How to Write a Nursing Care Plan (ADPIE Format With Example)

By the BrightMindNerds Editorial Team · Updated September 27, 2026 · 3 min read

Key takeaways

A nursing care plan follows the nursing process: ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation).

Write nursing diagnoses in the NANDA-I format: problem related to cause, as evidenced by signs and symptoms.

Goals must be SMART, and every intervention needs a rationale backed by evidence.

Care plans are one of the most common assignments in nursing school. They teach you to think like a nurse: collect data, identify the patient's problems, and plan care you can measure.

The ADPIE nursing process

Step	What you do
Assessment	Collect subjective and objective data
Diagnosis	Identify the patient's nursing problems (NANDA-I)
Planning	Set patient-centered SMART goals
Implementation	Choose nursing interventions, with rationales
Evaluation	Decide whether each goal was met, partly met or not met

Step 1: Assessment

Gather two types of data:

Subjective: what the patient or family says. "It hurts when I breathe in."
Objective: what you observe and measure: vital signs, lab results, physical exam findings, medications

Step 2: Nursing diagnosis

A nursing diagnosis describes the patient's response to a health problem, which nurses can treat independently. It is different from a medical diagnosis.

Format: [NANDA-I problem] related to [cause/etiology] as evidenced by [signs and symptoms]

Example: Ineffective breathing pattern related to pain on inspiration as evidenced by respiratory rate of 26/min, shallow breathing and oxygen saturation of 91% on room air.

Prioritize diagnoses using Maslow's hierarchy and the ABCs (Airway, Breathing, Circulation). Physiological, life-threatening problems come first.

Step 3: Planning (SMART goals)

Goals should be Specific, Measurable, Achievable, Relevant and Time-bound, and written about the patient:

"The patient will maintain oxygen saturation of 94% or higher on room air and a respiratory rate of 12–20/min within 24 hours."

Step 4: Implementation (interventions and rationales)

List nursing actions, each with a rationale explaining why it works:

Intervention	Rationale
Assess respiratory rate, depth and SpO₂ every 2 hours	Detects early deterioration so treatment can start promptly
Place the patient in semi-Fowler's or high-Fowler's position	Allows fuller lung expansion and easier breathing
Give prescribed analgesia and reassess pain 30–60 minutes later	Controlling pain allows deeper breaths
Teach deep breathing and incentive spirometer use every hour while awake	Promotes lung expansion and helps prevent atelectasis

Support rationales with current evidence, such as nursing textbooks, clinical guidelines or journal articles, and cite them in APA.

Step 5: Evaluation

State whether each goal was met, partially met or not met, with evidence:

"Goal met: after 24 hours, SpO₂ was 96% on room air and respiratory rate was 18/min. Continue the plan."

If a goal isn't met, explain what you'd change: new interventions, a revised goal or a new diagnosis.

Nursing care plan template

Assessment data: subjective and objective
Nursing diagnosis: problem r/t cause AEB signs and symptoms
Goal: SMART, patient-centered
Interventions: 3–5 nursing actions
Rationales: with citations
Evaluation: met / partially met / not met, with evidence

Common mistakes

Writing a medical diagnosis ("pneumonia") instead of a nursing diagnosis
Unmeasurable goals ("The patient will feel better")
Interventions that are doctor's orders only, with no nursing actions
Rationales with no evidence or citation
Not linking the evaluation back to the goal

Frequently asked questions

What is the difference between a nursing diagnosis and a medical diagnosis?

A medical diagnosis identifies a disease (e.g., pneumonia). A nursing diagnosis describes the patient's response to it (e.g., ineffective breathing pattern), which nurses can treat independently.

How many nursing diagnoses should a care plan include?

Most student care plans include two or three prioritized diagnoses, but follow your instructor's requirements.

What does "r/t" and "AEB" mean?

"r/t" means "related to" (the cause) and "AEB" means "as evidenced by" (the signs and symptoms that support the diagnosis).

Do nursing care plans need references?

Yes. Rationales should be supported by current evidence, such as nursing textbooks, clinical guidelines or peer-reviewed articles, usually cited in APA 7th edition.