A nursing care plan turns your assessment into a plan for one patient: each nursing diagnosis, the outcomes you expect, what you’ll do and why, and how the patient did. Copy the free template, see a plan after ankle fracture surgery and a heart failure plan with excessive fluid volume, and check how to fill each column.
Blank nursing care plan template
FreeNURSING CARE PLAN Patient: [Name, age, sex] Date of birth or ID: [Date or record number] Location: [Unit, room, and bed; or home, clinic, or long-term care home] Reason for care: [Admitting or medical diagnosis, procedure, and day of stay] Relevant history: [Conditions, baseline function, and home situation that shape the plan] Allergies: [Drug, food, and latex allergies with the reaction, or none known] Plan started: [Date, time, and nurse] Next review: [Date and time, each shift, or when the patient's condition changes] TABLE LAYOUT One row per nursing diagnosis, read left to right: Assessment data | Nursing diagnosis | Goals and outcomes | Interventions | Rationale | Evaluation Write each row as the block below, or paste the headings into the columns of your school's or unit's form. PRIORITIES Priority order: [Each nursing diagnosis by number, highest first, and the reason: airway, breathing, circulation, safety, then comfort and learning] Patient's own priority: [What matters most to the patient, in their words] Covered elsewhere: [Needs handled by a unit protocol or another plan, such as fall prevention or skin care, or none] DIAGNOSIS [Number]: [Short label] ASSESSMENT DATA Subjective: [What the patient or family said, quoted where the words matter] Objective: [Findings, vital signs, scores with the tool named, and lab values, each with its time] Baseline: [Usual values or function, for comparison] NURSING DIAGNOSIS Statement: [NANDA-I label, related to its cause, as evidenced by the signs and symptoms; for a risk diagnosis, the label and its risk factors] Type: [Actual, risk, or health promotion] GOALS AND OUTCOMES Goal: [The overall aim, in one sentence about the patient] Outcome 1: [What the patient will do, the measure, and the date and time] Outcome 2: [What the patient will do, the measure, and the date and time] Patient agrees: [Yes, with the patient's own goal in their words, or why not] INTERVENTIONS AND RATIONALE Monitor: [What you will assess, how often, and the values that need a call] Rationale: [Why it matters for this patient] Nursing care: [Actions nurses start on their own, with times or frequency] Rationale: [Why each works, tied to the assessment data] Ordered treatments: [Medications and treatments as ordered: drug, dose, route, and frequency] Rationale: [What each is expected to do, and what to watch for] Teaching: [What the patient or family will learn, and how you will check it] Rationale: [How it carries the outcome past this shift or discharge] Collaboration: [Referrals, other team members, and when to call the prescriber] Rationale: [What each adds] EVALUATION Evaluated: [Date, time, and nurse] Outcome 1: [The result, measured the way the outcome was written] Outcome 2: [The result, measured the way the outcome was written] Status: [Met, partly met, or not met, for each outcome] Decision: [Continue, revise with the new outcome and time, or resolve] Repeat from DIAGNOSIS for each nursing diagnosis, in priority order. HANDOVER AND DISCHARGE Still open: [Each active diagnosis, and what is due next] Before discharge or transfer: [Outcomes still to meet, and teaching still to check] Signed: [Nurse name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Orthopedic surgical unit, post-op day 1, plan updated at 07:30
47-year-old woman, post-op day 1 after open reduction and internal fixation of a right ankle fracture, from a fall off a stepladder. Type 2 diabetes on metformin, A1c 8.6% three weeks ago. Smokes 15 cigarettes a day. BMI 32. No known drug allergies. Plaster backslab splint on the right leg; no weight on the right leg for 6 weeks, per the surgeon. Lives with her husband and their children, 9 and 12, in a house with 5 front steps. Home tomorrow if her pain is controlled on oral medicine and she is safe with a walker. Priority order: 1. Acute pain, because it is stopping her from moving, sleeping, and breathing deeply now. 2. Risk for infection, a risk that builds over the coming days. Her priority: “I need to get to the bathroom on my own, or I can’t go home.” Covered elsewhere: the unit’s fall prevention bundle, and blood clot prevention as ordered.
