RN BasicsNursing school
How to Write a Nursing Care Plan (With Example)
To write a nursing care plan, follow the nursing process: assess the patient, state a nursing diagnosis, set a measurable goal, list interventions with the reason for each, and evaluate whether the goal was met. Every part should link to the next: the assessment data support the diagnosis, the goal answers the diagnosis, the interventions move the patient toward the goal, and the evaluation uses the goal's own measure.
This guide walks through each step the way instructors grade it, shows how to build a diagnosis statement and a SMART goal, and ends with one complete example care plan for a patient after knee replacement surgery.
How to write a nursing care plan: the five ADPIE steps
| Step | What you do | What goes on the care plan |
|---|---|---|
| Assessment | Collect subjective and objective data; cluster the cues that belong together | The data that support each diagnosis |
| Diagnosis | Name the patient's response that nursing can change | A diagnosis statement for each priority problem |
| Planning | Set goals and expected outcomes with the patient | SMART goals with a time frame |
| Implementation | Choose and carry out nursing interventions | Interventions, each with a rationale |
| Evaluation | Compare the patient's status with the goal | Met, partly met or not met, and what happens next |
The steps are a cycle, not a line. New data at any point can change the diagnosis or the plan. The clinical judgment model behind the NCLEX also rests on the nursing process, so a student who can build a tight care plan is practicing the same reasoning the exam tests.
Step 1: assessment that supports a diagnosis
- Subjective data: what the patient says, in their words (pain rating, worries, goals).
- Objective data: what you measure or observe (vital signs, wound, behavior, labs).
- Cluster related cues: guarding, grimacing and a pain rating of 7 point to one problem; a temperature and a red wound point to another.
- Use valid tools: a numeric pain scale for a patient who can rate, a behavioral scale for one who cannot.
A client with advanced dementia cannot report pain. After a fall the client grimaces, moans when repositioned, and refuses to eat. How should the nurse assess and manage pain?
- Use a behavioral pain scale and give analgesia as ordered
- Attribute the behaviors to the dementia itself
- Keep asking the client for a 0 to 10 rating until one is given
- Withhold analgesics until the client can rate the pain
Show the answer and rationale
Answer: A
- A. Correct. Behavioral indicators guide assessment, pain is assumed present, and treatment proceeds when self-report is not possible.
- B. Behavior changes often signal pain.
- C. Not feasible in advanced dementia.
- D. Inability to report does not mean absence of pain.
Pain in nonverbal clients: observe facial expression, vocalization, body movements, changes in activity or routine, and consolability; use tools such as PAINAD, CPOT or FLACC; consider an analgesic trial when pain is likely; and involve family who know the client’s baseline. Untreated pain causes agitation and delirium.
Bottom line: When a client cannot self-report pain, use a behavioral pain scale, assume pain is present when likely, and give ordered analgesia.
Sources: Ignatavicius, Med-Surg Nursing, 11th ed.; Potter & Perry Fundamentals, 12th ed.
Walk-through: the patient cannot give a self-report, so a numeric scale is the wrong tool. The cues (grimacing, moaning on movement, refusing food) are behavioral, which points to a behavioral pain scale, and a recognized problem needs action, so the answer pairs the right assessment with treatment. On a care plan, those same behaviors become the evidence for the diagnosis.
Step 2: writing the nursing diagnosis statement
A nursing diagnosis names the patient's response to a health problem, something nurses can treat on their own judgment. NANDA International (NANDA-I) publishes the standard labels and their parts; its taxonomy is licensed, so use the current edition your program provides for exact labels. The structure, though, is easy to learn:
| Type | Parts | Format |
|---|---|---|
| Problem-focused | Label, related factors (causes), defining characteristics (signs and symptoms) | Label related to [cause] as evidenced by [signs and symptoms] |
| Risk | Label and risk factors; no signs yet, because the problem has not happened | Risk for [problem] as evidenced by [risk factors] |
| Health promotion | Label and defining characteristics showing the patient wants to improve | Readiness for enhanced [area] as evidenced by [what the patient says or does] |
- Example: Acute pain related to surgical tissue trauma as evidenced by a pain rating of 7/10 with movement, guarding and grimacing.
- Example: Anxiety related to an unfamiliar procedure as evidenced by restlessness and repeated questions.
Step 3: SMART goals and expected outcomes
A goal states what the patient will do or show, not what the nurse will do. SMART goals are Specific, Measurable, Achievable, Relevant and Time-bound. The time frame is the part students most often leave out, and without it you cannot evaluate.
| Weak goal | SMART goal |
|---|---|
| Patient will have less pain. | Patient will rate knee pain 4/10 or less during physical therapy by the end of postoperative day 2. |
| Nurse will teach about the incision. | Patient will state 3 signs of wound infection to report before discharge. |
| Patient will walk more. | Patient will walk 30 m with a walker and one assist by the end of the day shift. |
Steps 4 and 5: interventions with rationales, then evaluation
- Each intervention is a specific nursing action with a frequency: assess, monitor, give, teach, position, coordinate.
- Include independent actions (positioning, teaching, ice) as well as giving ordered drugs.
- Each rationale explains why the action works, ideally from a source your instructor accepts.
