How to Write a Nursing Care Plan: Template and 3 Worked Examples

A nursing care plan is a written plan that links what you assessed in one client to a nursing diagnosis, measurable outcomes, nurse actions with rationales, and an evaluation of whether those actions worked. Below you’ll find a fill-in template, the rules for SMART outcomes and rationales, and three worked examples: acute pain, pneumonia and risk for falls.

Key takeaways

• Five parts, one chain: assessment data, nursing diagnosis, SMART outcomes, interventions with rationales, evaluation.
• A problem-focused diagnosis states the problem, related factor and evidence; a risk diagnosis lists risk factors only.
• Outcomes start with “The client will…” and carry one action, a number and a deadline.
• Every intervention needs a rationale that explains how it helps this client.
• The current NANDA-I classification is the 2024–2026 edition; check labels against your program’s reference.

What a Nursing Care Plan Is and Why Instructors Assign It

It’s the documented, individualized plan for one client’s care, built with the nursing process so every nurse on every shift works toward the same outcomes. RNs write and revise it; LPN/VNs contribute data and carry out interventions within their scope (Open RN Nursing Fundamentals). Many facilities use standardized plans in the health record that nurses tailor to each client (Open RN, Planning).

Instructors assign the long school version so you show your reasoning, not just your actions. That reasoning is what the NCLEX measures: specific NANDA-I labels aren’t tested, but analyzing cues, forming hypotheses and prioritizing are (Open RN, Diagnosis). Our guide to Next Generation NCLEX question types shows how those steps appear on the exam.

The Five Columns of a Care Plan (Fill-In Template)

The classic school layout has five columns: assessment data, nursing diagnosis, outcomes, interventions with rationales, and evaluation. Your program’s form may split goals from outcomes, but the logic holds: every entry must connect to the column before it.

Fill-in care plan template

Column	What to write
Assessment	Subjective quotes and objective findings, with numbers.
Diagnosis	[Label] related to … as evidenced by … Risk diagnoses list risk factors instead.
Outcomes	The client will … by … One measurable behavior per line.
Interventions	Specific action and frequency, plus a one-line rationale.
Evaluation	Met, partly met or not met; the data; any revision.

Diagnosis labels come from NANDA-I, now maintained by INKA (formerly NANDA International), whose current classification is the 2024–2026 edition (13th). The labels below appear in the NANDA-I list in Open RN, which uses the 2021–2023 edition, so confirm them in your program’s care plan reference.

Writing SMART Outcomes

A SMART outcome names one measurable thing the client will do, and by when. The letters stand for specific, measurable, attainable or action-oriented, relevant or realistic, and time-bound (Open RN, Outcome Identification). A goal is the broad direction; outcomes are the checkpoints that prove progress toward it. Swap words like “adequate” or “understands” for a number or a demonstration.

Weak outcomes rewritten

Weak	SMART rewrite
Pain will be controlled.	The client will rate pain at or below 3/10 within 1 hour of each analgesic dose today.
Client will understand insulin.	The client will draw up the prescribed insulin dose correctly before discharge.
Client will walk and shower.	Split it into two outcomes, each with its own measure and time frame.
Nurse will teach fall prevention.	The client will state two ways to prevent dizziness on standing by end of shift.

Choosing Interventions and Writing Rationales

Choose interventions that target the related factor or risk factors, specific enough that another nurse could carry them out. They fall into three types (Open RN, Planning):

• Independent: no order needed, such as repositioning, teaching or monitoring.
• Dependent: needs a provider’s order, such as giving a medication or titrating oxygen.
• Collaborative: planned with other professionals, such as a pharmacist’s medication review.

A rationale explains the mechanism. “Turn every 2 hours because turning helps” earns nothing; “to relieve pressure over bony prominences” does. If your rubric wants citations, cite your assigned textbook; our comparison of fundamentals of nursing textbooks shows which editions are current.

Worked Example 1: Acute Pain Nursing Care Plan

This acute pain care plan follows a post-operative client from cues to evaluation. All three examples are teaching cases; in real care, follow your program’s textbook, facility policy and your instructor’s parameters.

Assessment data: Mr. Hall, 58, is on day 1 after open abdominal surgery. He rates incisional pain 7/10, worse with coughing and turning, and guards his abdomen. HR is 104 and BP 148/88 (pre-op baseline: HR 82, BP 126/78). He refused his walk and incentive spirometer because “it hurts too much” and says 3/10 would let him do both. A scheduled non-opioid and an as-needed oral opioid are ordered.