Subjective: “It’s a deep, crushing ache, and it throbs when my foot goes down.” Pain 8/10 at rest on the 0 to 10 numeric scale since about 04:00, when the numbness from her nerve block wore off. Oxycodone 5 mg by mouth at 04:30 brought it to 6/10; back to 8/10 by 07:00. Slept about 3 hours. Objective, 07:30: grimacing, holding the leg still; declined to sit on the edge of the bed at 06:00. T 37.4 °C (99.3 °F), HR 102, BP 146/88, RR 18, SpO2 97% on room air. POSS 1. Right toes warm and pink, capillary refill under 3 seconds, moves all toes, feeling intact on the top and sole of the foot, no pain when the toes are gently stretched. Mild swelling of the toes. Baseline: no regular pain medicine at home. Diagnosis: Acute pain related to bone and tissue injury from the fracture and surgery, as evidenced by pain 8/10 at rest, grimacing, guarding the leg, a heart rate of 102, and declining to move.
Goal: pain low enough for her to move, sleep, and manage at home. Outcome 1: by 09:00 today, she will rate her pain 4/10 or lower at rest. Outcome 2: by 15:00 today, she will move from bed to chair and walk 10 m (33 feet) with a walker, keeping weight off the right leg, with pain 5/10 or lower while walking. Outcome 3: by discharge tomorrow, she will describe her home pain plan in her own words: scheduled acetaminophen, when to take oxycodone, raising the leg, cold packs, and the pain that needs a call. Patient agrees: “Three out of ten is fine. I just need to get to the bathroom.”
Monitor: pain score, sedation on POSS, and breathing rate before each opioid dose and 60 minutes after it. Rationale: shows whether the dose worked, and catches sedation before breathing slows. Monitor: neurovascular checks of the right foot every 2 hours until 24 hours after surgery, then every 4 hours: color, warmth, capillary refill, movement, feeling, and pain on gentle toe stretch. Rationale: pain that keeps climbing despite medicine, or pain when the toes are stretched, can be an early sign of compartment syndrome; that needs an urgent call to the surgeon, not more opioid. Nursing care: right leg on 2 pillows with the ankle above the heart; a cold pack in a dry cover over the front of the splint for 20 minutes every 2 hours while awake; the as-needed dose offered 45 minutes before physiotherapy. Rationale: raising the leg and cold reduce the swelling behind much of the throbbing; dosing ahead lets her take part in therapy. Ordered treatments: acetaminophen 1,000 mg by mouth every 6 hours, scheduled; oxycodone 5 to 10 mg by mouth every 4 hours as needed. Rationale: scheduled acetaminophen gives a steady base, so she needs less opioid; no other acetaminophen products while this order runs. Teaching: ask for the as-needed dose before pain passes 5/10; at home, keep the ankle above the heart for most of the first week. Rationale: pain caught early is easier to bring down, and the habit carries home. Collaboration: physiotherapy at 11:00 for transfers and walking without weight on the right leg; surgical resident called if pain stays 7/10 or higher an hour after oxycodone 10 mg, or for any change on the neurovascular check. Rationale: she needs a safe walking pattern to go home, and pain beyond the plan needs a medical review.
Evaluated at 14:30. Oxycodone 10 mg at 07:45; at 08:45, pain 4/10 at rest, POSS 1, RR 16. At 09:30, after the cold pack: 3/10. Outcome 1 met. Acetaminophen at 06:00 and 12:00. Oxycodone 5 mg at 10:15 for pain 5/10, ahead of physiotherapy. At 11:00: moved from bed to chair with standby help and walked 8 m (26 feet) with the walker, no weight on the right leg; pain 6/10 while walking and 3/10 resting afterward. Outcome 2 partly met: 8 of 10 m, and pain 6/10, not 5/10. Neurovascular checks normal at 08:00, 10:00, 12:00, and 14:00. Outcome 3 not yet due. Decision: continue. Second physiotherapy session at 15:30, with the as-needed dose offered at 14:45; outcome 2 kept as written, with the time moved to 19:00 today.
