A care plan is a promise you can measure.

01 / Context

Where the care plan fits in the nursing process.

The nursing process runs from assessment to diagnosis, outcome identification, planning, implementation, and evaluation. The care plan writes down the middle steps so that every nurse on every shift works toward the same goals. Open RN's Nursing Fundamentals describes the plan as individualized, holistic, and evidence-based, created with the patient, and documented for continuity of care across shifts and professionals.

Programs use different formats, including columns, tables, and concept maps. The thinking underneath is the same. This guide uses Mr. D., the fictional 72-year-old with pneumonia from our head-to-toe assessment and SOAP note guides.

02 / Diagnosis

Write the nursing diagnosis.

A nursing diagnosis names the patient's response to a health problem, which is something nurses can treat independently. "Pneumonia" is a medical diagnosis; "ineffective airway clearance" is the nursing response to it. NANDA International (NANDA-I) maintains the standardized list of nursing diagnosis labels and organizes them into four types:

Problem-focused

An undesirable response that exists now, supported by related factors and defining characteristics (signs and symptoms).

Risk

A vulnerability to developing a problem, supported by risk factors, since there are no symptoms yet.

Health promotion

A patient's readiness and motivation to improve a health behavior.

Syndrome

A cluster of nursing diagnoses that occur together and are best addressed with similar interventions.

A problem-focused diagnosis is usually written in PES format: the Problem, "related to" the Etiology, "as evidenced by" the Signs and symptoms. A risk diagnosis has no S, because nothing has happened yet; Open RN writes it as the problem "as evidenced by" its risk factors; some programs use "related to" instead. Either way, the etiology should be something the nurse can treat, not a medical diagnosis. Our nursing diagnoses guide covers this in more depth.

03 / Priority

Decide what comes first.

Most patients have more problems than one shift can solve, so rank them. Common rules of thumb: airway, breathing, and circulation first; actual problems before risks, unless a risk is severe and close; physiological needs before psychosocial ones (Maslow's hierarchy); and acute, changing problems before stable, chronic ones. Most importantly, ask what will hurt the patient soonest if nobody acts.

04 / Outcomes

Set outcomes you can actually measure.

An expected outcome describes the change you want to see in the patient, not what the nurse will do. Write it as "The patient will…" and make it SMART:

• Specific: name exactly what will change. "Clear lung sounds," not "breathing better."
• Measurable: use a number or an observable behavior someone else could verify.
• Action-oriented: start with a verb for the patient: demonstrate, maintain, state, drink, walk.
• Realistic and relevant: fit the patient's condition, values, and circumstances.
• Time-limited: say when you'll evaluate it, such as by end of shift, within 24 hours, or by discharge.

Weak: "Patient will have improved oxygenation." Stronger: "The patient will maintain SpO₂ at or above his prescribed target and demonstrate effective coughing within 24 hours."

05 / Interventions

Choose interventions, and say why.

Interventions are the nursing actions that move the patient toward the outcome. Where possible, they should target the etiology, the "related to" part of the diagnosis. They fall into three types:

Independent

Within the nurse's own scope, no prescription needed: positioning, coaching coughing and deep breathing, patient teaching, fall precautions.

Dependent

Requires a prescription: administering oxygen at a prescribed rate, giving antibiotics or IV fluids.

Collaborative

Carried out with other team members, such as respiratory therapy, physical therapy, or dietitians.

Every intervention needs a rationale: one sentence explaining why it works for this patient. Rationales show your instructor that you know why, not just what.

06 / Worked example

Mr. D.'s care plan, priority 1 in full.

Assessment data

"It hurts on my right side when I cough." Respirations 24; SpO₂ 90% on 2 L/min; crackles in the right lower lobe; productive cough with yellow sputum; temperature 38.4 °C.

Nursing diagnosis

Ineffective airway clearance related to retained secretions, as evidenced by right lower lobe crackles, productive cough, respirations 24, and SpO₂ 90% on 2 L/min.

Expected outcome

Within 24 hours, the patient will maintain SpO₂ at or above his prescribed target, have a respiratory rate within his baseline range, and demonstrate effective coughing and incentive spirometer use.

Intervention 1

Assess respiratory rate, effort, lung sounds, and SpO₂ per protocol and as needed. Rationale: early detection of worsening gas exchange allows timely escalation.

Intervention 2

Elevate the head of the bed and encourage upright positioning. Rationale: upright positioning improves lung expansion and makes coughing more effective.

Intervention 3

Coach coughing, deep breathing, and incentive spirometer use, splinting the right side with a pillow. Rationale: deep breaths help mobilize secretions, and splinting reduces the pleuritic pain that discourages coughing.

Intervention 4

Encourage oral fluids unless restricted. Rationale: adequate hydration helps keep secretions thinner and easier to clear.

Intervention 5

Administer oxygen and antibiotics as prescribed; collaborate with respiratory therapy. Rationale: these treat the hypoxemia and the underlying infection.

Evaluation

At 24 hours: compare SpO₂, respiratory rate, lung sounds, and cough effectiveness with the outcome. Mark it met, partially met, or not met, and revise the plan if needed.

Priorities 2 and 3 follow the same pattern. For example: Risk for deficient fluid volume, as evidenced by fever and decreased oral intake. The patient will drink at least the volume set with the care team each shift and have urine output within the expected range by end of shift. And: Risk for falls, as evidenced by dizziness on standing, unsteady gait, age, and acute illness. The patient will remain free of falls and will use the call light for help before getting up throughout the hospital stay.

07 / Evaluation

Evaluate, then revise.

Evaluation asks one question: did the patient meet the outcome by the time you set? If yes, the problem may be resolved or the goal can step up. If it's partially met or not met, ask why. Was the diagnosis wrong, the outcome unrealistic, or the intervention not done or not working? A plan that's never revised isn't being used.

The full Mr. D. series

Assessment, documentation, plan: one patient, three skills.