Example Nursing Care Plan (APA Format)
A complete step-by-step guide to writing nursing care plans in APA 7th edition format — covering the nursing process, NANDA-I diagnoses, SMART outcomes, NIC interventions with rationales, evaluation criteria, and three full worked examples for hypertension, type 2 diabetes, and post-surgical acute pain.
Few nursing assignments are as consistently challenging — or as consistently misunderstood — as the care plan. Students who understand pathophysiology, can recognise clinical presentations, and are comfortable in clinical settings often find the written care plan unexpectedly difficult, not because of what it requires clinically, but because of how it demands that clinical thinking be translated into a structured, formally referenced, APA-formatted academic document. A nursing care plan in academic format is simultaneously a clinical tool and an academic paper: it requires evidence-based practice, standardised diagnostic language, measurable outcomes, and proper citation — all formatted according to APA 7th edition conventions. This guide covers every component, from the five-step nursing process through NANDA-I diagnosis writing, SMART outcome construction, NIC intervention rationales, and APA formatting rules, with three full worked examples you can use as models for your own assignments.
What a Nursing Care Plan Is — and Why APA Format Is Required
A nursing care plan is the formal written expression of the nursing process — the systematic framework nurses use to plan, deliver, and evaluate individualised patient care. It translates clinical assessment data into prioritised nursing diagnoses, converts those diagnoses into measurable patient outcomes, and maps specific nursing interventions — each with an evidence-based rationale — to achieve those outcomes. In practice settings, care plans live in patient records and guide the entire care team. In academic settings, they are assessed assignments that demonstrate your ability to apply clinical reasoning, use standardised nursing language, and support every decision with evidence.
APA (American Psychological Association) 7th edition format is required by most nursing programmes in the United States and increasingly in nursing programmes internationally because it provides a standardised structure for presenting academic work and a consistent system for crediting the clinical and scientific evidence that underpins nursing practice. Every nursing diagnosis you write, every intervention you recommend, and every rationale you provide has a source — a NANDA-I classification, a pharmacology text, a clinical practice guideline, or a peer-reviewed study. APA format is the mechanism for making those sources transparent and verifiable.
The Five-Step Nursing Process — ADPIE From Assessment to Evaluation
Every nursing care plan is built on the nursing process. Understanding what each step requires — not just what it is called — is the foundation for writing a coherent, clinically sound care plan. The five steps are Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). Each generates a specific section of the written care plan and requires specific types of evidence and documentation.
Collect subjective and objective data through patient interview, physical examination, review of medical records, vital signs, and diagnostic findings. Document the clinical picture systematically using head-to-toe or body-systems approach.
Analyse assessment data to identify clusters of signs and symptoms. Select appropriate NANDA-I nursing diagnoses. Write in PES format: Problem related to Etiology as evidenced by Signs and Symptoms. Prioritise using Maslow’s hierarchy.
Establish SMART patient-centred outcomes (NOC) and select evidence-based nursing interventions (NIC) for each diagnosis. Set realistic time frames. Identify resources and collaborate with the multidisciplinary team.
Carry out the planned nursing interventions. Document actions taken, patient responses, medication administration, patient and family education provided, and any changes to the plan based on patient response.
Measure the patient’s progress toward each stated outcome. Determine whether outcomes were met, partially met, or not met. Revise the care plan accordingly — modify diagnoses, outcomes, or interventions based on evaluation data.
In academic care plan assignments, each step of ADPIE maps to a section of the written document. The Assessment section presents your clinical data. The Diagnosis section states your NANDA-I diagnoses in PES format. The Planning section documents your NOC outcomes and NIC interventions with rationales. The Implementation section (sometimes described as a separate section, sometimes integrated with Planning) details specific actions. The Evaluation section states whether outcomes were or would be met, and what modifications the clinical picture would require. Assignments vary in which sections they require — read your brief carefully, as some ask only for Diagnosis through Evaluation, assuming assessment data is presented separately in a patient history section.
When a patient has multiple nursing diagnoses, they must be prioritised. The universally accepted framework for this is Maslow’s Hierarchy of Needs, adapted for clinical nursing practice. Physiological survival needs — airway, breathing, circulation, hydration, nutrition — take highest priority. Safety and security needs — infection prevention, fall prevention, wound integrity — come next. Social and psychological needs follow. Cognitive and self-actualisation needs are addressed when physiological and safety needs are stable.
