat, can be used for short periods of time for tenderness.

Which nursing intervention is essential in caring for a client diagnosed with compartment syndrome?

• Apply ice to the affected extremity.
• Elevate the affected limb above heart level.
• Loosen or remove the tight bandage or cast.
• Alert the Rapid Response Team.

       3. Loosen or remove the tight bandage or cast.

Compartment syndrome is caused by increased pressure within a muscle compartment, which can compromise circulation to the area. If a tight bandage or cast is contributing to the pressure, it should be loosened or removed to alleviate the pressure. The other answers could potentially worsen the condition. The Rapid Response Team is notified for imminent deterioration, which this client is not manifesting

The nurse cares for a client diagnosed with pyelonephritis. Which nursing intervention does the nurse include in the plan of care?

• Encourage fluid restriction.
• Administer prescribed antibiotics.
• Apply a heating pad to the lower back.
• Instruct client to keep blood glucose lower.

      2. Administer prescribed antibiotics.

Pyelonephritis is a bacterial infection of the kidneys that usually requires antibiotic treatment for resolution. Fluid restriction is generally not recommended; in fact, increased fluids may be encouraged. A heating pad may provide temporary relief but doesn’t treat the underlying infection. If the client does have diabetes mellitus, it does increase the risk for pyelonephritis, but no mention of this is given. 

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Nursing Care Plan - Tips, Samples & Writing Guide

Ever wondered how nurses seamlessly take over care for a patient they've never met? How do they prioritize and know what actions to take? The answer lies in the nursing care plan—a vital tool that guides their critical thinking and patient care from the moment they start their shift.

This plan not only organizes the care process but also ensures clear communication among the nursing team. Without it, communication can become disjointed, patient information may be scattered, and important details might be overlooked, especially during hectic shifts.

In this article, the experts at our essay services will explain the essentials of care plans, how they're created, key practices to stick to, and give nursing care plan examples that can serve as practical templates.

What is a Nursing Care Plan

A nursing care plan outlines the specific needs and care required for a patient, serving as a vital tool for nurses, patients, and healthcare providers to collaborate effectively. It documents the patient's health journey consistently.

Nursing care planning begins upon admission and adapts as the patient's condition changes. The aim is to deliver tailored care that meets the patient's individual needs, whether in acute care, illness prevention, rehabilitation, or maintaining well-being. Even in cases where recovery isn't feasible, nursing care focuses on pain management and ensuring comfort.

By using a problem-solving process that combines nursing skills, systems theory, and the scientific method, nursing care plans become effective and personalized. This approach guarantees that each patient receives the best care for their unique needs. If you're feeling unsure, let us guide you with our nursing paper help until you gain confidence!

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Why Do People Use Nursing Care Plans?

People use nursing care plans because they contribute significantly to the overall quality, safety, and efficiency of healthcare delivery. Here's a more detailed look:

As you become more familiar with the nursing field, head over to our article that explains healthcare management salary entry-level in more detail.

Types of Nursing Care Plans

There are four main types of care plans that ensure patients get the right care tailored to their needs, with quality and consistency across different healthcare settings. Let's take a closer look at each one.

Formal Care Plans

Formal care plans detail specific nursing interventions based on standardized diagnoses and assessment data. They offer a structured approach to care, ensuring consistent and thorough treatment among different healthcare providers.

Main components:

• Detailed patient history and assessment data.
• Standardized nursing diagnoses.
• Specific, measurable goals and outcomes.
• Step-by-step nursing interventions.
• Evaluation criteria to assess progress.
• Long-term care facilities.

Informal Care Plans

Informal care plans are less structured and created on-the-go by nurses to address immediate patient needs and priorities. These plans are flexible and easily adaptable to changes in patient conditions or unexpected events. They allow for rapid response to patient needs, are highly adaptable to varying situations and useful in environments where quick decision-making is essential.

Characteristics:

• Created spontaneously based on real-time patient assessment.
• Focus on immediate and short-term needs.
• Flexible and adaptable to changing conditions.
• Outpatient settings.
• Emergency situations.

Standardized Care Plans

Standardized care plans are pre-written templates that outline interventions for common health conditions or procedures. They streamline care delivery by offering evidence-based guidelines that can be customized for individual patients.

Components:

• Templates based on best practices and clinical guidelines.
• Commonly used for frequent conditions (e.g., diabetes, hypertension).
• Includes standard interventions and expected outcomes.
• Surgical units.
• Rehabilitation centers.
• General medical wards.

Individualized Care Plans

Individualized care plans adapt to the unique circumstances and goals of each patient. They promote patient-centered care by involving patients in decision-making and addressing their specific health concerns.

Components :

• Comprehensive patient assessment.
• Personalized goals and outcomes.
• Custom interventions based on patient preferences and needs.
• Continuous evaluation and modification based on patient feedback and progress.
• Primary care clinics.
• Mental health facilities.
• Specialized care units (e.g., oncology, pediatrics).

Nursing Process: What are the 5 Main Components of a Care Plan?

The nursing process began in the 1950s with three steps: assessment, planning, and evaluation. These steps, based on scientific methods, included observing, measuring, gathering data, and analyzing findings. Over time, the process evolved to five steps and became essential in nursing education and practice.

Nursing Process Example

Here is an example illustrating how the nursing process unfolds:

A nurse assesses a patient who recently suffered a fall at home. The patient complains of sharp pain in their lower back, rated at 8 out of 10. After a thorough assessment, including imaging tests confirming a vertebral compression fracture, the nurse identifies acute pain as a nursing diagnosis. The nurse then starts planning on alleviating pain and promoting comfort. This involves administering prescribed pain relief medication intravenously and positioning the patient with supportive pillows. To evaluate the effectiveness of these interventions, the nurse asks the patient to rate their pain regularly on a scale of 0 to 10. Based on the patient's feedback, the nurse decides whether the interventions need adjustment or have been successful in managing the pain effectively.

Can’t wait to step into similar processes? First, let's see how long is a nursing school and find out how much time you need to start the career you truly enjoy.

How to Write a Nursing Care Plan

Now that you have a grasp of the fundamentals, let's proceed to writing a nursing care plan. This plan will follow the five steps we've covered. To make each step clearer, we'll go through some examples to help you learn more effectively.

Step 1: Assess the Patient's Condition

The first step in creating a nursing care plan is to assess the patient's condition thoroughly. This means carefully observing and gathering information about the patient's health status to understand their needs and challenges.

For example, a nurse might check the patient's vital signs like blood pressure, pulse rate, and temperature. They may also ask the patient questions about their symptoms, medical history, and any medications they are taking. Observing how the patient moves and interacts can also provide valuable insights into their condition.

In addition to direct observation, nurses may review medical records or consult with other healthcare providers to gather a complete picture of the patient's health. Assessment involves both subjective and objective data. Subjective data includes what the patient tells the nurse about how they feel, such as pain levels or concerns. Objective data includes measurable information like lab results or physical measurements.

Step 2: Determine Nursing Diagnoses

The next step in creating nursing care plans involves analyzing the data collected during the assessment. The goal is to pinpoint the specific health problems that the nursing interventions will focus on addressing.

Nursing diagnoses are clinical judgments about a patient's responses to health conditions or life processes. These diagnoses help nurses prioritize and plan interventions to address the patient's needs effectively.

For instance, based on assessment findings, a nurse might identify nursing diagnoses such as "Impaired Physical Mobility related to recent surgery" or "Ineffective Breathing Pattern related to chronic obstructive pulmonary disease (COPD)."

To determine nursing diagnoses, nurses use standardized classification systems like NANDA-I (North American Nursing Diagnosis Association International). These systems provide a framework for identifying common health issues and their related factors.

Step 3: Establish Goals with the Patient

When establishing goals, the nurse collaborates with the patient to set achievable and meaningful outcomes. This involves discussing with the patient what they hope to achieve in terms of their health and well-being.

For example, goals could include improving mobility after surgery, managing pain effectively, or achieving a certain level of independence in daily activities.

Goals should be SMART: Specific, Measurable, Achievable, Relevant, and Time-bound. This means they should clearly define what is to be achieved, how progress will be measured, and within what timeframe.

Involving the patient in goal-setting empowers them to take an active role in their own care and increases their motivation to participate in interventions. It also ensures that the care plan aligns with the patient's values and preferences, which can improve overall satisfaction and outcomes.

Step 4: Carry Out Nursing Interventions

The next step in writing a nursing care plan is to carry out interventions that are based on evidence-based practices and address the specific nursing diagnoses identified earlier. They can include a wide range of activities such as administering medications, providing wound care, assisting with activities of daily living, educating patients and families about health conditions and self-care, and implementing safety measures.

For example, if a patient's goal is to manage pain effectively, nursing interventions may include administering pain medications as prescribed, applying heat or cold therapy, teaching relaxation techniques, and monitoring the patient's response to treatment.

Nurses collaborate with other healthcare team members and use their clinical judgment to determine the most appropriate interventions for each patient. They also reassess and adjust interventions as needed based on the patient's response and changing health status.

Step 5: Evaluate Progress and Adjust the Care Plan Accordingly

Evaluation includes comparing the patient's current health status with the baseline established during the initial assessment. Nurses use both subjective feedback from the patient and objective data such as vital signs, lab results, and observations to measure progress.

For example, if a goal was set to improve a patient's mobility after surgery, the nurse would assess the patient's ability to move independently, any pain or discomfort experienced, and whether mobility aids are still necessary.

Based on the evaluation findings, the nurse determines whether the interventions are effective in meeting the patient's goals. If progress is satisfactory, the care plan may continue as planned. However, if goals are not being met or if there are new developments in the patient's condition, adjustments to the care plan are necessary.

Adjustments may involve modifying existing interventions, adding new interventions, or revising the goals themselves to better reflect the patient's current needs and priorities. This iterative process ensures that the care plan remains dynamic and responsive to the patient's changing health status.

Nursing Care Plan Examples

Below you'll find nursing care plan examples pdf to help you understand the concepts we've discussed. These examples show how nurses plan and provide care in real situations, giving you practical insights into effective patient care strategies.

7 Tips for Effective Care Planning

Before you start writing a nursing care plan, follow these tips from our professional custom writing service to ensure that your plan is effective, patient-centered, and supportive of positive health outcomes.

• Involve the Patient : Include the patient in setting goals and planning care. Their input helps tailor the plan to their needs and preferences.
• Be Specific : Set clear and detailed goals that are measurable and achievable. This helps track progress and ensures everyone understands what needs to be accomplished.
• Use Evidence-Based Practices : Base your interventions on proven methods and best practices in nursing so that the care provided is effective and safe.
• Collaborate with the Healthcare Team : Work closely with doctors, therapists, and other healthcare providers. Collaboration ensures comprehensive care and coordination across disciplines.
• Regularly Evaluate and Adjust : Continuously assess the patient's progress and adjust the care plan as needed. This keeps the plan relevant and responsive to changes in the patient's condition.
• Educate the Patient and Family : Provide clear instructions and education about the care plan. This empowers the patient and family to participate actively in their own care and promotes better outcomes.
• Document Thoroughly : Keep detailed records of assessments, interventions, and evaluations. Good documentation supports continuity of care and helps communicate the patient's status to the healthcare team.

The Bottom Line

As we conclude, remember the key takeaway: in order to provide the best care for each patient, follow these steps—assess, diagnose, plan, implement, and evaluate. Remember, failing to plan is planning to fail. By carefully creating your nursing plan and following a nursing student resume you'll keep things organized, make smart decisions, and adjust quickly to any changes in your patient's condition!

