How to Write a Nursing Care Plan: The Complete ADPIE Guide

A nursing care plan is your roadmap for a client: what is going on, what you want to happen, what you will do about it, and how you will know it worked. It keeps care organized, safe, and consistent from shift to shift, and it shows your clinical judgment on paper.

The 5 parts: ADPIE

1. Assessment. Collect subjective data (what the client tells you) and objective data (what you see, measure, and test). Use tools like a head-to-toe assessment and OLD CARTS for symptoms.
2. Diagnosis. Turn the data into a nursing diagnosis. A medical diagnosis names the disease (pneumonia). A nursing diagnosis names the client's response that nurses treat (Ineffective Airway Clearance).
3. Planning. Set goals that are SMART: specific, measurable, achievable, relevant, and time-bound. Write both short-term and long-term goals.
4. Intervention. List what you will do and why. Every intervention gets a rationale.
5. Evaluation. Check the goals. Met, partly met, or not met? Then keep, change, or end the plan.

How to write the diagnosis statement

Use this pattern: Diagnosis related to cause as evidenced by signs and symptoms.

Risk diagnoses (like Risk for Falls) have no "as evidenced by" part, because the problem has not happened yet. List the risk factors instead.

Types of nursing interventions

• Independent: things a nurse can start on their own, like repositioning, teaching, or coughing and deep breathing.
• Dependent: things that need a provider's order, like giving medication.
• Collaborative: things done with the team, like working with a dietitian or physical therapist.

Short-term vs. long-term goals

Short-term goals cover the next hours to days (pain at 3/10 or less within 1 hour). Long-term goals cover weeks to months (client manages their diabetes at home with an A1C under 7%).

Standardized vs. individualized plans

Standardized plans give a starting point for common conditions. Always individualize: add your client's own data, goals, culture, and preferences.

Pro tips

• Prioritize with ABCs, Maslow, and safety first.
• Make every goal measurable with a number and a time.
• Match each intervention to a goal, and each goal to the diagnosis.
• Involve the client in setting goals.
• Reassess and update the plan as the client changes.