Care plans are a strategic approach to streamline the nursing process. They also facilitate effective communication in a nursing team. Let’s review the fundamentals of a nursing care plan (NCP) and how to create one, step by step. We’ll outline best practices and provide 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 (NCP) 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 interventions or planned implementations. 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 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; an NCP 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?
NCPs 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 are subjective (e.g., verbal statements) and objective (e.g., height and weight, intake/output). The source of the subjective data could be 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, realistic health outcomes for the short and long term.
Step 4: Implementation
Once you’ve set patient goals, it’s time to implement actions that will support patients in achieving their objectives. The implementation stage of an NCP 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, evaluates if the desired outcome has been achieved. Then, you will adjust the nursing care plan based on this information.
Nursing Care Plan Formats
Nursing care plan formats are typically organized into four columns. However, some healthcare institutions use a three-column NCP and combine goals and evaluation in the same section. Student NCPs are also commonly used for educational purposes.1
3-Column formats
The three-column nursing care plan format includes sections for the nursing diagnosis, outcomes and evaluation and interventions.1
4-Column formats
Four-column NCPs include nursing diagnosis, goals and outcomes, interventions and evaluation.1
Student Care Plan formats
Student nursing care plans (NCPs) are generally more detailed and comprehensive than those used by practicing nurses, as they serve as a learning tool for student nurses.1
In many nursing care plan formats designed for students, NCPs are often handwritten and include two additional columns, labeled Rationale and Scientific Explanation, following the nursing interventions column. These sections present the reasoning and scientific basis behind the chosen nursing interventions.1
Although not typically used in hospital settings, student NCPs are submitted to clinical instructors as a part of coursework and are often graded as a component of the student’s clinical performance evaluation.7
Types of Nursing Care Plans
Nursing care plans (NCPs) are generally classified into standardized and individualized types.7 They are developed for a wide range of conditions, including hypertension, pneumonia, pain, wound infection and asthma.1
Standardized Care Plans
Standardized nursing care plans (NCPs) are pre-developed guides created by nursing staff and healthcare institutions to promote consistency and quality in patient care.1
Within nursing care plan formats, standardized NCPs help ensure that essential standards of care are met and save time by avoiding repeated planning for common conditions.1
Although this type of NCP is not customized to a patient’s unique needs or goals, standardized NCPs serve as an effective foundation for developing individualized nursing care plans.1
Individualized Care Plans
An individualized nursing care plan (NCP) involves adapting a standardized NCP within existing nursing care plan formats to address the unique needs, preferences and goals of a specific patient.1
This approach promotes more personalized and holistic care by incorporating interventions and strategies proven effective for that individual. Individualized NCPs can enhance the quality of care and improve patient satisfaction.1
When patients perceive that their care is tailored to their specific circumstances, they are more likely to feel heard, valued and engaged. This personalization is especially significant in today’s healthcare environment, where patient satisfaction serves as a key indicator of care quality.1
Nursing Care Plan for Hypertension
Hypertension is the term used to describe high blood pressure. It is repeatedly elevated blood pressure that exceeds 140 over 90 mmHg.
Nursing care management and NCPs play an essential role in caring for patients with hypertension. A nursing care plan for hypertension offers a structured framework for nurses to assess, plan, implement and evaluate patient-specific, individualized interventions. These NCPs support ongoing blood pressure monitoring, encourage medication adherence and provide patient education on lifestyle modifications.8
Ultimately, they can enhance treatment effectiveness and improve overall patient outcomes.8
Nursing Care Plan for Pneumonia
Pneumonia is an inflammation of the lung tissue, characterized by fluid buildup and congestion that impair gas exchange. It is usually caused by bacterial or viral infections, which can be transmitted through respiratory droplets or direct contact. It ranks as the sixth leading cause of death in the United States.9
A nursing care plan for pneumonia begins with a thorough assessment, including the patient’s medical history, a respiratory assessment every four hours, physical examination and arterial blood gas (ABG) measurements.9
Interventions may include oxygen therapy, suctioning, encouraging coughing and deep breathing, ensuring adequate hydration and providing mechanical ventilation when necessary.9
Nursing Care Plan for Pain
Pain is a complex, subjective experience influenced by multiple factors. The International Association for the Study of Pain (IASP) defines it as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”10
Acute pain lasts less than three months and is often predictable, while chronic pain persists beyond three months without an anticipated end.10
Nurses play an important role in relieving and managing pain, and developing a comprehensive nursing care plan for pain can help manage discomfort through interventions such as medication, emotional support and patient education on pain management.10
Nursing Care Plan for Wound Infection
As the global burden of skin diseases rises with age, understanding wounds and wound infection becomes increasingly important.11
A wound is a disruption of the skin and soft tissue structure, and wound healing is a complex process that restores its function. In a nursing care plan for wound infection, nurses collaborate with the healthcare team to assess and manage these factors, creating an environment that promotes optimal healing.11
Asthma Nursing Care Plan
In the U.S., asthma affects about 26 million people and is the most common chronic childhood disease. It is a chronic inflammatory disease of the airways. The inflammation typically leads to a recurrent cough, chest tightness, mucous membrane swelling, wheezing and dyspnea.12
An asthma nursing care plan is developed based on symptom severity and may include outpatient management for mild cases or hospitalization for severe episodes. Patients and families may feel anxious due to breathing difficulties, emphasizing the need for a calm NCP approach and open communication throughout care management.12
Care Plan Fundamentals
Nurse.org explains the core questions your plan of care should answer: what, why and how.13
- 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 NCPs 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 start 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 crucial 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 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.14
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.14
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.14
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; this will improve ventilation and allow for chest expansion.”
- Evaluation: “The patient maintained good gas exchange and normal respiratory rate.”
Student nursing care plans often include 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 we’ve outlined.
Wrapping Up: How to Write a Nursing Care Plan
To be successful, a nursing care plan needs effective communication, goal-oriented tasks, accessibility, 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 essential values, including 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 to choose the right nursing 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 on-campus and virtual 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 on-campus clinical intensive as part of the curriculum. The PMHNP role specialty includes one required virtual clinical intensive as part of the curriculum.
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, “Nursing Care Plan Guide for 2025 | Tips & Examples,” Nurse.org, March 4, 2025, https://nurse.org/articles/what-are-nursing-care-plans/.
- Matt Vera, “Hypertension Nursing Diagnosis & Care Plans,” Nurseslcom, November 24, 2024, https://nurseslabs.com/hypertension-nursing-care-plans/.
- Matt Vera, “Pneumonia Nursing Diagnosis & Nursing Care Plans,” Nurseslcom, May 27, 2025, https://nurseslabs.com/pneumonia-nursing-care-plans/.
- Matt Vera, “Acute Pain Nursing Diagnosis & Nursing Care Plan,” Nurseslcom, March 17, 2025, https://nurseslabs.com/acute-pain/.
- Gil Wayne, “Impaired Tissue/Skin Integrity (Wound Care) Nursing Diagnosis & Care Plans,” Nurseslabs.com, November 20, 2024, https://nurseslabs.com/impaired-tissue-integrity/.
- Paul Martin, “6 Asthma Nursing Care Plans,” Nurseslabs.com, August 9, 2024, https://nurseslabs.com/asthma-nursing-care-plans/.
- 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/.