Acute pain: diagnosis and outcomes

Column	Entry
Diagnosis	Acute pain related to surgical tissue trauma as evidenced by pain rated 7/10, guarding, HR and BP above baseline, and refusal to walk.
Outcomes	1. Within 1 hour of each analgesic dose today, he will rate pain at or below 3/10. 2. By 1600, he will walk 50 feet with standby assistance.

Acute pain: interventions and rationales

Intervention	Rationale
Assess pain with the same 0–10 scale every 4 hours, before activity and within 1 hour of each intervention. (Independent)	A consistent scale makes readings comparable; the follow-up shows whether the intervention worked (Open RN).
Give the scheduled analgesic on time; offer the as-needed opioid before pain is severe and before walks. (Dependent)	Early dosing lets him do the walking and breathing exercises recovery depends on (Open RN, Comfort).
Check sedation and respiratory rate before and after each opioid dose; hold and notify per facility parameters. (Independent)	Opioids can cause oversedation and respiratory depression. Open RN uses a rate below 12/min as a hold point.
Teach him to hug a pillow over the incision when coughing or turning. (Independent)	Supporting the incision eases discomfort during breathing exercises (MedlinePlus).
Notify the provider if pain stays above 3/10 or HR stays high once pain is controlled. (Collaborative)	The regimen may need changing, and post-op tachycardia isn’t always pain.

Evaluation: At 1000, 50 minutes after a dose, he rated pain 3/10 and walked 50 feet: outcome 2 met. At 1430, an hour after a dose he asked for only once the pain had built, he still rated it 5/10, so outcome 1 is partly met. Revision: give the dose before the afternoon walk instead of waiting for him to ask.

Worked Example 2: Pneumonia Nursing Care Plan (Impaired Gas Exchange)

When saturation is low, a pneumonia care plan leads with oxygenation, because breathing outranks other problems. Cough, fever, shortness of breath and, in older adults, confusion are common symptoms (MedlinePlus).

Assessment data: Mrs. Rivera, 74, was admitted with community-acquired pneumonia. SpO2 is 91% on 2 L/min nasal cannula, below her ordered range of 94% to 98%. RR is 26, HR 108, temperature 38.6 °C (101.5 °F). She has right lower lobe crackles and yellow sputum, doesn’t know the date (her daughter says she’s normally fully oriented), and rates breathlessness 6/10 walking to the bathroom.

Impaired gas exchange: diagnosis and outcomes

Column	Entry
Diagnosis	Impaired gas exchange related to ventilation-perfusion imbalance as evidenced by SpO2 91% on 2 L/min, RR 26, HR 108 and new confusion. Some programs want a related factor nursing can modify instead, such as retained secretions; follow your rubric.
Outcomes	1. From noon today, SpO2 will read 94% to 98% on prescribed oxygen at every check for 24 hours. 2. By day 2, she will be oriented to person, place and time.

Impaired gas exchange: interventions and rationales

Intervention	Rationale
Assess RR, effort, SpO2, lung sounds and orientation every 4 hours and with any change. (Independent)	Tachypnea, tachycardia, low saturation and confusion are cues of impaired gas exchange (Open RN, Oxygenation).
Keep the head of the bed high (high Fowler’s) or sit her in a chair. (Independent)	Upright positioning lets the chest expand and lowers the work of breathing (Open RN).
Titrate oxygen within the ordered range; check flow, tubing and cannula at each visit. (Dependent)	Keeps SpO2 on target; a kinked tube or displaced cannula is a fixable cause of a low reading.
Coach deep breathing, coughing and incentive spirometer use; encourage fluids unless restricted. (Independent)	These help clear the airway and reopen alveoli; fluids thin secretions.
Give antibiotics on schedule; report falling SpO2, rising RR or worse confusion. (Dependent, collaborative)	Bacterial pneumonia needs antibiotics started soon after admission; worsening cues need a provider’s decision.

Evaluation: On day 2 SpO2 ran 95% to 97% on 2 L/min: outcome 1 met. She was oriented by day but confused at 0200: outcome 2 partly met. Revision: check orientation every 4 hours overnight and report the night-time confusion. If you’re given blood gases, add them to the assessment; our guide to ABG interpretation shows how to read them.

Worked Example 3: Nursing Care Plan for Risk for Falls

A risk diagnosis has no symptoms yet, so the plan targets risk factors. Write it as the label “as evidenced by” the risk factors, the format Open RN uses. The label there is Risk for adult falls; older books say Risk for falls.

