Nursing Care-Plan Template Library
Written by Mark Vax, MSN — Senior Nursing Subject Expert · Reviewed by Rachel Thompson, MPH
Last updated: July 2026
A nursing care plan turns your patient assessment into a clear, prioritized plan of action. This guide walks you through the nursing process step by step, gives you a blank reusable template, and shows three fully worked examples you can model your own care plans on.
The nursing process (ADPIE)
Every care plan follows the same five-step cycle, remembered by the acronym ADPIE:
- 1
Assessment — Collect subjective data (what the patient reports) and objective data (vitals, labs, physical findings). Use a structured approach such as a head-to-toe assessment, and for symptoms like pain use a framework such as OLDCARTS (Onset, Location, Duration, Character, Aggravating/Relieving factors, Timing, Severity) or PQRST.
- 2
Diagnosis — Turn your data into a NANDA-I nursing diagnosis. This is a clinical judgment about the patient’s response to a health problem — not a medical diagnosis.
- 3
Planning (Outcomes) — Set SMART, patient-centered goals (Specific, Measurable, Achievable, Relevant, Time-bound), ideally with the patient’s input.
- 4
Implementation — Carry out the nursing interventions, each tied to a rationale.
- 5
Evaluation — Judge whether the outcome was met (met / partially met / not met) and revise the plan.
How to write a NANDA-I nursing diagnosis
Use the three-part (PES) format for an actual problem:
[Problem] related to [etiology / related factor] as evidenced by [signs & symptoms / defining characteristics].
Example: Acute pain related to surgical incision as evidenced by patient reporting pain 8/10, guarding of the operative site, and elevated heart rate.
- For a risk diagnosis (problem hasn't occurred yet), use the two-part format: [Risk problem] related to [risk factors] — there is no “as evidenced by,” because signs/symptoms aren't present yet.
Blank reusable care-plan template
Copy this structure for any care plan:
| Section | What to write |
|---|---|
| Assessment data | Subjective (patient statements) + Objective (vitals, labs, observations) |
| Nursing diagnosis (NANDA-I) | Problem related to etiology as evidenced by signs/symptoms |
| Goal / expected outcome | SMART, patient-centered (e.g., “Patient will report pain ≤3/10 within 4 hours”) |
| Interventions | Nursing actions (assess, do, teach) — be specific and measurable |
| Rationale | Why each intervention works (cite evidence where possible) |
| Evaluation | Was the outcome met? Revise if needed |
Worked example 1 — Acute Pain
Assessment: Subjective: “The pain is sharp, an 8 out of 10.” Objective: Post-op day 1, guarding the abdominal incision, HR 104, BP 142/88, grimacing.
Nursing diagnosis: Acute pain related to surgical incision as evidenced by report of 8/10 pain, guarding, and elevated heart rate.
Goal / outcome: Patient will report pain reduced to ≤3/10 within 4 hours and demonstrate one non-pharmacologic comfort measure by end of shift.
Interventions & rationales:
- Assess pain using a 0–10 scale every 1–2 hours and before/after interventions. Rationale: Consistent reassessment guides titration and shows whether the plan is working.
- Administer prescribed analgesia on schedule and before painful activities. Rationale: Treating pain early (preemptively) controls it with lower doses than waiting until it is severe.
- Position for comfort, splint the incision during coughing, and offer non-pharmacologic measures (relaxation, repositioning, ice/heat per order). Rationale: Non-drug measures complement analgesia and reduce total medication need.
- Teach the patient to report pain early. Rationale: Early reporting prevents escalation.
Evaluation: Goal met — patient reported 2/10 pain at 3 hours and used guided breathing during ambulation.
Worked example 2 — Risk for Infection
Assessment: Post-op abdominal surgery, indwelling urinary catheter, WBC 11.2, surgical drain in place; no current signs of infection.
Nursing diagnosis (risk / two-part): Risk for infection related to surgical incision, invasive lines, and impaired skin integrity.
Goal / outcome: Patient will remain free of signs of infection (no fever >38°C, no redness/purulent drainage) throughout hospitalization and verbalize two infection-prevention measures before discharge.
Interventions & rationales:
- Perform hand hygiene before and after every patient contact. Rationale: Hand hygiene is the single most effective way to prevent healthcare-associated infection.
- Assess incision, drain, and catheter sites each shift for redness, warmth, swelling, or drainage. Rationale: Early detection allows prompt treatment.
- Provide catheter/line care per protocol and advocate for early removal when no longer needed. Rationale: The longer invasive devices stay in, the higher the infection risk.
- Monitor temperature and WBC trend. Rationale: Fever and rising WBC are early systemic signs of infection.
Evaluation: Goal met — no signs of infection; catheter removed on day 2; patient described handwashing and wound care at discharge.
Worked example 3 — Impaired Gas Exchange
Assessment: Subjective: “I feel short of breath.” Objective: SpO₂ 88% on room air, RR 26, crackles in bases, using accessory muscles.
Nursing diagnosis: Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by SpO₂ 88%, tachypnea, and adventitious breath sounds.
Goal / outcome: Patient will maintain SpO₂ ≥94% with intervention within 1 hour and demonstrate effective deep-breathing technique by end of shift.
Interventions & rationales:
- Apply supplemental oxygen as ordered and titrate to target SpO₂. Rationale: Corrects hypoxemia and reduces the work of breathing.
- Position in high-Fowler’s. Rationale: Upright positioning maximizes lung expansion and diaphragm movement.
- Encourage incentive spirometry and deep breathing/coughing every 1–2 hours. Rationale: Promotes alveolar expansion and clears secretions.
- Monitor respiratory rate, effort, SpO₂, and breath sounds. Rationale: Trends show response and catch deterioration early.
Evaluation: Goal partially met — SpO₂ rose to 93% at 1 hour on 2 L O₂; plan continued and reassessed.
Common care-plan mistakes to avoid
- Writing a medical diagnosis (e.g., “pneumonia”) instead of the patient's response (e.g., “impaired gas exchange”).
- Vague goals (“patient will feel better”) instead of measurable ones with a timeframe.
- Interventions with no rationale, or rationales that just restate the intervention.
- Forgetting to evaluate and revise.
References & further reading (authoritative)
- University of St. Augustine for Health Sciences — How to Write a Nursing Care Plan. https://www.usa.edu/blog/how-to-write-a-care-plan/
- Nurse.org — How to Write a Nursing Care Plan in 5 Steps. https://nurse.org/articles/nursing-care-plan-how-to/
- RegisteredNurseRN — Nursing Care Plans. https://www.registerednursern.com/
- WisTech Open / Nursing Fundamentals 2e (open textbook) — Applying the Nursing Process. https://wtcs.pressbooks.pub/nursingfundamentals/
Educational resource only — always follow your school's care-plan format and your facility's protocols. Not medical advice.