# Nursing Care Plan: [Patient ID placeholder]

> Nursing care plan structured by the nursing process: assessment,
> diagnosis, planning, implementation and evaluation (ADPIE). Each
> nursing diagnosis is written in problem, etiology and signs format, with
> SMART goals, interventions with rationale and dated evaluation. Based on
> common nursing practice. This is a documentation format, not clinical
> advice. Use placeholders only in this template, and follow local privacy
> law (for example HIPAA or GDPR) and your institution's documentation
> policy when completing a real record.

<!--
Guidance: How to use this template
- Start with a complete assessment. Every nursing diagnosis must be
  traceable to assessment data in section 1.
- Prioritise diagnoses (for example airway, breathing, circulation, then
  safety, then comfort and education) and work on the top ones first.
- Write goals the patient can achieve and you can measure. "Patient will
  feel better" cannot be evaluated.
- Evaluate on the dates you set and revise the plan when goals are not met.
- Use your institution's approved terminology (for example NANDA-I, NIC,
  NOC) if required; the labels here are placeholders.
-->

| Field | Value |
|---|---|
| Patient name | [Patient name] |
| Patient identifier | [MRN / health number] |
| Age / sex | [Age] / [Sex] |
| Ward / unit | [Ward] |
| Admission date | YYYY-MM-DD |
| Medical diagnosis | [Diagnosis] |
| Plan started | YYYY-MM-DD |
| Primary nurse | [Name, role] |
| Next scheduled review | YYYY-MM-DD |

The plan follows the five steps of the nursing process, repeated until
goals are met:

```mermaid
flowchart LR
    A[Assessment] --> D[Diagnosis]
    D --> P[Planning]
    P --> I[Implementation]
    I --> E[Evaluation]
    E -->|Goals not met or new data| A
```

## 1. Assessment

<!-- Guidance: Collect subjective data (what the patient says) and objective data (what you observe and measure). Use validated tools for risk and record scores. -->

Assessment data that support the nursing diagnoses below:

| Domain | Subjective data | Objective data |
|---|---|---|
| Respiratory | [Patient statement] | [Rate, saturation, breath sounds] |
| Circulation | [Statement] | [Heart rate, blood pressure, capillary refill] |
| Pain and comfort | *Example:* "It hurts when I move" | Pain score 6/10 on movement, guarding of wound |
| Nutrition and hydration | [Appetite, thirst] | [Intake, weight, fluid balance] |
| Elimination | [Statement] | [Output, bowel pattern] |
| Mobility and safety | [Statement] | [Falls risk score, mobility aids] |
| Skin integrity | [Statement] | [Pressure injury risk score, wound description] |
| Psychosocial | [Concerns, coping] | [Behaviour, support present] |
| Knowledge | [Understanding of condition] | [Teach-back result] |

Risk assessment scores:

| Tool | Score | Date | Risk level |
|---|---|---|---|
| [Falls risk tool] | [Score] | YYYY-MM-DD | [Low / moderate / high] |
| [Pressure injury risk tool] | [Score] | YYYY-MM-DD | [Risk level] |
| [Nutrition screening tool] | [Score] | YYYY-MM-DD | [Risk level] |

## 2. Nursing diagnoses

<!-- Guidance: Write each diagnosis as problem, related to etiology, as evidenced by signs and symptoms. Risk diagnoses have risk factors instead of signs. Number them in priority order. -->

| ID | Priority | Problem | Related to (etiology) | As evidenced by (signs) |
|---|---|---|---|---|
| ND-01 | 1 | *Example:* Acute pain | Surgical incision | Pain score 6/10 on movement, guarding, reluctance to mobilise |
| ND-02 | 2 | [Impaired physical mobility] | [Etiology] | [Signs] |
| ND-03 | 3 | [Risk for falls] | [Risk factors: new mobility aid, analgesia] | Not applicable (risk diagnosis) |
| ND-04 | 4 | [Deficient knowledge] | [Etiology] | [Signs] |

