Writing NANDA-I (Nursing Diagnosis) Care Plan (+ Examples)

A NANDA Nursing Diagnosis Care Plan refers to a care plan that incorporates nursing diagnoses from the NANDA International (NANDA-I) classification system. NANDA-I provides a standardized language and framework for identifying, documenting, and addressing nursing diagnoses.

• A NANDA Nursing Diagnosis Care Plan is a written document that outlines the specific nursing interventions and actions to be taken to address the identified nursing diagnoses. It serves as a guide for nurses in providing individualized care to clients.
• The current version of NANDA-I is NANDA-I Nursing Diagnoses: Definitions & Classification 2021-2023.

Review: Nursing Care Plans Writing Guide:

• Writing a Nursing Care Plan (NCP)
• Writing a Nursing Diagnosis
• Writing Student Nursing Care Plans (NCPs)
• Writing an iHuman Care Plan Nursing Assessment
• Sample Robert Jones iHuman Care Plan

Key Components of a NANDA-I Nursing Diagnosis Care Plan

Here are the key components of a NANDA Nursing Diagnosis Care Plan:

1. Nursing Diagnosis: Each nursing diagnosis is clearly stated using the standardized NANDA-I label. It identifies the client’s health problem or potential complication.
2. Related Factors/Etiology: The underlying causes or contributing factors that led to the nursing diagnosis are identified. This helps determine the appropriate interventions and treatment strategies.
3. Defining Characteristics: The clinical cues or observable signs and symptoms that support the presence of the nursing diagnosis are documented. Defining characteristics provide evidence of the client’s response to the health problem.
4. Goals and Expected Outcomes: Specific, measurable goals are established to address the nursing diagnoses. These goals should be realistic, achievable, and tailored to the individual client’s needs.
5. Nursing Interventions: The nursing interventions are the actions, strategies, and activities that the nurse will implement to address the nursing diagnoses and achieve the identified goals. These interventions are evidence-based and individualized to meet the client’s specific needs.
6. Evaluation: The plan includes methods to evaluate the effectiveness of the nursing interventions and the achievement of the desired outcomes. This involves reassessing the client, comparing outcomes to the expected goals, and making adjustments to the care plan as necessary.

• A NANDA Nursing Diagnosis Care Plan provides a structured and systematic approach to nursing care, promoting effective communication, continuity of care, and individualized interventions.
• It helps guide nurses in delivering holistic, evidence-based care and serves as a valuable tool for interdisciplinary collaboration and communication.

Format of a NANDA Nursing Care Plan

When developing a NANDA Nursing Diagnosis Care Plan, it is important to use a structured format to ensure clarity and consistency. While different healthcare facilities may have their own preferred templates, here is a general format that can be used:

1. Client Information:
   • Include the client’s identifying information such as name, age, gender, and medical record number.
   • Provide a brief summary of the client’s relevant medical history, current condition, and any significant findings from the assessment.
2. Nursing Diagnosis:
   • State the nursing diagnosis using the standardized NANDA-I label.
   • Include the related factors and defining characteristics that support the diagnosis.
   • Prioritize the nursing diagnoses based on the client’s needs and acuity.
3. Goals and Expected Outcomes:
   • Clearly articulate the goals you intend to achieve for each nursing diagnosis.
   • Make sure the goals are specific, measurable, achievable, relevant, and time-bound (SMART).
   • Include the desired outcomes that demonstrate the client’s progress toward the goals.
4. Nursing Interventions:
   • List the specific nursing interventions that will be implemented to address each nursing diagnosis.
   • Each intervention should be concise, specific, and actionable.
   • Ensure that the interventions are evidence-based and align with best practices.
5. Rationale and Evidence:
   • Provide a rationale for each nursing intervention, explaining why it was chosen based on the nursing diagnosis and assessment data.
   • Support the rationale with evidence from reliable sources such as research studies or clinical guidelines.
6. Evaluation and Reassessment:
   • Describe the criteria and methods for evaluating the effectiveness of the nursing interventions.
   • Specify the timeframe for evaluating the client’s progress and identifying any necessary modifications to the care plan.
   • Mention the frequency of reassessment and the parameters to be assessed.
7. Collaboration and Interdisciplinary Care:
   • Identify any other healthcare professionals or disciplines involved in the care plan.
   • Specify their roles and responsibilities in relation to the nursing interventions.
   • Emphasize the importance of interdisciplinary collaboration to ensure comprehensive and holistic care.
8. Documentation and Communication:
   • Document any significant changes in the client’s condition or response to interventions.
   • Communicate the care plan effectively with the healthcare team, ensuring all members are informed and updated.
   • Follow the documentation standards and policies of your healthcare facility.

