{"id":69032,"date":"2021-01-29T11:45:05","date_gmt":"2021-01-29T17:45:05","guid":{"rendered":"https:\/\/www.mometrix.com\/academy\/?page_id=69032"},"modified":"2026-03-26T09:25:09","modified_gmt":"2026-03-26T14:25:09","slug":"plan-of-care","status":"publish","type":"page","link":"https:\/\/www.mometrix.com\/academy\/plan-of-care\/","title":{"rendered":"Plan of Care"},"content":{"rendered":"\n\t\t\t<div id=\"mmDeferVideoEncompass_IHsluPe1OOs\" style=\"position: relative;\">\n\t\t\t<picture>\n\t\t\t\t<source srcset=\"https:\/\/www.mometrix.com\/academy\/wp-content\/uploads\/2023\/01\/circle-play-duotone.webp\" type=\"image\/webp\">\n\t\t\t\t<source srcset=\"https:\/\/www.mometrix.com\/academy\/wp-content\/uploads\/2023\/01\/circle-play-duotone.png\" type=\"image\/jpeg\"> \n\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" loading=\"eager\" id=\"videoThumbnailImage_IHsluPe1OOs\" data-source-videoID=\"IHsluPe1OOs\" src=\"https:\/\/www.mometrix.com\/academy\/wp-content\/uploads\/2023\/01\/circle-play-duotone.png\" alt=\"Plan of Care Video\" height=\"464\" width=\"825\" class=\"size-full\" data-matomo-title = \"Plan of Care\">\n\t\t\t<\/picture>\n\t\t\t<\/div>\n\t\t\t<style>img#videoThumbnailImage_IHsluPe1OOs:hover {cursor:pointer;} img#videoThumbnailImage_IHsluPe1OOs {background-size:contain;background-image:url(\"https:\/\/www.mometrix.com\/academy\/wp-content\/uploads\/2023\/01\/750-thumb-final-1.webp\");}<\/style>\n\t\t\t<script defer>\n\t\t\t  jQuery(\"img#videoThumbnailImage_IHsluPe1OOs\").click(function() {\n\t\t\t\tlet videoId = jQuery(this).attr(\"data-source-videoID\");\n\t\t\t\tlet helpTag = '<div id=\"mmDeferVideoYTMessage_IHsluPe1OOs\" style=\"display: none;position: absolute;top: -24px;width: 100%;text-align: center;\"><span style=\"font-style: italic;font-size: small;border-top: 1px solid #fc0;\">Having trouble? <a href=\"https:\/\/www.youtube.com\/watch?v='+videoId+'\" target=\"_blank\">Click here to watch on YouTube.<\/a><\/span><\/div>';\n\t\t\t\tlet tag = document.createElement(\"iframe\");\n\t\t\t\ttag.id = \"yt\" + videoId;\n\t\t\t\ttag.src = \"https:\/\/www.youtube-nocookie.com\/embed\/\" + videoId + \"?autoplay=1&controls=1&wmode=opaque&rel=0&egm=0&iv_load_policy=3&hd=0&enablejsapi=1\";\n\t\t\t\ttag.frameborder = 0;\n\t\t\t\ttag.allow = \"autoplay; fullscreen\";\n\t\t\t\ttag.width = this.width;\n\t\t\t\ttag.height = this.height;\n\t\t\t\ttag.setAttribute(\"data-matomo-title\",\"Plan of Care\");\n\t\t\t\tjQuery(\"div#mmDeferVideoEncompass_IHsluPe1OOs\").html(tag);\n\t\t\t\tjQuery(\"div#mmDeferVideoEncompass_IHsluPe1OOs\").prepend(helpTag);\n\t\t\t\tsetTimeout(function(){jQuery(\"div#mmDeferVideoYTMessage_IHsluPe1OOs\").css(\"display\", \"block\");}, 2000);\n\t\t\t  });\n\t\t\t  \n\t\t\t<\/script>\n\t\t\n<p><script>\nfunction uy6_Function() {\n  var x = document.getElementById(\"uy6\");\n  if (x.style.display === \"none\") {\n    x.style.display = \"block\";\n  } else {\n    x.style.display = \"none\";\n  }\n}\n<\/script><\/p>\n<div class=\"moc-toc hide-on-desktop hide-on-tablet\">\n<div><button onclick=\"uy6_Function()\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.mometrix.com\/academy\/wp-content\/uploads\/2024\/12\/toc2.svg\" width=\"16\" height=\"16\" alt=\"show or hide table of contents\"><\/button><\/p>\n<p>On this page<\/p>\n<\/div>\n<nav id=\"uy6\" style=\"display:none;\">\n<ul>\n<li class=\"toc-h2\"><a href=\"#What_is_a_Nursing_Care_Plan\" class=\"smooth-scroll\">What is a Nursing Care Plan?