Subjective: “My sugars have been all over the place since the fall.” Cravings for a cigarette 7/10; last cigarette the morning before surgery. Asked about a nicotine patch. Objective: two incisions, over the outer and inner ankle, under the splint and not visible. Small spot of dried drainage on the inner side of the bandage, outlined by the night nurse at 22:00 and no larger at 07:30; no odor. T 37.4 °C (99.3 °F). Capillary glucose 11.2 mmol/L (202 mg/dL) at 22:00 and 9.4 mmol/L (169 mg/dL) at 07:30. Peripheral IV in the left hand, placed yesterday: site clean, saline lock. Antibiotic given before surgery, and the post-op doses finished overnight, as ordered. Diagnosis: Risk for infection, with risk factors of two surgical incisions, type 2 diabetes with an A1c of 8.6% and glucose up to 11.2 mmol/L since surgery, current smoking, swelling at the surgical site, and a peripheral IV.
Goal: no surgical site infection while the incisions heal. Outcome 1: each shift until discharge, she will show no signs of infection: temperature below 38.0 °C (100.4 °F), no new or spreading drainage on the bandage, no odor, and no rise in incision pain. Outcome 2: from today, every capillary glucose will read 4.0 to 10.0 mmol/L (72 to 180 mg/dL). Outcome 3: by discharge, she will name 4 signs of infection to report, show how she’ll keep the splint dry, and choose a plan for smoking while the bone heals. Patient agrees: “I’ll try the patch. I don’t want this to go bad.”
Monitor: temperature every 4 hours; check the outlined drainage every 4 hours and mark any spread with the time; report a temperature of 38.0 °C or higher, new drainage through the splint, odor, or rising pain to the surgical team. Rationale: the incisions can’t be seen under the splint, so these are the earliest signs available. Monitor: capillary glucose before meals and at bedtime. Rationale: high glucose slows wound healing and weakens the body’s defense against infection. Nursing care: hand hygiene before and after every contact; splint kept clean, dry, and intact, with nothing pushed inside it; IV site checked each shift and the IV removed as soon as it is no longer needed. Rationale: hands are the main route for germs between patients, and every extra day with an IV adds risk. Ordered treatments: correction insulin per the ordered scale; nicotine patch 21 mg daily, ordered at her request. Rationale: correction insulin brings high readings back into range. Smoking narrows small blood vessels and slows wound and bone healing; the patch eases cravings, so she is less likely to smoke. Teaching: signs to report at home, which are fever, drainage or a smell from under the splint, pain that gets worse instead of better, and redness or swelling above the splint; a cast cover for showering; glucose checks twice a day until her follow-up. Rationale: she will be home before her first wound check at 2 weeks. Collaboration: diabetes educator today; referral to a quit-smoking program, with her consent. Rationale: her A1c shows her diabetes plan needs review, and quit support makes a quit attempt more likely to last.
Evaluated at 14:30. Highest temperature 37.6 °C (99.7 °F) at 12:00. Drainage spot unchanged since 22:00; no odor; incision pain not rising. IV removed at 10:00, as ordered, now that she is drinking well and on oral medicine; site clean. Outcome 1 met for this shift. Glucose 9.4 mmol/L (169 mg/dL) before breakfast and 12.4 mmol/L (223 mg/dL) before lunch; correction insulin given per the scale at 11:45. Outcome 2 not met. Reported to the medical resident at 12:00; diabetes educator booked for 15:00. Patch on at 09:00; cravings 3/10, down from 7/10. Quit-program referral sent with her consent. Teaching on infection signs started; teach-back due tomorrow. Decision: continue all three outcomes; the glucose plan to be reviewed after the educator’s visit.
Medical unit with telemetry, hospital day 2, plan written at 07:30
79-year-old man, hospital day 2 with acute decompensated heart failure. Heart failure with preserved ejection fraction, LVEF 55% on last year’s echo; atrial fibrillation on apixaban; high blood pressure; chronic kidney disease, stage 3a. No known drug allergies. Ten days of growing breathlessness and leg swelling, after a week away for a family wedding: restaurant meals most days, and he skipped his furosemide 40 mg on 4 travel days to avoid bathroom stops. Lives with his wife in a second-floor apartment with an elevator. Before this, walked 2 blocks and did his own shopping. Priority order: 1. Excessive fluid volume, because fluid in his lungs is affecting his breathing and oxygen now. 2. Decreased activity tolerance, which will ease as the fluid comes off, and decides when he can go home. His priority: “I want to sleep in a bed again, not a chair.” Covered elsewhere: the fall prevention bundle, and the skin care plan for a Braden score of 16.