Assessment data: Mr. Chen, 81, is on day 1 of an admission for a urinary tract infection. He fell at home two months ago, uses a walker and gets up at night with urgency. He takes a diuretic and an antihypertensive, his BP drops from 134/78 lying to 112/70 standing with light-headedness, and he has twice tried to walk to the bathroom alone.

Risk for adult falls: diagnosis and outcomes

Column	Entry
Diagnosis	Risk for adult falls as evidenced by a recent fall, walker use, nighttime urgency, light-headedness on standing, and diuretic and antihypertensive use.
Outcomes	1. He will have no falls during this stay. 2. Starting tonight, he will call and wait for staff every time he gets out of bed.

Risk for adult falls: interventions and rationales

Intervention	Rationale
Bed low and locked; call light, walker and urinal within reach; non-skid socks; night light. (Independent)	Universal fall precautions remove common hazards for every inpatient (Open RN, Preventing Falls).
Have him demonstrate the call light from bed. (Independent)	A demonstration proves he can reach and use it.
Round hourly and offer toileting each time, including overnight. (Independent)	Meeting toileting needs early removes his main reason to get up alone.
Check orthostatic vital signs per policy; have him sit on the bed’s edge, then rise slowly. (Independent)	His medications can drop his BP on standing; rising in stages gives it time to adjust (MedlinePlus).
Ask the pharmacist to review his medications; reassess fall risk every shift with your facility’s tool. (Collaborative)	Medication changes can lower risk, and risk shifts as his infection and drugs change.

Evaluation: By day 3 he had no falls: outcome 1 met. He called for help five of six times but was once found on the bed’s edge at 0300, so outcome 2 is partly met. Revision: scheduled toileting at 2200 and every 2 hours overnight.

Common Care Plan Mistakes Instructors Mark Down

Each of these breaks the link between columns:

• A medical diagnosis as the nursing diagnosis. “Pneumonia” is the provider’s; yours names the client’s response to it.
• A related factor nursing can’t change, such as age or a disease name.
• Outcomes with no number or deadline, like “will have adequate oxygenation.”
• Nurse tasks written as outcomes. Outcomes describe the client.
• Vague interventions. “Monitor vitals” needs a frequency and a reason.
• Evaluation with no data. “Goal met” needs findings, and unmet outcomes need a revision (Open RN, Evaluation).

Frequently asked questions

How do you write a nursing care plan step by step?

List the subjective and objective cues, cluster them, and choose the NANDA-I diagnosis whose defining characteristics match, with a related factor and evidence. Set two or three SMART outcomes, pick interventions aimed at the related factor, and give each a rationale. After care, compare new data with each outcome, mark it met, partly met or not met, and revise.

How many nursing diagnoses should a care plan have?

There’s no universal number; your assignment rubric sets it, so ask if it doesn’t say. Rank them with airway, breathing, circulation and safety first, and remember a risk diagnosis such as Risk for adult falls can outrank an actual problem. Our guide to prioritization and delegation NCLEX questions uses the same logic.

What is the difference between a goal and an outcome?

A goal is the broad direction of care, such as “the client will maintain effective gas exchange.” An outcome is a measurable checkpoint with a time frame, such as “SpO2 will stay at 94% to 98% on prescribed oxygen for 24 hours.” You evaluate outcomes; together they show whether the goal is being reached.

Do nurses use care plans after school?

Yes, though they look different. Open RN notes that care plans are required in long-term care by CMS and in hospitals by The Joint Commission. Many facilities use standardized care plans in the electronic health record that nurses tailor to each client, so you rarely write every rationale by hand, but the reasoning is the same.

Can I use a care plan book or template?

Yes, as a reference. Nurses use care planning books and the Nursing Interventions Classification (NIC) to choose interventions. Your plan must still fit your client’s data, so copying a published plan word for word misses the point of the assignment and may break your program’s academic integrity rules. Check your syllabus first.

Bottom line: practice on one real client

After your next clinical day, fill the template for one client before opening a care plan book: cues, one diagnosis, two SMART outcomes and five interventions with rationales. Check each column against the one above it. For extra self-testing on the content behind the plan, browse our nursing test banks by course.

Sources & further reading

• Open RN Nursing Fundamentals 2e — 4.4 Diagnosis
• Open RN Nursing Fundamentals 2e — 4.5 Outcome Identification
• Open RN Nursing Fundamentals 2e — 4.6 Planning
• Open RN Nursing Fundamentals 2e — 11.5 Applying the Nursing Process
• Open RN Nursing Fundamentals 2e — 5.6 Preventing Falls
• MedlinePlus — Community-acquired pneumonia in adults
• INKA — NANDA-I Nursing Diagnoses: Definitions and Classification

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