Nursing Care Plan Template with Guidance

Comprehensive Nursing Care Plan Template with Guidance

Patient Information Section

Patient Name: ________________________
Age: ______ Gender: _______ Room #: _______
Medical Record #: _____________________
Date of Admission: ____________________
Primary Diagnosis: ____________________
Secondary Diagnoses: __________________
Allergies: ___________________________
Code Status: _________________________
Assigned Nurse: ______________________
Date Care Plan Initiated: ______________

Assessment Data Collection

Subjective Data (What the patient reports)

• Chief complaint:
• Pain assessment (location, intensity 1-10, quality, triggers):
• Patient’s understanding of condition:
• Cultural/spiritual concerns:
• Social support system:
• Patient goals/concerns:

Objective Data (Observable/measurable findings)

• Vital signs:
• Physical assessment findings:
• Laboratory results:
• Diagnostic test results:
• Medication compliance:
• Functional status:

Care Plan Framework

Priority Nursing Diagnosis #1

Nursing Diagnosis: ________________________________________________ (Use NANDA-I approved terminology)

Related to (R/T): ____________________________________________ (Etiology – the underlying cause or contributing factors)

As evidenced by (AEB): _____________________________________ (Defining characteristics – signs and symptoms)

Patient Goals/Expected Outcomes:

• Short-term goal (24-48 hours): _________________________________
• Long-term goal (by discharge): ________________________________ (Use SMART criteria: Specific, Measurable, Achievable, Relevant, Time-bound)

Nursing Interventions:

Intervention	Rationale	Frequency	Evaluation
1.
2.
3.
4.

Evaluation:

• Goal met ☐ Partially met ☐ Not met ☐
• Outcome: ________________________________________________
• Continue plan ☐ Modify plan ☐ Discontinue ☐
• Date: _______________

Priority Nursing Diagnosis #2

Nursing Diagnosis: ________________________________________________

Related to (R/T): ____________________________________________

As evidenced by (AEB): _____________________________________

Patient Goals/Expected Outcomes:

• Short-term goal (24-48 hours): _________________________________
• Long-term goal (by discharge): ________________________________

Nursing Interventions:

Intervention	Rationale	Frequency	Evaluation
1.
2.
3.
4.

Evaluation:

• Goal met ☐ Partially met ☐ Not met ☐
• Outcome: ________________________________________________
• Continue plan ☐ Modify plan ☐ Discontinue ☐
• Date: _______________

Priority Nursing Diagnosis #3

Nursing Diagnosis: ________________________________________________

Related to (R/T): ____________________________________________

As evidenced by (AEB): _____________________________________

Patient Goals/Expected Outcomes:

• Short-term goal (24-48 hours): _________________________________
• Long-term goal (by discharge): ________________________________

Nursing Interventions:

Intervention	Rationale	Frequency	Evaluation
1.
2.
3.
4.

Evaluation:

• Goal met ☐ Partially met ☐ Not met ☐
• Outcome: ________________________________________________
• Continue plan ☐ Modify plan ☐ Discontinue ☐
• Date: _______________

Discharge Planning

Anticipated Discharge Date: _______________
Discharge Disposition: ___________________
Patient/Family Teaching Needs:

Community Resources/Referrals:

Follow-up Appointments:

Comprehensive Guidance for Using This Template

Understanding the Nursing Process

The nursing care plan follows the systematic nursing process:

ADPIE Framework:

• Assessment: Collect comprehensive patient data
• Diagnosis: Identify nursing problems using NANDA-I terminology
• Planning: Set goals and select interventions
• Implementation: Carry out the planned interventions
• Evaluation: Assess effectiveness and modify as needed

Step-by-Step Instructions

1. Assessment Phase

Collect comprehensive data through:

• Patient interviews and history taking
• Physical examination using inspection, palpation, percussion, auscultation
• Review of medical records and diagnostic results
• Collaboration with healthcare team members
• Family input when appropriate

Key Assessment Areas:

• Physiological (airway, breathing, circulation, neurological status)
• Psychological (anxiety, coping mechanisms, mental status)
• Social (support systems, cultural factors, economic status)
• Spiritual (beliefs, values, meaning-making)

2. Diagnosis Phase

Prioritize nursing diagnoses using:

• Maslow’s hierarchy of needs (physiological needs first)
• ABCs (Airway, Breathing, Circulation)
• Life-threatening conditions first
• Patient’s stated priorities

Common High-Priority Diagnoses:

• Ineffective airway clearance
• Impaired gas exchange
• Decreased cardiac output
• Acute pain
• Risk for infection
• Deficient knowledge
• Anxiety

3. Planning Phase

Writing Effective Goals:

• Patient-centered (focus on patient outcomes, not nursing actions)
• Measurable and observable
• Time-specific
• Realistic and achievable
• Include conditions under which behavior will occur

Example of Well-Written Goal: “Patient will ambulate 50 feet in hallway with walker and minimal assistance by post-operative day 2 without shortness of breath or dizziness.”

