Nursing Care Plan Examples with NANDA-I Format (2026)

Writing care plans is part of every nursing program’s curriculum, and the pressure to get them right — especially during clinical rotations and before the NCLEX — is real. The difference between a passing care plan and a failing one usually comes down to one thing: how precisely you write your nursing diagnosis using PES format.

This guide gives you everything you need — five complete, fully worked NANDA-I care plan examples, a quick-reference table of common diagnoses organized by Gordon’s Functional Health Patterns, a side-by-side guide to writing correct PES diagnoses, and a downloadable template you can use immediately.

• A nursing care plan follows the ADPIE framework (Assessment, Diagnosis, Planning, Implementation, Evaluation) and maps directly onto the NextGen NCLEX’s Clinical Judgment Measurement Model (CJMM).
• Every nursing diagnosis should be written in PES format (Problem, Etiology, Signs/Symptoms) using the NANDA-I 13th Edition classification.
• “Risk for” diagnoses use risk factors instead of “as evidenced by” — this is one of the most common student mistakes.
• 3-column formats are for clinical documentation; 4-column formats are for academic assignments; 5-column formats add evaluation criteria.
• Use a downloadable PDF template to stay organized during clinical rotations and assignments.

We’ve distilled the best elements from ChartFlow, PatientNotes, Osmosis, and Nurseslabs into one resource that actually saves you time instead of making you sift through fragmented pages.

What Is a Nursing Care Plan?

A nursing care plan is a structured document that outlines a patient’s health problems, the nursing diagnoses, expected outcomes, planned interventions, and the evaluation criteria. It’s the roadmap nurses use to guide patient care from admission through discharge.

But here’s the practical truth: in nursing school, care plans aren’t just about patient care. They’re graded assignments that test whether you can think like a nurse — not just follow a doctor’s orders. Your instructor wants to see that you can take assessment data, cluster cues, and translate them into a nursing diagnosis with specific, measurable outcomes.

The framework every nursing program uses is called ADPIE — the five steps of the nursing process:

If you want to learn the process step-by-step before diving into examples, check our How to Write a Nursing Care Plan Step-by-Step Guide.

How to Use the ADPIE Framework in Care Plans

Here’s where most students don’t realize the bigger picture: ADPIE isn’t just a textbook framework — it’s how the NextGen NCLEX tests clinical judgment.

The NCSBN’s Clinical Judgment Measurement Model (CJMM), which is the foundation of the NextGen NCLEX starting in 2024, maps directly onto the ADPIE steps:

Why this matters for your NCLEX prep: The NextGen NCLEX doesn’t ask you to list ADPIE steps. It gives you patient scenarios and asks you to recognize cues, prioritize decisions, and evaluate outcomes. That’s exactly what ADPIE teaches you to do. Osmosis covers this integration extensively, with editorial review by DNP/PhD faculty, providing an excellent walkthrough of how ADPIE maps to clinical judgment testing.

When you write a care plan in class, you’re actually practicing the exact cognitive process the NCLEX tests. Think of every care plan as a mini-NextGen simulation.

The PES Format: Writing Correct Nursing Diagnoses

This is the single most important section in this article. According to Nurseslabs — which maintains a database of 1,000+ individual care plans — 60%+ of student care plan failures come from incorrect PES formatting. Your instructor is looking for specificity, and vague diagnoses = failing grades.

What PES Stands For

Correct vs. Incorrect PES Format

This comparison table (adapted from PatientNotes) shows exactly what instructors look for:

The PES Precision Rule

Specificity drives everything. Here’s the formula your instructor wants:

PES Format = [NANDA-I Diagnosis] r/t [Specific Related Factor] AEB [Specific Assessment Data]

Good example: “Decreased Cardiac Output r/t altered myocardial contraction AEB BP 110/72, HR 100, crackles at left base, patient reports fatigue with ADLs”

Bad example: “Decreased Cardiac Output r/t heart problem AEB cardiac symptoms”

See the difference? The good example includes specific vitals, specific symptoms, and specific assessment data. The bad example is generic and would get a lower grade because it doesn’t demonstrate clinical reasoning.

NANDA-I 13th Edition Quick Reference

Here’s a condensed NANDA-I 13th Edition (2024-2026) quick reference table organized by Gordon’s Functional Health Patterns (the standard organizational framework). This is the kind of reference students wish they had during clinical rotations.

