42+ Sample Care Plan Templates

What Is a Care Plan?

Care plans usually refer to nursing care plans. An NCP involves a process of identifying a patient’s needs and recognizing the associated risks. Also, care plans serve as instruments of communication between healthcare professionals to attain a patient’s healthcare goals. Without a care plan, the patient will most likely receive low-quality care. A care plan comes to play when a patient is under the custody of a healthcare facility. There are two types of care plans: a formal and informal nursing care plan. The former only exists in a nurse’s mind, while the latter is written on paper or is computerized. Also, formal care plans can be standardized or individualized. The first-mentioned details guidelines on how to care for a group of patients. The second one meets the needs of individual patients. It is vital to have a care plan because it defines a nurse’s role, serves as a guideline for care, encourages consistency in care planning, and serves documentation purposes.

According to Statista, as of 2016, there were about 2.86 million nurses in the U.S.

Additionally, Statista reports that over 6 million individuals were working at U.S. hospitals in 2016.

In 2017, there were more than 36.5 million admissions in U.S. hospitals.

Common Cases that Require a Care Plan

Several illnesses require a care plan. Note that care plans can come in different forms. Examples include pediatric, cardiac, endocrine, gastrointestinal, genitourinary care plans, and more. So, here are some common cases that require a care plan.

Cerebral palsy. Cerebral palsy is a neurological disorder that affects a child’s posture, balance, and movement. Also, it affects a child’s mental health, speech, and vision. It is a result of damage to a particular section of the brain controlling movement. Typically, it appears in early childhood or infancy. Symptoms may vary from one individual to another. Commonly it includes the following: (1) a delay in achieving developmental milestones, (2) muscle weakness, (3) poor coordination or ataxia, (4) too stiff muscles or spasticity, (5) too floppy muscles or flaccidity, (6) jerky movements, (7) excessive drooling, and (8) difficulty in speaking or swallowing. The care plan’s goal includes preventing deformity, optimizing mobility, improving nutritional status, and improving the quality of life.Congenital heart disease. Congenital heart disease is the outcome of heart malformations of the large arteries, valves, and septums. The heart defects can either be cyanotic or acyanotic. Acyanotic defects result in a mixture of unoxygenated and oxygenated blood. Cyanotic defects include the tetralogy of Fallot, which refers to four heart defects: pulmonic stenosis, ventricular hypertrophy, septal defect, and overriding of the aorta over the ventricular septum. For that reason, the child’s heart won’t be able to pump enough blood to the body resulting in risk for infection, injury, and activity intolerance.Hypertension. Hypertension is another term for high blood pressure. It refers to a consistent blood pressure reading that is more than 140 over 90 milligrams of mercury. It can be because of a primary or secondary cause, which is the result of another underlying disease (e.g., renal disease). The focus of the care plan is to lower a person’s blood pressure by adhering to a therapeutic regimen, changing one’s lifestyle, and preventing complications.Myocardial infarction. Myocardial infarction is another term for heart attack. It happens when the heart doesn’t get enough blood due to obstruction of the arteries, specifically coronary arteries. Note that blood carries oxygen, and without it, the muscles of the heart will die. In the U.S. and western Europe, MI is one of the leading causes of death. It has a high mortality rate, and almost half of the deaths are due to a heart attack that is not addressed within an hour. The care plan goals for MI are to stabilize vital signs, relieve chest pain, reduce heart workload, revascularize the arteries, and preserve the heart tissue.Diabetes Mellitus Type 2. D.M. is a disease caused by the pancreas’ inability to produce enough insulin for the body, resulting in a high amount of blood glucose (hyperglycemia). Also, the condition influences the body’s ability to metabolize fat, protein, and carbohydrate. Prolonged hyperglycemia can pose complications to the body, including the eyes, kidneys, blood vessels, and nerves. The nursing care plan aims to normalize a patient’s blood glucose, use insulin replacements, and decrease complications through proper nutrition and exercise.Obesity. Obesity is the accumulation of too much body fat. When a person has a Body Mass Index that is over 30 kg/m2, he/she is obese. It increases a person’s risk of developing other diseases such as hypertension, diabetes, and heart disease. An individual becomes obese when he/she always take in more calories without exercising or without burning them. Factors that can affect a person’s weight can be his/her genetic makeup, eating habits, and kind of lifestyle. The focus of the care plan includes identifying eating behaviors, making a nutrition plan, and educating the patient regarding nutrition.Hepatitis. Hepatitis refers to the inflammation of most parts of the liver resulting in the death of its cells. It can be because of toxic substances (e.g., alcohol, drugs, industrial chemicals), bacterial infection, viral infections, or autoimmune reactions. Though most cases are self-limiting, meaning it can go away on its own, people with hepatitis B and C usually lead to liver cirrhosis. Nursing management aims to reduce liver demands by changing one’s lifestyle, educating a patient, and treatment.Pneumonia. Pneumonia is the inflammation of the lungs, specifically the parenchyma. It is a disease that impairs the exchange of gas happening within the body. Also, it can be due to a viral or bacterial infection that quickly spreads through contact or droplets. Note that pneumonia is one of the leading causes of death in the U.S. People at high risk for this type of the disease are the following: very old or very young individuals, smokers, bedridden patients, and malnourished individuals, and people who are immunocompromised. The care plan addresses symptoms such as coughing, chest pains, shallow breathing, chills, and fever.Lung Cancer. Lung cancer is characterized by the abnormal growth of cells in the lungs. It may be due to the constant inhalation of harmful substances such as tobacco. Of course, lung cancer is common for smokers. One can determine the risk of cancer by counting the number of sticks smoked daily, the span of smoking, and the content of nicotine found in cigarettes.Schizophrenia. Schizophrenia is a psychiatric disorder characterized by illogical thinking, delusions, hallucinations, behavioral, emotional, and intellectual disruptions. The signs of schizophrenia include social withdrawal, depression, short attention span, suspiciousness, insomnia, lack of hygiene, and strange beliefs. The care plan seeks to address all these signs and provide quality care.

