Nursing care
Nursing care plan template: columns, a filled example and common mistakes
Written and reviewed by Nicole Ramirez, BSN, RN, CMSRN · 5 min read · Updated November 2026
Short answer
A nursing care plan template has six columns: assessment data, nursing diagnosis, goal or expected outcome, nursing interventions, rationale, and evaluation. Each row follows one priority problem from the cues you collected to whether the outcome was met. Below is the blank layout, a filled example for a hypothetical client with pneumonia, and the mistakes that cost students points.
The template: six columns and what goes in each
Copy the table below into a document or spreadsheet and give each nursing problem its own row. The columns follow the nursing process: assess, name the problem, set an outcome, plan and carry out interventions, then evaluate. Open RN's Nursing Fundamentals text treats outcome identification as a separate step, which is why goals sit in their own column.
| Column | What to write | Quick check |
|---|---|---|
| Assessment data | Subjective cues in the client's own words plus objective findings such as vital signs, exam findings and lab results | Could another nurse observe or measure each objective cue? |
| Nursing diagnosis | Problem, related factor, and the cues that show it; a risk diagnosis lists risk factors instead of signs | Is it a nursing problem rather than a medical diagnosis? |
| Goal or expected outcome | One measurable client behavior or finding with a deadline | Specific, measurable, one action verb, realistic, time-limited |
| Nursing interventions | Actions the nurse performs, teaches or monitors, with frequency | Does each action target the related factor? |
| Rationale | Why the action works, tied to physiology or evidence | Does it explain, rather than repeat, the intervention? |
| Evaluation | Met, partially met or not met, the data that proves it, and what changes next | Does it use the same measure as the outcome? |
Most programs ask for three to five problems ranked by priority. Airway, breathing and circulation problems usually come first, then safety, then comfort and knowledge gaps, unless your rubric says otherwise. Diagnosis labels come from the NANDA-I taxonomy; describe them in your own words rather than copying the published definitions.
Filled example for a hypothetical client with pneumonia
Practice client, not a real case: a 72-year-old woman admitted with community-acquired pneumonia says, 'I can't catch my breath when I walk to the bathroom.' Respirations are 26 per minute, oxygen saturation is 89 percent on room air, crackles are heard in the right lower lobe, and she has a weak cough with thick yellow sputum.
| Nursing diagnosis | Outcome | Interventions | Rationale | Evaluation |
|---|---|---|---|---|
| Impaired gas exchange related to fluid in the alveoli as evidenced by SpO2 89 percent on room air, respirations 26 and dyspnea on exertion | SpO2 at or above the prescribed target and respirations 20 or below at rest within 24 hours | Assess rate, effort and SpO2 every 2 hours and with activity; raise the head of the bed; apply oxygen as prescribed; cluster care to allow rest | Upright position lets the diaphragm descend; trended values catch early decline; rest lowers oxygen demand | Partially met: SpO2 92 percent on oxygen, respirations 22; continue and reassess before weaning |
| Ineffective airway clearance related to thick secretions as evidenced by weak cough and right lower lobe crackles | Coughs up secretions without suctioning and crackles decrease by end of shift | Coach deep breathing and huff coughing every 2 hours while awake; encourage oral fluids unless restricted; help her sit up or walk as tolerated | Deep breaths move air behind mucus; fluids thin secretions; movement shifts secretions from dependent lung areas | Met: clears sputum with coaching; fewer crackles on reassessment |
| Activity intolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea walking to the bathroom | Walks to the bathroom with SpO2 at target and no rest stops within 48 hours | Plan rest between activities; check SpO2 before, during and after walking; offer a bedside commode until tolerance improves | Pacing limits oxygen debt; measured response shows when to advance activity | Not yet due; evaluate at 48 hours |
The first two rows share data but name different problems: one is oxygen crossing the alveolar wall, the other is mucus blocking the airway. That split keeps each rationale specific. Oxygen appears as an intervention because applying and titrating it per the order is nursing work; the prescription itself belongs to the provider.
How to write a nursing care plan step by step
Start with cues, not with the medical diagnosis. List what the client said and what you measured, then group cues that point the same way. Open RN separates subjective data, recorded in the client's words, from objective data that others can observe and reproduce, and that split maps onto your first column.
Next, write the problem as a statement with three parts: the problem, related to a cause nursing can act on, as evidenced by the cues. Then write one outcome per statement with a measurable verb and a deadline; Open RN's model is clear bilateral lung sounds within 24 hours. Choose interventions that hit the related factor, give each a rationale, and evaluate against the exact measure you set.
Mistakes instructors mark down
The most common error is a medical diagnosis in the diagnosis column. Pneumonia or heart failure does not tell a nurse what to do, and Open RN notes that a medical condition can inform a nursing diagnosis but cannot be one. A close second is a related factor that is itself a disease, such as related to pneumonia, which leaves nothing for nursing to change.
Vague outcomes come next: breathing will improve, or vital signs will be normal, cannot be judged met or not met. Also watch for two actions in one outcome, interventions that are only provider orders, rationales that restate the action, and an evaluation that says goal met with no data. A partially met outcome with no change to the plan misses the purpose of evaluation, which is revision.
Sources and further reading
Open RN Nursing Fundamentals: Diagnosis. Problem, related factors and defining characteristics format; risk diagnosis format; medical diagnoses cannot be nursing diagnoses.
Open RN Nursing Fundamentals: Outcome Identification. Outcome identification as a separate step, SMART outcome criteria, one action per statement, example outcome on lung sounds within 24 hours.
Open RN Nursing Fundamentals: Evaluation. Outcomes judged met, partially met or not met, and revision of the plan when outcomes are not met.
Open RN Nursing Fundamentals: Assessment. Subjective data recorded in the client's words versus objective data others can observe and reproduce.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our fundamentals practice questions are the closest set to what this page covers.
Common questions
What are the 5 parts of a nursing care plan?
Assessment, diagnosis, planning (goals and outcomes), implementation (interventions with rationales) and evaluation, which match the ADPIE steps of the nursing process. Some textbooks, including Open RN, list outcome identification as its own step, giving six; the template columns stay the same either way.
What is an example of a nursing care plan?
A short one: ineffective airway clearance related to thick secretions as evidenced by a weak cough and crackles. Outcome: coughs up secretions without suctioning by end of shift. Interventions: coach huff coughing, encourage fluids unless restricted, get the client upright. Evaluation: met, partially met or not met, with the findings that show it.
How many nursing diagnoses should a student care plan include?
Student plans commonly include three to five, ranked by priority, but your program's rubric sets the number. A short list where every cue, outcome and evaluation lines up scores better than a long list of loosely supported labels.
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