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• Ernstmeyer, K., & Christman, E. (2021). Chapter 4 Nursing Process . National Library of Medicine; Chippewa Valley Technical College. https://www.ncbi.nlm.nih.gov/books/NBK591807/
• Toney-Butler, T. J., & Thayer, J. M. (2023, April 10). Nursing Process . National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499937/  
• Doenges, M., & Murr. (n.d.). The very best patient care begins with the very best care planning resources …now and throughout your career! Nurse’s Pocket Guide diagnoses, Prioritized interventions and rationales . https://alraziuni.edu.ye/uploads/pdf/Nursing-Care-Plans-Edition-9-Murr-Alice-Doenges-Marilynn-Moorehouse-Mary.pdf  

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Nursing Care Plan Guide

If you ask someone what a nurse does, they will likely say, “Take care of people.”

While that is true, there’s much more to nursing than providing bedside care. Nurses must retain a lot of information on various diseases, conditions, and treatments to provide the best care possible.

They must also have critical thinking skills to assess and meet each client’s needs.

One way nurses organize, prioritize, and manage client care is through nursing care plans.

In this guide, we’ll explore the types of nursing care plans, why they’re essential, and how to create them.

What is a Nursing Care Plan?

The significance of nursing care plans, understanding formal vs. informal care planning.

• Exploring Standardized vs. Individualized Care Plans 

Care Plan for a Client with Type 2 Diabetes

Care plan for a client with hypertension, short-term vs. long-term goals: strategy and implementation, deciphering nursing interventions: independent, dependent, and collaborative, pro tips for optimal care planning, need a plan to navigate nursing school.

A nursing care plan outlines the type of care a client needs and the steps nurses will take to meet them.

  It’s a dynamic tool that evolves with the client’s condition, guiding nursing interventions and ensuring continuity of care.

  Creating a nursing care plan is critical to ensure client safety, quality of care, and legal documentation.

  It also facilitates communication among the healthcare team and supports the nursing workflow. Let’s explore some of these in more detail.

• Organization: Care plans help nurses organize all the information they need to know about their client’s current conditions and potential complications. This includes medical histories, medications, lab results, and more.
• Prioritization: Nursing care plans help nurses prioritize their client’s needs based on the most urgent or critical issues.
• Communication: Care plans also serve as a tool for communication between healthcare team members. Nurses can share information with other healthcare professionals directly involved in the client’s care.
• Continuity of Care: Nursing care plans provide a consistent framework for client care. This helps to ensure that all caregivers have all the necessary information to carry out the proper interventions.
• Documentation: Finally, nursing care plans serve as a formal record of the care provided to the client. This is important for legal purposes, tracking progress, and adjusting the plan.

Suppose a nurse has a client with high blood pressure. In that case, creating a nursing care plan helps the nurse monitor the client’s blood pressure levels, track the effectiveness of interventions, and communicate with other healthcare professionals about potential complications.

Formal care planning involves the systematic development of nursing care plans using standardized formats and protocols.

These plans adhere to established guidelines. In contrast, informal care planning may involve quick, on-the-spot decision-making based on clinical judgment and experience.

Exploring Standardized vs. Individualized Care Plans  

Nurses may use several different types of nursing care plans depending on the type of client and their specific healthcare needs.

These include:

• Standardized: Standardized care plans provide a general framework applicable to most clients with similar conditions. For example, a client with diabetes may have a standardized care plan that outlines general interventions for managing their blood sugar levels.
• Individualized: Individualized care plans are tailored to meet each client’s specific needs . This type of planning requires a thorough assessment of the client’s health status, preferences, and goals. For example, a client with diabetes who also has high blood pressure may require an individualized care plan that addresses both conditions.

What Do You Write In a Nursing Care Plan?

A nursing care plan includes the client’s health status, potential risks, and desired outcomes.

It also includes the actions and interventions nurses take to achieve those outcomes.  

What Are the Five Components of a Nursing Care Plan?  

The foundation of any nursing care plan is the ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation) nursing process .

Each part plays a crucial role:

• Assessment: This is the first step in developing a care plan and involves gathering information about the client’s health status, medical history , and current needs.
• Diagnosis : Based on the collected information, nurses identify potential health problems or risk factors that require intervention. E.g., (Medical diagnosis – Pneumonia) (Nursing diagnosis – Ineffective airway clearance)
• Planning: This step involves setting goals and developing interventions to achieve them.
• Implementation: In this step, the nurse carries out the interventions selected in the previous step. This can involve administering medications, completing skills, providing client education, and coordinating with other healthcare professionals.
• Evaluation: The last step is to evaluate the effectiveness of the care plan in meeting the desired outcomes. If necessary, a nurse makes adjustments to improve the plan.

An easy way to remember ADPIE is to think of it as A D elicious PIE that the nurse carefully prepares for their client’s well-being.

Here are two nursing care plan examples.

• Medical history includes Type 2 diabetes
• Blood glucose levels consistently above the normal range
• Difficulty controlling blood sugar levels through diet and exercise alone
• Diagnosis: At risk for unstable blood glucose related to poorly managed diabetes
• Provide education on the proper administration of insulin injections.
• Coordinate meal planning with a registered dietitian to control carbohydrate intake.
• Recommend a regular exercise routine tailored to the client’s abilities.
• Administer prescribed insulin as directed and monitor blood glucose levels regularly.
• Coordinate with a registered dietitian to develop a personalized meal plan.
• Assist the client in incorporating regular exercise into their daily routine.
• After one month, blood glucose levels have consistently stayed within the normal range.
• Client reports feeling more knowledgeable and in control of their diabetes management.
• Adjust care plan as needed based on ongoing evaluations and client feedback.
• History of high blood pressure
• Blood pressure readings consistently above the normal range
• Client reports experiencing headaches and dizziness
• Diagnosis: At risk for potential complications related to uncontrolled high blood pressure
• Educate the client on the importance of taking prescribed medication as directed by their healthcare provider (HCP).
• Encourage a healthy, low-sodium diet high in fruits and vegetables.
• Recommend regular physical activity such as brisk walking or swimming.
• Monitor blood pressure regularly and adjust medication based on the HCP’s recommendation.
• Work with client to develop a personalized meal plan that meets their dietary needs.
• Assist in setting realistic exercise goals. Provide support and resources for maintaining an active lifestyle.
• Within three months, the client’s blood pressure readings have consistently improved and are within normal range. The client reports feeling more energized and experiencing fewer headaches or dizziness.
• Adjust the care plan as needed based on client feedback and blood pressure monitoring.
• Continue to provide education and support for maintaining healthy lifestyle habits. Consider involving a registered dietitian or exercise specialist if necessary.

The ADPIE framework is a structured approach that helps nurses consider all aspects of the client’s well-being and address them appropriately.

Nursing care plans should include short-term and long-term goals .

Short-term goals focus on immediate client needs, while long-term goals aim for sustained health improvements. For example, a short-term goal may be to control a client’s pain after surgery.

A long-term goal is to help the client achieve long-lasting pain management.

Nurses use different nursing interventions when implementing care plans depending on the client’s goals. For short-term goals, interventions focus on addressing immediate needs and improving symptoms.

These can include:

• Administering medication
• Providing comfort measures
• Performing assessments to monitor progress

On the other hand, interventions for long-term goals focus on promoting health and preventing disease recurrence.

• Providing education on healthy lifestyle choices
• Developing self-management plans
• Coordinating with members of the client’s healthcare team to provide ongoing care

A nursing intervention can be independent (nurse-initiated), dependent (requiring an HCP prescription), or collaborative (involving a multidisciplinary team).

Understanding these categories is crucial for effective care planning.

• Independent interventions are actions that nurses can initiate without an HCP prescription. They typically fall within the nurse’s scope of practice and don’t require supervision or direction from other healthcare professionals.
• Dependent interventions are actions nurses perform based on an HCP prescription. These interventions may include administering medications, conducting procedures, or providing specific treatments.
• Collaborative interventions involve working with other healthcare professionals to provide comprehensive care for the client. This can include developing a care plan with input from multiple professionals, such as physical therapists or dietitians, or coordinating care between different departments within a healthcare facility.

To enhance the effectiveness of nursing care plans, consider the following tips:

• Involve clients in the care planning process to promote autonomy and engagement.
• Use evidence-based practice guidelines and clinical protocols to inform decision-making .
• Regularly reassess and revise care plans based on clients’ responses and changing needs.
• Foster interdisciplinary collaboration to ensure comprehensive and coordinated care delivery.

Nursing care plans are indispensable tools for delivering high-quality, client-centered care. Nurses can optimize client outcomes and enhance the overall healthcare experience by understanding their significance, components, and implementation strategies.

For nursing students, creating effective care plans can seem overwhelming.

That’s where SimpleNursing comes in. Our online platform provides simplified and easy-to-understand content for nursing students, including tips on creating care plans and study materials for various topics.

With SimpleNursing, you can confidently navigate your nursing education journey and become a skilled nurse who excels in care planning.

See how SimpleNursing can help make nursing school simpler.

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Nursing Care Plans from A to Z: a Complete Guide for Registered Nurses

Posted on: Mar 9, 2022;

Nursing care plans are one of the most valuable tools nurses have at their disposal. They aid RNs in strategically outlining the best course of care for patients and enable quality communication within the healthcare team. Thus, writing and using a nursing care plan is one of the nursing skills that nursing students and experienced professionals have to cultivate consistently. 

Much attention is devoted to mastering this aspect of the nursing process in nursing school, so nursing care plans are an integral part of any nursing school curriculum. And the need to write care plans continues after graduation because a critical part of nursing practice relies on efficiently written and implemented care plans. 

This guide will walk you through everything you need to know about nursing care plans. Stick around to find the best practices for making a care plan , how to write it , and how to use this instrument to deliver quality care. 

What Is a Nursing Care Plan?

The nursing care plan (NCP) is a process through which the nurse identifies, documents, and keeps track of a parent’s state or condition, needs, and risks . The elaboration of the care plan starts when the patient is admitted to the medical facility. The NCP is continuously updated throughout the patient’s stay based on their condition and response to treatment. Typically, creating a nursing care plan follows a five-step framework. 

The nursing care planning process ensures that the quality of patient care is always up to the highest standards. It sets the groundwork for patient-centered care and is a sign of excellence in nursing practice .

Nursing care plans have a few significant objectives. First off, they aim to encourage evidence-based nursing care . Accounting for the fact that psychological, social, and spiritual health are as potent as physical health, nursing care plans advocate for holistic care to manage and prevent diseases. Other aims of this practice include:

• Identifying achievable goals for the nursing team.
• Spelling out desired care outcomes .
• Measuring nursing care . 

What Are The Types of Nursing Care Plans?

Nursing care plans are either informal or formal. The informal care plans are courses of action in response to a patient’s state that the nurse has thought of but hasn’t yet documented or formalized. 

A formal nursing care plan is the written version of the plan. It details the patient’s care information, information about the nursing interventions, the patient’s state, response to nursing interventions, and more. 

Standardized care plans are formal nursing care plans in which the RN specifies the care they offer to a group of clients with everyday needs. 

Individualized care plans are formal nursing care plans tailored to the needs of a particular patient. They are specific and unique to each patient’s condition or requirements. 

Student Nursing Care Plans vs. Professional Nursing Care Plans

Student nursing care plans and the care plans written by professional registered nurses have the same overall goal: to guide the process of nursing care . However, there are some important differences between them. 

Care plans formulated by aspiring RNs in nursing schools are significantly longer . They are written with greater detail and contain more thorough information. It is more time-consuming to devise student nursing care plans. Still, it’s a good training exercise. It solidifies the students’ knowledge and ensures they grasp and apply essential nursing concepts. 

Nursing care plans written by Registered Nurses in clinical settings are generally more concise . Unlike students, working professionals don’t have to write down every nursing judgment and decision-making step. Additionally, the clinical setting version of nursing plans does not include the rationale – an extra column in which nursing students have to present the scientific explanations for the chosen interventions. 

What Are the Main Reasons to Have a Care Plan?