Note: NANDA-I (NANDA International) has rebranded to the International Nursing Knowledge Association (INKA) while retaining “NANDA-I” as the classification system name. We use “NANDA-I” throughout this article because that’s what the organization itself confirms. The NANDA-I diagnosis definitions and examples in this table are sourced from NCBI/NIH, Appendix A: Sample NANDA-I Diagnoses.

NANDA-I Quick Reference by Gordon’s Patterns

Student tip: When your instructor asks you to pick a nursing diagnosis, review your assessment data first, cluster the cues, and match them to the NANDA-I list. Nurse.org explains this process in detail — they break down the 4 types of nursing diagnoses (problem-focused, health promotion, risk, syndrome) and the Taxonomy II structure (13 domains, 47 classes).

Complete NANDA-I Care Plan Examples

Here are five fully worked care plan examples using NANDA-I 13th Edition format. Each includes assessment data (subjective and objective), PES diagnosis, SMART outcomes, NIC interventions with rationales, and evaluation criteria.

Example 1: Decreased Cardiac Output (Heart Failure / CHF)

Patient Scenario: 68-year-old admitted with acute decompensated heart failure. History of hypertension, diabetes mellitus type 2.

Assessment Data:

• Subjective: Patient reports “I can’t catch my breath,” dyspnea at rest, fatigue with ADLs, decreased urine output over 12 hours
• Objective: BP 110/72 mmHg, HR 100 bpm, RR 22 breaths/min, SpO2 92% on room air, crackles at left base, JVD present, edema +2 in bilateral lower extremities, BUN 28 mg/dL, creatinine 1.4 mg/dL

NANDA-I Diagnosis (PES Format):

Decreased Cardiac Output r/t altered myocardial contraction AEB BP 110/72, HR 100, crackles at left base, patient reports fatigue with ADLs, edema +2

Expected Outcomes (SMART Goals):

• Short-term (24 hours): Patient will maintain BP ≥ 100/60 mmHg, HR < 100 bpm, SpO2 ≥ 94% on room air
• Long-term (48 hours): Patient will demonstrate understanding of fluid restriction (< 2L/day) and report adherence to medication schedule

Nursing Interventions (NIC):

1. Monitor vital signs every 2 hours; assess for changes in cardiac output patterns — Rationale: Early detection of hemodynamic instability allows timely intervention
2. Administer diuretics (furosemide) per order and monitor I&O — Rationale: Reduces preload and decreases pulmonary congestion
3. Position patient in semi-Fowler’s position — Rationale: Facilitates lung expansion and reduces venous return
4. Educate patient on sodium restriction (< 2g/day) and fluid restriction (< 2L/day) — Rationale: Prevents fluid overload and reduces cardiac workload
5. Monitor electrolytes (especially K+ and Mg++) — Rationale: Diuretic use increases risk of electrolyte imbalance; hypokalemia can precipitate dysrhythmias

Evaluation:

• Met: BP improved to 118/76, HR 94, SpO2 96% on room air
• Partially Met: Patient verbalized understanding of fluid restriction but admitted occasional sodium indiscretions
• Not Met: Crackles persist, edema +2 — needs continued monitoring and possibly increased diuretic dose

Example 2: Ineffective Airway Clearance (COPD)

Patient Scenario: 72-year-old with COPD exacerbation, history of 40-pack-year smoking.

Assessment Data:

• Subjective: Patient states “I just can’t seem to cough anything up,” reports chest tightness, increased anxiety about breathing
• Objective: RR 28 breaths/min, SpO2 89% on room air, HR 104 bpm, breath sounds with diffuse wheezing and decreased bases, productive cough with thick, yellow-green sputum, ABG: pH 7.32, PaCO2 52 mmHg, PaO2 68 mmHg

NANDA-I Diagnosis (PES Format):

Ineffective Airway Clearance r/t thick, tenacious secretions and ineffective ciliary function AEB productive cough with yellow-green sputum, diffuse wheezing, SpO2 89%, ABG pH 7.32/PaCO2 52

Expected Outcomes (SMART Goals):

• Short-term (12 hours): Patient will cough up secretions effectively and maintain SpO2 ≥ 92%
• Long-term (48 hours): Patient will demonstrate proper use of incentive spirometer and report decreased dyspnea (score ≤ 2/10)

