Clinical template
Nursing Care Plan Template with Examples
A nursing care plan turns an assessment into named problems, measurable goals, interventions, and an evaluation. Use the blank below, then three fictional Canadian plans: post-operative ileus risk after bowel surgery, acute heart-failure fluid overload, and fall risk on a medical unit.
Blank nursing care plan template
Copy this into the Kardex, the EMR care-plan module, or a Scribeberry custom template. Canadian schools still teach the nursing process (assess, diagnose, plan, implement, evaluate). Use PES (problem, etiology, signs) if your program requires a nursing diagnosis label.
Nursing care plan
Date initiated / review date: Patient: [initials, age] | Unit / service: | Nurse / team: Medical diagnoses (context only): Priority problem 1 (PES): [problem] related to [etiology] as evidenced by [signs/symptoms] Goal (SMART, timed, patient-agreeable): Expected outcomes (observable): Interventions (who, how often, independent vs collaborative): Rationale (short, optional on the unit copy): Evaluation (date/time, met / partially met / not met, next action): Priority problem 2: Goal: Interventions: Evaluation: Priority problem 3 (safety / teaching / discharge): Goal: Interventions: Evaluation: Patient / family teaching recorded: Discharge barriers:
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for college standards, unit protocols, or your own clinical judgment. Review every generated plan before it becomes the team's working document.
What a care plan is for
The shift note is what happened today. The care plan is what the team is aiming at for the next 24–72 hours, or until discharge. If every nurse rewrites the problems from scratch, teaching is missed and the same IV site infection risk is 'discovered' each morning. Keep three priorities, not twelve. Pain, airway, and safety beat a theoretical nursing diagnosis nobody on nights will open.
| Piece | What belongs here | What does not |
|---|---|---|
| Problem (PES) | A nursing problem you can act on, with evidence from this patient | A restatement of the medical diagnosis alone ('has pneumonia') |
| Goal | A timed, measurable target the patient could recognize | 'Patient will feel better' with no number and no date |
| Interventions | Who does what, how often, independent vs needs an order | Copied textbook lists that this unit cannot staff |
| Evaluation | Dated judgment: met, partial, not met, and the change to the plan | Leaving the goal untouched for four days after it failed |
CNO, BCCNM, CRNA, and other Canadian nursing regulators expect a plan of care that is individualized, current, and evaluated. Students are often marked on NANDA-I language. Practising units often use problem lists in the EMR ('impaired gas exchange,' 'fall risk,' 'knowledge deficit insulin'). Either is fine if the evidence and the interventions are real.
How to write goals and interventions
Goals are SMART enough that nights can evaluate them at 05:00. 'Pain ≤4/10 at rest by 20:00 on POD 1, able to sit at the bedside' can be checked. Interventions name frequency: incentive spirometer q1h while awake, daily weight before breakfast, toilet schedule q2h from 07:00–22:00. Collaborative interventions need the order (furosemide, PCA, bed alarm) and the nursing piece (when you hold the diuretic, who you call).
Evaluation is a new note, not a checkbox from admission. If the patient still desaturates walking to the bathroom, the goal is not met and the plan changes: portable O2, rest breaks, or a hold on discharge. Involve the patient in the goal when they can speak. 'I want to get to the chair for supper' is a better goal than a textbook oxygenation percentage they have never heard.
Example 1 — post-op bowel resection
Inpatient surgical, POD 0–2
58-year-old man, laparoscopic right hemicolectomy, Kingston. Fictional.
