Nursing Care Plan Guide for 2025 | Tips & Examples

Nursing care plans provide a means of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes. Read on to learn everything you need to know about nursing care plans. 

What is a Nursing Care Plan?

A nursing care plan contains relevant information about a patient’s diagnosis, the goals of treatment, the specific nursing orders (including what observations are needed and what actions must be performed), and an evaluation plan. 

Over the course of the patient’s stay, the plan is updated with any changes and new information as it presents itself. In fact, most hospitals require nurses to update the care plan during and after each shift. 

Types of Nursing Care Plans

There are four main types of nursing care plans: informal, formal, standardized, and individualized. 

Informal care plans exist in the nurse’s mind and are actions that a nurse wishes to accomplish during their shift. Oftentimes, these care plans are not written down but are based more on quick in-the-minute decisions. 

Formal care plans are written or computerized plans that organize and coordinate the patient’s care information and plan. These follow a structured plan and are based on the needs of the patient. 

Standardized nursing care plans are pre-determined based on the specific needs of a group of patients with a similar diagnosis and/or disease process. 

Individualized care plans are tailored to the specific needs of the patient. It involves assessing the patient, developing a plan, and then documenting it. 

What is the Purpose of a Nursing Care Plan?

Regardless of the type of nursing care plan used for a specific shift or a specific patient, they have many benefits. Some might consider nursing care plans outdated, but in reality, they are a great tool to provide one central document for nurses to provide information on the patient's diagnosis, progress during treatment, and goals. 

Nursing care plans can also help organize a nurse’s goals for the shift and the patient. It can also help in organizing your thoughts. 

Other purposes include, 

• Keeping patients engaged in their care
• Guide for medical insurance reimbursement
• Evidence of care provided by nursing staff
• Continuity of care
• Patient-centered care

What are the Components of a Nursing Care Plan?

Nursing care plans follow a five-step process: 

• Assessment
• Diagnosis
• Expected outcomes
• Interventions
• Rationale and Evaluation

>> Related: The Nursing Process Explained

How to Write a Nursing Care Plan

When writing a nursing care plan, you first have to determine what type of care plan you are interested in. If it is for your own use throughout the shift, then an informal one may be beneficial; however, if it is for the patient’s chart and required during your shift, then an individualized care plan is the way to go. 

Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and objective nursing data. This information can come from, 

• Verbal statements from the patient and family
• Vital signs
• Physical complaints
• Body conditions
• Medical history
• Height and weight
• Intake and output

Step 2: Diagnosis

Using the information and data collected in Step 1, a nursing diagnosis is chosen that best fits the patient, the goals, and objectives for the patient’s hospitalization. 

According to North American Nursing Diagnosis Association (NANDA),  a nursing diagnosis is “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.”

A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid and helps prioritize treatments. Based on the nursing diagnosis chosen, the goals to resolve the patient’s problems through nursing implementations are determined in the next step. 

Step 3: Outcomes and Planning

After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-based practices. SMART goals stand for Specific, Measurable, Achievable, Relevant, and Time-Bound. It is important to consider the patient’s medical diagnosis, overall condition, and all of the data collected. 

Examples of SMART goals include, 

• The patient will ambulate five times around the unit by the end of the shift. 
• The patient will rate their pain as less than four on a scale of 0-10 by the time of discharge. 
• The patient will have a bowel movement by the end of the shift without the assistance of additional medications.

It is also during this time you will consider goals for the patient and outcomes for the short and long term. These goals must be realistic and desired by the patient. For example, if a goal is for the patient to seek counseling for alcohol dependency during the hospitalization but the patient is currently detoxing and having mental distress - this might not be a realistic goal. 

The outcomes and planning section is also when you should determine the patient's long-term vs. short-term goals. Long-term goals are generally for patients with chronic health conditions.

Step 4: Implementation

Now that the goals have been set, you must put the actions into effect to help the patient achieve the goals. While some of the actions will show immediate results (ex. giving a patient with constipation a suppository to elicit a bowel movement) others might not be seen until later on in the hospitalization. 