There are many advantages to writing and implementing nursing care plans. They may be tedious to create, but they benefit nurses, patients, and the entire healthcare system in the long run. These are some of the reasons why care plans play such a vital part in patient care: 

• Nursing care plans are a roadmap to quality patient-centered care . Care plans help structure and organize patient care. When elaborating them, the nurse employs critical and holistic thinking, leading to better patient outcomes. 
• Nursing care plans ensure the continuity of care . Nurse care plans need to be written or computerized, and so they become a part of a patient’s health record. Consequently, nurses have access to the same patient information. Despite working different shifts, all RNs caring for a patient will be aware of the diagnosis, prior nursing interventions, and their coworkers’ observations and insights. This means that nurses work towards the same goal, which leads to better patient results. 
• Nursing care plans ensure collaboration with other members of the healthcare team . In addition to their fellow RNs, nurses also have to collaborate with physicians, assistants, social workers, physical therapists, and other health team members. Nursing plans put all the information in one place and make it easily accessible for all members of this interprofessional team. Thus, everyone is aware of the desired outcomes and can work towards them. 
• Nursing care plans keep patients engaged . An important part of formulating nursing care plans is setting goals for and with patients. This step motivates patients to be more involved in their recovery, makes them more compliant to treatment, and ensures better outcomes. 
• Nursing care plans can serve as evidence of given care . These are documents through which nurses document their interventions, thus acting as a record in case of lawsuits or accusations that they failed to adhere to nursing standards. They maximize the efficiency of the nurses while also shielding them from potential problems. 
• Nursing care plans act as guides for reimbursement . Insurance companies use medical records to determine the amount they will pay concerning the care the patient received. 

What Are the Components of a Nursing Care Plan?

Nursing care plans are essentially the written outcome of the nursing process. For this reason, the structure of a nursing care plan closely follows the five steps of the nursing process : assessment, diagnosis, planning, implementation, evaluation. 

More precisely, nursing care plans usually follow this template: 

• Nursing diagnosis
• Desired outcomes/goals
• Nursing interventions (or implementations)

Let’s look at each step more closely. 

Before everything else, a care plan must include a nursing diagnosis . To formulate a nursing diagnosis, you need to conduct a thorough assessment of the patient’s health, consisting of objective or subjective data. 

Learn everything you need to know about nursing diagnoses in our complete guide on the subject . 

After establishing a nursing diagnosis, the next step in your care plan is outlining desired outcomes and goals . The goals may be long-term or short-term, but all of them ought to be realistic and achievable. 

Following that, you need to start documenting the nursing interventions you carry out. 

The last component of the nursing plan is evaluation . This step covers the information about the outcomes of the nursing interventions. 

How to Write a Nursing Plan?

Developing a nursing plan may seem daunting at first. But it doesn’t have to be. Now that you’re familiar with the components, all you have to do is follow the step-by-step guide that we included below. 

Conduct patient assessment. 

When you start creating a nursing plan, you first gather information about the patient’s state using specific nursing assessment techniques and other data collection methods. This may include conducting a head-to-toe physical assessment, taking vitals, reviewing the patient’s health history and medical records, asking questions directly to the patient or their family, performing diagnosis studies. It is essential to be thorough and careful in gathering health data. 

Analyze and catalog all the information you got in the previous step. 

By now, you have large chunks of information about your patient’s state, their history, the health risks they encounter, and more. You need to structure it and pick the relevant details. Based on that, formulate a nursing diagnosis, which will help set your priorities and determine some desired outcomes. 

Formulate your nursing diagnosis. 

All the data you collected will help you in the diagnosing process. You should write the nursing diagnosis in line with the NANDA-I format, the internationally recognized way to identify and catalog RN diagnoses. Prioritizing will play a vital role in creating a nursing diagnosis. For this, Maslow’s hierarchy of needs will prove a helpful tool. Once you have indicated a diagnosis, you can set goals and pinpoint the desired nursing outcomes. 

Find everything you need to know about writing a nursing diagnosis in our complete guide on the subject. 

Set SMART patient goals.

After writing a diagnosis, you must set goals for the direction of care. This is essentially the planning stage, where you outline what you hope to achieve once the nursing process is implemented. These goals will pave the path for planning nursing interventions. Later on, they will be the standards by which you evaluate the patient’s health progress. 

It’s crucial to keep the goals clear, realistic, and specific. A good strategy for setting goals as part of the nursing plan is by employing the SMART technique: 

S pecific – Make sure the nursing goals you choose are unambiguous and well-defined. 

M easurable – Set specific metrics to determine/measure the efficacy of your actions and the patient’s progress.

A chievable – The nursing goals must be realistic and possible to achieve.

R ealistic – They need to be appropriate in relation to the overarching care plan.

T ime-bound – Deadlines can help you keep better track of your interventions and how efficient they are. These can be flexible. 

Goals can also be short-term or long-term . For the most part, as a nurse, you will devise short-term goals because you are mostly focused on the patient’s immediate (or near future) needs or concerns. Long-term nursing goals are mostly used by nurses working in home healthcare , nursing homes, or with patients suffering from chronic health problems. 

Choose appropriate nursing interventions

Nursing interventions are the actions a nurse takes to achieve patient goals and reach the desired outcomes. The interventions focus on reducing the causes of the nursing diagnosis or decreasing the risk factors. You may follow the doctor’s guidelines – dependent nursing interventions – to choose the appropriate interventions. Also, you can develop nursing interventions yourself, drawing from evidence-based practice – independent nursing interventions . Another type of nursing intervention is collaborative , which refers to the actions or activities you carry out in collaboration with other healthcare team members. 

There are seven categories of nursing interventions : family, behavioral, physiological, complex physiological, community, safety, and health system interventions. Some of the most common nursing interventions you can expect to perform during each shift include: assessing pain, giving medications, checking vital signs at specific intervals, changing the resting position, initiating fall precautions, or educating the patient.

After identifying the appropriate interventions, you will perform them in the implementation phase of the nursing process. 

Provide rationale for the chosen nursing interventions

This additional step is only included in student nursing care plans . Writing down the rationale in the student care plan serves as an exercise for students to ensure that they are fully aware of why a specific nursing intervention was the best course of action. 

Perform evaluation

Evaluation is the final step of the nursing care plan. In this phase, the nurse will analyze whether the care goals have been met and whether or not the nursing plan was effective. Importantly, evaluation is an ongoing process . Based on its conclusions, you can continue, change, or cancel nursing interventions. 

Tips and Tricks for Writing Efficient Nursing Care Plans

Keep your writing skills sharp. .

More than just an important document, a nursing care plan is a guide to efficient nursing care and interdepartmental collaboration. That’s why you need to be efficient in writing it. As much as possible, try to write everything down immediately not to miss or forget any details. Write clearly and concisely, but make sure you and the other members of the team understand the terms or abbreviations you use. Include dates and times. 

Always keep the plan up to date.

Make sure your care plans are constantly updated with the latest information. You should always document the changes in a patient’s state, the updates in the nursing interventions, or other developments that may occur in the process of care. 

Keep the plans accessible and easily shareable.

An essential characteristic of care plans is that they must be easily shareable with relevant stakeholders. These may include patients, other doctors or nurses, or insurance companies. The format for the nursing care plans may differ from one medical institution to another. Still, for the most part, they are electronic and become part of the electronic health record (EHR). Thus, they can be easily accessed by everyone. 

Nursing Care Plan Examples

As a nurse, you’ll have to write nursing plans for a wide variety of conditions: from hypertension, infection, decreased cardiac output, impaired skin integrity, acute pain to constipation, anxiety, diabetes, dehydration, and many more. To better illustrate how to write nursing care plans, we have assembled some examples. Bear in mind that the template of the nursing plan may differ from one institution to another. 

Are you Ready to Start Writing Efficient Nursing Care Plans?

Writing efficient, goal-oriented, easily-accessible, clear, and evidence-based nursing care plans is pivotal for any Registered Nurse.

In order to develop nursing care plans that encompass all these qualities, you need to be knowledgeable, display critical thinking, engage in teamwork, and focus on offering patient-centric care. If you follow these guidelines, the care plans you write will help elevate your professional status and the entire healthcare process.

We’re here to make your journey a little easier. Enroll in Nightingale College’s BSN program or advance your education with an online RN-to-BSN and discover that writing nursing care plans doesn’t have to be a daunting process.

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Nursing Care Plans | Free Care Plan Examples for a Registered Nurses (RN) & Students

Nursing care plan overview & introduction: what is a care plan in nursing.

A nursing care plan is a part of the nursing process which outlines the plan of action that will be implemented during a patients’ medical care. LPNs (Licensed Practical Nurses) and Registered Nurses ( RNs) often complete a care plan after a detailed assessment has been performed on the patients’ current medical condition and prior medical history. The nurse can then take action with the patient by fulfilling the care plan’s goals and objectives.

On this page, you will get some free sample care plans that you can use as examples to understand more about how they help nurses treat people. If you want to view our care plan database, make sure to visit our free care plans section.

Search Care Plan Database

When I was in nursing school I bought some books to help me with nursing care plans. Care plans take practice but once you catch on they are a piece of cake. Here are the books I recommend on using to help you with your nursing care plans. I believe they are the best books for nursing care plans. The first one is called “ Nursing Care Planning Made Incredibly Easy! ” It is like one of those “made for dummies” books. Here is a picture of it and you can find it on Amazon.com for less than $25.

Another great book is called “ Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span “. This book is excellent because it is universal for all areas in nursing for developing your care plans. This book is awesome for developing your care plans and is used by many nursing students.

*See disclosure at the end of this article.

Care plans are occasionally used by other medical staff, such as doctors, Respiratory therapists, physical therapists, and more. However, they are most often used and associated with the field of nursing.

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Why Should Nurses Use Care Plans? Aren’t Care plans a Waste of Time?

In addition, care plans can be easily revised to provide new outcomes or treatment plans if a patient’s condition changes. This flexibility helps the nurse maintain focus during potentially stressful situations. Since the patient’s information will be conveniently located within the care plan, this will save time and reduce the risk of misinformation or mistakes.

Care plans are also helpful during a patient’s discharge process. Nurses can review the care plan to see if the patient met the nursing outcome during their treatment, and can base the patient’s later discharge care based on those outcomes.

Video About Nursing Care Plans

Why Do Nursing Students Use Care Plans?

Nursing school professors often require nursing students to complete many care plans throughout their college career. The reason is simple: Care plans are important. Nursing students should thoroughly learn about care plans for the following reasons:

• It Instills critical thinking and analytical skills related to nursing. This will help future nurses evaluate and treat patients more efficiently.
• By completing care plans, it helps the nursing student successfully pass their board’s test (NCLEX), HESI tests, and acquire their licensing.
• Since care plans are used in the nursing profession and in nursing care, it is vital that all nurses know how to complete them.

What’s the Difference Between Care Plans in Nursing School vs. Care Plans on the Job?

Care Plans In Nursing School:

• Very detailed and comprehensive. This is done so the nurse can become familiar with care plan development, processes, and outcomes, and terminology.
• Often completed on a blank sheet of paper, and each part of the care plan must be completed manually (typed or hand written). This often requires an extensive amount of time and research to complete.
• Often requires a NANDA Nursing Diagnosis book to help guide you when selecting a nursing diagnosis.

Care Plans on the Job:

• Less detailed–Nurses are generally not required to list as many interventions, outcomes, or other values. Instead of having a comprehensive nursing diagnosis statement, it is usually a “focus” that you need to have.
• Care plans are often created on pre-made templates that are “diagnosis-specific” for your patient. These templates often include small boxes or fields you can click or check. This greatly reduces the time it takes to complete.
• Care plans are often completed and stored electronically in many medical settings. However, they are also sometimes printed on templates.

How to Create a Nursing Care Plan: The Process of Developing a Care Plan

If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, keep reading to learn the basics of how to complete a care plan in nursing school.