A practical rule: an actual nursing diagnosis (the problem is present) always takes priority over a risk diagnosis (the problem might develop), which takes priority over a wellness or health-promotion diagnosis. A respiratory diagnosis outranks a nutrition diagnosis. A safety diagnosis outranks a knowledge deficit. Documenting your prioritisation rationale in the care plan — citing Maslow (1943) — demonstrates clinical reasoning that markers are specifically assessing.
NANDA-I Nursing Diagnoses and the PES Format
NANDA International (NANDA-I) is the professional organisation that develops, researches, and maintains the standardised classification of nursing diagnoses used worldwide. A nursing diagnosis is defined by NANDA-I as “a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community” (Herdman & Kamitsuru, 2018, p. 86). It is fundamentally different from a medical diagnosis: a medical diagnosis names a disease (hypertension, type 2 diabetes), while a nursing diagnosis names the patient’s human response to that disease and to the experience of being unwell.
The PES Format — How to Construct a NANDA-I Nursing Diagnosis
Example: Acute pain | Ineffective health management | Risk for falls
Example: …related to surgical tissue disruption | …related to insufficient knowledge of disease management
Example: …as evidenced by pain score 7/10, facial grimacing, and guarding behaviour
Problem is present and evidenced
Describes a health problem that is currently occurring and confirmed by observable signs and symptoms. Uses full PES format. Examples: Acute pain related to surgical incision as evidenced by verbal report of pain 6/10, guarding behaviour, and diaphoresis. Impaired skin integrity related to pressure from immobility as evidenced by stage 2 sacral pressure injury. These diagnoses require immediate nursing intervention and take priority when present alongside risk diagnoses.
Problem may develop — prevent it
Describes a patient’s vulnerability to developing a problem. Uses only P + E format — no “as evidenced by” component because no defining characteristics exist yet. Examples: Risk for infection related to surgical wound and immunosuppression. Risk for falls related to altered gait, polypharmacy, and post-operative sedation. These diagnoses direct preventive interventions and are equally important to actual diagnoses in clinical planning.
Patient wants to enhance wellbeing
Describes a patient’s readiness to improve a specific health behaviour or condition. They reflect the patient’s own expressed desire to enhance functioning in a specific area. Examples: Readiness for enhanced health management as evidenced by patient’s expressed desire to understand medication regimen and lifestyle modification. Less common in acute care; more frequently encountered in community, primary care, and mental health settings.
Cluster of diagnoses that occur together
Represents a clinical syndrome — a cluster of actual or risk diagnoses that predictably occur together in response to a specific situation or event. Examples: Rape-Trauma Syndrome, Post-Trauma Syndrome, Relocation Stress Syndrome. These diagnoses allow a single diagnostic label to represent multiple related nursing problems that require a coordinated response rather than separate diagnosis and planning for each component.
Frequently used in cardiac/hypertension care plans
Ineffective health maintenance r/t insufficient knowledge of disease management. Decreased cardiac output r/t altered heart rate or rhythm. Activity intolerance r/t insufficient oxygen with activity. Risk for decreased cardiac tissue perfusion r/t hypertension. Excess fluid volume r/t compromised regulatory mechanism. These are commonly required diagnoses in medical-surgical and cardiovascular nursing assignments.
Frequently used in post-surgical care plans
Acute pain r/t surgical tissue disruption aeb verbal report and behavioural indicators. Risk for infection r/t surgical wound and invasive procedures. Impaired physical mobility r/t pain and surgical restriction. Risk for ineffective breathing pattern r/t pain-limited respiratory effort. Deficient knowledge r/t post-operative care requirements aeb patient questions and inaccurate return demonstration.
The single most frequent and most heavily penalised error in student nursing care plans is writing a medical diagnosis where a nursing diagnosis is required. “Hypertension,” “Type 2 diabetes mellitus,” “Post-operative status,” and “Pneumonia” are medical diagnoses — they name disease processes diagnosed by physicians. A nursing diagnosis names the patient’s human response to those disease processes: what the patient experiences as a result of hypertension, what their knowledge gaps about diabetes management are, what their post-surgical pain and mobility challenges look like.
A reliable check: if a physician could write the diagnosis (and it would appear on a medical problem list), it is a medical diagnosis. If a nurse identifies it through clinical observation, patient interview, and nursing assessment — and it describes a response to a health condition that nursing interventions can address — it is a nursing diagnosis. Always match your diagnosis to the NANDA-I taxonomy before writing it in your care plan.
