How To Write the Perfect Nursing Care Plan with Examples

Struggling to Write a Nursing Care Plan

I recently met a nursing student named, Sarah who had just started on her journey to become a nurse.  She was struggling with writing nursing care plans.  Sarah struggled with gathering comprehensive patient information, identifying appropriate nursing diagnoses, and formulating effective interventions.

Writing a nursing care plan is an essential skill that every nursing student should master. It serves as a roadmap for providing individualized and effective care to your patients.

In this blog post, you will:

• Know what a nursing care plan is
• Purpose of Nursing Care Plans
• Know the 5 Steps to Writing a Nursing Care Plan
• Be provided with 3 Nursing care plan examples

Before we dive into this blog post I know how difficult learning everything in nursing school can be.  That is why I am offering you a free nursing mnemonic cheat sheet.  Just click below to get your copy!

Alright, lets begin!

What is a Nursing Care Plan

A Nursing Care Plan is the way a nurse documents and communicates the Nursing Process.

Nursing care plans are one of the most common assignments in nursing school and can be a valuable resource in the clinical setting. They start when a patient is admitted and document all activities and changes in the patient’s condition. Using a care plan will encourage patient-centered care and make your nursing care more consistent. These plans are also a great communication tool among nurses, other healthcare professionals, patients, and their families.

Nursing students learn to assess a patient, make a nursing diagnosis, create a plan, implement the plan, and evaluate the plan to ensure best practices and outcomes. This process teaches them to problem-solve and make critical decisions. A nursing care plan helps nurses organize their day, know when things need to be accomplished, and balance their workload.

The nursing care plan serves as a communication tool between healthcare professionals, ensuring a coordinated approach to patient care. It guides nurses in delivering evidence-based, patient-centered care, while also promoting continuity of care among different healthcare providers.

Nursing care plans are essential in various healthcare settings, including hospitals, clinics, and long-term care facilities. They facilitate efficient and effective care delivery, enhance patient outcomes, and promote individualized care tailored to each patient's unique needs.

Purpose of Nursing Care Plans

Nursing Care Plans are a written form of The Nursing Process. These plans ensure nurses deliver consistent, patient-centered, and holistic care. Each step in the nursing process is covered in the nursing care plan and helps nurses plan, implement, and evaluate nursing care.

The fives steps in the nursing process are:

• Assessment - The first step in delivering nursing care. It collects and analyzes physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors data.
• Diagnosis - Using the data, patient feedback, and clinical judgment to form nursing diagnoses. The diagnosis considers the patient’s signs, symptoms, pain, and the problems their condition has caused, such as anxiety, poor nutrition, conflict with family, and complications that may arise. The nursing diagnosis is the basis for the care plan. 
• Planning - Setting short-term and long-term goals based on the nurse’s assessment and diagnosis.  Ideally, with input from the patient. This is where you determine nursing interventions to meet these goals.
• Implementation -  Implementing nursing care according to the care plan, based on the patient’s health conditions and the nursing diagnosis. This is where you will document the care the nurse performs. 
• Evaluation - Monitoring and documenting the patient’s status and progress toward meeting the planned goals. This allows you to modify the care plan as needed. 

5 Steps to Writing a Nursing Care Plan

Writing a nursing care plan can seem overwhelming, but breaking it down into five simple steps can make the process more manageable. Here are five steps to help you write a nursing care plan:

Step 1 – Collect Information (Assess)

Gather relevant data about the patient's health status, medical history, current condition, and other pertinent factors. It involves systematically obtaining and organizing information to inform the development of the care plan.

• Head-to-toe-assessment
• Conversations with your patients and loved ones
• Observations (lab values, vital signs)
• Report (or your report sheet)
• Chart review notes
• Discussions with the healthcare team members

Step 2 – Analyze the Information (Diagnose & Prioritize)

Critically examining and interpreting the collected information and data to identify patterns, relationships, and underlying factors related to the patient's health condition. It involves synthesizing the information to gain a comprehensive understanding of the patient's needs and develop appropriate nursing diagnoses and interventions.

• Look at all information
• What are areas in which this patient has trouble and therefore needs to progress in?
• Think about the ways you could see the patient improving and how you would know they were improving
• Write down the general issues, how you’d help them progress in that area, and how you’d know they were progressing

Step 3 – Think About How (Plan, Implement, & Evaluate)

The process of critical thinking and considering various factors and possibilities when developing the plan. It involves evaluating different options, anticipating potential outcomes, and making informed decisions based on the patient's unique needs and circumstances.

• Think about how you knew these were issues:
  • How did you know he was in pain? Did he tell you? Did you observe it? Was he getting pain medications?
• Look at each “how” and decide if it is subjective (is this pain or something the patient told you about?) or objective (did you gather this info with your 5 senses?):
  • Write an S or an O next to them
• What could these issues be related to? 
  • A recent surgery, trauma, or disease process?
• Write all of your reasons (again in layman's terms) under the problem(s) you’ve identified.
• What would you do to make this better? (Interventions)
• How would you know it got better? (Evaluation)

Step 4 – Translate

The process of converting the collected information, nursing diagnoses, goals, and interventions into clear and actionable language that can be easily understood and implemented by the healthcare team. 

