Care plans are a way to strategically approach and streamline the nursing process. They also facilitate effective communication in a nursing team. Let’s review the fundamentals of a nursing care plan and how to create one, step by step. We’ll outline best practices and provide you with a nursing care plan example that you can download and print.
Table of Contents
- What Is a Nursing Care Plan?
- What Are the Components of a Care Plan?
- Care Plan Fundamentals
- Sample Nursing Care Plan
What Is a Nursing Care Plan?
A nursing care plan documents how to identify a patient’s needs and facilitate holistic care, typically according to a five-step framework. A plan of care ensures collaboration among nurses, patients and other healthcare providers.1, 2, 3, 4
What Is the Purpose of the Nursing Care Plan?
The purpose of a nursing care plan is to document the patient’s needs and wants, as well as the nursing interventionsor implementations planned to meet these needs. As part of the patient’s health record, the care plan establishes continuity of care.1 The following are the main reasons to write a care plan:
Patient-Centered Care
A care plan helps nurses and other care team members organize aspects of patient care according to a timeline. It’s also a tool for them to think critically and holistically in a way that supports the patient’s physical, psychological, social and spiritual care. Sometimes, a patient should be assigned to a nurse with specific skills and experience; a nursing care plan makes that process easier. For patients, having clear goals to achieve will encourage them to be more active in their treatment and recovery.3
Nursing Team Collaboration
Writing a care plan allows a team of nurses, as well as physicians, assistants and other care providers, to access the same information, share opinions and collaborate to provide the best possible care for the patient.
Documentation and Compliance
A well-written nursing care plan enables nurses to evaluate the effectiveness of care and record evidence that the care was provided. This is important to maximize care efficiency and to provide documentation for healthcare providers.
What Are the 5 Components of a Nursing Care Plan?
Nursing care plans are structured as a five-step framework: assessment, diagnosis, outcomes and planning, implementation and evaluation.4
Step 1: Assessment
The first step of writing a plan of care requires critical thinking skills and data collection. Different healthcare organizations use distinct formats for the assessment phase. Generally, the data you will collect here is subjective (e.g., verbal statements) and objective (e.g., height and weight, intake/output). The source of the subjective data could be the patients or their caretakers, family members or friends.
Nurses can gather data about the patient’s vital signs, physical complaints, visible body conditions, medical history and current neurological functioning. Digital health records may help in the assessment process by automatically populating some of this information from previous records.
Step 2: Diagnosis
Using the collected data, you will develop a nursing diagnosis—which NANDA International Inc. (NANDA-I) defines as “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.”5
A nursing diagnosis sets the basis for choosing nursing actions to achieve specific outcomes. A nursing diagnosis is grounded in Maslow’s Hierarchy of Needs, identifying and ranking human needs to help prioritize treatments effectively.6 In terms of nursing care plan examples, physiological needs (such as food, water and sleep) are more fundamental to survival than love and belonging, self-esteem and self-actualization, ensuring they take precedence in nursing actions.6
Based on the diagnosis, you’ll set goals (Step 3) to resolve the patient’s problems through nursing implementations (Step 4).
Step 3: Outcomes and Planning
When learning how to write a nursing care plan, the planning stage follows the diagnosis. Here, you will prepare SMART goals based on evidence-based practice (EBP) guidelines. You will consider the patient’s overall condition, diagnosis and other relevant information as you set goals for them to achieve desired and realistic health outcomes for the short and long term.
Step 4: Implementation
Once you’ve set patient goals, it’s time to implement the actions that will support patients in achieving their goals. The implementation stage of a nursing care plan consists of performing the nursing interventions outlined in the care plan. As a nurse, you will follow doctors’ orders for nursing interventions or develop them using evidence-based practice guidelines.
Interventions are classified into the following seven domains: family, behavioral, physiological, complex physiological, community, safety, and health system interventions. There are several basic interventions that you need to implement during each shift: pain assessment, changing the resting position, listening, cluster care, preventing falls and promoting fluid consumption.
Step 5: Evaluation
In the final step of a care plan, the health professional, a doctor or nurse, will evaluate if the desired outcome has been met. Then, you will adjust the nursing care plan based on this information.
Care Plan Fundamentals
Nurse.org explains the core questions your plan of care should answer: what, why and how.7 A nursing care plan should include:
- The What: What does the patient suffer from? What do they risk suffering from?
- The Why: Why does your patient suffer from this? Why do they risk suffering from this?
- The How: How can you make this better?
Successful nursing care plans use the fundamental principles of critical thinking, client-centered techniques, goal-oriented strategies, evidence-based practice (EBP) recommendations and nursing intuition.4
SMART Goals
As you plan how to write a nursing care plan, leverage goal-oriented strategies. A SMART goals template can help in this process:
- Specific: Your goals for the patient must be well-defined and unambiguous.
- Measurable: Set specific metrics to measure the patient’s progress toward these goals.
- Achievable: Their goals should be achievable.
- Realistic: Their goals must be within reach and relevant to the care plan.
- Time-bound: The patient’s goals should have a starting time and end date (which can be flexible).
Effective Communication
Unless your care plan is communicated effectively to all relevant stakeholders, it will only be a plan. A nursing care plan is not a static document, but a dynamic tool designed to guide the nursing process, foster teamwork and enhance patient care. Writing skills are crucially important for nurses— be accurate and current in your descriptions. For effective communication, consider the following best practices when writing a plan of care:
- Write down everything immediately so you don’t forget the details.