Subjective: “I can’t lie down. I’ve been sleeping in my recliner for a week.” Breathless walking the 8 m to the bathroom; legs feel “tight and heavy.” Objective, 07:30: T 36.8 °C (98.2 °F), HR 94 and irregular, BP 148/82, RR 24, SpO2 91% on room air and 95% on 2 L/min by nasal cannula. Crackles in both lungs from the bases to the mid-back. Neck veins distended to the jaw with the head of the bed at 45 degrees. Pitting edema 3+ to the knees in both legs; sacral edema. Weight at 06:00 on the standing scale, after voiding: 89.0 kg (196.2 lb), down from 90.2 kg (198.9 lb) on admission. Intake 1,150 mL and output 2,350 mL in the last 24 hours. Labs at 05:00: sodium 134 mmol/L, potassium 3.6 mmol/L, creatinine 1.4 mg/dL (124 µmol/L). Chest X-ray yesterday: congestion, and small effusions on both sides. Baseline: dry weight 84.0 kg (185.2 lb) at his August heart failure clinic visit; creatinine 1.3 mg/dL (115 µmol/L). Diagnosis: Excessive fluid volume related to high sodium intake and missed diuretic doses, with heart failure as the associated condition, as evidenced by a weight 5.0 kg above his dry weight, 3+ edema, crackles to the mid-back, distended neck veins, needing to sleep upright, and SpO2 91% on room air.
Goal: back to his dry weight and breathing comfortably, with a plan to stay there at home. Outcome 1: net fluid balance at least 1 L negative each 24 hours while on IV furosemide, by intake and output totals. Outcome 2: by 06:00 on hospital day 4, weight 87.0 kg (191.8 lb) or lower on the same scale. Outcome 3: by hospital day 3, SpO2 92% or higher on room air at rest, and sleeping in bed with the head of the bed at 30 degrees or less. Outcome 4: by discharge, he and his wife will show how to weigh him and log it, and name when to call the clinic. Patient agrees: yes; outcome 3 is his own goal.
Monitor: weight at 06:00 daily on the same standing scale, after voiding, before breakfast, in a hospital gown. Rationale: 1 kg of weight change is about 1 L of fluid, the most reliable bedside measure of fluid loss. Monitor: strict intake and output, totaled each shift; lungs, breathing rate, SpO2, and edema every 4 hours; BP and dizziness on standing before each furosemide dose. Rationale: shows whether diuresis is working, and whether it has gone too far; low BP or dizziness means a call before the dose. Monitor: potassium, sodium, and creatinine each morning, as ordered; call for potassium below 3.5 mmol/L or a creatinine rise of 0.3 mg/dL (27 µmol/L) or more. Rationale: furosemide washes out potassium, and low potassium raises the risk of dangerous heart rhythms; a rising creatinine can mean the kidneys are getting too little blood flow. Nursing care: head of the bed at 45 degrees or more, or sitting in the chair; oxygen adjusted to the ordered SpO2 target; fluid limit of 1.5 L a day as ordered, split with him into 600 mL by 16:00, 600 mL by 22:00, and 300 mL overnight; mouth care, and ice chips counted in his intake, for thirst; turn every 2 hours and check heels and sacrum. Rationale: sitting up lets the lungs expand; a split he chose is easier to keep to; swollen skin breaks down easily. Ordered treatments: furosemide 40 mg IV twice daily at 08:00 and 16:00; potassium replaced per the order; 2 g sodium diet. Rationale: a loop diuretic clears sodium and water through the kidneys, and giving the second dose by 16:00 means fewer trips to the bathroom at night. Teaching: daily weights at home; reading sodium on labels and restaurant menus; taking furosemide on travel days, with a plan for bathroom stops; call the clinic for a gain of more than 1 kg (2 lb) in a day or 2 kg (5 lb) in a week. Rationale: this admission came from salty meals and skipped doses, both things he can change. Collaboration: hospitalist for diuretic doses and call limits; dietitian before discharge; pharmacist to check his medicines; heart failure clinic visit within 7 days of discharge. Rationale: the first weeks after a heart failure admission carry the highest risk of coming back.
