A nursing care plan is a written record of the nursing process for one patient: assessment data, a NANDA-I nursing diagnosis in PES format, measurable NOC outcomes, NIC interventions with rationales, and an evaluation. Each example below follows that five-part structure exactly as nursing faculty expect it.
Every plan below uses the same five columns your rubric grades: assessment data, the NANDA-I diagnosis in PES format, a measurable NOC outcome, NIC interventions, and the rationale that justifies each one. Copy the structure, never the wording, and swap in your own patient data.
| Component | What graders look for | Common deduction |
|---|---|---|
| Assessment | Subjective and objective data, both present | Only vital signs, no patient statements |
| Diagnosis | Approved NANDA-I label plus PES structure | Medical diagnosis used as the label |
| Outcome | Measurable, patient-centred, time-bound | Nurse-centred goal ("I will educate...") |
| Intervention | Independent and collaborative actions | Physician orders listed as nursing actions |
| Rationale | Physiology or evidence with a source | Restating the intervention |
| Evaluation | Met, partially met, or not met plus revision | Section left blank |
Assessment. Subjective: "I can't catch my breath." Objective: SpO2 88 percent on room air, respiratory rate 28, accessory muscle use, ABG pH 7.31 with PaCO2 55 mmHg.
Diagnosis. Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by SpO2 of 88 percent, PaCO2 of 55 mmHg and use of accessory muscles.
Outcome. Patient will maintain SpO2 at or above 90 percent on prescribed oxygen and report reduced dyspnoea within 24 hours.
Interventions and rationales.
| Intervention | Rationale |
|---|---|
| Administer oxygen at 1-2 L/min via nasal cannula and titrate to SpO2 88-92 percent | Chronic CO2 retainers rely partly on hypoxic drive; high-flow oxygen can blunt respiratory effort |
| Position in high Fowler's or tripod position | Increases thoracic expansion and reduces work of breathing |
| Teach pursed-lip breathing | Creates back-pressure that keeps small airways open during exhalation and reduces air trapping |
| Monitor ABGs and capnography as ordered | Detects worsening respiratory acidosis before clinical decompensation |
| Cluster care and pace activity | Reduces oxygen consumption and prevents desaturation |
Evaluation. Outcome met if SpO2 stays 90 percent or above and the patient reports easier breathing; if not met, reassess oxygen delivery and escalate for possible non-invasive ventilation.
For the full disease-process breakdown, read our guide to nursing care plans for COPD.
Diagnosis. Ineffective Airway Clearance related to excessive tracheobronchial secretions as evidenced by coarse crackles, productive cough and inability to expectorate.
Outcome. Patient will maintain a patent airway with clear breath sounds and expectorate secretions independently by discharge.
Key interventions. Encourage 2-3 L fluid intake daily unless contraindicated (thins secretions), teach splinted coughing and incentive spirometry every hour while awake (mobilises secretions and prevents atelectasis), auscultate lungs every four hours (tracks response), and administer prescribed mucolytics and bronchodilators before chest physiotherapy (maximises clearance).
Diagnosis. Decreased Cardiac Output related to altered myocardial contractility as evidenced by ejection fraction of 30 percent, blood pressure 88/54, S3 gallop and 3+ pitting oedema.
Outcome. Patient will demonstrate stable haemodynamics with blood pressure above 90/60, heart rate 60-100, and no more than 1 kg weight gain over 48 hours.
Key interventions. Daily weights at the same time on the same scale before breakfast (the single most reliable fluid-status indicator), strict intake and output, sodium and fluid restriction as ordered, monitor for digoxin toxicity if prescribed, and assess for orthopnoea and paroxysmal nocturnal dyspnoea each shift.
Diagnosis. Acute Pain related to surgical tissue injury as evidenced by a self-reported score of 8/10, guarding of the incision and heart rate of 108.
Outcome. Patient will report pain at 3/10 or lower within 60 minutes of analgesic administration and will participate in ambulation.