• Remember, the specific layout and sections of the care plan may vary based on institutional preferences.
• It’s essential to follow your healthcare facility’s guidelines and templates while maintaining a clear and organized structure for effective communication and continuity of care.

How to Write a NANDA Nursing Care Plan

Writing a NANDA Nursing Diagnosis Care Plan involves several steps and considerations. Here is a guide along with important tips to help you create an effective care plan:

1. Collect Comprehensive Assessment Data: Gather all relevant information about the client’s physical, psychological, social, and environmental aspects. Conduct a thorough assessment to identify nursing diagnoses accurately.
2. Select Appropriate NANDA-I Nursing Diagnoses: Choose the most relevant nursing diagnoses from the NANDA-I list that accurately reflect the client’s health problems or potential complications. Ensure the selected nursing diagnoses are supported by the assessment data.
3. Prioritize Nursing Diagnoses: Determine the priority of the nursing diagnoses based on the client’s needs, acuity, and potential for harm. Focus on the most urgent or significant nursing diagnoses for intervention.
4. Set Clear and Measurable Goals: Establish specific, measurable, achievable, relevant, and time-bound (SMART) goals for each nursing diagnosis. Goals should be client-centered and reflect desired outcomes.
5. Develop Nursing Interventions: Identify evidence-based nursing interventions that align with the goals and nursing diagnoses. Consider the client’s preferences, cultural background, and available resources. Interventions should be specific, actionable, and based on best practices.
6. Consider Collaboration and Interdisciplinary Care: Recognize the importance of interdisciplinary collaboration. Involve other healthcare team members, such as physicians, therapists, or social workers, when developing the care plan to ensure comprehensive and holistic care.
7. Individualize the Care Plan: Tailor the care plan to the unique needs, preferences, and circumstances of the client. Consider their age, cultural background, health literacy, and resources available. Individualized care plans promote patient engagement and improve outcomes.
8. Document Rationale and Evidence: Provide a rationale for each nursing intervention, linking it to the identified nursing diagnosis and supporting evidence. This demonstrates the clinical reasoning behind the chosen interventions and promotes evidence-based practice.
9. Include Evaluation and Reassessment: Plan for ongoing evaluation and reassessment of the client’s response to interventions and the achievement of goals. Regularly review and update the care plan as needed based on the client’s progress or changes in their condition.
10. Communicate and Share the Care Plan: Ensure effective communication and collaboration with the healthcare team by sharing the care plan. Use clear and concise language, standardized terminology, and ensure the care plan is easily accessible and understood by all team members.

Important Tips:

By following these additional writing tips, you can develop a NANDA Nursing Diagnosis Care Plan that promotes individualized, evidence-based care and improves client outcomes:

• Involve the client and their family in the care planning process, seeking their input and collaboration.
• Continuously assess and reassess the client’s condition to ensure the care plan remains relevant and effective.
• Use evidence-based practice guidelines, clinical protocols, and reputable resources to guide your nursing interventions.
• Regularly review and update the care plan to reflect any changes in the client’s condition, goals, or priorities.
• Document the care plan accurately and comprehensively, adhering to your healthcare facility’s documentation standards and policies.

Examples of NANDA Nursing Diagnosis Care Plans

Below are 3 examples of NANDA Nursing Diagnosis Care Plans for specific case scenarios on: Impaired Gas Exchange, Risk for Falls, and Risk for Suicide.

A. Impaired Gas Exchange NANDA Nursing Diagnosis Care Plan Example

Case Scenario: Mr. Johnson, a 65-year-old male, has been admitted to the hospital with a diagnosis of heart failure. He presents with shortness of breath, lower extremity edema, and fatigue.