• Take your textbooks (NANDA-I, NIC, NOC, or whatever you may be using)
• Look up the official terms for the problem(s) and write them down
• Look up outcomes and interventions that may align with what you wrote down

Step 5 – Transcribe

The process of accurately documenting the care plan in a written format. It involves transferring the information, including nursing diagnoses, goals, and interventions, into a standardized care plan document or electronic medical record.

• Get your nursing care plan template out
• Put the pieces together (problem + related to factor(s) + defining characteristics/”hows”)
• Create your nursing diagnosis
  • Use your S’s and O’s to place your subjective and objective data
• Write out your interventions and outcomes/evaluation

3 Nursing Care Plan Examples

Sometimes all you need are a few examples to help you learn how to do a difficult task and to get the brain juices flowing.  Here are 3 care plans that I personally wrote during nursing school.

Nursing Care Plan Example 1

Medical Diagnosis: Abdominal Pain

Pathophysiology of Abdominal Pain: 

Abdominal pain can be a minor issue that is easy to resolve or a medical emergency. Many different things can cause abdominal pain and their pathophysiology can differ widely. Abdominal pain can is classified as either acute or chronic. When a patient presents to the emergency department or outpatient environment with abdominal pain, it generally constitutes a lengthy workup to determine the cause and its pathophysiology. Additionally, abdominal pain can be referred pain, which can complicate the clinical picture even further.

Etiology of Abdominal Pain

Abdominal pain can be the result of pregnancy, ectopic pregnancy, trauma, a long list of gastric issues (gastroenteritis, constipation, diarrhea, irritable bowel syndrome, GERD, Chron’s disease, appendicitis, to name a few), hernias, allergic response, endometriosis, gallstones, severe menstrual cramps, hepatitis, miscarriage, and many more. Many disease processes result in abdominal pain, and some may present with abdominal pain even though it is not the typical clinical picture.

Desired Outcome

Cease painful stimuli, resolve the underlying cause, and minimize any subsequent damage.

Assessment

Making an individualized assessment of abdominal pain begins by focusing on the available background information of the patient: health history, current health status, psychological state, and other relevant data.

Subjective Data:
Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of abdominal pain, a patient might report feeling:

• Abdominal pain
• Decreased appetite
• Nausea
• Rebound tenderness
• Muscle tension
• Restlessness

Objective Data:
Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of abdominal pain, a patient may present with:

• Constipation
• Diarrhea
• Electrolyte imbalances
• Guarding
• Vomiting

Diagnosis

A nursing diagnosis is a basis for establishing and carrying out a nursing care plan. After performing a proper assessment, formulate a nursing diagnosis based on problems associated with abdominal pain. This will be your clinical judgment about the patient’s health conditions or needs.

Select the appropriate nursing diagnostic label from the NANDA-I list of approved nursing diagnostic statements that best identify with the patient’s signs and symptoms. One or more nursing diagnoses may be given.

Planning / Outcomes

Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes.

In the case of abdominal pain, a plan may include:

• Return to normal bowel movements
• Eat
• Taking medications
• Receiving fluids
• Understanding their condition and treatment

Implementation

Implementations are actions and activities you will take to achieve the nursing plan goals.
In the case of abdominal pain, an implementation may include:

• Encourage evacuation
• Encourage eating
• Administer medications as prescribed
• Provide fluids
• Educate the patient and family members

Evaluation

The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions.

In our abdominal pain example, an evaluation might include:

• The patient had 2 normal bowel movements
• The patient ate 3 meals
• Patient took medications
• Patient received fluids
• The patient understood information about their care

Nursing Care Plan Example 2

Medical Diagnosis: Infection

Pathophysiology of Infection: 

An infection is a disease caused by microorganisms infecting tissues. 

Etiology of Infection

The organisms that can cause disease are very diverse that include viruses, bacteria, fungi, and parasites. You can acquire such infections by contaminated food/water, a bite, cut, or being in contact with someone with an infection.

Desired Outcome

Patient will remain free from infection and demonstrate proper hand hygiene

Assessment

Subjective Data:
Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of infection, a patient might report feeling:

• Diarrhea
• Fatigue
• Muscle aches
• Coughing
• Pain
• Chills
• Sore throat

Objective Data:
Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of infection, a patient may present with:

• Fever
• Tachycardia
• BP changes
• Elevated WBC count
• Redness/swelling/heat/drainage from wound

Diagnosis

Risk for Infection related to compromised skin integrity and invasive procedures.

Planning / Outcomes

Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes.

In the case of infection, a plan may include:

• The patient will maintain intact skin and mucous membranes.
• The patient will demonstrate understanding of infection prevention techniques.
• The patient's vital signs will remain within normal limits.
• The patient will report a decrease in signs and symptoms of infection.
• The patient will be free from healthcare-associated infections.