4. Implementation Phase

Selecting Evidence-Based Interventions:

• Independent nursing actions (within nursing scope)
• Dependent actions (require physician orders)
• Collaborative actions (require teamwork)
• Consider cultural preferences and patient values

Documentation Requirements:

• Record all interventions performed
• Note patient responses
• Document any deviations from plan
• Include patient/family teaching provided

5. Evaluation Phase

Evaluate systematically:

• Compare actual outcomes to expected outcomes
• Determine if goals were met, partially met, or not met
• Identify factors that helped or hindered goal achievement
• Modify plan as needed based on evaluation

Writing Tips for Each Component

Nursing Diagnoses

Format: Problem + Etiology + Signs/Symptoms

• Use only NANDA-I approved diagnoses
• Be specific rather than vague
• Ensure the etiology is something nursing can address
• Include relevant defining characteristics

Examples:

• “Acute pain related to surgical incision as evidenced by patient rating pain 8/10, guarding behavior, and facial grimacing”
• “Risk for falls related to medication side effects, advanced age, and history of falls”

Goals/Outcomes

SMART Goals Format:

• Specific: Clearly defined behavior
• Measurable: Quantifiable criteria
• Achievable: Realistic for patient
• Relevant: Related to nursing diagnosis
• Time-bound: Specific timeframe

Interventions

Include:

• What action to take
• How often to perform it
• Any specific parameters or conditions
• Who will perform the intervention

Rationales should:

• Provide scientific basis for intervention
• Reference current evidence or standards
• Explain how intervention addresses the problem
• Be concise but informative

Common Mistakes to Avoid

Assessment Errors

• Collecting insufficient or inaccurate data
• Failing to validate findings with patient
• Missing cultural or spiritual considerations
• Not involving patient/family in assessment

Diagnosis Errors

• Using medical diagnoses instead of nursing diagnoses
• Writing vague or unclear problem statements
• Incorrect use of “related to” and “as evidenced by”
• Failing to prioritize appropriately

Planning Errors

• Setting unrealistic or unmeasurable goals
• Goals that are nursing-focused rather than patient-focused
• Interventions that don’t address the etiology
• Failing to consider patient preferences

Implementation Errors

• Not following through on planned interventions
• Poor documentation of care provided
• Failing to communicate with team members
• Not adapting interventions based on patient response

Evaluation Errors

• Not evaluating outcomes at specified intervals
• Continuing ineffective interventions
• Failing to modify plan based on evaluation
• Inadequate documentation of evaluation findings

Quality Indicators for Care Plans

An effective care plan should:

• Be individualized to the specific patient
• Address priority problems first
• Include realistic, measurable goals
• Have evidence-based interventions
• Show clear rationales for each intervention
• Be updated regularly based on evaluation
• Include patient/family input and preferences
• Consider cultural and spiritual factors
• Plan for discharge from admission

Documentation Standards

Legal Considerations:

• Use black or blue ink (if handwritten)
• Write legibly and use correct grammar
• Sign and date all entries
• Never leave blank spaces
• Correct errors according to facility policy
• Include complete assessment data
• Document patient responses to interventions

Professional Standards:

• Follow facility policies and procedures
• Use approved abbreviations only
• Include relevant details without being excessive
• Maintain patient confidentiality
• Ensure continuity between shifts
• Coordinate with interdisciplinary team

Technology Integration

Electronic Health Records (EHR) Considerations:

• Utilize dropdown menus for standardized language
• Customize templates for different patient populations
• Link interventions to evidence-based protocols
• Set up alerts for goal evaluation dates
• Use clinical decision support tools when available

This template provides a foundation for developing comprehensive, individualized nursing care plans that promote optimal patient outcomes while meeting professional and legal documentation standards.