How to Write a Nursing Care Plan: NANDA Diagnoses Guide
Master the five-step nursing process (ADPIE), formulate accurate NANDA Diagnoses using the PES format, and integrate NOC and NIC classifications for evidence-based patient care.
The Nursing Care Plan (NCP) and the Nursing Process
A Nursing Care Plan (NCP) is a standardized document that guides patient care delivery. It translates patient needs identified during the Assessment phase into measurable patient outcomes and specific nursing interventions. The entire NCP is governed by the cyclical, five-step nursing process: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). Mastering this process is crucial for transitioning from theory to clinical practice.
The focus of this guide is the structural implementation of the five-step nursing process, emphasizing the critical Diagnosis and Planning phases. We detail how to use NANDA Diagnoses, NOC (Outcomes), and NIC (Interventions) systems to ensure your NCP is precise, evidence-based, and patient-centered.
Goal of the NCP:
The Nursing Care Plan ensures continuity of care and guides critical thinking. It is a legal document used in Electronic Health Records (EHR) to track and validate the nurse’s clinical judgment.
Mandatory Components of a Rigorous Nursing Care Plan
NANDA-I PES Format
Required structure for the nursing diagnosis (Problem, Etiology, Symptoms), linking patient data to the NANDA-I diagnostic labels.
Measurable Outcomes (NOC)
Goals must be SMART (Specific, Measurable, Attainable, Realistic, Time-bound). NOC classifications provide the language for these patient outcomes.
Evidence-Based Interventions (NIC)
Nursing interventions must be justified by current research. NIC labels ensure the actions are standardized, precise, and relevant to the NANDA Diagnoses.
Phase 1: Comprehensive Patient Assessment
The Assessment phase of the five-step nursing process is the foundation of the entire Nursing Care Plan. It involves systematic data collection (subjective and objective) from the patient, family, and medical records. Crucially, the data must be validated. If you skip validation, you risk basing your NANDA Diagnoses on inaccurate information, leading to flawed nursing interventions and poor patient outcomes.
Assessment Data Checklist:
- Subjective Data: Direct quotes from the patient (e.g., “My pain is 7/10,” or “I feel lonely”).
- Objective Data: Measurable and observable facts (e.g., Vitals, Lab Results, Physical Exam findings).
- Data Clustering: Grouping related subjective and objective findings to identify patterns that point toward a NANDA-I diagnostic label.
Phase 2: Formulating NANDA Diagnoses (PES Format)
The Diagnosis phase requires translating the clustered data into an official nursing diagnosis using the NANDA-I taxonomy. The PES format is mandatory for all actual diagnoses: Problem (NANDA-I label) **related to** Etiology (cause/related factor) **as evidenced by** Symptoms (defining characteristics). Using the precise PES format ensures clarity and directs the subsequent Planning phase.
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Phases 3 & 4: Setting Goals (NOC) and Interventions (NIC)
Phase 3: Planning (Setting Measurable Outcomes using NOC)
The Planning phase sets the patient outcomes—the specific, measurable results expected after intervention. You must convert the NANDA Diagnosis into positive goals, often using the standardized NOC (Nursing Outcomes Classification) labels. These outcomes must be patient-centered and time-bound. Example: If the diagnosis is ‘Impaired Skin Integrity,’ the outcome is ‘The patient will demonstrate improved wound healing by discharge.’ This measurable goal directly guides the selection of nursing interventions.
NOC Example: “Pain Level” scale will decrease from a 7/10 to a 3/10 within 4 hours. The timeframe is mandatory for rigor NOC Overview, 2024.
Phase 4: Implementation (Executing Interventions using NIC)
The Implementation phase involves executing the planned nursing interventions (actions). Use the NIC (Nursing Interventions Classification) taxonomy to standardize your interventions. Each intervention must be specific, evidence-based, and directly address the etiology (E) identified in the NANDA Diagnosis. Documenting the patient’s immediate response to the nursing interventions is critical for the final Evaluation phase. The process requires sound Clinical Judgment.
Properly justified nursing interventions ensure the Nursing Care Plan is defensible. All actions should be prioritized based on Maslow’s Hierarchy of Needs (e.g., Airway always first). The use of NIC helps streamline this complex prioritization process AHRQ, 2012.