Evaluated on hospital day 3 at 07:00. Weight 87.6 kg (193.1 lb), down 1.4 kg in 24 hours. Net balance −1,350 mL. Crackles at both bases only. Oxygen off since 22:00; SpO2 93% on room air at rest at 06:00. Slept in bed with the head of the bed at 30 degrees: “First night in a bed in over a week.” Edema 2+ to mid-shin. BP 128/74; no dizziness on standing. Potassium 3.3 mmol/L at 05:00: reported to the hospitalist at 06:15, replaced by mouth per the order, recheck at 14:00. Creatinine 1.5 mg/dL (133 µmol/L), a rise of 0.1. Outcome 1 met. Outcome 2 progressing: 0.6 kg to go by day 4. Outcome 3 met. Outcome 4 started: he weighed himself with the nurse this morning and wrote it in his log. Decision: continue. At rounds, the team kept IV furosemide for 1 more day, with a plan to switch to oral tomorrow if his weight keeps falling.
Subjective: “Walking to the bathroom feels like climbing a hill.” Breathlessness 7 on the 0 to 10 Borg scale after the walk. Objective, 09:30, walking 8 m (26 feet) to the bathroom with a walker on 2 L/min of oxygen: HR 94 to 121, SpO2 95% to 89%, RR 30; stopped twice to rest; back to resting values after 6 minutes. Baseline: walked 2 blocks and did his own shopping until these 10 days. Diagnosis: Decreased activity tolerance related to fluid in the lungs and limited heart reserve, as evidenced by breathlessness 7/10 and a heart rate rise of 27 beats on an 8 m walk, SpO2 falling to 89%, and needing to stop twice.
Goal: walking on the unit, then at home, without getting badly out of breath. Outcome 1: by hospital day 4, he will walk 30 m (98 feet) in the hallway with a walker, 3 times a day, with his heart rate no more than 20 beats above resting, SpO2 90% or higher, and breathlessness 4/10 or lower. Outcome 2: by discharge, he will use 2 ways to save energy at home, chosen with him: sitting to wash and dress, and resting for 30 minutes after meals. Patient agrees: “If I can get down to the mailbox, I’ll be happy.”
Monitor: heart rate, SpO2, breathing rate, and breathlessness before, during, and 3 minutes after each walk; stop and rest if his heart rate rises more than 20 above resting, SpO2 falls below 90%, or he has chest pain, dizziness, or new palpitations. Rationale: keeps each walk safe, and shows his tolerance improving as the fluid comes off. Nursing care: walks at 10:00, 14:00, and 18:00, starting at 10 m and adding 5 m a walk when the last one stayed within limits; care grouped so he rests for 60 minutes after meals and before each walk; washing seated at the sink, and a shower chair. Rationale: short, frequent walks build tolerance without exhausting him, and sitting lowers the oxygen his heart and lungs must supply. Teaching: pace tasks through the day, sit for grooming, and stop to rest before he gets breathless. Rationale: these habits let him do more at home with less breathlessness. Collaboration: physiotherapy assessment today for the walker and a walking plan. Rationale: confirms the right aid and a safe distance before discharge.
Evaluated on hospital day 3 at 11:00. Day 2: walked 10 m at 10:00, 15 m at 14:00, and 20 m at 18:00, on 2 L/min of oxygen, within limits each time. Day 3 at 10:00, on room air: 25 m (82 feet) with the walker; heart rate 86 to 104, a rise of 18; SpO2 91%; breathlessness 4/10; back to resting values in 3 minutes. Washed seated at the sink this morning with setup only. Outcome 1 progressing: 25 of 30 m, within all limits. Outcome 2 progressing: sits to wash; rest after meals not yet tried. Physiotherapy cleared him for hallway walks with nursing staff. Decision: continue, with the next walk at 30 m at 14:00. Discharge planning started for hospital day 4 or 5.
Who the plan is for, why they need care, and the order you’ll work through their nursing diagnoses.
Avoid: Ranking every risk below every actual problem by habit. A risk that could do harm today, such as a fall on new crutches, can come before a current problem like constipation.
The cues behind each diagnosis: what the patient told you and what you found, grouped under the diagnosis they support.