Initiated: 14 Apr 2026 18:00 Review: each shift Nurse: K. MacLeod RN Context: POD 0 laparoscopic right hemicolectomy for adenocarcinoma. Epidural in situ. NPO, NG to gravity. Problem 1: Acute pain related to surgical incision and visceral inflammation as evidenced by pain 8/10 on arrival to unit, splinting, HR 102. Goal: Pain ≤4/10 at rest and ≤6/10 on transfer by 08:00 POD 1, able to sit at edge of bed. Interventions: - Assess pain q1h x 4 h then q4h and PRN using 0–10 scale; watch epidural dermatome and motor. - Maintain epidural per APS protocol; call APS for dense motor block or pain >6 despite bolus. - Splint abdomen with pillow for cough; ice to port sites 20 min q4h while awake. - Reposition q2h; avoid sitting fully upright until epidural motor ok. Evaluation 15 Apr 07:30: Pain 3/10 rest, 5/10 on sit. Goal met. Continue. First stand with PT at 10:00. Problem 2: Risk of paralytic ileus / pulmonary complication related to anaesthesia and abdominal surgery as evidenced by absent bowel sounds, NPO, shallow breaths 12/min. Goal: Incentive spirometer 1000 mL x 10 q1h while awake by POD 1; flatus or bowel sounds by POD 2; SpO2 ≥94% RA. Interventions: - IS teaching on admission to unit; document volumes. - Head of bed 30°; early sit POD 1. - NG output q4h; do not clamp without order; oral swabs. - Ambulate to chair POD 1 with PT; notify MRP if no flatus by 16 Apr 18:00 or vomiting. Evaluation 16 Apr 16:00: IS 1200 mL. Bowel sounds present, flatus 14:00. NG discontinued per order. Partial then met. Advance diet as ordered. Problem 3: Knowledge deficit, discharge ostomy not applicable (anastomosis). Teaching: wound, VTE, when to call. Goal: Patient and partner demonstrate wound support and state 3 return precautions by discharge. Interventions: Teaching POD 1–2; written sheet; VTE injections return-demo. Evaluation: pending discharge 18 Apr.
Example 2 — acute heart failure
Inpatient medicine, day 1–3
79-year-old woman, decompensated HFpEF, Edmonton. Fictional.
Initiated: 2 Nov 2026 10:00 Review: daily with MRP Nurse: A. Begum RN Context: HFpEF, AF rate-controlled, CKD G3a. Admitted with 4 kg gain, orthopnea, O2 90% RA. Problem 1: Excess fluid volume related to heart-failure exacerbation as evidenced by 4 kg gain, 2+ pretibial edema, crackles to scapulae, NT-proBNP elevated on admission labs. Goal: Weight down ≥1.5 kg by 08:00 day 3, sitting out of bed for meals, SpO2 ≥94% on ≤2 L NP. Interventions: - Daily weight before breakfast, same scale, chart vs admission 82.4 kg. - Strict I&O; fluid restriction 1.5 L as ordered; teach the pitcher system. - Furosemide IV per order; hold and call if SBP <95 or Cr rise per MRP parameters. - High-Fowler; O2 to keep SpO2 ≥94%; lung sounds q4h. - Skin: legs up on pillow, waffle mattress, heel-offload. Evaluation 4 Nov 08:00: Weight 80.1 kg (−2.3). SpO2 95% 1 L. Edema 1+. Goal met. Convert to PO diuretic today. Problem 2: Impaired gas exchange related to pulmonary edema as evidenced by SpO2 90% RA, RR 26, orthopnea. Goal: RR ≤20 and SpO2 ≥94% on RA or 1 L by day 2, able to lie on two pillows. Interventions: Titrate O2, sit upright for 1 h after diuretic, watch for over-diuresis (dizziness, Cr). Evaluation 3 Nov 20:00: RR 18, SpO2 94% 1 L, sleeps on two pillows. Partial. Wean O2 in a.m. Problem 3: Knowledge deficit, self-weighing and salt. Goal: Before discharge, patient states dry weight, 3 red-flag symptoms, and which foods she will drop (canned soup, deli meat). Interventions: Teach-back with daughter on day 2; dietitian referral; written HF sheet (Heart & Stroke). Evaluation: daughter present 4 Nov; teach-back complete. Follow-up clinic booked.
Example 3 — fall risk, medical unit
Inpatient medicine, night of admission
83-year-old man, community-acquired pneumonia, post-fall at home, Moncton. Fictional.
