Nursing Care Plan Template (ADPIE)

Nursing care plan by the nursing process: assessment, diagnoses (problem, etiology, signs), SMART goals, interventions, evaluation

Y tếChuẩnNursing process (ADPIE)care planCập nhật 20 thg 10, 2026

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Cách dùng: Use when planning nursing care for an admitted patient or teaching the nursing process. Complete the assessment first so each diagnosis traces to data. Main pitfall: goals that cannot be measured or are never evaluated on the target date.

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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.

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:

1. Assessment

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

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

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

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

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

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

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

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.

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