• The first process in completing a care plan is the patient assessment. A nurse should review the patient’s medical history, diagnosis, lab values, medications, and familiarize themselves with the patient. This information is critical to creating an effective and accurate care plan.
• The nurse should then create a main focus for the patient’s treatment. Nurses often use the “A, B, C’s” (airway, breathing, and circulation) during this focus.  Your focus should come from the NANDA Nursing Diagnosis text.
• The nurse should then locate the focus in the NANDA book to help develop the “related to” and “as evidenced by” part of the nursing diagnosis statement.
• The nurse should select some outcomes and interventions based on the nursing diagnosis. At least 3 outcomes should be selected for the patient. Outcomes need to be measurable, patient specific, and have a definite time-frame.
• Intervention should also be measurable, patient-specific, and have parameters. The intervention should correlate with the outcomes. Often times, it is easier to develop the outcomes before the interventions.
• Review the care plan to make sure all of the information is correct.
• Implement the care plan into the nursing actions to provide care for the patient.
• Re-evaluate the care plan as treatment continues. Make any revisions if necessary if the patient’s condition improves or worsens.

What Do Care Plans Look Like in Nursing School?

The care plans given in nursing school are often on a blank sheet of paper with grid-lines for each focus, treatment, and outcome. Nursing students must then manually complete each field using a very comprehensive set of terms and goals. Sometimes, nursing students are intimidated by the care plan process, and often feel overwhelmed when faced with their first care plan. However, they should keep in mind that many nursing students feel this way, and they will become much easier to complete over time.

It is important to note that often times, nursing care plans can have a slightly different appearance. The exact design or appearance of the care plan can vary from school to school. In addition, many hospitals or medical centers adopt their own unique care plan versions. So each basic care plan design can be totally different from another.

An example picture of a basic blank care plan can be found below:

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How to Write a Nursing Care Plan with Examples for Nursing School

Wilson logan.

• August 17, 2022
• Nursing Writing Guides

Nursing Care Plan Examples, Nursing Interventions Documentation and Guide For Nursing Students

A nursing care plan is a document that outlines the specific needs of an individual who requires nursing care. It is an essential tool in the nursing profession, serving as a comprehensive guide for delivering high-quality, patient-centered care.

These plans are based on the nursing process (assessment, diagnosis, planning, implementation, and evaluation) and are structured to incorporate current evidence-based practices and standards of care.

Nursing care plans are often emphasized in nursing education, as writing comprehensive care plans is a critical skill for nursing students to develop.

Student care plans may be more detailed than those used in clinical practice, as they are designed to reinforce the nursing process, promote critical thinking, and enhance decision-making abilities.

It should be created before any care is given to ensure that all needs are met and that the individual receives the best possible care. This article offers examples of nursing care plans and includes an NANDA outline and a guide on developing one. 

Components Of A Nursing Care Plan and Nursing Intervention

Nursing Care Plans have specific components that should be included;

• A diagnosis of the individual’s illness or injury
• A description of the individual’s symptoms and how they impact their daily life
• A description of any treatments or therapies the individual will require
• A plan for home health care, if necessary
• A timetable for when each step in the treatment or rehabilitation process will happen
• A list of any personal belongings that need to be transferred to a designated caregiver or hospice staff
• An inventory of all medications prescribed to the individual and a list of phone numbers for pharmacists, doctors and other healthcare providers
• The name and contact information for a representative from the facility where the individual will receive their nursing care
• A nursing care plan should be updated as new information arises so that it can reflect the individual’s current needs . Caregivers should also keep a copy of the plan on hand in case questions or concerns arise .

Elements Of A Nursing Care Plan

There are many elements that should be included in a nursing care plan, including: (importance of nursing care plan pdf)

• A diagnosis of the individual’s illness or injury(Nursing Care Plan Examples)
• A plan for home health care, if necessary(Nursing Care Plan Examples)

When preparing the nursing care plan, consider the following

• Evaluation of the patient’s wellness, clinical findings, and diagnosis. This is the initial step in developing a care plan.
• Patient evaluation is focused on the essential categories and capabilities in specific: bodily, psychological, interpersonal, psychological, ethnic, religious, intellectual, physiological, age-related, financial , and societal. This data might be both biased and factual.(Nursing Care Plan Examples)
• The expected client results are mentioned. They might be both lengthy and brief.(Nursing Care Plan Examples)
• This care plan includes documentation of treatment plans.(Nursing Care Plan Examples)
• Treatments must have a justification to constitute proof-centred healthcare(Nursing Care Plan Examples).
• Assessment: This is a record of the outcomes of treatment plans . (nursing care examples)

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NANDA nursing care plan examples

Nursing care plans are essential for providing the best possible care to patients. They outline what type of nursing care a patient will need , who will provide it, and when it will be provided.(Nursing Care Plan Examples)

There are many different types of nursing care plans, but the most common is the care plan template . This template can be customized to fit the needs of each patient. It includes information such as the patient’s medical history, current condition, expected discharge date, and preferences. The care plan should also include a list of nurses responsible for providing the care, their contact information, and their duties.(Nursing Care Plan Examples)

To create a nursing care plan, you first need to gather information about your patient . This includes their medical history and current condition. You also need to know their discharge date and any preferences they have concerning their care.(Nursing Care Plan Examples)

Once you have this information, you can start creating your nursing care plan template. The template should include a list of all the nurses responsible for providing the patient’s care. Their contact information and their duties should also be included.(Nursing Care Plan Examples)

Once your nursing care plan is complete, you can print it out and bring it with you when you visit your patient. (Nursing Care Plan Examples)

5 Steps of Writing a Good Nursing Care Plan

Nursing care plans do not always follow the same format. In any case, following these 5 steps should give you content that satisfies your professor.

Step 1: Write an assessment section for your care plan.

To make a care plan, an assessment is the first step. You need to answer certain questions on the assessment form such as “Why is the patient here?” Answer this and other questions on your assessment form in order to create a thorough evaluation .

Gathering information is vital to understanding a patient’s pain. In the assessment section of a nursing care plan, you should capture lifestyle information and physiological data about the person, as well as more about their pain.

Step 2: Fill Out the Diagnoses Part of the Care Plan Template

The diagnosis part of a nursing care plan is where you determine the conditions and health problems a patient faces . The diagnoses section provides information about the patient, which nurses use to decide how best to provide care for them.

Step 3: Write the Planning Part of Your Nursing Care Plan

With measurable goals, you and your patient can pursue the right short- and long-term plans of care . For instance, you may decide that the patient should move once from their bed to a chair per day within 24 hours of injury. You can also set other goals such as tolerating clear liquids without nausea within 18 hours and pain relief within three hours. You can even make a contract where within 12 hours your patient should be reporting decreased nausea.

Step 4: Complete the Implementation/Interventions Part

Interventions section focuses on the course of action nurses should take to meet the patient’s needs. A patient’s record provides clinicians with specific actions that need addressing, such as “Nurse will assess patient’s nausea every 6 hours.”

Step 5: Finally, Evaluate the Nursing Care Plan; Decide if the Plan Needs Modification

Nurses must keep evaluating their patients’ health to make sure they are healthy or not. Nurses must also evaluate the effectiveness of their nursing care by considering the goals set for each patient. The evaluation section carefully considers each goal. When a goal is not met, you may have to re-evaluate other steps in taking care of a patient.

Tips for Nursing Care Plan Writing for Nursing Students

When you are a nursing student, planning and preparing for your nursing care is essential. The following tips will help you develop a care plan that meets the needs of your individual patient.

• Understand Your Patient’s Condition and Symptoms The first step in developing a nursing care plan is understanding your patient’s condition and symptoms. Do not hesitate to ask your preceptor or faculty member for additional information when you do not have a solid understanding of the situation.
• Assess the Patient’s Needs Once you have an understanding of your patient’s condition, it is time to assess their needs. This may include taking into account their age, health history, medications they are taking, and any other factors that could affect their care.
• Create a Treatment Plan Based on the Patient’s Needs Once you have assessed the patient’s needs, it is important to create a treatment plan that meets those needs. This may include anything from administering medication to providing physical therapy.
• Follow the Treatment Plan as Appropriate It is important to follow the treatment plan as it is appropriate for your patient . This includes ensuring that all necessary medication is administered, that the necessary equipment is available, and that the patient’s care is monitored regularly.

Adjust the Treatment Plan as Necessary As the situation changes, so may the treatment plan. This includes taking into account any new information you have about the patient’s condition or symptoms.

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3 Sample Nursing Care Plan for CHF [Congestive Heart Failure] (with rationales and case scenario)

Last updated on December 28th, 2023

Sample Nursing Care Plan for CHF [Congestive Heart Failure]

What is congestive heart failure.

Heart failure is a chronic, progressive condition. It occurs when the heart is unable to pump effectively and produce enough cardiac output to successfully perfuse the rest of the body’s tissues and organs. An individual can have right-sided or left-sided heart failure as well as systolic or diastolic heart failure.

Left-sided heart failure is also known as Congestive Heart Failure (CHF) . In CHF, the heart is either unable to contract completely or fill completely during relaxation. It can lead to an inadequate amount of blood pumping out of the heart. Thereby, backing up into the right side and then ultimately to the lungs and throughout the body causing congestion.

Systolic heart failure means the heart is not able to contract completely and affects its ability to pump blood out of the heart.

Diastolic heart failure means the heart is unable to relax fully between heartbeats and allows the appropriate amount of blood into the ventricle.

In this post, we’ll formulate a sample nursing care plan for a patient with Congestive Heart Failure (CHF) based on a hypothetical case scenario .

CHF Case Scenario

A 74-year old Hispanic male presents to the Emergency Department with complaints of increased dyspnea, reduced activity tolerance, ankle swelling, and weight gain in recent days. He has a known history of hypertension and heart failure. He reports over the past 3 days his shortness of breath, particularly with activity, has increased significantly.

He is also now using 3 pillows to sleep at night instead of his usual 1 pillow, and he has experienced a 10-pound weight gain in 3 days. He states he is now only able to ambulate 1 block before needing to stop and rest whereas in the past he could walk half a mile. 

The nurse notes dyspnea upon minimal excretion with position changes.  Upon physical assessment his breathing is shallow and labored, respiratory rate is 30 breaths per minute, heart rate 115 beats per minute, oxygen saturation 83% on room air, blood pressure 179/98 mm Hg, he has +4 pitting edema in bilateral lower extremities, and crackles are heard in his lung fields throughout.

The patient’s lab work reveals an elevated BNP level of 954pg/mL and a chest x-ray shows pulmonary congestion. The last echocardiogram in the patient’s chart (completed 3 months prior) showed an Ejection Fraction (EF) of 40%.

The patient is to be admitted to the hospital for Acute Exacerbation of Congestive Heart Failure (CHF) . 

Case Discussion

The main assessment findings the nurse should be aware of for this patient begin with his vital signs, all of which are listed are abnormal.

The patient has labored, tachypneic, breathing. He is also tachycardic and has a decreased oxygen saturation. This demonstrates to the nurse that the patient is not hemodynamically stable and the main goal is stabilizing the patient’s respiratory status. 

In addition, the nurse should also note the reported weight gain and visibly apparent edema. These assessment findings are able to help the nurse critically think and identify a potential list of differential diagnoses prior to lab and imaging results becoming available.

When assessing this patient, the nurse will want to remember ABCs (airway, breathing, circulation) of care.  The patient’s airway is protected and he is able to breathe on his own.

However, his breathing is compromised due to excessive fluid. Therefore, that becomes the priority for the patient and the nurse should begin by improving his oxygen saturation and breathing status.  

Once the patient’s breathing status is stabilized the next likely task will be to diuresis the patient.  In doing this, it will help to remove additional fluid thereby improving his oxygen and breathing capability further.

#1 Sample nursing care plan for CHF – Impaired gas exchange

Nursing assessment.

Subjective Data:

• Reported increased shortness of breath
• Using 3 pillows to sleep at night (increase from usual 1 pillow)
• Decreased activity level due to shortness of breath

Objective Data:

• Tachypneic, respiratory rate of 30 breaths/minute
• Crackles in lung fields
• Oxygen saturation 83% on room air
• Congestion on chest x-ray
• +4 pitting edema

Nursing Diagnosis [ Impaired gas exchange ]

Impaired gas exchange related to fluid overload as evidenced by labored, tachypneic breathing, decreased oxygen saturation, crackles in lung fields, pitting edema, congestion on chest x-ray.

