How to Write a

Nursing Care Plan

  A nursing care plan has several key components including, 
• Nursing diagnosis
• Expected outcome
• Nursing interventions and rationales
• Evaluation

Nursing Care  Each of the five main components is essential to the overall
nursing process and care plan. A properly written care plan
Plan must include these sections otherwise it won’t make sense!
Components • Nursing diagnosis - A clinical judgment that helps nurses
determine the plan of care for their patients
• Expected outcome - The measurable action for a patient to be
achieved in a specific time frame. 
• Nursing interventions and rationales - Actions to be taken to
achieve expected outcomes and reasoning behind them.
• Evaluation - Determines the effectiveness of the nursing
interventions and determines if expected outcomes are met
within the time set.
  Nursing care plans contain information about a patient’s
diagnosis, goals of treatment, specific nursing interventions,
and an evaluation plan. The nursing plan is constantly updated
with changes and new subjective and objective data. 
Nursing Care  Key aspects of the care plan include,
Plan •
•
Assessment
Diagnosis
Fundamentals • Outcome and Planning
• Implementation
• Evaluation
  Write an organized care
plan gathering subjective • Body conditions
and objective data.  • Head-to-toe assessment
How to Write • Vital signs
findings
• Medical history
a Nursing •
•
Blood pressure
Heart rate • Height and weight
Care Plan • Respirations • Intake and output
• Temperature
• Oxygen Saturation • Patient feelings, concerns,
Step 1: • Physical complaints
perceptions
• Laboratory data
Assessment •
•
Pain
Headache • Diagnostic testing
• Nausea • Echocardiogram
• Vomiting • X-Ray
• EKG

Subjective data is what the patient tells us their symptoms are, including feelings, perceptions, and concerns. Objective
data is observable and measurable.
  There are 4 types of nursing
diagnoses.   the four diagnoses you will use,
1.Problem-focused - Patient
How to Write problem present during a
nursing assessment is known
a Nursing as a problem-focused
diagnosis
Care Plan 2.Risk - Risk factors require
intervention from the nurse
and healthcare team prior to
a real problem developing
3.Health promotion - Improve
Step 2: the overall well-being of an
individual, family, or
Diagnosis community
4.Syndrome - Cluster of
nursing diagnoses that occur
in a pattern or can all be
addressed through the same
or similar nursing
interventions
A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid and helps prioritize treatments.
 After determining which type of
start building out the nursing
diagnosis statement. 
 The three main components of a
nursing diagnosis are:
1.Problem and its definition -
Patient’s current health
problem and the nursing
interventions needed to care
for the patient.
2.Etiology or risk factors -
Possible reasons for the
problem or the conditions in
which it developed
3.Defining characteristics or risk
factors - Signs and symptoms
that allow for applying a
specific diagnostic label/used in
the place of defining
characteristics for risk nursing
diagnosis
  It’s important to remember
that a medical diagnosis
How to Write  After determining the
does not change if the
condition is resolved, and it
a Nursing nursing diagnosis, it is time remains part of the
patient’s health history
Care Plan to create a SMART goal
based on evidence-based forever. 
practices. SMART is an  Examples of medical
acronym that stands for, diagnosis include, 
Step 3: • Specific • Chronic Lung Disease
• Measurable (CLD)
Outcomes • Achievable • Alzheimer’s Disease
and Planning •
•
Relevant
Time-Bound
• Endocarditis
• Plagiocephaly 
• Congenital Torticollis 
• Chronic Kidney Disease
(CKD)

A medical diagnosis is made by a physician or advanced healthcare practitioner. 

  The implementation phase
How to Write means performing the
a Nursing nursing interventions
outlined in the care plan.
 Some interventions will be
patient or diagnosis-
Care Plan Interventions are classified
into seven categories: 
specific, but there are
several that are completed
• Family each shift for every patient:
Step 4: •
•
Behavioral
Physiological
•
•
Pain assessment
Position changes
Implementati • Complex physiological •
•
Fall prevention
• Community Providing cluster care
on • Safety • Infection control
• Health system
interventions
How to Write  The fifth and final step of
a Nursing the nursing care plan is the
evaluation phase. This is  Based on the evaluation, it
Care Plan when you evaluate if the
desired outcome has been
can determine if the goals
and interventions need to
met during the shift. There be altered. Ideally, by the
are three possible time of discharge, all
Step 5: outcomes,  nursing care plans including
• Met goals should be met. 
Evaluation  • Ongoing
• Not Met

A medical diagnosis is made by a physician or advanced healthcare practitioner. 

Nursing Care Plan Fu
ndamentals