Implementation

Implementations are actions and activities you will take to achieve the nursing plan goals.
In the case of infection, an implementation may include:

• Assess the patient's skin integrity, paying close attention to areas at risk for infection such as surgical wounds, intravenous (IV) sites, and urinary catheter insertion sites.
• Implement proper hand hygiene techniques before and after providing care to the patient.
• Promote adequate hydration and provide a balanced diet to enhance the immune system.
• Educate the patient on proper wound care techniques, including keeping the wound clean, dry, and covered with appropriate dressings.
• Administer prescribed antibiotics and other medications as ordered.
• Monitor the patient's vital signs regularly and report any abnormalities or signs of infection promptly.

Evaluation

The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions.

In infection example, an evaluation might include:

• Assess the patient's skin regularly to ensure integrity and identify any signs of infection.
• Evaluate the patient's understanding and implementation of infection prevention techniques.
• Monitor vital signs and note any abnormalities.
• Assess the patient for any improvement in signs and symptoms of infection.
• Evaluate the patient's risk for healthcare-associated infections and implement appropriate preventive measures.

Nursing Care Plan Example 3

Medical Diagnosis: Fluid Volume Deficit

Pathophysiology of Fluid Volume Deficit: 

Fluid Volume deficit (dehydration) is a state or condition where the fluid output exceeds the fluid intake. The body loses both water and electrolytes from the ECF in similar proportions. Common sources are the gastrointestinal tract, polyuria, and increased perspiration.

Etiology of Infection

Common causes are decreased fluid intake, bleeding, diarrhea, diuresis, abnormal drainage, increased metabolic rate, movement of fluid into third space, and abnormal losses through the skin, GI tract, or kidneys.

Desired Outcome

Patient has normal vital signs. Demonstrates adequate lifestyle changes to avoid dehydration. Patient has normal urine output

Assessment

Subjective Data:
Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of Fluid Volume Deficit, a patient might report feeling:

• Weakness 
• Extreme thirst 
• Dizziness

Objective Data:
Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of Fluid Volume Deficit, a patient may present with:

• Alterations in mental state
• Weight loss
• Concentrated urine/decreased urine output
• Dry mucous membranes
• Weak pulse/tachycardia
• Decreased skin turgor
• Hypotension
• Postural hypotension
• Sunken eyes/cheeks

Diagnosis for Fluid Volume Deficit

Fluid Volume Deficit related to excessive fluid loss (e.g., vomiting, diarrhea, hemorrhage) as evidenced by decreased urine output, dry mucous membranes, and decreased skin turgor.

Planning / Outcomes for Fluid Volume Deficit

Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes.

In the case of Fluid Volume Deficit, a plan may include:

• The patient will maintain adequate fluid balance as evidenced by stable vital signs and improved hydration status.
• The patient will maintain optimal tissue perfusion.
• The patient will demonstrate understanding of fluid management and prevention of fluid volume deficit.

Implementation for Fluid Volume Deficit

Implementations are actions and activities you will take to achieve the nursing plan goals.
In the case of Fluid Volume Deficit, an implementation may include:

• Assess and monitor vital signs, including blood pressure, heart rate, respiratory rate, and temperature, to identify signs of hypovolemia.
• Measure and record the patient's intake and output accurately to assess fluid balance.
• Monitor daily weights to track changes in fluid status.
• Encourage and assist the patient with oral fluid intake as tolerated, offering small, frequent sips of water or other fluids.
• Administer IV fluids as prescribed, ensuring accurate infusion rates and monitoring for any adverse reactions.
• Assess the patient's skin turgor, mucous membranes, and capillary refill time regularly to evaluate hydration status.
• Collaborate with the healthcare team to determine the underlying cause of fluid volume deficit and address it accordingly (e.g., treating the underlying infection or stopping excessive fluid losses).
• Monitor laboratory values, including electrolytes and hematocrit levels, and collaborate with the healthcare team to make any necessary adjustments to fluid therapy.

Evaluation for Fluid Volume Deficit

The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions.

In Fluid Volume Deficit example, an evaluation might include:

• Monitor and document the patient's vital signs and fluid intake and output regularly.
• Assess the patient's hydration status, including skin turgor, mucous membranes, and capillary refill time.
• Evaluate the patient's response to fluid therapy, including improvement in vital signs and hydration status.
• Assess the patient's understanding and implementation of fluid management strategies.
• Collaborate with the healthcare team to determine the need for further interventions or adjustments to the care plan.

Mastering the Art of Writing the Perfect Nursing Care Plan

Mastering the art of writing the perfect nursing care plan is crucial for delivering effective and individualized patient care.

By following the five essential steps -

1. Collect Information (Assess)
2. Analyze the Information (Diagnose & Prioritize)
3. Think About How (Plan, Implement, & Evaluate)
4. Translate
5. Transcribe

You can create comprehensive care plans that address the unique needs of each patient.

Remember to utilize evidence-based practice, collaborate with the healthcare team, and continuously evaluate and modify the care plan as needed. With these strategies in place, you can confidently navigate the complexities of care planning, ensuring optimal patient outcomes and promoting the highest standards of nursing practice.

You Can Do This

Happy Nursing!