Phase 5: Evaluation and Plan Revision
The Evaluation phase completes the five-step nursing process cycle. You compare the patient’s current status against the predetermined, measurable patient outcomes (NOC). The outcome is simple: goal met, goal partially met, or goal unmet. Based on this evaluation, the entire Nursing Care Plan is revised. If the goal was unmet, the nurse must reassess the Diagnosis, the etiology, or the selected nursing interventions. Continuous revision is a sign of dynamic, high-quality care.
Actual Diagnosis vs. Risk Diagnosis
The type of NANDA Diagnosis dictates the structure of the NCP. An Actual Diagnosis describes a problem currently experienced by the patient, evidenced by signs and symptoms (the full PES format). A Risk Diagnosis describes a potential problem (e.g., Risk for Falls) and only includes the Problem and Etiology (PE format), as symptoms are not yet present. The nursing interventions for a risk diagnosis focus purely on prevention.
Clinical Judgment and Critical Thinking
Effective Nursing Care Plans rely heavily on Clinical Judgment. This involves recognizing patient cues, interpreting the data, prioritizing the NANDA Diagnoses, and taking appropriate action. Writing the NCP is an exercise in documenting this judgment process. The entire five-step nursing process formalizes critical thinking, transforming intuition into verifiable, documented healthcare decisions.
The ability to apply Clinical Judgment within the ADPIE framework is vital for clinical success NCBI, 2023.
The Role of the NANDA-I Taxonomy
NANDA-I (North American Nursing Diagnosis Association – International) provides the universal language for the Diagnosis phase. Using these standardized labels ensures all nurses understand the patient’s prioritized needs, regardless of location or specialty. Misusing the NANDA Diagnoses labels or deviating from the PES format undermines the entire care process.
Patient Outcomes (Goals)
Patient outcomes must focus on what the patient will achieve, not what the nurse will do. They should directly counter the problem identified in the NANDA Diagnosis. This is the objective criteria used in the Evaluation phase. Goals must always be specific, measurable, and realistically achievable within a specified timeframe.
Nursing Interventions and Rationale
Every nursing intervention listed in the Planning phase must include a rationale—the scientific justification for the action. This rationale must be grounded in evidence (e.g., textbook knowledge, research, or clinical practice guidelines). Providing a robust rationale proves the NCP is evidence-based, moving the plan beyond routine tasks to critical care management.
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Success in Nursing Assignments: Client Testimonials
Hear from students who achieved mastery in their Nursing Care Plan writing.
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“The NANDA Diagnoses were flawless in the PES format. It helped me truly understand the distinction between nursing and medical diagnoses.”
– A. Johnson, BSN Student
“The expert ensured my patient outcomes were measurable using NOC criteria, which was exactly what my clinical instructor required.”
– M. Patel, Nursing Program
“Crucial support in the Planning phase. The rationale for every nursing intervention was evidence-based and perfectly cited.”
– S. Chen, RN-to-BSN
FAQs: NANDA Diagnoses and Care Planning
Q: What does the PES format stand for in a NANDA Diagnosis?
A: The PES format is mandatory for writing an actual nursing diagnosis. P stands for Problem (the NANDA-I diagnostic label), E stands for Etiology (related factors), and S stands for Symptoms (defining characteristics). Risk Diagnoses only use the P and E components.
Q: What is the difference between an Actual Diagnosis and a Risk Diagnosis?
A: An Actual Diagnosis describes a problem currently existing and validated by signs and symptoms (S). A Risk Diagnosis describes a potential problem (e.g., Risk for Infection) that the patient is vulnerable to, requiring only the P and E components of the PES format, as symptoms are not yet present.
Q: What are NOC and NIC, and how are they used in a Nursing Care Plan?
A: NOC (Nursing Outcomes Classification) provides standardized labels for patient goals (outcomes), ensuring they are measurable. NIC (Nursing Interventions Classification) provides standardized labels for the nursing interventions (actions). Both systems are used in the Planning phase to create precise, evidence-based care plans.
Q: Where should I include the rationale for my nursing interventions?
A: Every nursing intervention must be followed by a rationale—the scientific justification for the action. This ensures the Nursing Care Plan is evidence-based and defensible. The rationale connects the specific NIC action to medical or nursing research, supporting your Clinical Judgment.
Master the Five-Step Nursing Process Today
Precision in NANDA Diagnoses and NOC/NIC classification determines clinical success. Secure expert help to ensure your Nursing Care Plan is perfectly structured and evidence-based.