The implementation phase means performing the nursing interventions outlined in the care plan. Interventions are classified into seven categories: 

• Family
• Behavioral
• Physiological
• Complex physiological
• Community
• Safety
• Health system interventions

Some interventions will be patient or diagnosis-specific, but there are several that are completed each shift for every patient:

• Pain assessment
• Position changes
• Fall prevention
• Providing cluster care
• Infection control

Step 5: Evaluation 

The fifth and final step of the nursing care plan is the evaluation phase. This is when you evaluate if the desired outcome has been met during the shift. There are three possible outcomes, 

• Met
• Ongoing
• Not Met

Based on the evaluation, it can determine if the goals and interventions need to be altered. 

Sample Nursing Care Plans

Nursing Diagnosis:  Ineffective breathing pattern related to right pulmonary agenesis as evidenced by high carbon dioxide levels and absent breath sounds on the right side of the chest. 

Assessment: 

• Vital signs: Monitor the patient’s heart rate, respiratory rate, and SpO2 levels. Signs of respiratory distress include tachypnea, dyspnea, and a SpO2 <95%. 
• Breathing patterns: If the patient shows signs of respiratory distress, it should alarm the nurse, and interventions should take place. Signs of respiratory distress include nasal flaring, accessory muscles, grunting, shortness of breath, and retractions.
• CO2 lab values: When the body has an ineffective breathing pattern, inadequate gas exchange will take place. During this, the body retains CO2 and can enter into a stage of respiratory acidosis. Monitor for respiratory acidosis with blood gas lab values.
• Skin assessment: A person experiencing respiratory distress may experience pallor, cyanotic, and/or mottled skin.

SMART Goal: The patient will maintain a SpO2 level of >95%, RR of 30 to 55 breaths per minute, and heart rate of 80 to 140 beats per minute until the end of the shift. 

Interventions: 

• Check manual heart rate and respiratory rate every four hours. 
• Check patient is on continuous SpO2 monitor with pulse oximetry on the same extremity throughout the shift. 
• Obtain blood gases as ordered.
• Monitor for signs and symptoms of increased work of breathing and respiratory distress. 

Evaluate:

• The patient is observed and/or documented to have SpO2, HR, and RR all within normal limits by the end of the shift.
• The patient is documented to have received blood gas results that contain a CO2 value that is within the normal range.
• The patient is observed and documented to not experience any symptoms of respiratory distress throughout the shift. 

Nursing Care Plan Formats

There are two main nursing care plan formats: three-column and four-column. Three-column nursing care plans include nursing diagnosis, outcomes and evaluation, and interventions.  Four-column nursing care plans include nursing diagnosis, goals and outcomes, interventions, and evaluation. 

While not used in the hospital, student nursing care plans are very lengthy and contain much more information. They are used as a learning experience and are turned in to clinical instructors and often graded. These are often a minimum of six columns, including assessment, diagnosis, outcomes, interventions, rationales, and evaluation. 

Tips for Writing Nursing Care Plans

Writing a good nursing care plan takes time and practice. Nursing students are required to complete multiple nursing care plans during clinical rotations, providing ample opportunity for practice. Unfortunately, student nursing care plans often contain information that is not needed and is for purely academic purposes. 

Here are the top tips for writing a nursing care plan, 

• Be specific and concise 
• Continue to adjust the nursing care plan based on the patient’s ongoing assessment
• Utilize care plan templates 
• Remember the individual patient’s needs
• Use evidence-based practice
• Remember patient safety
• Use professional language

Nursing Care Plan FAQs

• How do you write a nursing care plan?

  • Writing a nursing care plan takes time and practice. It is something you will learn during nursing school and will continue to use throughout your nursing career. First, you must complete an assessment of your patient to determine the nursing diagnosis and include relevant patient information. Next, utilize a NANDA-approved diagnosis and determine expected and projected outcomes for the patient. Finally, implement the interventions and determine if the outcome was met. 

• What is the purpose of the nursing care plan?

  • Nursing care plans provide a means of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes.

• What are the 5 main components of a care plan?

  • There are five main components to a nursing care plan including; assessment, diagnosis, expected outcomes, interventions, and rationale/evaluation. 

• What is included in a nursing care plan?

  • Nursing care plans include relevant information about the patient’s assessment, goals of treatment, interventions that need to occur, and observations. These observations may include subjective and objective data.

 

*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.