Nursing Interventions (NIC):

1. Administer bronchodilator (albuterol/ipratropium) per respiratory therapy order — Rationale: Opens airways and reduces airway resistance; works synergistically with mucolytics
2. Encourage increased fluid intake to 2-2.5L/day (unless contraindicated) — Rationale: Hydration thins secretions and facilitates expectoration
3. Perform chest physiotherapy (postural drainage, percussion) and assist with effective coughing techniques — Rationale: Mobilizes secretions from peripheral airways
4. Administer mucolytic agent (acetylcysteine) as ordered — Rationale: Breaks down mucus viscosity, making secretion clearance more effective
5. Monitor ABGs and SpO2 every 4 hours — Rationale: Tracks respiratory status and oxygenation adequacy; guides O2 therapy adjustments

Evaluation:

• Met: Patient expectorated thick secretions after bronchodilator; SpO2 improved to 93% on 2L O2
• Partially Met: Sputum volume decreased but still thick; patient needs continued hydration encouragement
• Not Met: Patient still exhibits accessory muscle use; needs respiratory therapy reassessment

Example 3: Acute Pain (Post-Operative)

Patient Scenario: 55-year-old post-op day 1, status post total hip replacement.

Assessment Data:

• Subjective: Patient reports pain at 8/10 on pain scale; “The pain in my hip is sharp and I can’t rest”
• Objective: HR 110 bpm, BP 148/88 mmHg, patient guards surgical site, facial grimacing, verbalizes protectiveness, incision site clean with serosanguinous drain output

NANDA-I Diagnosis (PES Format):

Acute Pain r/t surgical incision AEB patient reports pain at 8/10, guards incision, displays facial grimacing, HR 110, BP 148/88

Expected Outcomes (SMART Goals):

• Short-term (4 hours): Patient will report pain at ≤ 4/10 within 2 hours of analgesic administration
• Long-term (24 hours): Patient will demonstrate ability to perform prescribed ROM exercises independently (pain ≤ 3/10)

Nursing Interventions (NIC):

1. Administer prescribed analgesics (e.g., oxycodone 5mg PO) and reassess pain 30 minutes post-administration — Rationale: Addresses pain causally; timely reassessment ensures effective dosing
2. Implement non-pharmacologic pain management (positioning, ice pack, guided relaxation) — Rationale: Multimodal approach reduces opioid requirements; positioning can reduce incisional tension
3. Administer NSAIDs as prescribed for adjunctive pain control — Rationale: Targets inflammatory pathway of post-surgical pain; reduces need for opioids
4. Teach patient to use pain scale before movement/exercise — Rationale: Optimal pain management (≤ 4/10) is needed for safe mobilization and ROM exercises
5. Monitor drain output and incision site for signs of infection — Rationale: Infection increases pain; early detection prevents complications that compound pain

Evaluation:

• Met: Patient’s pain decreased to 3/10 after oxycodone + positioning; performed ROM exercises independently
• Partially Met: Pain score 5/10 before next scheduled dose; needs timing adjustment
• Not Met: Patient refuses analgesic due to fear of addiction; requires education and alternative strategies

Example 4: Risk for Self-Directed Violence (Depression / MDD)

Patient Scenario: 34-year-old admitted following suicide attempt. History of major depressive disorder (MDD), anxiety, substance use history.

Assessment Data:

• Subjective: Patient states “I don’t see the point anymore,” reports sleep disturbance (2 hours/night), appetite loss, social withdrawal
• Objective: Dependent facial affect, poor eye contact, flat affect during initial interview, weight loss reported over prior month, history of two prior suicide attempts

NANDA-I Diagnosis (PES Format):

Risk for Self-Directed Violence r/t feelings of hopelessness and inadequate coping AEB patient states “I don’t see the point anymore,” history of two prior suicide attempts, social withdrawal

Expected Outcomes (SMART Goals):

• Short-term (24 hours): Patient will remain free of suicidal ideation and verbalize no intent to self-harm
• Long-term (7 days): Patient will identify at least three coping strategies and agree to safety contract

Nursing Interventions (NIC):