Short-term goal

To increase oxygen saturation ≥92% prior to transfer from ED and admission to hospital floor unit

Nursing Interventions with Rationales

Long-term goal

To decrease excess fluid by 10 pounds by discharge to return patient to baseline dry weight

Expected Outcome

• This will reduce hypoxemia resulting in improved oxygen saturation and reduce dyspnea.
• Excess fluid will be removed and the patient’s weight will return to baseline.
• Reduced congestion will improve gas exchange.

#2 Sample nursing care plan for CHF – Decreased cardiac output

• Needs 3 pillows at night to sleep
• 10-pound weight gain
• Ankle swelling
• Tachycardia
• Hypertension
• Crackles in lung fields throughout
• Ejection fraction (EF) 40%
• Elevated BNP 954pg/mL
• Congestion seen on chest x-ray

Nursing Diagnosis [ Decreased cardiac output ]

Decreased cardiac output related to altered contractility as evidenced by tachycardia, hypertension, orthopnea, edema, abnormal lab work, and reduced EF.

To stabilize vital signs and maintain adequate oxygen saturation prior to transfer from ED to the hospital unit.

To improve cardiac contractility by discharge

• Maintain oxygen saturation above 92%
• Decrease in blood pressure to patient’s baseline (ideally <120/80)
• Improved contractility by decreasing excess fluid, improvement in breathing status, and stabilization of vital signs

#3 Sample nursing care plan for CHF – Decreased activity tolerance

• Only able to ambulate 1 block
• Reduced activity level
• Dyspnea on minimal exertion
• Tacypnea (RR 30 bpm)
• Tachycardia (PR 115 bpm)
• Decreased oxygen saturation (83% at room air)

Nursing Diagnosis [ Decreased activity tolerance ]

Decreased activity tolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea, tachypnea, tachycardia, decreased oxygen saturation, and fatigue.

To limit activity to decrease oxygen demand while also increasing oxygen supply

To increase activity level to patient’s baseline prior to discharge.

• Improved oxygenation status (≥92%)
• Patient’s activity level will return to baseline

It is vital to monitor patients admitted with congestive heart failure closely.  In particular, detailed and accurate intake and output records should be kept to show the progress and success of treatments being administered.

This will also help to determine if additional medications are warranted or dosage adjustments need to be made.

Close monitoring of types of food and drinks is also important. Because some food may cause patient to retain more fluid than others. Providing proper patient education is key for these patients to support them in understanding their condition and diagnosis.  

Likewise, education will help the patient to be aware of specific things to avoid at home in terms of food or drink and why these should be avoided.

Click here to see a full list of Nursing Diagnoses related to Congestive Heart Failure (CHF).

Congestive heart failure is a chronic condition that can progress over time. Acute exacerbations of this chronic condition can also be very common especially if an individual is not following or is unaware of the appropriate guidelines and recommendations.

It is important for nurses to understand the various symptoms a patient may present with when experiencing an acute exacerbation. It is also imperative that the nurse assesses the individual’s airway and breathing status immediately and prioritizes this above any other nursing intervention. 

Lastly, providing thorough patient education both verbally and in writing is essential for these individuals to help them understand their diagnosis and what measures they can take at home to prevent additional exacerbations.

Ackley, B.J., Ladwig, G.B., Flynn-Makic, M.B., Martinez-Kratz, M.R., & Zanotti, M. (2020). Nursing Diagnosis Handbook: An Evidence-based Guide to Planning Care [eBook edition]. Elsevier.

Comer, S. and Sagel, B. (1998). CRITICAL CARE NURSING CARE PLANS . Skidmore-Roth Publications.

Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing Care Plan: Guidelines for Individualizing Client Care Across the Lifespan [eBook edition]. F.A. Davis Company.

Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.

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Plan of Care

Introduction, pulmonary aspiration, impaired physical mobility, ineffective cerebral tissue perfusion, legal and ethical consideration, inter-professional consideration.

Pulmonary aspiration is the entry of materials from the gastrointestinal tract into the lower respiratory system. The foreign materials may be inhaled or delivered into the trachea system Nason, 2015). When pulmonary aspiration occurs during feeding, then it is considered as food going down the wrong pipe. Pulmonary aspiration symptoms include coughing, difficulty in breathing and in some cases the patient can exhibit signs of chocking. In our case, the patient, Harold Blake, upon admission showed the symptoms of choking, shortness of breath, crushing pain in the upper chest and chest tightness. The symptoms that the patient showed were similar to those of pulmonary aspiration and thus it was rational to diagnose the disease since it could be a possibility.

Impaired physical mobility is the restriction in the self-reliant physical motion of the body or one of the functions of the body. When impaired physical mobility happens, it can turn to be a complex health issue that involves different healthcare team. The happening of this disease continues to rise with the increase in the age of an individual. After discharge from hospitals in most cases, the patient is moved to a rehabilitation center or goes home with a physical therapy (Wu, Han, Xu, Lu, Cong, Zheng, & Sun, 2014). In this case, the patient had previously suffered a left cerebral vascular accident. Upon admission, the doctor had noted that he was drowsy, drooling, and is having difficulty speaking. Upon observation, the patient ’s right limbs were moderately weak and sluggish as compared to their left counterparts which were possible leads to impaired physical mobility.

Ineffective cerebral tissue perfusion is as a result of decreased oxygen supply resulting from failure to supply tissues at the capillary level. The ineffective cerebral tissue perfusion results from the insufficient flow of blood in arteries which causes decreased movement of nutrients and oxygen to the cellular level (Hasanin, Mukhtar, & Nassar, 2017). This conditions could be short-lived with few effects on the health of the patient but it could also be chronic. When Ineffective cerebral tissue perfusion becomes degenerative, it could consequence in tissue and organ damage or even death. The patient, in this case, showed symptoms of pain in the chest, chest retraction, change in motor response, speech abnormalities and nausea. These symptoms are same as those of the  Ineffective cerebral tissue perfusion.

1. Crawford A., & Harris, H. (2016). Caring for adults with impaired physical mobility. Nursing. 46, 36-41.

2. Green SM, Mason KP, & Krauss BS. (2017). Pulmonary aspiration during procedural sedation: a comprehensive systematic review. British Journal of Anaesthesia. 118, 344-354.

3. Hasanin, A., Mukhtar, A., & Nassar, H. (2017). Perfusion indices revisited. Journal of Intensive Care. 5.

4. Iskhandar Shah, L., & Christensen, M. (2012). Ineffective cerebral perfusion related to increased intracranial pressure secondary to subarachnoid haemorrhage: An examination of nursing interventions. Singapore Nursing Journal. 39, 15-24.

5. Manolis, A. J., Poulimenos, L. E., Ambrosio, G., Kallistratos, M. S., Lopez-Sendon, J., Dechend, R., Mancia, G., & Camm, A. J. (2016). Medical treatment of stable angina: A tailored therapeutic approach. International Journal of Cardiology. 220, 445-453.

6. Marik PE. (2011). Pulmonary aspiration syndromes. Current Opinion in Pulmonary Medicine. 17, 148-54.

7. Mckenna CJ, & Sugrue DD. (2015). The medical management of chronic stable angina. National Institute of Health 38, 131-136

8. Nason, K. S. (2015). Acute Intraoperative Pulmonary Aspiration. Thoracic Surgery Clinics. 25, 301-307.

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• Advanced Practice Nurse (ADN)
• American Nurses’ Association (ANA)
• Communication

5 Steps to Writing a (kick ass) Nursing Care Plan (plus 5 examples) | NURSING.com

What are you struggling with in nursing school?

NURSING.com is the BEST place to learn nursing. With over 2,000+ clear, concise, and visual lessons, there is something for you!

How can I put this lightly?  The sooner you come to love nursing care plans, the easier your career as a nurse will be.

The relationship that most nurses have with care plans goes something like this:

• What the hell is a care plan?
• This seems easy!
• Agh! Why do they keep telling me my diagnosis is wrong?
• Screw it! I’ll just Google and copy some random care plan.
• I’ll never do these again once a graduate.
• Finally! I graduated . . . goodbye care plans.

"The sooner you come to love nursing care plans, the easier your career as a nurse will be."

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But allow me to present an alternate reality to you.  There is an evolution that occurs in new grad nurses (I’ve seen it over and over again).  They come out of school bright-eyed and excited to care for “real” patients.  They are “so glad” that they never have to do another care plan . . . This (stuff) get’s real.  They discover how hard being a nurse is . . .

After about 6 months they begin to get the hang of things . . . by a year . . . they’re really getting their own legs as a nurse.  They walk into a room and can assess the situation fully.  They can determine how a shift will go within a couple of minutes.  They have a sixth sense about them . . . a nurses sense.

Care Plan Database

We’ve created an enormous database of care plans for you to reference in nursing school. Check them out below.

View the Care Plans

What Has Happened?

The new nurse has developed “ critical thinking ” without even knowing it.  They are working through nursing care plans while considering a million different variables right on the spot . . . without even realizing it!

Those pesky little care plans are being developed, adjusted, evaluated . . . patient after patient, shift after shift.

And the nurse doesn’t even realize it.

So they continue to talk about how pointless care plans are and tell students: “ You’ll never do those in REAL life .” . . . little do they know, they’ve worked through multiple care plans during that shift .

I mean . . . think about it.

I arrive for a shift and hear about a patient who has some blanchable redness on the coccyx. BOOM!!!

The care plan is done . . . “ risk for impaired skin integrity ” . . .never technically entered my mind, but I’m already planning out the shift . . . how will I keep the skin dry, how often will I turn the patient, are they eating enough, do I need to get some barrier cream for them . . . see what I’m saying?

5 Steps to Writing a Nursing Care Plan

At NURSING.com, we want you to find a bit of excitement and comfort when writing care plans . . . little tip: they aren’t going away!  So, here are the 5 steps:

• Collect Information
• Think About How

Step 1 – Collect Information

• Your head-to-toe assessment
• Conversations with patients and loved ones
• Observations (lab values, vital signs)
• Report (or your report sheet)
• Chart review and notes
• Discussions with health care team members

Step 2 – Analyze

• Look at all information
• What are areas in which this patient has trouble and therefore needs to progress in?
• Think about the ways you could see the patient improving and how you would know they were improving
• Write down the general issues, how you’d help them progress in that area, and how’d you’d know they were progressing

(Tip – don’t worry about writing it in perfect NANDA-I, NIC or NOC terminology… just write it down in as you think of it)

Step 3 – Think About How

• How did you know he was in pain? Did he tell you? Did you observe it? Was he getting pain medications?
• Write an S or an O next to them
• A recent surgery, trauma, or disease process?
• Write all of your reasons (again in layman's terms) under the problem(s) you’ve identified
• What would you do to make this better? (Interventions)
• How would you know it got better? (Evaluation)

Step 4 – Translate

• Take your textbooks (NANDA-I, NIC, NOC, or whatever you may be using)
• Look up the official terms for the problem(s) and write them down
• Look up outcomes and interventions that may align with what you wrote down

Step 5 – Transcribe

• Get your nursing care plan template out
• Put the pieces together (problem + related to factor(s) + defining characteristics/”hows”)
• Use your S’s and O’s to place your subjective and objective data
• Write out your interventions and outcomes/evaluation
• Put your feet up – you’re done!

How to Write a Care Plan in 10 Minutes

5 Nursing Care Plan Examples

Sometimes all you need are a few examples to help you learn how to do a difficult task and to get the brain juices flowing.  Here are 5 care plans that I personally wrote during nursing school.

