Nursing Care Plan: Format, Steps and Examples | NPrep

A nursing care plan is a written plan of a patient's nursing needs, built on the nursing process: assessment, diagnosis, planning, implementation and evaluation (ADPIE). Each plan states the nursing diagnosis, a measurable goal, the nursing interventions with their rationale, and how you will evaluate the result. Below are the format and two worked examples.

Updated 10 November 2026. The format follows the nursing process as taught in the B.Sc and GNM curriculum. The worked examples are NPrep teaching examples, not orders for a real patient: follow your institution's protocols and the prescriber's orders.

Explore nursing courses on NPrep

Nursing care plan at a glance

Part	What you write
Assessment	Subjective data (what the patient says) and objective data (what you observe and measure)
Nursing diagnosis	The patient's problem, its cause and the signs that show it
Goal or expected outcome	A specific, measurable result with a time frame
Interventions	What the nurse will do, including independent and collaborative actions
Rationale	Why each intervention works
Evaluation	Whether the goal was met, partly met or not met, and what changes

What are the steps of a nursing care plan?

The steps follow the nursing process, often remembered as ADPIE:

1. Assess. Collect subjective and objective data: history, vital signs, examination, reports.
2. Diagnose. Turn the data into a nursing diagnosis. A nursing diagnosis is about the patient's response, such as pain or fever, not the medical disease.
3. Plan. Set a goal that is specific, measurable, achievable, relevant and time-bound.
4. Implement. Carry out the interventions and record them.
5. Evaluate. Compare the result with the goal, then continue, change or close the plan.

How do I write a nursing diagnosis?

Use the PES format: Problem, Etiology and Signs and symptoms.

Problem related to cause as evidenced by signs and symptoms.

For example: Acute pain related to the surgical incision as evidenced by a pain score of 7 out of 10 and guarding of the abdomen.

Type of diagnosis	What it means	Example
Problem-focused (actual)	The problem is present now	Hyperthermia related to infection
Risk	The problem may develop	Risk for infection related to an IV cannula
Health promotion	The patient wants to improve health	Readiness for enhanced nutrition

Write a risk diagnosis without "as evidenced by", because the problem has not happened yet.

What does a care plan for fever look like?

Part	Example
Assessment	Patient reports feeling hot and weak. Temperature 39.2°C, pulse 112 a minute, skin warm and flushed
Nursing diagnosis	Hyperthermia related to infection as evidenced by a temperature of 39.2°C and a pulse of 112 a minute
Goal	Temperature below 37.5°C within 4 hours
Interventions	Monitor temperature, pulse and respiration every 2 hours; give the prescribed antipyretic; encourage oral fluids unless restricted; tepid sponging if ordered; light clothing and a ventilated room; record intake and output
Rationale	Monitoring shows the trend; the antipyretic resets the raised set point; fluids replace losses from sweating and fast breathing; sponging and light clothing increase heat loss
Evaluation	Temperature 37.4°C after 4 hours; goal met; continue monitoring

What does a care plan for post-operative pain look like?

Part	Example
Assessment	Patient says the wound pain is 7 out of 10, worse on moving. Guarding of the abdomen, grimacing, pulse 98 a minute
Nursing diagnosis	Acute pain related to the surgical incision as evidenced by a pain score of 7 out of 10 and guarding
Goal	Pain score of 3 out of 10 or less within 1 hour of intervention
Interventions	Assess pain with a scale and record it; give the prescribed analgesic and reassess after the expected onset; position for comfort and support the wound when coughing; teach slow deep breathing; check the dressing
Rationale	A scale makes pain measurable; reassessment shows whether the analgesic worked; supporting the wound reduces strain on the incision; breathing exercises reduce tension
Evaluation	Pain score 3 out of 10 after 1 hour; goal met; reassess every 4 hours

What are the common mistakes in care plans?

• Writing a medical diagnosis. "Pneumonia" is a medical diagnosis. "Ineffective airway clearance related to secretions" is a nursing diagnosis.
• Goals that cannot be measured. "Patient will feel better" cannot be evaluated. "Pain score 3 or less within 1 hour" can.
• Interventions with no rationale. Every action needs a reason.
• Copying one plan for every patient. The data, and so the plan, are different for each patient.
• Skipping evaluation. A plan is only finished when you record whether the goal was met.

How is the care plan asked in exams?

University papers ask you to write a full care plan for a condition, usually for 10 or 15 marks. Nursing Officer exams such as NORCET ask about the nursing process as MCQs. This is an NPrep practice question, not a past-paper question.

Which of the following is a nursing diagnosis rather than a medical diagnosis?

A. Myocardial infarction B. Acute pain related to tissue injury C. Type 2 diabetes mellitus D. Pneumonia

Answer: B. A nursing diagnosis describes the patient's response to a health problem, which nurses can treat. The other three are medical diagnoses.

For more on the nursing process and procedures, see Fundamentals of Nursing for NORCET.

FAQs

What is a nursing care plan?

A written plan of a patient's nursing needs, made using the nursing process. It lists the nursing diagnosis, goals, interventions with rationale, and evaluation.

What are the 5 steps of a nursing care plan?

Assessment, diagnosis, planning, implementation and evaluation, often remembered as ADPIE.

How do you write a nursing diagnosis?

Use the PES format: the problem, related to its cause, as evidenced by the signs and symptoms. For example, hyperthermia related to infection as evidenced by a temperature of 39.2°C.

What is the difference between a nursing diagnosis and a medical diagnosis?

A medical diagnosis names the disease, such as pneumonia. A nursing diagnosis names the patient's response that nurses can treat, such as ineffective airway clearance.

What is the nursing diagnosis for fever?

Commonly hyperthermia, related to the cause such as infection, as evidenced by a raised temperature and related signs. Base it on your own patient's assessment data.

What is a risk nursing diagnosis?

A problem that may develop but has not happened yet, such as risk for infection related to an IV cannula. It has no "as evidenced by" part.

What to read next

• Up: Fundamentals of Nursing for NORCET
• Across: Hand hygiene in nursing and Medical-Surgical Nursing for NORCET
• Practice: free NORCET mock test