1. Maintain continuous observation (1:1 or 15-minute checks per unit protocol) — Rationale: Ensures patient safety; continuous monitoring allows rapid intervention if suicidal ideation escalates
2. Establish therapeutic rapport using non-judgmental communication — Rationale: Builds trust; patient must feel safe expressing suicidal thoughts rather than hiding them
3. Remove all potentially dangerous items from environment and environment — Rationale: Environmental safety is the first line of defense against impulsive self-harm
4. Collaborate with psychiatric team for medication management — Rationale: Pharmacologic treatment of depression addresses the underlying etiology; SSRIs, mood stabilizers, or antipsychotics as indicated
5. Teach patient coping strategies (grounding techniques, crisis hotline numbers, journaling) — Rationale: Provides immediate tools to manage emotional distress between therapy sessions

Evaluation:

• Met: Patient verbalizes no suicidal intent; identified three coping strategies (calling support person, calling crisis line, using grounding exercise)
• Partially Met: Patient denies current suicidal ideation but still withdrawn; requires ongoing mental health support
• Not Met: Patient refuses to sign safety contract; may need increased level of care (psychiatric hospitalization)

Example 5: Risk for Falls (Geriatric)

Patient Scenario: 82-year-old admitted for dehydration and electrolyte imbalance. History of hypertension, benign prostatic hyperplasia, takes multiple medications.

Assessment Data:

• Subjective: Patient reports “I get dizzy when I stand up,” admits difficulty with ambulation, history of two falls in past 6 months
• Objective: BP 105/68 (drop of 15 mmHg on standing), gait unsteady with cane, bilateral lower extremity weakness, taking 5+ medications including antihypertensives, urinary frequency nocturia

NANDA-I Diagnosis (PES Format):

Risk for Falls r/t age-related mobility changes and polypharmacy AEB patient reports dizziness on standing, history of two falls in past 6 months, gait unsteady, BP drop 15 mmHg on standing

Expected Outcomes (SMART Goals):

• Short-term (24 hours): Patient will remain free from falls during hospitalization and verbalize understanding of fall precautions
• Long-term (discharge): Patient will demonstrate safe ambulation with assistive device and report use of call bell before attempting to get out of bed

Nursing Interventions (NIC):

1. Implement fall precautions protocol (non-slip footwear, call bell within reach, bed in lowest position, night light on) — Rationale: Environmental modifications reduce fall risk; call bell ensures patient asks for help
2. Assist patient with ambulation using gait belt and cane; accompany patient to bathroom — Rationale: Direct supervision prevents unassisted attempts; gait belt provides safety during transfers
3. Review medications with pharmacist for fall-risk contributors (antihypertensives, sedatives, anticholinergics) — Rationale: Polypharmacy increases fall risk; medication timing adjustments can reduce dizziness
4. Educate patient on orthostatic hypotension — “Sit at edge of bed for 2 minutes before standing” — Rationale: Gradual position changes prevent BP drops and subsequent dizziness
5. Assess urinary frequency/nocturia and adjust fluid schedule — Rationale: Urgency to urinate at night increases fall risk; scheduled voiding reduces nocturia

Evaluation:

• Met: Patient remained free from falls; demonstrated safe ambulation with gait belt; verbalized understanding of fall precautions
• Partially Met: Patient still required assistance for all ambulation; needs continued supervision
• Not Met: Patient left bed without call bell during night shift; requires environmental education and increased supervision

3-Column vs 4-Column vs 5-Column Format

Not every care plan format is the same. Heidi Health explains that nursing programs and clinical settings use different formats depending on purpose. Here’s what each means:

Which one should you use?

• If your instructor requires rationales, use the 4-column format
• If you’re documenting for clinical shifts, the 3-column format is standard
• If your program emphasizes evaluation criteria (Met/Partially Met/Not Met), use the 5-column format

When in doubt, check your syllabus or ask your instructor. Format compliance is an easy way to lose points even when your clinical reasoning is sound.

Common Nursing Care Plan Mistakes (And How to Avoid Them)

Even strong students make these errors. Here are the most common mistakes nursing students make — and how to avoid them:

Mistake #1: Confusing Medical Diagnosis with Nursing Diagnosis

The error: Writing “Pneumonia” or “Heart Failure” as the nursing diagnosis.

Why it’s wrong: Medical diagnoses are diagnosed by physicians. Nursing diagnoses are diagnosed by nurses and focus on human responses to health conditions.

How to fix it: Instead of “Pneumonia,” write Ineffective Airway Clearance. Instead of “Heart Failure,” write Decreased Cardiac Output. Nurse.org’s comprehensive guide on nursing diagnosis types explains this distinction in detail.