How To Write a Care Plan

The goals of a nursing care plan depend on what illness or disease a nurse is addressing. The steps below are ways to write a care plan correctly.

Step 1: Perform Subjective and Objective Assessment

Subjective assessment refers to client reports (e.g., family history, medical history, etc.). On the other hand, objective assessment applies to the information a nurse gathers from his/her assessment (e.g., physical assessment, vital signs, etc.). By performing an assessment, a nurse can put together a “nursing diagnosis.”

Step 2: Analyze the Data and Organize

After collecting data, you need to analyze them to formulate the right nursing diagnosis. Also, you must organize and prioritize them to prevent confusion. By doing that, you will be able to create SMART goals for the betterment of your patient.

Step 3: Put Together a Nursing Diagnosis

By using the North American Nursing Diagnosis Association or NANDA diagnosis, you can identify and deal with your patient’s needs. The nursing diagnosis will serve as a guide for your intervention. There is a correct way to make a diagnosis, but that is over the bounds of this article.

Step 4: Set Your Priorities

When setting priorities, you can refer to Maslow’s hierarchy of needs, which includes physiological, safety, belonging, esteem, and self-actualization. It would be best if you first prioritized physiological needs and safety more than feelings of esteem and self-actualization. That is because physiological problems can be life-threatening.

Step 5: Document Your Plan

The way you document a care plan depends on the policies of the hospital. The written plan you make becomes the patient’s official medical record, which will be reviewed by the next nurse. Note that different programs can have different formats.

FAQs

What is the difference between assessment and evaluation?

Evaluations are for documenting the achievement attained, while assessment focuses on measuring performance, skill, or working results to provide feedback on weaknesses and strengths and give direction for improvement.

What are the examples of residential care facilities?

Examples of residential care facilities are care and board homes. They are small and private facilities composed of less than 20 residents. Each person under custody may have a private room for themselves, especially when the facility is big. Typically, residents will get personal care, food, and staff members to take care of them 24/7. However, medical and nursing care is usually not available for such facilities.

What does aged care mean?

In the name itself, aged care is for the elderly who can’t live anymore in their homes due to disability, illness, an emergency, or bereavement. It can also be because the elderly cannot manage living at home without help. Aged care can be short-term or permanent. Short term aged care is also known as respite care if lesser care is needed, then it’s advisable to live in retirement villages or single living units.

Do nursing homes also utilize care plans?

Yes, care plans are not only used in hospitals but also in other healthcare facilities. What are nursing homes? Nursing homes are facilities that provide services that focus on health care. Services usually include food service, assistance with activities of daily living, round the clock supervision, and nursing care. Also, they provide rehabilitation services like occupational, physical, and speech therapy.

A care plan serves as a guide for nurses in delivering quality care. Also, it is a basis for diagnosis and intervention. Most importantly, by following the steps of a nursing care plan, healthcare providers will be able to achieve their desired goals for every patient. You can check and download one of our care plan templates above for reference and use.