Nursing Care Plan

Clinical Use Cases

• Post-Operative Respiratory Monitoring: A nurse developing a care plan for a patient with impaired gas exchange after abdominal surgery uses the tool to generate a plan with NOC outcome "Respiratory Status: Gas Exchange" (target SpO2 >= 94%, PaO2 80-100 mmHg) and NIC interventions including airway management, oxygen therapy, and vital signs monitoring with specific Q2-4 hour activity schedules
• Fall Prevention in Elderly Inpatients: A charge nurse assigns a care plan for a newly admitted 78-year-old with a history of falls, altered mental status, and IV therapy. The tool generates a Risk for Falls plan with the Morse Fall Scale risk factors documented, NOC outcomes for "Risk Control: Falls" and "Fall Prevention Behavior," and NIC interventions including multi-component fall prevention (bed alarm, non-skid footwear, hourly rounding) citing Cameron et al. (Cochrane 2018)
• Acute Pain Management on a Surgical Unit: A bedside nurse creates a care plan for a patient reporting 7/10 pain post-operatively. The tool generates an Acute Pain plan with NOC outcomes for "Pain Level" (target <= 4/10) and "Pain Control," NIC Pain Management intervention including PQRST assessment, multimodal analgesia approach, non-pharmacological options, and reassessment timing (30 min after IV, 60 min after PO medications)
• Nursing Education and Competency Training: A clinical educator uses the tool to demonstrate standardized care planning for new graduate nurses, showing how NANDA-I diagnoses link to measurable outcomes and evidence-based interventions in a structured, auditable format

Safety & Evidence

• Safety Classification: Caution -- Care plans must be individualized to each patient by a licensed nurse. These templates provide a starting framework based on published NNN linkages but do not account for individual patient factors, comorbidities, allergies, or institutional policies
• Evidence Level: Moderate -- Care plan structures based on Herdman TH, et al. NANDA International Nursing Diagnoses: Definitions and Classification, 2024-2026 (13th Ed), Moorhead S, et al. Nursing Outcomes Classification (NOC) (6th Ed), Butcher HK, et al. Nursing Interventions Classification (NIC) (7th Ed), and Johnson M, et al. NANDA, NOC, and NIC Linkages (3rd Ed)

Example Usage

Generating a care plan for impaired gas exchange:

Generate a nursing care plan for impaired gas exchange

Returns a complete care plan with NANDA code 00030, PES statement "Impaired Gas Exchange related to ventilation-perfusion imbalance as evidenced by abnormal arterial blood gases, abnormal skin color, confusion or restlessness," NOC outcome "Respiratory Status: Gas Exchange" with 6 measurable indicators, and 3 NIC interventions (Airway Management, Oxygen Therapy, Vital Signs Monitoring) with 18 specific nursing activities.

Listing available diagnosis templates:

List available nursing care plan diagnosis templates

Returns all available diagnoses with NANDA codes, domains, risk/actual classification, and the number of linked outcomes and interventions for each.

Technical Details

• Category: Nursing
• Author: Open Medical Skills Community
• License: MIT
• Version: 1.0.0
• Script Language: Python
• Specialty: Nursing
• Available Diagnoses: Impaired Gas Exchange (00030), Risk for Falls (00155), Acute Pain (00132)

References

• Herdman TH, Kamitsuru S, Lopes CT. NANDA International Nursing Diagnoses: Definitions and Classification, 2024-2026. 13th Ed. Thieme.
• Moorhead S, et al. Nursing Outcomes Classification (NOC). 6th Ed. Elsevier.
• Butcher HK, et al. Nursing Interventions Classification (NIC). 7th Ed. Elsevier.
• Johnson M, et al. NANDA, NOC, and NIC Linkages. 3rd Ed. Elsevier.
• Cameron ID, et al. "Interventions for Preventing Falls in Older People in Care Facilities and Hospitals." Cochrane Database Syst Rev. 2018.
• Chou R, et al. "Management of Postoperative Pain." J Pain. 2016;17(2):131-157.