A nursing care plan is a written plan that sets out a patient's problems, the outcomes you want to reach, the nursing actions that will get there, and why each action works. At university, writing one tests whether you can turn assessment data into safe, logical, evidence-based care. This guide walks through the five stages, shows how to write each part, and works through a COPD example step by step.
Your university will have its own template, and it always takes priority. Some courses use a three-part diagnosis statement, some ask for NIC and NOC labels, and some want a column for rationales with references. The method below works for all of them.
What is a nursing care plan for?
In practice, a care plan makes sure every nurse caring for a patient is working to the same goals. In an assignment, it shows your marker that you can:
collect and sort assessment data into what matters most
identify nursing problems, which are different from the medical diagnosis
set goals that are specific and measurable
choose interventions you can justify with evidence
say how you will know whether the plan worked
That last point is where many student plans fall short. A plan without evaluation is a list of tasks, not a plan.
The five stages: ADPIE
Most care plans follow the nursing process, often remembered as ADPIE:
Assessment: gather subjective data (what the patient tells you) and objective data (what you observe and measure).
Diagnosis: identify the nursing problems the data points to.
Planning: set goals and expected outcomes for each problem.
Implementation: choose the nursing interventions, with a rationale for each.
Evaluation: decide how you will check each goal and what you will do if it isn't met.
Some UK courses use other frameworks alongside this, such as the Roper-Logan-Tierney model of activities of living. If your module names one, organise your assessment under its headings.
Step 1: Assessment
Start by listing the data from the case study under two headings. Subjective data is what the patient or family reports, such as "I can't catch my breath when I walk to the bathroom." Objective data is measurable: vital signs, oxygen saturation, breath sounds, test results, and what you see.
Then cluster the data. Group the findings that point to the same problem. Wheezing, a weak cough and thick sputum belong together. Low oxygen saturation and a raised carbon dioxide level belong together. These clusters become your nursing diagnoses.
Only use the data you are given. Markers notice when a plan relies on symptoms the case never mentions.
Step 2: Nursing diagnosis
A nursing diagnosis describes a problem nurses can act on. It is not the medical diagnosis. "COPD" is a medical diagnosis. "Ineffective airway clearance" is a nursing diagnosis, because there are nursing actions that address it.
Many courses ask you to use the standard labels from NANDA International (NANDA-I). You select a label from your textbook's list rather than inventing one. You then write it as a three-part statement, often called the PES format:
Problem: the NANDA-I label, e.g. Ineffective airway clearance
Etiology (related to): the cause, e.g. related to bronchospasm and thick secretions
Signs and symptoms (as evidenced by): your assessment data, e.g. as evidenced by wheezing and an ineffective cough
For a risk diagnosis, such as Risk for falls, there are no signs yet, so you write the problem and the risk factors instead.
Put your diagnoses in priority order. A common approach is ABC (airway, breathing, circulation) first, then safety, then other needs. Most assignments ask for two or three priority diagnoses, not every possible one.
Step 3: Goals and expected outcomes
Each diagnosis needs at least one goal, written from the patient's point of view and made SMART: specific, measurable, achievable, relevant and time-bound.
Weak: "The patient's breathing will improve."
Better: "The patient will cough up secretions effectively and have clear or improved breath sounds within 48 hours."
The test is simple. Could another nurse read the goal and say, at the stated time, whether it was met? If not, make it more specific.
Step 4: Interventions and rationales
Interventions are the nursing actions that move the patient towards the goal. Each one needs a rationale: a short explanation of why it works, ideally supported by a reference.
Start each intervention with an action verb: assess, monitor, position, teach, encourage, administer.
Include assessment, treatment and teaching actions, not only treatment.
For medicines and oxygen, write "as prescribed". Nurses give medicines that are prescribed, they don't choose them.
Make the rationale specific. "To improve breathing" is weak. "Sitting upright lowers the diaphragm and allows fuller lung expansion" is a rationale.