Mistake #2: Using “As Evidenced By” for “Risk For” Diagnoses

The error: “Risk for Falls AEB patient is elderly” or “Risk for Infection AEB weakened immune system”

Why it’s wrong: “Risk for” diagnoses don’t have actual signs and symptoms yet — that’s why it’s a risk. They use risk factors instead of AEB.

How to fix it: “Risk for Falls r/t age-related mobility changes and history of two falls in past 6 months” — the “history of falls” is a risk factor, not an “as evidenced by” symptom.

Mistake #3: Vague or Unrealistic Goals

The error: “Patient will be more comfortable” or “Patient will recover”

Why it’s wrong: These aren’t measurable. Instructors need to know what “more comfortable” means numerically, physiologically, or behaviorally.

How to fix it: Use SMART goals: “Patient will report pain at ≤ 3/10 within 2 hours of analgesic administration” or “Patient will maintain SpO2 ≥ 94% on room air”

Mistake #4: Missing Rationales for Interventions

The error: Listing interventions without explaining why you chose them.

Why it’s wrong: Instructors want to see your clinical reasoning. A list of interventions without rationales doesn’t demonstrate that you understand why you’re doing what you’re doing.

How to fix it: For every intervention, add a rationale: “Administer bronchodilator — Rationale: Opens airways and reduces airway resistance”

Mistake #5: Failing to Update or Reassess

The error: Writing a care plan and never evaluating it — or assuming the patient’s status won’t change.

Why it’s wrong: Patients change. Interventions need adjustment based on patient response. AMN Healthcare emphasizes that underestimating the importance of ongoing care plan evaluation is a common contract nurse mistake.

How to fix it: Always include an Evaluation section with “Met / Partially Met / Not Met” criteria. Reassess and update the care plan regularly.

How to Write a Care Plan Template

Now that you’ve seen five worked examples, here’s your step-by-step process for writing any care plan.

Step 1: Collect Assessment Data (Subjective + Objective)

Start with the ADPIE Assessment step. Gather:

• Subjective: Patient-reported symptoms, pain levels, feelings, history
• Objective: Vital signs, lab values, physical assessment findings, diagnostic tests

Pro tip: Your subjective + objective data should cluster together (e.g., all respiratory findings) so you can identify patterns and cluster cues — exactly what the NextGen NCLEX tests.

Step 2: Identify the NANDA-I Diagnosis (PES Format)

Match your clustered cues to the NANDA-I list. Write the diagnosis in PES format:

[Problem] r/t [Etiology] AEB [Signs/Symptoms]

Remember: “Risk for” diagnoses use risk factors, not AEB.

Step 3: Set SMART Expected Outcomes

Write measurable goals:

• Short-term (24-48 hours): Patient will maintain X vital sign at Y level
• Long-term (discharge or 1-2 weeks): Patient will demonstrate X behavior/independence

Step 4: Select Interventions (NIC) + Add Rationales

Choose evidence-based interventions and explain why:

• Administer medication → Rationale: [mechanism of action / clinical reason]
• Position patient → Rationale: [physiological benefit]
• Educate patient → Rationale: [expected outcome of teaching]

Step 5: Include Evaluation Criteria

Document how you’ll measure success:

• Met: Patient achieved the expected outcome
• Partially Met: Patient made progress but didn’t fully achieve outcome
• Not Met: Patient didn’t achieve outcome; needs reassessment and possible plan revision

Writing care plans is time-consuming — especially when you’re juggling clinical rotations, NCLEX prep, and a full course load. If you need a customized care plan that meets your instructor’s exact requirements, our nursing writers can create one for you — fast. Visit our order page to get started.

Related Nursing Guides

• How to Write a Nursing Care Plan: Step-by-Step Guide — Learn the ADPIE process in detail before diving into examples
• Nursing Capstone Project: BSN, MSN, and DNP Guide — Comprehensive guide for advanced nursing students
• How to Write a Reflection Paper on Nursing Clinical Experience — Learn reflective writing for clinical documentation
• Looking for a downloadable template? Order a customized care plan from our nursing writers — include your program’s specific requirements and get a template tailored to your class.

This article is for educational purposes only and does not constitute medical advice. Always follow your nursing program’s specific formatting requirements and consult your instructor for guidance.