- Write clearly and concisely, using terms that your team will understand.
- Include dates and times.
Although you will learn communication skills in an undergraduate or graduate nursing program, you will also develop them over time and with practical experience.8
Shareable and Easy to Access
Nursing care plans also need to be easy to share with relevant stakeholders—patients, doctors, other members of the nursing team, insurance companies, etc. The documentation format will vary according to hospital policy. Typically, a nursing care plan is created in electronic format and integrated into the electronic health record (EHR) for easy access to everyone.8
Up to date
Finally, update your nursing care plans often with the latest information. Check-in with patients frequently and record data about how the patient is progressing toward their goals, an important step to prepare for the evaluation stage of the care plan.8
What Is an Example of a Care Plan?
Despite the general objective, nursing care plan examples written by students are not the same as those created by registered nurses in clinical settings. The student version is much longer, has greater detail and is exhaustively thorough. On the other hand, nurses often assume basic concepts and mentally note certain steps of the care plan.1
As a care plan example, a student would write in the interventions section: “Vital signs recorded every four hours: blood pressure, heart rate, three- or five-lead electrocardiograms, functional oxygen saturation, respiratory rate and skin temperature,” while an experienced registered nurse might write “Q4 vital signs.”
Why this difference? As a student or recent graduate, including all the information in your care plan will help you solidify your training. While writing nursing care plan examples in school can be very time-consuming, mastering this information in nursing school will improve your competency and confidence. Most of the information you’ll have to look up while you’re still in school will become second nature in the future. Here’s a care plan example that a student might write:
- Assessment: “Heart rate 100 bpm, dyspnea, restlessness, guarding behavior.”
- Diagnosis: “Impaired gas exchange RT collection of mucus in the airway.”
- Outcomes and planning: “Patient must maintain optimal gas exchange.”
- Implementations: “Assess respiration; encourage breathing and position changes.”
- Rationale: “Respiration will indicate the level of lung involvement, as the patient will adjust their breathing to facilitate gas exchange; these will improve ventilation and allow for chest expansion.”
- Evaluation: “The patient maintained good gas exchange and normal respiratory rate.”
Student nursing care plans often have an additional column, rationale, where students document the scientific explanation behind their chosen implementations. To help you get started with a care plan writing practice, we’ve created a printable nursing care plan example, which you can use to practice writing all the steps outlined in this article.
Wrapping Up: How to Write a Nursing Care Plan
To be successful, a nursing care plan needs effective communication, goal-oriented tasks, accessibility and shareability and evidence-based practice.
When it meets these skilled nursing qualities and is supported by the nurse’s intuition, critical thinking and a general focus on the patient, a nursing care plan becomes a go-to resource for nurses to record and access the information they need. A care plan is your roadmap for effective nursing care, and a collaboration tool that improves the entire healthcare process.
While all nursing programs teach the basics of writing a care plan, your communication, goal setting and critical thinking skills will be shaped by the program you attend.
For example, one of the benefits of writing nursing care plans is that it will allow you to develop professionalism, along with important values like accountability, respect and integrity. Key results of professionalism include better overall care, improved team communication and a more positive work environment.
That’s why it’s important that you choose the right program for your needs—one that will help you develop communication and critical thinking skills, as well as professionalism, to be ready for the day-to-day of nursing life.
The University of St. Augustine for Health Sciences (USAHS) offers a Master of Science in Nursing (MSN), a Doctor of Nursing Practice (DNP) and Post-Graduate Nursing Certificates designed for working nurses. Our degrees are offered online, with optional on-campus immersions.* Role specialties include Family Nurse Practitioner (FNP), Psychiatric Mental Health Nurse Practitioner (PMHNP)** and Nurse Executive. The MSN and DNP have options to accelerate your time to degree completion. Earn your advanced nursing degree while keeping your work and life in balance.
*The FNP role specialty includes one required hands-on clinical intensive as part of the curriculum.
**The Psychiatric Mental Health Nurse Practitioner role specialty is not available for the DNP program.
Sources
- Matt Vera, “Nursing Care Plans (NCP): Ultimate Guide and List”, November 16, 2024, https://nurseslabs.com/nursing-care-plans/.
- Medical Dictionary “nursing care plan”, 2024, https://medical-dictionary.thefreedictionary.com/nursing+care+plan.
- Healthify, “Care planning for healthcare providers”, 2024, https://healthify.nz/healthcare-providers/c/care-planning-hcps/.
- Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, April 10, 2023, https://www.ncbi.nlm.nih.gov/books/NBK499937/.
- NANDA International, Inc., “Glossary of Terms”, NANDA International, 2024, https://nanda.org/publications-resources/resources/glossary-of-terms/.
- Saul McLeod, “Maslow’s Hierarchy of Needs,” Simply Psychology, January 24, 2024, https://www.simplypsychology.org/maslow.html.
- Kathleen Gaines, “How to Write a Nursing Care Plan,” Nurse.org, April 26, 2023, https://nurse.org/articles/nursing-care-plan-how-to/.
- Nikki Manuel, “How to Develop a Nursing Care Plan for Your Hospital,” TigerConnect, May 25, 2023, https://tigerconnect.com/resources/blog-articles/how-to-develop-a-nursing-care-plan-for-your-hospital/.
