NURSING 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]