Nursing Care Plan Examples
🎓 Educational study aid — NOT medical advice. Use fictional/initials data only.
A worked nursing care plan example shows all five components filled in for one realistic scenario: the assessment data that was gathered, the nursing diagnosis it points to, a measurable goal, the interventions taken with their rationale, and how the outcome was evaluated. Seeing the columns filled in side by side makes it much easier to write your own than reading a definition alone.
Below are three short worked examples for common student scenarios: acute pain after surgery, risk for infection, and activity intolerance. Each one is a simplified, own-words version of a standard teaching scenario — not a real patient record. After the tables, there's guidance on adapting any example to the patient actually in front of you. For the underlying definitions of each column, see what a nursing care plan is and how to write one step by step.
Example 1: Acute pain, post-operative
A patient one day after abdominal surgery who is guarding the incision and rating pain 7 out of 10.
| Assessment | Nursing diagnosis | Goal (SMART) | Interventions + rationale | Evaluation |
|---|---|---|---|---|
| Pain 7/10 on 0–10 scale; guarding incision; grimacing and shallow breathing with movement; BP 138/88, HR 96 (both mildly elevated) | Acute pain related to surgical tissue trauma as evidenced by patient-reported pain of 7/10, guarding, and grimacing with movement | Patient will report pain at 4/10 or lower within 1 hour of intervention, and will ambulate to the bathroom with tolerable pain by end of shift | Administer prescribed analgesic before activity (rationale: peak effect covers movement, reducing guarding); reposition and splint incision during coughing/turning (rationale: reduces tension on the incision line); reassess pain 30–60 min after medication (rationale: confirms effectiveness and timing for next dose) | At 1 hour, patient reports pain 3/10 and ambulates to bathroom with steady gait — goal met |
Example 2: Risk for infection, surgical wound
The same post-op patient has an incision but no signs of infection yet — this is a risk diagnosis, so there's no "evidenced by" line because the problem hasn't happened.
| Assessment | Nursing diagnosis | Goal (SMART) | Interventions + rationale | Evaluation |
|---|---|---|---|---|
| Surgical incision, postoperative day 1; dressing dry and intact; no redness, warmth, or drainage noted; WBC 9.8 (within normal range); temperature 98.9°F | Risk for infection related to a break in skin integrity from surgical incision | Incision will remain free of redness, swelling, purulent drainage, and fever through discharge | Assess incision each shift for redness, warmth, swelling, or drainage (rationale: early detection allows prompt treatment); maintain sterile technique during dressing changes (rationale: limits introduction of new organisms); monitor temperature and WBC trend (rationale: systemic signs often appear before local ones worsen); teach hand hygiene before touching the dressing (rationale: reduces contamination from patient or visitors) | Day 3: incision clean, dry, intact; no redness or drainage; temperature 98.6°F — goal met, continue monitoring |
Example 3: Activity intolerance, cardiac patient
A patient recovering from a cardiac event who becomes short of breath and fatigued with minimal exertion.
| Assessment | Nursing diagnosis | Goal (SMART) | Interventions + rationale | Evaluation |
|---|---|---|---|---|
| Reports fatigue and shortness of breath after walking to the bathroom (~20 feet); HR rises from 78 to 118 with exertion; SpO2 drops from 97% to 91%; patient states "I have to stop and catch my breath" | Activity intolerance related to imbalance between oxygen supply and demand as evidenced by exertional dyspnea, tachycardia, and desaturation with minimal activity | Patient will ambulate 50 feet with HR remaining below 100 and SpO2 at or above 94% within 3 days | Monitor HR, SpO2, and exertion level before/during/after activity (rationale: identifies the safe activity threshold and catches decompensation early); schedule activity in short sessions with rest periods (rationale: prevents cumulative oxygen debt); teach pacing and controlled breathing techniques (rationale: gives the patient a tool to manage exertion independently); collaborate with cardiac rehab for a graded activity plan (rationale: builds tolerance safely over time) | Day 3: patient ambulates 50 feet, HR peaks at 94, SpO2 stays at 95% — goal met, advancing distance goal |
How to adapt an example to your own patient
These three examples are teaching scaffolds, not patients. Turning one into a real, individualized care plan means changing every column, not just the numbers:
- Assessment — replace the sample vitals and quotes with your patient's actual documented findings. If your patient's pain is 5/10 with different triggers, use that, even though it changes everything downstream.
- Nursing diagnosis — check that the "related to" cause and "as evidenced by" signs still match your patient's specific data. A diagnosis copied from an example but paired with different assessment findings won't hold together under questioning.
- Goal — adjust the timeframe and target number to your patient's realistic condition and length of stay. A frail 82-year-old and a fit 40-year-old shouldn't get the same ambulation target in the same timeframe.
- Interventions — keep interventions that still apply, drop ones that don't fit (e.g., cardiac rehab referral only applies if that patient has cardiac involvement), and add anything specific to your patient's comorbidities, allergies, or care setting.
- Evaluation — write this last, after care is actually given, comparing the real outcome to the goal you set — not a copied "goal met" line.
For the full walkthrough of writing each column from scratch, including how to phrase a diagnosis correctly, see how to write a nursing care plan. For how these five components fit into the broader clinical cycle, see the nursing process (ADPIE).
Skip the blank template → the free Care Plan Builder assembles all five components into a formatted, exportable plan for any condition, so you start editing instead of starting from nothing.
Note on terminology: these examples are written in plain, own-words PES format (problem related to cause as evidenced by signs) to make the reasoning clear. They are not reproductions of any official diagnosis taxonomy or code list — check your program's approved reference for exact required wording. Browse more filled-in scenarios by condition in the care plan examples library.
Educational content for nursing students — not medical advice.
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Build a care plan freeNursing care plan examples: FAQ
Can I copy one of these care plan examples for my clinical paperwork?
Copy the structure and reasoning, not the exact wording. Instructors expect your assessment data, diagnosis, and goal timeframe to match your actual patient. Use these examples as a template for how the pieces fit together, then swap in your patient's real (or fictionalized/initials-only) findings.
How many nursing diagnoses should one care plan example include?
Most student care plans focus on one to three priority diagnoses at a time, ranked by urgency. Trying to cover every possible problem a patient has dilutes the plan and makes it harder to show deep reasoning on the ones that matter most.
What makes a care plan example "individualized" instead of generic?
Specific numbers and patient wording. "Pain 7/10, guarding incision, grimacing with movement" is individualized; "patient has pain" is generic. The same rule applies to goals — a time-bound, measurable target beats a vague one like "patient will feel better."
Do these examples use real NANDA-I diagnosis codes?
No. These examples are written in plain PES-format wording (problem related to cause as evidenced by signs) so you can see the reasoning clearly. Your program's official diagnosis list may use specific NANDA-I terminology and codes — check your course materials or care-planning reference for the exact approved wording.
What is the fastest way to build a care plan from an example like this?
Start from the closest matching scenario, then replace every assessment detail with your patient's actual data before touching the diagnosis or goal. The free Care Plan Builder does this assembly for you — pick a condition and it structures all five components so you're editing instead of starting from a blank page.
For nursing education only — NOT medical advice and not a clinical decision-making tool. Nothing here should be used to assess, diagnose, or treat any real patient. Care plans and answers are unverified study drafts to review with your instructor or a licensed clinician and adapt to the individual patient and your institution’s protocols before any use.