Key interventions. Assess pain with a validated scale before and 30-60 minutes after every intervention, administer multimodal analgesia on schedule rather than as-needed during the first 48 hours (prevents peaks that are harder to control), splint the incision during coughing, and add non-pharmacological measures such as repositioning and cold therapy.
Our pain assessment scales guide covers which tool to use for non-verbal and paediatric patients.
Diagnosis. Risk for Infection as evidenced by invasive urinary catheter and immunosuppressive therapy.
Note the structure: a risk diagnosis has no "as evidenced by" signs and symptoms because the problem has not occurred. List risk factors instead.
Outcome. Patient will remain free of infection, with temperature below 38 degrees Celsius and clear urine, throughout hospitalisation.
Key interventions. Perform hand hygiene before and after every catheter contact, maintain a closed drainage system below bladder level, provide daily perineal care, and review catheter necessity every shift (early removal is the single most effective CAUTI prevention measure).
| # | Nursing diagnosis | Common condition | Priority outcome |
|---|---|---|---|
| 6 | Impaired Skin Integrity related to pressure over bony prominences | Immobility, stage 2 pressure injury | Wound bed shows granulation with no increase in size in 7 days |
| 7 | Deficient Fluid Volume related to active fluid loss | Gastroenteritis, vomiting | Urine output above 0.5 mL/kg/hr and moist mucous membranes in 24 hours |
| 8 | Excess Fluid Volume related to compromised regulatory mechanism | Renal failure | Weight returns to dry weight; no peripheral oedema in 72 hours |
| 9 | Risk for Unstable Blood Glucose related to insufficient diabetes management knowledge | Type 2 diabetes | Blood glucose 80-180 mg/dL and patient demonstrates glucometer use |
| 10 | Impaired Physical Mobility related to neuromuscular impairment | Stroke | Patient transfers bed to chair with one assist in 5 days |
| 11 | Risk for Falls related to altered gait and sedating medication | Older adult admission | No falls during hospitalisation |
| 12 | Anxiety related to threat to health status | Pre-operative patient | Patient reports anxiety 3/10 or lower and uses one coping strategy |
| 13 | Imbalanced Nutrition: Less Than Body Requirements related to inability to ingest food | Dysphagia after stroke | Patient maintains weight and consumes 75 percent of meals |
| 14 | Disturbed Sleep Pattern related to environmental stimuli | ICU admission | Patient reports 5 or more hours of uninterrupted sleep |
| 15 | Ineffective Health Maintenance related to knowledge deficit of the therapeutic regimen | Newly diagnosed hypertension | Patient states three lifestyle modifications and correct medication schedule before discharge |
Each of these follows the same pattern: pick the NANDA-I label that names the human response, attach the etiology your assessment supports, and prove it with data you actually collected.
ASSESSMENT (subjective + objective)
DIAGNOSIS: [NANDA-I label] related to [etiology] as evidenced by [signs/symptoms]
OUTCOME: Patient will [measurable behaviour] by [time frame]
INTERVENTIONS: 1... 2... 3... (independent and collaborative)
RATIONALES: one per intervention, sourced
EVALUATION: met / partially met / not met + revision
Need a care plan built around your own clinical data and rubric? Our care plans and clinical documentation service is staffed by MSN and PhD nurses who write these every day.
Assessment, nursing diagnosis, planning with measurable outcomes, implementation with interventions and rationales, and evaluation. Faculty usually grade each part separately, so no section can be skipped.
State the NANDA-I problem, then the etiology after 'related to', then the objective and subjective evidence after 'as evidenced by'. Example: Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by SpO2 of 88 percent and use of accessory muscles.
Most course rubrics ask for one to three prioritised diagnoses. Rank them with the ABCs and Maslow's hierarchy so airway, breathing and circulation problems come before psychosocial ones.
A medical diagnosis names the disease, for example pneumonia. A nursing diagnosis names the patient's response that nurses can treat independently, for example Ineffective Airway Clearance.