Care Plan (Nursing)
A nursing care plan is a written document that outlines a patient's identified health problems, measurable goals, and specific nursing interventions. It is developed by the RN based on nursing assessment data and guides the entire nursing team in providing consistent, individualized care.
Exam Tip
RN develops the care plan; LPN contributes data and implements it. Goals must be measurable and time-specific. Prioritize using ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy. LPNs report changes to the RN for care plan modifications.
What Is a Nursing Care Plan?
A nursing care plan is a formal, structured document that organizes and prioritizes patient care. It is based on the nursing process (Assessment, Diagnosis, Planning, Implementation, Evaluation) and ensures all members of the healthcare team provide consistent, goal-directed care.
Components of a Care Plan
| Component | Description | Example |
|---|---|---|
| Nursing Assessment Data | Objective and subjective findings | VS: BP 160/95, patient reports headache |
| Nursing Diagnosis | Clinical judgment about patient response | Risk for falls related to unsteady gait |
| Goals/Expected Outcomes | Measurable, time-specific desired results | Patient will ambulate 50 feet without assistance within 3 days |
| Nursing Interventions | Specific actions to achieve goals | Assist with ambulation TID using gait belt |
| Evaluation | Assessment of goal achievement | Patient ambulated 50 feet independently on day 3 |
Priority Setting in Care Plans
Care plans use priority frameworks to determine which problems to address first:
| Framework | Order of Priority |
|---|---|
| Maslow's Hierarchy | Physiological > Safety > Love/Belonging > Esteem > Self-Actualization |
| ABCs | Airway > Breathing > Circulation |
| Acute vs. Chronic | Acute/life-threatening problems before chronic conditions |
LPN/LVN Role in Care Planning
| LPN Responsibility | NOT an LPN Responsibility |
|---|---|
| Contribute data from assessments | Independently develop the care plan |
| Implement interventions as directed | Create nursing diagnoses |
| Document patient responses | Modify the care plan independently |
| Report changes to the RN | Delegate tasks to other LPNs |
| Reinforce patient teaching | Perform initial patient education |
Exam Alert
Care planning appears in the Coordinated Care category on the NCLEX-PN. Know that the RN develops the care plan, the LPN contributes data and implements interventions. Goals must be SMART (Specific, Measurable, Achievable, Relevant, Time-bound). Always prioritize using ABCs and Maslow's Hierarchy.
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Related Terms
Nursing Process
The nursing process is a systematic, five-step problem-solving framework used by nurses to provide patient-centered care: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). It is the foundation of all nursing practice and the organizing framework for the NCLEX.
Maslow's Hierarchy of Needs
Maslow's Hierarchy of Needs is a motivational theory organized as a five-level pyramid, used in nursing to prioritize patient care. From bottom to top: physiological needs, safety and security, love and belonging, self-esteem, and self-actualization. Lower-level needs must be met before addressing higher-level needs.
Delegation (Nursing)
Delegation in nursing is the process of transferring responsibility for performing a specific nursing task to another qualified individual (such as a CNA or UAP) while retaining accountability for the outcome. The five rights of delegation guide safe delegation decisions.
Scope of Practice (Nursing)
Scope of practice defines the legal boundaries of what a healthcare professional is authorized to do based on their education, licensure, and state Nurse Practice Act. For LPNs/LVNs, the scope includes basic nursing care, data collection, medication administration, and care plan implementation under RN or physician supervision.
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