- Evaluation restates the goal's measure and the result: met, partly met or not met, with the data.
- If the goal is not met, say what changes: reassess, revise the goal or the interventions, or continue.
Nursing care plan example: after total knee replacement
Patient: 68-year-old, day 1 after a right total knee replacement. Says her knee pain is 7/10 when moving and 4/10 at rest. Grimaces and guards the knee; declined morning physical therapy because of pain. Heart rate 98/min, blood pressure 148/86, breathing 16/min, awake and alert. Orders: scheduled acetaminophen and an NSAID, an oral opioid as needed, ice and elevation.
| Care plan part | Content |
|---|---|
| Nursing diagnosis | Acute pain related to surgical tissue trauma and swelling as evidenced by pain 7/10 with movement, guarding, grimacing and declining therapy |
| Goal | Patient will rate knee pain 4/10 or less during physical therapy and walk 30 m with a walker by the end of postoperative day 2 |
| Intervention 1 | Assess pain at rest and with movement on a 0 to 10 scale every 4 hours and 30 to 60 minutes after each as-needed dose. Rationale: gives a baseline and shows whether treatment worked |
| Intervention 2 | Give scheduled acetaminophen and the NSAID on time as ordered. Rationale: multimodal non-opioid analgesia controls pain and lowers opioid needs |
| Intervention 3 | Give the as-needed opioid so it peaks before therapy sessions. Rationale: pain control during movement lets the patient take part in mobilization |
| Intervention 4 | Before and after each opioid dose, check sedation level and breathing rate; notify the provider if she is frequently drowsy (sedation scale 3 or more) or breathing under 10/min. Rationale: opioids, especially with other sedating drugs, can cause oversedation and respiratory depression |
| Intervention 5 | Apply ice and elevate the leg per protocol. Rationale: adjunct measures that reduce swelling and pain |
| Intervention 6 | Monitor for nausea and constipation; offer the ordered bowel regimen and fluids. Rationale: common opioid effects that also limit recovery |
| Intervention 7 | Teach her to report pain early, use slow breathing and positioning, and expect a tolerable level rather than zero. Rationale: active participation improves pain control |
| Evaluation | Day 2: pain 3/10 during therapy; walked 30 m with a walker; alert, breathing 16/min. Goal met. Continue the plan and begin discharge teaching |
Frequently asked questions
What are the 5 steps of a nursing care plan?
Assessment, diagnosis, planning, implementation and evaluation (ADPIE). The care plan records the diagnosis, the goals, the interventions with rationales and the evaluation.
What is the difference between a nursing diagnosis and a medical diagnosis?
A medical diagnosis names a disease, such as osteoarthritis. A nursing diagnosis names the patient's response that nurses treat, such as acute pain or anxiety, and it changes as the patient's response changes.
How many nursing diagnoses should a care plan have?
As many as your assignment asks for, ranked by priority. Put threats to airway, breathing and circulation and other urgent physical needs first, then safety, then the rest.
What makes a care plan goal measurable?
It names something you can observe or count, a target and a time frame, for example pain 4/10 or less during therapy by the end of day 2.
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Related cheat sheets
- Next Gen NCLEX: Clinical JudgmentThe six NCJMM steps, NGN item types and partial-credit scoring on the 2026 NCLEX-RN and NCLEX-PN
- Prioritization and DelegationWho to see first, five rights, scope, SBAR and escalation for NCLEX-RN and PN
- Perioperative CareConsent, NPO times, home medications, checklist and time-out; PACU priorities and Aldrete; post-op complications by timing, dehiscence, malignant hyperthermia
- Therapeutic Communication and Defense MechanismsTechniques vs blocks, defense mechanisms, relationship phases, crisis, suicide screening, de-escalation, grief and “best response” items
Sources
- Jabraeelzadeh Kamblash A, Jafari MJ, Nemati-Vakilabad R, et al. Nursing Students' Competency about Writing Nursing Care Plan: An Exploratory Study in Iran. J Nurs Manag. 2024;2024:6653850. Link
- Patiraki E, Katsaragakis S, Dreliozi A, Prezerakos P. Nursing Care Plans Based on NANDA, Nursing Interventions Classification, and Nursing Outcomes Classification: The Investigation of the Effectiveness of an Educational Intervention in Greece. Int J Nurs Knowl. 2017;28(2):88-93. Link
- NANDA International. Diagnosis Development: Problem-Focused (submission elements). Link
- NANDA International. Diagnosis Development: Health Promotion (submission elements). Link
- Ernstmeyer K, Christman E, eds. Nursing Fundamentals (Open RN). 4.4 Diagnosis. Medicine LibreTexts. Link
- National Council of State Boards of Nursing. NCSBN Clinical Judgment Measurement Model. NCLEX.com. Link
- Wang Q, Zhao D, Hu J, et al. Implementing Evidence-Based, Phase-Specific Multimodal Analgesia for Total Joint Arthroplasty: An Interprofessional Review for Nursing Practice and Management. J Nurs Manag. 2026;2026:1182729. Link
- Sezerano ML, Niyonkuru E. Personalized Multimodal and Opioid-Sparing Analgesia for Postoperative Pain Management. J Pain Res. 2026;19:597049. Link