Avoid: Cues with no time. A pain score or a glucose reading means little unless the next nurse knows when it was taken and what came before it.
Your judgment of how the patient is responding to their condition, written as a statement another nurse can act on. Most programs and many units use NANDA-I labels.
Avoid: A medical diagnosis in its place. “Heart failure” is why he was admitted; “excessive fluid volume” is what your care treats and can measure.
What the patient will achieve, and how you’ll know. Write each outcome to be SMART: specific, measurable, achievable, relevant, and time-bound.
Avoid: “Pain will be controlled” or “fluid status will improve.” Neither can be marked met or not met. Write the number and the time: “weight 87.0 kg or lower by 06:00 on hospital day 4.”
What the nursing team will do to reach each outcome, and why each action works for this patient. Many forms give the rationale its own column.
Avoid: “Raise the leg: to promote comfort” explains nothing. “Raising the ankle above the heart reduces the swelling behind the throbbing” does.
Whether each outcome was reached by its time, and what happens to the plan next.
Avoid: “Goal met” with no number. Put the result beside the target: “25 of 30 m, SpO2 91%, heart rate within limits.”
A plan with eight diagnoses in no order gets skimmed, not used. Choose the two or three that drive care now, and number them in priority order with the reason.
Every intervention should answer something in the assessment data. If the plan says “monitor for bleeding” and nothing in the data points to bleeding, cut it, or add the cue that explains it.
A rationale copied from a textbook, with no link to this patient, adds length but not reasoning. Tie it to a finding: “potassium 3.6 mmol/L on IV furosemide, so it is checked each morning.”
Without a date and time, no one knows when to evaluate it, and it stays open for the whole stay. Set short outcomes for the shift and longer ones for discharge.
Revise the plan when the patient changes. If an outcome was met or the cues have moved, update it before the next shift works from yesterday’s version.
Vero Scribe writes the care plan in your template from your dictation, or from your conversation with the patient, with their consent. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Follow the nursing process. Gather your assessment data, then choose two or three nursing diagnoses and number them in priority order. For each one, write outcomes the patient will reach, with a measure and a time, and list the interventions, each with a rationale tied to this patient. At the time you set, evaluate each outcome and decide to continue, revise, or resolve. On a form, these are the columns of one row: assessment data, nursing diagnosis, goals and outcomes, interventions, rationale, and evaluation.
Most programs use a three-part statement: the problem as a NANDA-I label, “related to” its cause, and “as evidenced by” the signs and symptoms you found. For example: “Acute pain related to bone and tissue injury from surgery, as evidenced by pain 8/10 at rest and guarding the leg.” A risk diagnosis has no signs yet, so it names the risk factors instead: “Risk for infection, with risk factors of two surgical incisions and high blood glucose.”
An outcome that is specific, measurable, achievable, relevant, and time-bound, with the patient as the subject. “Improve activity tolerance” is none of those. “He will walk 30 m with a walker 3 times a day, with SpO2 90% or higher and his heart rate no more than 20 beats above resting, by hospital day 4” is all of them, and the next nurse knows exactly what to check.
The care plan looks ahead: it sets the diagnoses, outcomes, and interventions, and is revised when the patient changes. PIE and DAR notes look back over a shift: they record the care given and how the patient responded. A DAR entry can name the care plan problem it relates to. PIE charting goes further and carries the plan’s numbered problems in the notes themselves.
Yes. Copy it, or download it as a Word or text file. No account needed.
System-by-system nursing assessment with pressure injury and fall risk, lines and drains, and escalation.
The shift note: assessment, timed vital signs and interventions, the response, provider calls, teaching, and the plan for the next shift.
The bedside handoff in I-PASS order: severity, systems, lines, meds due, pending labs, risks, to-dos, and read-back.
Focus charting in four parts: the focus, the data behind it, nursing actions, and the timed patient response.
Problem, Intervention, Evaluation: numbered nursing problems carried from shift to shift, with the assessment on a flow sheet.
The longer guide: from assessment evidence to priorities, weighing competing needs, revising a partly met goal, and a review checklist.
Nursing notes, DAR entries, SBAR handoffs, and teaching records, drafted for your review.
Nursing note examples in several formats, side by side.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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