1. Nursing Diagnosis: Impaired Gas Exchange related to pulmonary congestion due to heart failure, as evidenced by shortness of breath, decreased oxygen saturation, and adventitious lung sounds.
2. Goals and Expected Outcomes:
   1. Within 24 hours, the patient’s oxygen saturation levels will improve to ≥95% on room air.
   2. Within 48 hours, the patient will report a decreased level of shortness of breath to a tolerable level of 1-2 on a scale of 0-10.
   3. Within 72 hours, the patient’s lung sounds will clear, and no adventitious sounds will be heard during auscultation.
3. Nursing Interventions:
   1. Monitor respiratory status:
      • Assess respiratory rate, rhythm, depth, and effort regularly.
      • Measure oxygen saturation using pulse oximetry at regular intervals.
      • Auscultate lung sounds to identify changes or abnormalities.
   2. Position for optimal ventilation:
      • Elevate the head of the bed to a semi-Fowler’s or high-Fowler’s position.
      • Encourage and assist the patient with positioning for maximum comfort and lung expansion.
      • Instruct the patient to perform deep breathing and coughing exercises.
   3. Administer supplemental oxygen:
      • Administer oxygen therapy as prescribed to maintain oxygen saturation within the target range.
      • Monitor the oxygen flow rate and adjust as needed based on oxygen saturation levels.
      • Educate the patient on the purpose and proper use of oxygen therapy.
   4. Promote adequate fluid balance:
      • Monitor the patient’s fluid intake and output closely.
      • Implement fluid restriction as ordered by the healthcare provider.
      • Teach the patient about the importance of adhering to fluid restrictions and monitoring daily weight.
   5. Collaborate with the healthcare team:
      • Communicate any changes in the patient’s respiratory status promptly.
      • Collaborate with the respiratory therapist for respiratory treatments as indicated.
      • Consult with the healthcare provider for medication adjustments or additional interventions.
4. Rationale and Evidence:
   • Monitoring respiratory status helps identify any deterioration or improvement in gas exchange.
   • Positioning the patient in a semi-Fowler’s or high-Fowler’s position enhances lung expansion and reduces venous congestion.
   • Administering supplemental oxygen improves oxygenation and helps maintain target oxygen saturation levels.
   • Promoting adequate fluid balance helps reduce fluid overload and congestion in the lungs.
   • Collaboration with the healthcare team ensures comprehensive care and timely interventions.
5. Evaluation and Reassessment:
   • Assess the patient’s oxygen saturation levels, respiratory effort, and lung sounds at regular intervals.
   • Monitor the patient’s self-reported level of shortness of breath.
   • Document any changes observed and compare them with the expected outcomes.
   • Reassess and modify the care plan as necessary based on the patient’s response and progress.
6. Documentation and Communication:
   • Document the patient’s respiratory assessment findings, interventions provided, and the patient’s response to interventions.
   • Communicate the care plan to the healthcare team through verbal handoff reports, nursing notes, and electronic health records.
   • Collaborate with other healthcare professionals involved in the patient’s care to ensure continuity and coordinated interventions.

B. Risk for Falls NANDA Nursing Diagnosis Care Plan Example

Case Scenario: Mrs. Anderson, a 70-year-old female, has been admitted to the hospital following a hip fracture. She experiences chronic pain, impaired mobility, and fear of falling.

1. Nursing Diagnosis: Risk for Falls related to impaired mobility, history of falls, and fear of falling.
2. Goals and Expected Outcomes:
   1. Within 24 hours, the patient will verbalize understanding of fall risks and identify strategies to prevent falls.
   2. Within 48 hours, the patient will demonstrate safe mobility techniques, including the use of assistive devices and proper body mechanics.
   3. Within 72 hours, the patient will express reduced fear of falling and actively engage in mobility activities with increased confidence.
3. Nursing Interventions:
   1. Conduct fall risk assessment:
      • Perform a comprehensive fall risk assessment upon admission and reassess regularly.
      • Evaluate factors such as history of falls, gait and balance, and cognitive status.
      • Involve the patient and family in fall prevention discussions and education.
   2. Implement fall prevention strategies:
      • Ensure the patient has a safe and clutter-free environment.
      • Provide a call bell within easy reach and instruct the patient on its proper use.
      • Place non-slip mats or rugs in the bathroom and near the bedside.
   3. Educate the patient and family:
      • Teach the patient about fall risk factors, such as wearing appropriate footwear and taking medications as prescribed.
      • Instruct the patient on the use of assistive devices, such as a walker or cane, and ensure proper fitting.
      • Discuss the importance of regular exercise, including strength and balance training.
   4. Encourage active mobility:
      • Collaborate with physical therapy to develop an individualized mobility plan.
      • Assist the patient in practicing safe transfer techniques, including getting in and out of bed or a chair.
      • Promote the use of assistive devices during ambulation.
   5. Address fear of falling:
      • Explore the patient’s fears and concerns regarding falling.
      • Provide emotional support and reassurance.
      • Collaborate with the healthcare team to address underlying causes of fear, such as pain management or anxiety.
4. Rationale and Evidence:
   • Conducting fall risk assessments helps identify factors contributing to the risk of falls and tailor interventions accordingly.
   • Implementing fall prevention strategies and creating a safe environment reduces the likelihood of falls.
   • Education empowers the patient and family to actively participate in fall prevention measures.
   • Encouraging active mobility promotes strength, balance, and confidence, reducing the risk of falls.
   • Addressing fear of falling through emotional support and collaboration helps alleviate anxiety and promotes engagement in mobility activities.
5. Evaluation and Reassessment:
   • Assess the patient’s understanding of fall risks and their ability to implement fall prevention strategies.
   • Observe the patient’s use of assistive devices and mobility techniques.
   • Engage in open communication to evaluate changes in the patient’s fear of falling.
   • Modify the care plan as needed based on the patient’s progress and response to interventions.
6. Documentation and Communication:
   • Document fall risk assessments, education provided, and the patient’s response to interventions.
   • Communicate the care plan to the healthcare team, including physical therapy and other involved disciplines.
   • Ensure accurate and timely documentation of any changes, falls, or near-miss incidents to facilitate interdisciplinary collaboration and continuity of care.

