A nursing care plan can present in two forms: informal and formal. Informal is a care plan for the individual use of the nurse and goals they wish to accomplish during their shift. Informal care plans are not included in the patient chart. A formal nursing care plan is a written or computerized guide that organizes patient care. It is further subdivided into two: standardized and individualized care plans. Standardized care plans are pre-populated care plans for specific patient populations, such as post-operative patients. Individualized care plans are tailored to the specific needs of the patient and adjust as the patient care journey evolves.
When developing and writing a nursing care plan, the nurse typically follows a five-step process:
- Assessment: Gather objective and subjective data from primary and secondary patient resources. Examples of sources of data include verbal statements from patients and family members, medical history, physical assessment findings, and vital signs.
- Diagnosis: Develop a nursing diagnosis according to the data and information collected from the assessment. Using Maslow's Hierarchy of Needs aids in the priority diagnosis selection and interventions to follow.
- Planning Outcomes: After selecting a diagnosis, the nurse will create Specific, Measurable, Achievable, Relevant and Time-Bound (SMART) short and long-term goals according to the patient's needs. The goals must also be desired by the patient. For example, suppose the goal is for the patient to select nutritious dietary choices during their hospitalization, but the patient wants to focus on their mental health. In that case, dietary choices may not be a realistic goal.
- Implementation: The implementation phase is when the nursing interventions outlined in the care plan are executed. Some interventions will show immediate results, while others may only be seen later in the shift or hospital stay.
- Evaluation: Evaluation allows the nurse to evaluate the outcomes of the interventions and determine if the goals were met. There are three possible outcomes for the SMART goals: met, ongoing, and not met. The nurse can decide if the goals and interventions need adjustment based on the evaluation.