MEDICAL DIAGNOSIS: Pneumonia

MEDICAL DIAGNOSIS: Aspiration Pneumonia

MEDICAL DIAGNOSIS: Amputation

MEDICAL DIAGNOSIS: Appendicitis

Additional Resources

We’ve created with tons of other resources on the topic of Critical Thinking and Nursing Care Plans:

Blog Posts:

• Critical Thinking and Nursing Care Plans Go Together Like Chicken and Waffles
• Coming up with a Nursing Diagnosis Shouldn’t Give You HTN
• 7 Nursing Interventions You Should be Using Every Shift
• 2 Examples of Using Critical Thinking to Care for a Patient
• 4 “Real World” Examples of Using Clinical Judgement
• How to Come Up With a Nursing Care Plan . . . Plan
• Writing a Nursing Care Plan in Less Than 10 Minutes
• Nursing Care Plans and Why They Matter
• Critical Thinking on the Floor (real life examples)
• What is Critical Thinking and Why Should I Care

Newborn Assessment

4 steps to master critical thinking in nursing school.

Chances are you’ve heard about   critical thinking over and over from your nursing instructors,   read about it in textbooks, and seen it on tests.

Has anyone actually shown you how to use critical thinking in a nursing setting? I break it down into 4 simple steps on how you can master critical thinking.

This will not only serve you well in nursing school but also in your career as a nurse. We can all fall into the ruts of assuming things prior to taking in all the available information even as practicing nurses.

If you apply these 4 steps to master critical thinking without prior judgment it will make you a better nurse and keep your patients safe.

OMG! Please Don’t Make Me Take Report from Him . . . (plus Nursing Report Sheet Download) | NURSING.com

Patient positioning pictures cheat sheet for nursing students | nursing.com, similar blog posts.

Critical Thinking and Nursing Care Plans Go Together Like Chicken and Waffles | NURSING.com

How To Write the Perfect Nursing Care Plan with Examples

Stress Overload Nursing Diagnosis and Care Plan | NURSING.com

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Open Access

Study Protocol

The OASIS walking study— O lder a dults with cognitive impairment performing sit to s tands and walking in transitional care programs: Protocol for a feasibility study

Roles Conceptualization, Funding acquisition, Methodology, Writing – original draft, Writing – review & editing

Affiliations KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

Roles Conceptualization, Supervision, Writing – review & editing

Affiliation KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada

Affiliation Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

* E-mail: [email protected]

• Alexia Cumal, 
• Tracey J. F. Colella, 
• Martine T. Puts, 
• Katherine S. McGilton

• Published: September 16, 2024
• https://doi.org/10.1371/journal.pone.0308268
• Peer Review
• Reader Comments

Older adults with cognitive impairment often experience low mobility and functional decline in hospital, transfer to facility-based transitional care programs, and have poorer outcomes compared to those without cognitive impairment. This protocol paper describes a study which aims to determine the feasibility of, satisfaction with, and efficacy of a nurse-led mobility intervention (OASIS Walking Intervention) for older adults with cognitive impairment in facility-based transitional care programs in Ontario, Canada. A quasi-experimental one-group time series feasibility study will be conducted. A sample size of 26 participants will be recruited from two transitional care programs in Ontario, Canada. Participants will receive the OASIS Walking Intervention for up to 45 minutes per session, 5 sessions per week, for 6 weeks. The intervention consists of: 1) a patient-centered communication care plan; 2) sit to stand activity; and 3) a walking program. Feasibility will be determined by: a) recruitment rate; b) retention rate; and c) adherence. Efficacy of the intervention will be determined by the change over time in older adults’ lower extremity muscle strength, mobility, and functional status and by their discharge destination (home vs. nursing home). Satisfaction will be measured using the Client Satisfaction Questionnaire. Efficacy outcomes will be measured before the start of the intervention, after 3 weeks of the intervention, and immediately after 6-week intervention. Descriptive statistics will be used for measures of feasibility, satisfaction, and discharge destination. Repeated measures analysis of variance (RM-ANOVA) will be used to analyze efficacy. Ethics approval has been received for this study. Findings from the study will be used to refine the intervention for use in a definitive pilot trial. Results will be disseminated via peer-reviewed publications, international conferences, through group presentations at the study sites, and through the study site networks.

Trial registration : The trial has been registered on Clinicaltrials.gov ( NCT06150339 ).

Citation: Cumal A, Colella TJF, Puts MT, McGilton KS (2024) The OASIS walking study— O lder a dults with cognitive impairment performing sit to s tands and walking in transitional care programs: Protocol for a feasibility study . PLoS ONE 19(9): e0308268. https://doi.org/10.1371/journal.pone.0308268

Editor: Mario Ulises Pérez-Zepeda, Instituto Nacional de Geriatria, MEXICO

Received: January 10, 2024; Accepted: July 19, 2024; Published: September 16, 2024

Copyright: © 2024 Cumal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The participants of this study are not providing written consent for their data to be shared publicly, so due to the sensitive nature of the research, supporting data is not available. The Research Ethics Committee in accordance with the Tri-Council Statement in Canada has not given permission to share the data. Due to the nature of the interviews, the data cannot be de-identified further to be able to share them anonymously. The contact information of the University Health Network is [email protected] contact info+ 1 416-581-7849.

Funding: Funding This work is supported by a Doctoral Research Award: Canada Graduate Scholarships from the Canadian Institutes of Health Research grant number [202111FBD-476735-DRA-ADHD-96200] ( https://cihr-irsc.gc.ca/e/193.html ) and by funding from the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto ( https://bloomberg.nursing.utoronto.ca/ ) for A.C. K.S.M. is supported by the Walter & Maria Schroeder Institute for Brain Innovation and Recovery ( https://schroederfoundation.org/ ). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Cognitive impairment (CI), which can include dementia, delirium, and unspecified CI [ 1 , 2 ], has a global prevalence of 5.1% to 41%, and a median of 19.0% [ 3 ]. For dementia in particular, the number of people living with this condition globally is expected to nearly double from 50 million in the year 2020 to 82 million in 2030, and 152 million in 2050 [ 4 ]. In Canada, the number is expected to nearly triple from about 600,000 in 2020 to 1.7 million in 2050 [ 5 ].

Older adults (≥65 years) [ 6 ] with CI are frequently hospitalized [ 7 ]. While in hospital, they often experience mobility limitations [ 8 ], low activity levels [ 9 ], and hospital-associated functional decline (HAFD) [ 10 ], that is, the inability to perform usual activities of daily living (ADLs) due to weakness, reduced muscle strength, and reduced exercise capacity, which occurs due to bedrest, deconditioning, and acute illness during hospitalization [ 11 ].

Older adults often experience HAFD [ 11 – 13 ], with a recent meta-analysis reporting a 30% prevalence of HAFD among hospitalized older adults [ 13 ]. This is problematic as HAFD can have serious consequences for the health of older adults with CI. HAFD can lead to not only decreased mood and quality of life [ 14 ], but also to pressure injuries, falls, increased morbidity, and mortality [ 15 ]. Moreover, HAFD can lead to rehospitalization, increased health care costs, and institutionalization [ 15 ]. Many older adults with CI who experience HAFD are subsequently transferred to facility-based transitional care programs (TCPs), which are short-term, post-acute care facilities that provide low-intensity restorative care [ 6 ]. In Ontario, facility-based TCPs have been created for patients with a prolonged hospital length of stay who are labelled as Alternate Level of Care (ALC) and are unable to be discharged home; many are waiting to be discharged to a nursing home post hospitalization [ 16 ] and many experience a decline in their ability to perform ADLs [ 17 ]. However, in a systematic review led by the first author [ 18 ], it was found that older adults with CI in facility-based TCPs experience worse outcomes than those without CI. While those with CI had improvements in functional status in eight of 13 studies, a greater percentage of participants without CI experienced higher functional improvement and gains in functional status were smaller for older adults with CI compared to those without CI [ 18 ]. Moreover, a smaller percentage of older adults with CI were discharged home post TCP, compared to those without CI [ 18 ]. Given the growing number of older adults with CI, there is an urgent need for additional supports and interventions in the TCP setting to improve outcomes for this population.

HAFD can be explained using the pathophysiology of functional decline as described by the Cascade to Dependency [ 19 ] and functional decline secondary to muscle disuse models [ 20 ]. Together, these models explain that aging-related factors (reduced muscle strength and aerobic capacity) combined with hazards of hospitalization (such as bedrails and tethers that promote immobility, inactivity, and bedrest) result in disuse-induced functional decline [ 19 , 20 ]. Disuse-induced functional decline is characterized by muscle atrophy, loss of muscle strength, and functional deterioration, all of which increase the risk for admission to a nursing home [ 19 , 20 ]. To counteract the deconditioning and functional decline, there is a need for anabolic strategies. which build muscle, such as walking and resistance training which promote muscle growth [ 20 ]. Resistance training such as rising from a seated chair position to standing as fast as possible, using one’s body weight as resistance, can greatly increase muscle mass and strength and improve functional ability [ 20 ].

Literature review

A comprehensive search of the literature involving mobility interventions led by nurses yielded: zero studies in the TCP setting; six studies with significant results involving older adults with cognitive impairment and walking interventions that were led by nurses or that could be done by nurses in the nursing home setting [ 21 – 28 ]; and one study with significant results involving sit to stand activity in the nursing home setting [ 29 ]. No studies were found that combined these two interventions, mobility and sit to stand.

In nursing homes, walking had a typical dose of 30 minutes per session [ 22 , 23 , 26 – 28 ], ranged from two [ 21 ] to seven [ 25 ] sessions per week; and duration ranged from six weeks [ 26 ] to six months [ 27 ]. Overall, the most effective intervention was administered by a nurse and involved 2–4 walking sessions per week for 4 months and incorporated a person-centred communication care plan [ 21 ]. This study had the highest recruitment and adherence rates, monitored intervention fidelity, and resulted in a significant improvement to all outcomes (functional mobility, activities of daily living function, and quality of life). One study involving older adults with dementia from seven nursing homes found that doing six sit to stands per day for six months resulted in maintained mobility (measured by the amount of time to perform one sit-to-stand) (p = 0.01), which can also be a measure of lower extremity muscle strength [ 29 ].

Gap in the literature

To the authors’ knowledge, there have been no nurse-led intervention studies completed to date which combine sit to stand activity, a walking intervention, and a patient-centred communication care plan for older adults with CI in facility-based TCPs. In order to address this gap in the literature, a feasibility study needs to be undertaken. A feasibility study is designed to assess an intervention, including optimal content, delivery, and adherence to the intervention, as stated in the new framework on complex intervention research that was commissioned by the Medical Research Council (MRC) and the National Institute of Health Research (NIHR) [ 30 ]. This framework outlines that a feasibility study should be done to test the feasibility of a complex intervention in order to make decisions about progression to the next stage of evaluation [ 30 ].

The aim of this study is to determine the feasibility of and participant satisfaction with a novel intervention–the OASIS Walking Intervention (that is, the O lder A dults with cognitive impairment performing Si t to S tands and Walking Intervention ) in facility-based TCPs. The second aim is to determine the efficacy of the OASIS Walking intervention on muscle strength, mobility, functional status, quality of life, and discharge destination.

Research questions

What is the feasibility of implementing the OASIS Walking Intervention in community-dwelling older adults with CI in facility-based TCPs, as determined by recruitment rate, retention rate, and adherence?

What is the satisfaction of older adults with CI with the OASIS Walking Intervention?

• Does the OASIS Walking Intervention result in improved muscle strength, mobility, functional status, and quality of life in older adults with CI?
• What percentage of the participants are discharged home and how many are discharged to the nursing home post intervention?

Study hypotheses

• It is hypothesized that the OASIS Walking Intervention will be feasible, defined as a recruitment rate (>50%), high retention rate (≥80%), and high adherence rate (attendance to ≥75% of all intervention sessions) [ 26 ].
• It is hypothesized that the participant satisfaction will be high (CSQ of 3 or more on all SCQ items) [ 31 ].
• It is hypothesized that the OASIS Walking Intervention will result in improved muscle strength (reduction in the time to perform one sit to stand by ≥0.87 seconds, p = 0.01 [ 29 ], mobility (minimum detectable change (MDC) ≥9.1 meters on two-minute walk test [ 32 ]), functional ability (≥1 point improvement in Barthel Index (BI) considered as clinically meaningful [ 33 ]) in older adults with CI in facility-based TCPs, and quality of life (minimally clinical important difference is an increase in 3 points [ 34 ]).