Initiated: 9 Jan 2026 22:30 Review: each shift Nurse: J. LeBlanc RN Context: CAP, confusion on admission (CAM positive, likely delirium), MORSE high, fell at home last night, no fracture on x-ray. Problem 1: Risk for falls related to delirium, IV pole, nocturia, and pneumonia as evidenced by MORSE 75, unsteady gait, attempt to climb rails at 22:10. Goal: No unassisted bed exit this admission; 0 falls. Patient remains in bed or chair with supervision for toileting through night 1. Interventions: - Bed alarm on; lowest bed; non-slip socks; call bell in reach (he does not use it reliably — do not rely on it). - Toileting round 23:00, 01:00, 03:00, 05:00; urinal at bedside. - 1-person assist; second person if IV pole + O2. - Night light; glasses on; hearing aid in by day. - Avoid benzodiazepines; treat pain and fever that drive climbing. - Sitters if climbing persists after toileting and reorientation — charge RN to call. Evaluation 10 Jan 07:00: 0 falls. Climbed rails x1 at 01:20; toileted, reoriented, alarm reset. Goal met for night 1. Continue. PT in a.m. for gait. Problem 2: Acute confusion related to infection and unfamiliar environment as evidenced by CAM+, calling for his late wife, picking at IV. Goal: CAM negative or improved by day 3; IV intact; oriented to hospital by name of nurse at each encounter. Interventions: Orient each care; family photo; lights day/night; glasses; no extra lines; treat pneumonia; Foley not indicated (voiding). Evaluation 11 Jan: CAM negative in daytime, sundowning milder. Partial. Keep toileting schedule. Problem 3: Ineffective airway clearance related to weak cough as evidenced by coarse crackles, sputum retained. Goal: SpO2 ≥92% on ordered O2, sputum mobile, no new fever spike after day 2. Interventions: Sit for meals, IS or deep-breathe q2h while awake, oral care, physio. Evaluation: pending.
Mistakes that show up in care plans
- Copying a textbook NANDA list that does not match this patient.
- Goals with no time and no number.
- Interventions the unit cannot staff ('continuous 1:1' when no sitter exists and nobody called).
- Never evaluating; the same 'acute pain' plan from admission still open on discharge day.
- Writing medical orders in the nursing plan (starting antibiotics) instead of the nursing actions and the call parameters.
- Ignoring the patient's stated goal in favour of a school-perfect oxygenation phrase.
- Leaving fall-risk interventions on paper while the bed alarm is off.
College documentation standards treat the plan of care as part of the record, not a student worksheet. If a fall, pressure injury, or missed teaching becomes a complaint, the plan and the evaluation are what was supposed to happen. CMPA hospital files follow the same logic: the working document has to match the shift notes. Update it when the problem changes.
Care plan vs shift note
The care plan sets the targets. The DAR or narrative proves the work. If the plan says q2h toileting and the notes never mention a round, the plan is fiction. Keep them aligned, including when you discontinue a problem.
Draft the care plan from the assessment
Scribeberry takes dictation or the admission audio and drafts PES problems, SMART goals, and interventions in your template. Edit to what this unit can actually do, then Smart Push. Pro is $99/month after the free trial.
Frequently asked questions
What is a nursing care plan?
A care plan names priority nursing problems, timed goals, interventions, and evaluations. It sits above the shift note so every nurse on the service is working toward the same targets until those problems resolve or the patient is discharged.
Do I have to use NANDA diagnoses?
Schools often require NANDA-I or PES format. Practising Canadian units may use EMR problem lists in plain language. Follow the unit and your college. The evidence and the interventions matter more than the taxonomy.
How many problems should a care plan have?
Three priorities that this shift can act on is more useful than twelve copied diagnoses. Pain, airway/breathing, fluid, safety, and discharge teaching cover most medical-surgical stays.
Can Scribeberry write nursing care plans?
Yes. Use a care-plan template, generate from the admission or shift assessment, then edit goals and interventions to match staffing and orders before the team uses the plan.
Templates