<\/a><\/li>\n<li class=\"toc-h2\"><a href=\"#The_5_Essential_Steps_in_a_Nursing_Care_Plan\" class=\"smooth-scroll\">The 5 Essential Steps in a Nursing Care Plan<\/a><\/li>\n<li class=\"toc-h2\"><a href=\"#Diagnosis\" class=\"smooth-scroll\">Diagnosis<\/a><\/li>\n<li class=\"toc-h2\"><a href=\"#Potential_Problems_and_Risk_Factors\" class=\"smooth-scroll\">Potential Problems and Risk Factors<\/a><\/li>\n<\/ul>\n<\/nav>\n<\/div>\n<div class=\"accordion\"><input id=\"transcript\" type=\"checkbox\" class=\"spoiler_button\" \/><label for=\"transcript\">Transcript<\/label>\n<div class=\"spoiler\" id=\"transcript-spoiler\">\n<p>Welcome! In this video we will be covering nursing care plans.<\/p>\n<h2><span id=\"What_is_a_Nursing_Care_Plan\" class=\"m-toc-anchor\"><\/span>What is a Nursing Care Plan?<\/h2>\n<p>\nA nursing care plan is developed to <strong>guide nursing care<\/strong> for individual patients and communities. It serves as a model to give individualized care to a patient, or on a larger scale, direct care for a group of individuals.<\/p>\n<p>It is not a medical diagnosis or medical plan, but it is a vital part of patient care.<\/p>\n<p>Nursing care plans have changed and evolved over the years as nursing practices have advanced. This is based on <strong>evidence<\/strong>, science, trends in the population, community health concerns, and other health needs as they arise.<\/p>\n<h2><span id=\"The_5_Essential_Steps_in_a_Nursing_Care_Plan\" class=\"m-toc-anchor\"><\/span>The 5 Essential Steps in a Nursing Care Plan<\/h2>\n<p>\nThe nursing care plan consists of 5 steps that follow the acronym AD-PIE: Assessment, Diagnosis, Planning, Intervention, and Evaluation.<\/p>\n<h3><span id=\"Assessment\" class=\"m-toc-anchor\"><\/span>Assessment<\/h3>\n<p>\nThe first and most important part of a nursing care plan is the assessment. When a patient or population interfaces with healthcare, or when a healthcare professional sees a need, the first step is to <strong>gather data<\/strong>.<\/p>\n<p>Let\u2019s start with the patient report, which is the subjective data. This is what the patient reports to the nurse as the problem. The patient also gives the nurse their past medical history, and a variety of questions can be asked at this time as to the status of their current state of health.<\/p>\n<p>Next, the nurse verifies the patient report by collecting objective data, the measurable data of the physical assessment, such as vital signs, height and weight.<\/p>\n<h3><span id=\"Physical_Assessment_Tools\" class=\"m-toc-anchor\"><\/span>Physical Assessment Tools<\/h3>\n<p>\nThe physical assessment of a patient to develop a plan of care utilizes the tools of inspection, percussion, palpation, auscultation, and performance of minor testing to gather data about the patient to form a nursing diagnosis.<\/p>\n<p><strong>Inspection<\/strong> simply means to look at the patient. Look at their posture, skin, signs of distress, lumps, bumps, bruises, deformities, and make a note of anything you find. Always compare one side of the body to another and inquire if this is the patient\u2019s baseline. Often the subjective questions a patient is asked about their health history can be gathered while their physical assessment is performed.<\/p>\n<p><strong>Percussion<\/strong> is a technique where you use your hands to elicit certain types of sounds by tapping on your fingers as they are placed on various parts of the patient\u2019s body. For example, you would expect to percuss dullness over bone or an organ, and tympani over the intestines. If the opposite is found, this may be an abnormal finding.<\/p>\n<p><strong>Palpation<\/strong> is touching the patient and pressing in. Light palpation is about an inch, deeper palpation about 1.5 to 2 inches. This can help us feel something abnormal or elicit a pain response from the patient.<\/p>\n<p><strong>Auscultation<\/strong> involves using a stethoscope to listen for sounds such as the heartbeat, or breathing of the lungs.