Methods and analysis

Study design.

A feasibility study will be undertaken for this three-component intervention project. A feasibility study is in keeping with the MRC and NIHR framework which states that for complex interventions, a feasibility study is done to assess and refine the intervention prior to carrying out a full-scale evaluation [ 30 ]. In terms of study design, a quasi-experimental single group time series design will be used.

The trial was registered on Clinicaltrials.gov (NCT06150339) on November 29, 2023.

The study will take place in two Transitional Care Units (TCUs) in Ontario, Canada, one in Pickering and one in Scarborough. The units have a combined total of 107-bed capacity. From January 2024-June 2024, patients will be enrolled in the study on an ongoing basis. Up to 8 patients will be enrolled in the study at a given time.

Participants and recruitment

Older adult patients will be eligible if they meet the following criteria: 1) aged 65 years and older; 2) have cognitive impairment (dementia, delirium, mild cognitive impairment, or unspecified cognitive impairment) as documented in the medical record or Quick Dementia Rating Scale (QDRS) score of ≥2) ( S1 Appendix ); 3) admitted to a transitional care unit after a hospitalization; 4) can speak English; 5) has received clearance from the physiotherapist to participate in the study; 6) has received clearance from the nurse practitioner to participate in the study; 7) were community-dwelling (lived in a home or retirement home; not a nursing home) prior to hospitalization; 8) were able to ambulate independently or with the assistance of one person (with or without a gait aid) prior to hospitalization; 9) is currently able to ambulate either independently or with the assistance of one person (with or without a gait aid); 10) has a care partner (family member, friend) who is willing participate in an interview about the patient for the study.

A diagnosis of CI, such as dementia is often under-reported in clinical records [ 35 ], and so the second inclusion criterion of have CI (dementia, delirium, mild cognitive impairment, or unspecified CI) will be ascertained in one of two ways: 1) a diagnosis of CI in the medical record; or 2) QDRS score of ≥2. The QDRS is a rapid (3–5 minutes) 10-item questionnaire that is used in clinical research to assess the presence of CI for inclusion and inclusion into studies [ 36 ]. The questionnaire is informant-based; informants can be spouses, adult children, relatives and friends, and paid caregivers [ 36 ]. For this study, the informant will be the substitute decision maker (SDM) of the participant and the QDRS will be evaluated by the interventionist (AC), who is a Registered Nurse. A score of 0–1 indicates a high likelihood of normal cognition; 2–5 indicates mild cognitive impairment, 6–12 indicates mild dementia; 13–20 indicates moderate dementia; and 20–30 indicates severe dementia [ 37 ]. The QDRS has good reliability (Cronbach α 0.86–0.93), demonstrates similar validity as the longer clinical dementia rating (CDR) scale to detect the presence of CI in older adults [ 36 ].

Exclusion criteria

Patients will be excluded if they are: 1) Palliative (having <six months prognosis as defined by Hui and colleagues [ 38 ]) as documented in the medical chart; 2) have Parkinson’s disease as documented in the medical chart (due to impairments in muscle and motor function) [ 21 ].

Recruitment

To achieve adequate participant enrolment, staff have been provided with detailed information regarding eligibility of patients for the study. Staff at the TCUs will screen participants for eligibility into the study. If the patients meet eligibility criteria, the staff will inform the interventionist (AC) who will approach patients for interest in the study. Informed consent ( S2 and S3 Appendix) will be obtained from patients who pass the Evaluation to Sign Consent (ESC) Measure ( S4 Appendix ) [ 39 ]. For patients who do not pass the ESC but who assent to the study, informed consent will be obtained from their substitute decision maker (SDM). The SPIRIT Schedule of enrolment, interventions, and assessments for this study is outlined in S1 Fig .

Sample size

An activity-based study involving older adults with dementia in the nursing home setting [ 29 ] that used time to perform one sit to stand found a moderate effect size (Cohen’s d) of 0.48. Since the present study will use repeated measures ANOVA, a Cohen’s f of 0.25 (a suggested value for moderate effect size) [ 40 ] was used in the sample size calculation. Based on an f of 0.25, a power of 0.8 and an alpha of 0.1, in keeping with those used in a mobility study involving older adults with dementia [ 21 ], a sample of 21 participants will be needed for this study. Using an alpha of 0.1 can be acceptable for exploratory or preliminary studies [ 41 ] (p. 188). An attrition rate of just under 20% over the course of a 6-week study will be taken into account, as was experienced in a 6-week intervention study involving older adult residents with dementia [ 26 ]. Thus, a sample of 26 participants will be recruited for this study. G*Power 3.1.9.7 software [ 42 ] was used for the sample size calculation for an ANOVA: Repeated measures, within factors statistical test with one group, three measurements, 0.6 for the correlation among repeated measures, and 0.8 for nonsphericity correction (which is a mild departure from sphericity) [ 41 ].

Intervention

The OASIS Walking Intervention is a nurse-led intervention that consists of three components: 1) Patient-Centred Communication Care Plan; 2) Sit to Stand Activity; and 3) Walking program. The interventionist is a Master’s prepared registered nurse with 10 years of clinical nursing experience on a General Internal Medicine Unit in an urban acute care hospital working with older adults with cognitive impairment, including walking, transferring, and communicating with these patients. The interventionist and research assistants will have received additional training from the unit physiotherapist on transfer training, walking, and performing the two-minute walk test. The intervention is grounded using a patient centred approach. An intervention manual has been created for this study ( S5 Appendix ).

Intervention dose

The dose of the intervention is: up to 45 minutes per session, five sessions per week, for six weeks. Approximately up to 30 minutes will be spent walking with the participant and up to 15 minutes will be spent performing the sit-to-stand activity as per their tolerance levels.

This intervention goes beyond usual care provided the TCUs. There is no change to usual care provided to patients as a result of participating in this intervention. For patients in the long-term care stream usual care consists of: one-to-one sessions 2–3 times per week of strengthening and balance exercises. For patients in the Rehab stream, usual care consists of: one-to-one sessions 5 times per week of strengthening, balance, and may include some walking and group therapy 5 times per week.

Intervention components

Component 1..

Patient-Centred Communication Care Plan. This care plan will be informed by interviews that the interventionist will have with the participant and their care partner. During the interviews, the interventionist will ask questions about three areas of a patient-centred assessment: 1) Participant’s biography (work history, family, interests); 2) Participant’s communication abilities and preferences; 3) Engagement with the Participant; [ 21 , 43 ]. The information gained from the interviews will be added to the patient-centred communication template ( S2 Fig ). The individualized care plan will be used during the walking and sit to stand activity sessions to promote enjoyment, engagement, adherence, and communication.

Component 2.

Sit to Stand Activity. The procedure for the sit to stand activity, which is adapted from the sit to stand protocol used by Barreca 2004 and colleagues [ 44 ], is outlined in Table A, which is embedded in the intervention manual ( S5 Appendix ).

Target Number of Sit to Stands. The interventionist will measure the number of sit to stands that a participant can do in 30 seconds at baseline, as used in previous study [ 29 ]. Based on that number, a target number of sit to stands to do per session will be determined, based on the algorithm used in the study by Slaughter and colleagues [ 29 ]). Halfway into the intervention (after 3 weeks), the target number of sit to stands will be progressed. The target number of sit to stands and the algorithm used by Slaughter et al. [ 29 ] (Personal communication with S. Slaughter January 2023) was adapted into the formula for this study:

Table 1 outlines the calculated target numbers of sit to stands for the present study.

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Component 3.

Walking Program. Based on the findings from the patient-centred assessment interviews as well as the performance of the participants on the two-minute walk test at baseline (Time 1), an individualized walking program will be carried out with participants, in a manner similar to the process done in the study by Chu and colleagues [ 21 ]. The goal will be to walk up to 30 minutes each session, five days per week. The interventionist will personalize the dose duration and speed of each walking session as tolerated by the participant [ 21 ] and as assessed using the Borg Rate of Perceived Exertion (RPE) scale [ 45 , 46 ].

Outcome measures

Data collection.

Demographic variables, including age, sex, gender, race/ethnicity, education, socioeconomic status, highest level of education, and number of co-morbidities will be collected before the start of the intervention ( S6 Appendix ). Data on hospital admission diagnosis and length of hospital stay prior to TCP admission will also be collected ( S6 Appendix ). Table 2 outlines the outcome measurement tools that will be used to assess the participants, time points at which they will be measured, and the type of statistical test that will be used to analyze the results.

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Sex and gender considerations during data collection

Participants’ sex (defined as a set of biological attributes; sex is usually categorized as female or male [ 47 ]) and gender (defined as socially constructed roles, behaviours, expressions, and identities of women, men, and gender diverse people; gender is usually conceptualized as a binary (woman and man) yet there is considerable diversity in how individuals understand, experience, and express it [ 48 ]. Sex and gender will be assessed in the demographic questionnaire ( S6 Appendix ).

Primary outcome.

Feasibility . Feasibility will be measured through recruitment rate, retention rate, and adherence [ 49 ].

• Recruitment rate . Recruitment rate will be calculated as the percentage of participants who enroll in the study out of the total number of eligible participants [ 21 ]. Reasons for nonenrolment and ineligibility for the study will also be recorded. A recruitment rate of >50% is considered moderate [ 26 ].
• Retention rate . Retention rate will be calculated as the percentage of participants who complete the study (i.e., receive the full dose of the intervention and provided post-test outcome data) out of the number of participants who were enrolled (i.e., signed a consent form and provided baseline data) [ 49 ]. A retention rate of ≥80% is considered high [ 26 ].
• Adherence . Participants’ adherence will be determined by: 1) the average number of treatment sessions attended; and 2) the level of engagement with the treatment [ 49 ], that is, a) the duration of each walking session, duration of each intervention session, and number of sit to stands done per session; and 2) b) the number of sit to stands done per session, divided by the goal number of sit to stands. An adherence of ≥75% is considered high [ 26 ]. The adherence checklist can be found in S7 Appendix .

Secondary outcomes.

Efficacy will be assessed using measures for muscle strength, mobility, functional status, quality of life, and discharge destination. The primary outcome for efficacy will be lower extremity muscle strength .