Support rationales with current sources such as nursing textbooks, journal articles and national guidance. In the UK, that might be NICE guidance. For COPD, see NICE guideline NG115. Many nursing courses use Vancouver or Harvard referencing. Our free Vancouver referencing generator formats references from a DOI or a few details, but check the result against your university's guide.
Step 5: Evaluation
For each goal, say how you will measure it, when, and what you will do if it isn't met. For example: "Goal partly met at 48 hours: breath sounds improved but sputum remains thick. Continue the plan, review fluid intake, and discuss with the physiotherapy team."
Evaluation shows that care is a cycle. If a goal isn't met, you reassess and change the plan.
Worked example: a patient with a COPD flare-up
Here is how the steps fit together for a short case: a 68-year-old man with COPD is admitted with breathlessness, a productive cough with thick sputum, wheezing and an oxygen saturation of 86% on room air.
Priority diagnosis 1
Ineffective airway clearance related to bronchospasm and thick secretions, as evidenced by wheezing, an ineffective cough and thick sputum.
Goal: The patient will clear secretions effectively and show improved breath sounds within 48 hours.
Intervention | Rationale |
|---|---|
Assess breath sounds, respiratory rate and sputum (amount, colour, thickness) every 4 hours, or more often if he deteriorates. | Gives a baseline and shows early whether the plan is working. |
Position him upright or leaning forward, supported with pillows. | An upright position helps the lungs expand and makes coughing more effective. |
Teach and encourage huff coughing and controlled breathing. | Huff coughing moves secretions with less effort and less airway collapse than a forceful cough. |
Give bronchodilators as prescribed and monitor his response. | Bronchodilators relax airway smooth muscle and reduce bronchospasm. |
Encourage fluids unless they are restricted. | Good hydration helps keep secretions thinner and easier to clear. |
Priority diagnosis 2
Impaired gas exchange related to air trapping and changes to the alveoli, as evidenced by low oxygen saturation and breathlessness.
Goal: the patient will keep his oxygen saturation within the target range set by the medical team.
A point students often miss: people with COPD who are at risk of retaining carbon dioxide are often given a lower target saturation, commonly 88–92% in UK guidance, instead of the usual 94–98%. Giving too much oxygen can be harmful for these patients. Always use the target range prescribed for the patient, and explain why it is lower in your rationale.
For the full version, with assessment data, NIC/NOC labels and a complete intervention table, see our COPD nursing care plan sample.
Common mistakes that lose marks
Using the medical diagnosis as the nursing diagnosis. "COPD" can't be a nursing diagnosis.
Goals that can't be measured. "Will feel better" can't be evaluated.
Interventions without rationales, or rationales that just repeat the intervention.
Writing interventions for doctors. "Prescribe antibiotics" is not a nursing action. "Give antibiotics as prescribed" is.
Too many diagnoses. Two or three well-developed priority diagnoses beat eight shallow ones.
No evaluation, or an evaluation that doesn't link back to the goals.
Old or weak sources. Use current guidance and textbooks, and reference them consistently.
Checklist before you submit
Assessment data is sorted into subjective and objective, and only uses the case details.
Each diagnosis uses a NANDA-I label and the "related to… as evidenced by…" format.
Diagnoses are in priority order.
Every goal is SMART and written about the patient.
Every intervention has a specific rationale, with references where your course requires them.
Medicines and oxygen are "as prescribed".
Each goal has an evaluation.
You have used your university's template and referencing style.
Reflective writing often goes with care plans in nursing courses. To write clearly and reference correctly, see our academic writing tips and our guide to avoiding plagiarism.
Getting help with a care plan
If you want to see how an experienced nurse would approach your case study, our nursing experts can write an original model care plan you can learn from. Explore nursing assignment help, or assignment help in other subjects. Use the model to understand the reasoning, then write your own plan in line with your university's academic integrity rules.
This guide is for study purposes. In clinical practice, always follow your placement's policies, the patient's prescriptions and your mentor's direction.