<\/p>\n<p>Some minor testing can also be done, such as using a reflex hammer to test reflexes or observing a patient\u2019s gait as they walk across the room.<\/p>\n<h2><span id=\"Diagnosis\" class=\"m-toc-anchor\"><\/span>Diagnosis<\/h2>\n<p>\nOnce all the subjective and objective data have been gathered, a nursing diagnosis can be created based on problems or potential problems you assess. Nursing diagnoses are a way of identifying actual or potential health problems that can be prevented or resolved by independent nursing intervention.<\/p>\n<p>The North American Nursing Diagnosis Association (NANDA) provides nurses with a current list of nursing diagnoses.<\/p>\n<h3><span id=\"Planning\" class=\"m-toc-anchor\"><\/span>Planning<\/h3>\n<p>\nThe next stage in the nursing care plan is the <strong>planning<\/strong> stage, where goals and outcomes are formulated. These patient-specific goals provide a course of direction for a personalized plan of care. Goals should be specific, measurable, attainable, realistic, and timely.<\/p>\n<h3><span id=\"Intervention\" class=\"m-toc-anchor\"><\/span>Intervention<\/h3>\n<p>\nThe fourth step in the nursing care plan is <strong>intervention<\/strong>. Intervention involves actually doing the care the patient requires, such as administering medication or turning the patient in bed. Rationales for these interventions are included to show that the intervention is evidence-based.<\/p>\n<h3><span id=\"Evaluation\" class=\"m-toc-anchor\"><\/span>Evaluation<\/h3>\n<p>\nThe last step of the nursing care plan is <strong>evaluation<\/strong> of the interventions. Based on the patient\u2019s response to the interventions, they can continue or be reassessed if not achieving the expected outcome.<\/p>\n<h2><span id=\"Potential_Problems_and_Risk_Factors\" class=\"m-toc-anchor\"><\/span>Potential Problems and Risk Factors<\/h2>\n<p>\nNursing diagnoses do not always have to be an actual problem. They can also be a potential problem, or a lack of knowledge regarding health, or something the patient may be <strong>at risk<\/strong> for, such as in prolonged bed rest, which may cause them to be at risk for skin breakdown.<\/p>\n<p>Currently, in addition to using the standard linear way to document a nursing care plan, we have seen the development of nursing care planning through <strong>concept mapping<\/strong>, which is just another way to look at the assessment, plan interventions, and evaluation through a map of sorts versus the standard linear way of writing them.<\/p>\n<p>Thanks for watching, and happy studying!<\/p>\n<\/div>\n<\/div>\n\n<div class=\"home-buttons\">\n<p><a href=\"https:\/\/www.mometrix.com\/academy\/patient-care\/\">Return to Patient Care Videos<\/a><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Return to Patient Care Videos<\/p>\n","protected":false},"author":1,"featured_media":99850,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":{"0":"post-69032","1":"page","2":"type-page","3":"status-publish","4":"has-post-thumbnail","6":"page_category-general-patient-care-videos","7":"page_category-patient-care-videos","8":"page_category-video-pages-for-study-course-sidebar-ad","9":"page_type-video","10":"subject_matter-nursing"},"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/pages\/69032","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/comments?post=69032"}],"version-history":[{"count":5,"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/pages\/69032\/revisions"}],"predecessor-version":[{"id":279529,"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/pages\/69032\/revisions\/279529"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/media\/99850"}],"wp:attachment":[{"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/media?parent=69032"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}