• Lower extremity muscle strength . Lower extremity muscle strength will be measured using the time to perform one sit-to-stand [ 50 , 51 ]. Time to perform one sit-to-stand has good validity and reliability. The ability to perform one sit to stand has been used in a study involving sit-to-stand activity with older adults with dementia in nursing homes [ 29 ]. Repeated observations of the sit to stand test by one observer yielded correlations of 0.89 to 0.96 [ 52 ].
• Mobility . Mobility will be measured using the two-minute walk test (2MWT). The testing procedure for the 2MWT to be used will be similar to those used in a studies involving older adults with cognitive impairment in nursing homes [ 32 , 53 ]. The 2MWT has been used in studies involving older adults with dementia in nursing homes [ 21 , 32 ] and has a test-retest reliability coefficient of 0.98 (0.96–0.99) and an inter-rater reliability of 0.92 (0.86–0.96) when assessed in frail older adults with dementia [ 32 ]. The minimal detectable change (MDC), that is, the minimum change that is considered a true change in performance, for the 2MWT is 9.1 metres [ 32 ].
• Functional status . Functional status will be measured by the Barthel Index (BI), which has been shown to have a good reliability (kappa > 0.75) and validity for short stay older adult patients [ 54 ] and has acceptable item reliability (1.0) and person reliability (0.88) in older adults with dementia [ 55 ]. BI is a 10-item questionnaire which is scored out of 20, with higher scores meaning a better outcome. A change in BI score of 1 point is considered a meaningful change in a person’s level of independence [ 33 ]. When the BI score is multiplied by 5, a score of 0–20 indicates total dependency, 21–60 indicates severe dependency, 61–90 indicates moderate dependency, and 91–99 indicates slight dependency [ 56 ]. BI scores will be measured at pretest, time 2, and post-test.
• Quality of life . Quality of life will be measured using the QOL-AD Quality of Life–Alzheimer’s Disease, a 13-item questionnaire that asks about physical health, energy, mood and other quality of life measures that can be answered by older adults with CI [ 57 ]. The QOL-AD has good reliability (α from 0.83 to 0.90) and validity correlation with measures of depression (r = −0.41 to −0.65) [ 57 ]. The QOL-AD will be completed by the SDM if the patient is not able to complete it.
• Satisfaction . Participant satisfaction will be determined using the Client Satisfaction Questionnaire (CSQ) [ 58 ], modified to the TCP setting, which includes 8 Likert scale questions, a comments section; and three open ended questions, similar to those used in the work by Sano and colleagues [ 31 ]. The CSQ will be completed by the SDM if the patient is not able to complete it. As well, qualitative data in the form of field notes will also be taken on interventionists’ report of challenges, issues, and ease of intervention delivery [ 49 ]. Field notes taken within the intervention fidelity checklist will also capture interventionists’ perspectives on elements of the intervention that are satisfactory to participants and their care partners. The CSQ will be completed by the SDM if the patient is not able to complete it (see S8 Appendix for Time 3 outcome measures with the CSQ and 3 open-ended questions).
• Discharge destination . Planned and actual discharge destinations will be determined by the interventionist through a chart review or confirmation with TCU staff.

Intervention fidelity.

Intervention fidelity will also be measured through the interventionist’s self-report [ 49 ] of 12 intervention items. The percentage will be calculated as the number of items done divided by the 12 items on the intervention fidelity checklist. Any safety events (such as falls) that occur during the intervention sessions will also be documented.

Additional data collected

At Time 3, the RA will review the participant’s chart to document services provided to the participants in addition to the OASIS Walking Intervention, to increase the internal validity of the study. A shortened version of a checklist of services/treatments related to mobility ( Table 3 ) provided to patients in TCPs developed by McGilton and colleagues based on their scoping review [ 6 ] will be completed for this study.

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Statistical analysis

Research question 1..

Data will be analyzed using SPSS version 28.0.1.0. Descriptive statistics will be used for the demographic variables as well as for measures of feasibility (recruitment rate, retention rate, and adherence). Specifically, for measures of adherence, the mean number of treatment sessions attended will be calculated and the range of treatment sessions will be provided. In terms of level of engagement with the treatment, the mean duration of each walking session, of each intervention session, and number of sit to stands done per session will be calculated. As well, the range of each of these durations will be provided. Furthermore, the mean number of sit to stands done per session, divided by the goal number of sit to stands will be calculated.

Research question 2.

Satisfaction will be also assessed through the opened ended questions in the CSQ satisfaction surveys. Quantitative data will be analyzed using descriptive statistics; qualitative data will be analyzed using content analysis [ 59 ].

Research question 3.

Does the OASIS Walking intervention result in improved muscle strength, mobility, functional status, and quality of life in older adults with cognitive impairment?

Means and standard deviations for each of the outcome measures will be summarized. Longitudinal plots of overlaid individual trajectories will be used to visualize observed change over time. Repeated measures analysis of variance (ANOVA) [ 60 , 61 ] will be used to determine if the intervention results in an improvement in participants’ time to perform one sit to stand, 2MWT, BI, and quality of life over time. Repeated measures ANOVA is a parametric test that determines if the means of three or more measures from the same person are similar or different [ 61 ]. Scatter plots will be used to demonstrate any changes in outcomes. If there is missing data, paired t-tests will be used to determine if there is an improvement in participants’ time to perform one sit to stand, 2MWT, BI, and quality of life between two time points.

As well, simple tests of before–after (paired t-tests) will be used to determine the differences between Time 1 (baseline) and Time 2 (after 3 weeks of the intervention), and between Time 1 and Time 3 (after the 6-week intervention) for the outcome variables of interest. These tests will yield corresponding 95% confidence intervals, allowing investigators a sense of the magnitude of changes that one might look for in any subsequent trial.

Research question 4.

What percentage of the participants were discharged home and how many were discharged to the nursing home post intervention? Percentages will be used to describe discharge destination of participants.

Sex and gender considerations in analysis

Descriptive statistics will be used to report on sex and gender. Specifically, descriptive statistics will be used to report data that is disaggregated by sex and gender.

Criteria to evaluate feasibility and potential for success of a future definitive trial

Feasibility of this study is being evaluated by recruitment rate, retention rate, and adherence rate. If the study has a recruitment rate of >50%, a retention rate of ≥80%, and an adherence rate of ≥75%, these will demonstrate feasibility of the study, and therefore potential for success in a future definitive trials. Moreover, if there is high satisfaction with the intervention (CSQ of 3 ore more on the CSQ-8 Questionnaire), this will provide additional evidence to support the testing of this intervention in a more definitive trial.

Access to source documents and confidentiality

Data will only be accessed by the research staff for the purpose of the study. These individuals will complete privacy training and signed confidentiality agreements and/or will be required by law to keep all collected information confidential. Representatives of the University Health Network (UHN) including the UHN Research Ethics Board may be given remote access to an electronic portal (via the internet) to look at the study records to check that the information collected for the study is correct and to make sure the study is following proper laws and guidelines. The electronic data will be kept in a secure one drive storage database hosted by UHN, which has restricted access and safety backup.

All personal information such as participants’ name will be removed from the data and will be replaced with a number. A list linking the number with participants’ names will be kept by the study investigator in a secure place, separate from participant files. Whether on-site or remotely, UHN makes all efforts to ensure that participant information is shared in a way that is secure and private (encrypted). The research team will keep any personal health information about participants in a secure and confidential location for 10 years.

Procedures for data security

The research team will engage in systematic data management and adhere to high standards to protect participants’ confidentiality. Study data will be protected using several strategies. Participants will be given a unique identifier number. This code will not have anything to do with participants’ names. Physical copies of data will be stored in a locked cabinet at the PI’s office. Participants’ contact information, study assigned ID, signed consent forms will be stored securely and separately from completed data collection records. All data will be stored on the TRI–UHN server. The interview with participants and care partners at the beginning of the study will be audiorecorded and then transcribed. All transcripts will be anonymized, and audio recordings will be destroyed upon transcription. Upon completion of the study, data will be archived in a secure, locked location for ten years, then destroyed. In the event of inappropriate release of data, all attempts will be made to stop further release, and any information that could be retrieved will be retrieved. The UHN Privacy Office will be notified, and further actions will be taken according to the UHN Privacy Office and REB recommendations.

Ethics statement and dissemination

The study has received written ethical approval from the University Health Network Research Ethics Board (Study ID 23–5543). Specifically, the approval letter stated: “The University Health Network Research Ethics Board approves the above mentioned study as it has been found to comply with relevant research ethics guidelines, as well as the Ontario Personal Health Information Protection Act (PHIPA), 2004” (p. 2). Should there be any important protocol modifications, the relevant parties (research ethics boards, investigators, trial participants, trial registry) will be notified. Informed written consent will be received from each participant in the study.

If participants are harmed as a direct result of taking part in this study, all necessary medical treatment will be made available to them at no cost.

Findings from the study will be used to refine the intervention for use in a definitive pilot trial. Results will be disseminated via peer-reviewed publications, international conferences, through group presentations at the study sites, and through the study site networks.

The study has been registered on Clinicaltrials.gov (NCT06150339). The study details can be found at https://clinicaltrials.gov/study/NCT06150339 .

Remuneration

Participants will not have to pay for any procedures involved in this study. As a token of appreciation and in recognition of their time and effort, a $5 gift card to a coffee shop will be given to participants at each of the three outcome measurement stages of the research. By the end of the study, participants will be given a total of $15 in gift cards. A $10 gift card to a coffee shop will be given to care partners of participants after their interview as a token of appreciation for their time. Providing a token gift at each stage of the research follows the guidance provided by the Division of the Vice President, Research & Innovation at the University of Toronto [ 62 ]. Moreover, a recent Cochrane systematic review by Gillies and colleagues found that monetary incentives can increase participant retention in intervention studies [ 63 ].

Plan for missing data

A plan to minimize the risk of missing data will be put in place. Specifically, an Ethical Protocol and Algorithm for Data Collection and Intervention Session: Procedure for Assessing Assent and Dissent for the OASIS Walking Intervention ( S9 Appendix ) will be used. This protocol is adapted from the Ethic Protocol used by Chu and colleagues [ 21 ]. For their study, all follow up assessments were completed and there was no missing data [ 21 ]. This protocol includes establishing rapport with participants, obtaining assent prior to initiating data collection, and re-approaching if the participant initially refuses ( S9 Appendix ). Data on paper sheets will also be visually inspected for missing data prior to transferring them onto the secure One drive. In addition to the above retention strategy, remuneration will also be provided to reduce the risk of drop out and thus reduce the risk of missing data.

This article describes the protocol for a feasibility study of a nurse-led mobility intervention. Hospitalized community-dwelling older adults with CI often experience functional decline and are admitted to facility-based TCPs, where they have poorer outcomes, including functional status and discharge destination [ 18 ]. Walking programs in hospitals and long-term care homes have been found to improve outcomes for older adults with CI such as functional status, quality of life, and mobility. As well, programs involving sit to stand activity have shown significant results in terms of lower extremity muscle strength in long-term care homes. However, to the authors’ knowledge, no such combined intervention has been done in facility-based TCPs.

This protocol outlines a 6-week nurse-led mobility intervention for older adults with CI in TCPs which incorporates a patient-centred communication care plan, sit to stand activity, and a walking program. Outcome measurements will take place at pretest, after 3 weeks of intervention, and posttest.

The results of this feasibility study will be valuable for optimizing the design of a definitive controlled trial that could impact clinical practice in this population and setting. If the study demonstrates a recruitment rate of >50%, a retention rate of ≥80%, and an adherence rate of ≥75%, these will demonstrate feasibility, and will thus provide evidence to proceed with a definitive controlled trial. Moreover, if the study results in high satisfaction with the intervention, it will provide further evidence for potential for success in a future definitive trials. Furthermore, the open-ended questions, which includes the question, “If I could change one thing about the walking program, it would be:” which will be asked together with the satisfaction questionnaire will provide additional data which might inform modifications to the design of a trial.

The use of one group rather than having two groups is a limitation of this feasibility study. Still, this study will provide evidence on the feasibility and efficacy of a nurse-led mobility intervention in TCPs. It will provide valuable insight on the feasibility of the components of the intervention and on patients’ satisfaction with the intervention. Furthermore, it will provide preliminary evidence which can inform a definitive pilot study.

A six-week nurse-led mobility intervention which aims to improve functional status, mobility, quality of life, and satisfaction among older adults with CI in TCPs was described. This study will provide valuable insight into the feasibility of this intervention in this setting. Study findings will allow for the refinement of intervention components for a full-scale pilot study.

Supporting information

S1 text. spirit checklist..

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S1 Fig. SPIRIT schedule of enrollment, interventions, and assessments.

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S2 Fig. Patient-centred communication care plan.

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S1 Appendix. Quick dementia rating scale.

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S2 Appendix. Consent form–participant + SDM.

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S3 Appendix. Consent form–care partner.

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S4 Appendix. Evaluation to sign consent.

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S5 Appendix. Intervention manual.

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S6 Appendix. Time 1 assessment.

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S7 Appendix. Adherence checklist.

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S8 Appendix. Time 3 assessment with CSQ-8 and 3 open ended questions.

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S9 Appendix. Assent and ethical protocol.

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S10 Appendix. Protocol for OASIS walking study that was approved by ethics committee.

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