C. Risk for Suicide NANDA Nursing Diagnosis Care Plan Example

Case Scenario: Ms. Rodriguez, a 45-year-old woman, has been admitted to the psychiatric unit with a diagnosis of major depressive disorder. She presents with feelings of hopelessness, lack of interest in previously enjoyed activities, and difficulty with daily functioning.

1. Nursing Diagnosis: Risk for Suicide related to depressed mood, hopelessness, and previous suicide attempt.
2. Goals and Expected Outcomes:
   1. Within 24 hours, the patient will verbalize increased hope for the future and identify at least three coping strategies to manage suicidal thoughts.
   2. Within 48 hours, the patient will actively participate in therapeutic activities and engage in interactions with others, demonstrating decreased isolation.
   3. Within 72 hours, the patient will demonstrate a safety plan and verbalize an understanding of the importance of reaching out for help during moments of crisis.
3. Nursing Interventions:
   1. Establish a therapeutic relationship:
      • Provide a non-judgmental, empathetic, and supportive environment.
      • Engage in active listening and validate the patient’s feelings.
      • Build trust through consistent and therapeutic communication.
   2. Assess suicide risk factors:
      • Perform a thorough assessment of suicide risk factors, including previous attempts, access to means, and presence of a safety plan.
      • Collaborate with the healthcare team to determine the level of observation and appropriate precautions.
   3. Encourage expression of feelings:
      • Encourage the patient to discuss and express their emotions in a safe and supportive environment.
      • Utilize therapeutic techniques such as reflection, exploration, and validation.
      • Provide outlets for creative expression, such as art therapy or journaling.
   4. Implement safety measures:
      • Conduct a safety assessment to identify potential hazards and remove or minimize them.
      • Maintain a safe environment by removing any potentially harmful objects.
      • Establish a suicide watch and ensure close observation as determined by the healthcare team.
   5. Collaborate with the treatment team:
      • Participate in interdisciplinary meetings to discuss the patient’s progress and adjust the treatment plan as needed.
      • Share relevant information and observations to ensure a comprehensive approach to care.
      • Collaborate with the psychiatrist and therapist to provide appropriate medication management and therapy sessions.
4. Rationale and Evidence:
   • Establishing a therapeutic relationship creates a safe and supportive environment for the patient to express their emotions and concerns.
   • Assessing suicide risk factors helps determine appropriate interventions and precautions to prevent self-harm.
   • Encouraging expression of feelings promotes emotional release and may decrease feelings of isolation and hopelessness.
   • Implementing safety measures aims to create a physically safe environment for the patient.
   • Collaboration with the treatment team ensures coordinated and comprehensive care for the patient.
5. Evaluation and Reassessment:
   • Regularly assess the patient’s suicidal ideation, mood, and level of engagement in therapeutic activities.
   • Review the patient’s safety plan and its effectiveness in managing crisis situations.
   • Evaluate changes in the patient’s overall well-being, engagement in treatment, and self-reported levels of hopefulness.
   • Modify the care plan as necessary based on the patient’s progress and response to interventions.
6. Documentation and Communication:
   • Document assessments, interventions provided, and the patient’s response to interventions.
   • Communicate the care plan and relevant updates to the healthcare team, including psychiatrists, therapists, and other involved disciplines.
   • Ensure clear and concise documentation of any significant changes, observations, or concerns to facilitate effective communication and continuity of care.

• Note: These are sample NANDA nursing diagnosis care plans, and actual care plans should be individualized based on the specific needs and circumstances of the patient, as well as institutional policies and guidelines.
• If you are in college, review student nursing care plans.