## 3. Planning: goals and outcomes

<!-- Guidance: Each goal is SMART: specific, measurable, achievable, relevant and time-bound. Agree goals with the patient where possible. -->

| ID | Diagnosis | Goal (SMART) | Outcome measure | Target date |
|---|---|---|---|---|
| G-01 | ND-01 | *Example:* Patient reports pain at or below 3/10 on movement within 48 hours | Pain score every 4 hours and before mobilising | YYYY-MM-DD |
| G-02 | ND-02 | [Patient walks 20 m with frame and one assist by day 3] | [Distance, assistance level] | YYYY-MM-DD |
| G-03 | ND-03 | [Patient remains free of falls during admission] | [Incident reports] | [Discharge] |
| G-04 | ND-04 | [Patient demonstrates wound care correctly before discharge] | [Teach-back, observed demonstration] | YYYY-MM-DD |

## 4. Implementation: interventions and rationale

<!-- Guidance: List nursing interventions for each goal, with the scientific or practical rationale. Include assessment, therapeutic, educational and collaborative actions. -->

| Goal | Intervention | Frequency / time | Rationale | Responsible |
|---|---|---|---|---|
| G-01 | Assess pain using [scale] at rest and on movement | Every 4 hours and 30 min after analgesia | Establishes baseline and effect of treatment | [Nurse] |
| G-01 | Give prescribed analgesia before planned mobilisation | 30-60 min before activity | Peak effect coincides with activity | [Nurse] |
| G-01 | *Example:* Support the incision with a pillow when coughing | With each episode | Reduces tension on the wound and pain | [Nurse / patient] |
| G-02 | [Mobilise with physiotherapy plan] | [Frequency] | [Rationale] | [Physiotherapist / nurse] |
| G-03 | [Bed in low position, call bell in reach, non-slip footwear] | [Continuous] | [Rationale] | [Nurse] |
| G-04 | [Teach wound care using teach-back] | [Daily until competent] | [Rationale] | [Nurse] |

Interventions given are recorded in the care record with time and
signature: [link or location in record].

## 5. Evaluation

<!-- Guidance: Compare the patient's actual response with each goal on the target date. Decide: met, partially met or not met, and continue, revise or close the goal. -->

| Goal | Date evaluated | Evidence | Status | Decision |
|---|---|---|---|---|
| G-01 | YYYY-MM-DD | *Example:* Pain 2/10 at rest, 3/10 on walking | Met | Continue regimen; close goal at discharge |
| G-02 | YYYY-MM-DD | [Evidence] | [Met / partially met / not met] | [Continue / revise / close] |
| G-03 | YYYY-MM-DD | [Evidence] | [Status] | [Decision] |
| G-04 | YYYY-MM-DD | [Evidence] | [Status] | [Decision] |

## 6. Plan revisions

<!-- Guidance: When a goal is not met, reassess. Record why, what changed and the new target date. -->

| Date | Diagnosis or goal | Reason for revision | Change made | By |
|---|---|---|---|---|
| YYYY-MM-DD | [G-02] | [Goal not met because of dizziness on standing] | [Added lying and standing blood pressure; new target date] | [Name] |

## 7. Discharge and handover considerations

<!-- Guidance: Link unresolved diagnoses to discharge planning and community follow-up. -->

- Diagnoses still active at discharge: [list and handover destination]
- Education completed: [topics, teach-back result]
- Equipment and services arranged: [list]
- Information given to carers: [summary]

## 8. Sign-off

<!-- Guidance: Each nurse who updates the plan records name, role and date. -->

| Name | Role | Signature | Date |
|---|---|---|---|
| [Name] | [Registered nurse] | [Signature] | YYYY-MM-DD |
| [Name] | [Role] | [Signature] | YYYY-MM-DD |

## Standard and licence note

Based on common nursing practice using the nursing process (assessment,
diagnosis, planning, implementation, evaluation). Where your institution
requires standardised terminologies such as NANDA-I, NIC or NOC, use
their licensed labels in place of the placeholders. This is a
documentation format, not clinical advice; follow local privacy law and
your institution's documentation policy. Template licence: MIT.