NOC Outcomes — Writing SMART Patient Goals
Nursing Outcomes Classification (NOC) provides standardised, measurable outcomes that evaluate the effectiveness of nursing care. Each NOC outcome includes a label, a definition, and a set of indicators measured on a five-point Likert scale from “severely compromised” to “not compromised” (or similar scale depending on the outcome domain). In academic care plans, you will typically write outcomes as SMART goals — patient-centred, measurable statements that specify what the patient will do or demonstrate, by when, and at what level.
Not SMART — Avoid These
“Patient will feel better.” “Patient will have improved mobility.” “Patient will understand their diabetes.” “Pain will decrease.” “Patient will be educated about medications.” None of these are measurable, time-bound, or specific enough to evaluate.
Partially SMART — Improve These
“Patient will report reduced pain by discharge.” This has a time frame but lacks a measurable criterion (what level on what scale?). “Patient will demonstrate insulin technique correctly” has no time frame. Add the missing SMART elements.
Fully SMART — Model These
“Patient will report pain ≤3/10 on the NRS within 30 minutes of analgesic administration by end of shift.” “Patient will independently demonstrate correct insulin injection technique in two consecutive supervised attempts before discharge.” Both are specific, measurable, achievable, relevant, and time-bound.
NIC Interventions and Clinical Rationales
Nursing Interventions Classification (NIC) provides over 500 standardised nursing intervention labels with definitions and associated activities. In academic care plans, interventions are written as specific, actionable nursing activities — what the nurse will do, how often, and why. The clinical rationale is the evidence-based explanation of why each intervention is expected to achieve the stated outcome, and it is the component most consistently missing or inadequate in student care plans.
Every intervention in an academic care plan requires a rationale. Not a vague statement that the intervention is good practice, but a specific, cited explanation of the mechanism by which the intervention addresses the patient’s problem. “Administer prescribed analgesic as ordered” is an intervention; “Opioid analgesics reduce pain perception by binding to mu-opioid receptors in the central and peripheral nervous system, decreasing the transmission of pain signals (Hinkle et al., 2022)” is a rationale. The rationale is where your pharmacological, pathophysiological, and evidence-based practice knowledge is demonstrated — and where most marks for clinical reasoning are earned.
Pharmacological Interventions
Include medication name, dose, route, and frequency. Rationale must cite mechanism of action from a pharmacology text (e.g., Karch, Lewis, or Lilley). Include relevant monitoring parameters (blood pressure checks for antihypertensives, blood glucose for insulin) and patient education points about the medication.
Assessment Interventions
Monitoring interventions — vital sign frequency, pain scale assessment, wound assessment, neurological checks, fluid balance monitoring. Rationale explains what the assessment data will detect and why early detection of changes matters for this diagnosis. Cite clinical guidelines for assessment frequencies.
Patient Education Interventions
Teach the patient and family about their condition, medications, dietary requirements, activity restrictions, wound care, and self-monitoring. Rationale cites evidence linking patient education to improved self-management, medication adherence, and reduced readmission rates. Include plans for health literacy assessment and teach-back verification.
Independent interventions are within the nurse’s scope of practice without requiring a physician order: patient positioning, patient education, skin care, fall prevention, emotional support, oral hygiene, ambulation assistance, pain assessment. Dependent interventions require a physician order: administering prescribed medications, performing ordered procedures, collecting ordered specimens. Collaborative interventions involve working with other members of the healthcare team: referral to physiotherapy, dietitian consultation, social work liaison, wound care specialist.
A well-rounded care plan includes all three types where clinically appropriate. Relying exclusively on dependent (physician-ordered) interventions underrepresents the autonomous scope of nursing practice and suggests limited understanding of what nursing-specific care involves. Independent interventions — those requiring nursing knowledge and judgement rather than a medical order — demonstrate the most about your clinical understanding of the nursing role.
Evaluation — Assessing Outcome Achievement and Revising the Plan
Evaluation is the final step of ADPIE and closes the care plan loop. In academic care plans, evaluation requires you to assess whether each stated outcome was met, partially met, or not met — and to document what clinical data supports that assessment. If writing a hypothetical care plan (for a case study patient), you write a prospective evaluation: stating what data you would collect to evaluate the outcome and what findings would indicate success or the need to revise the plan.
The evaluation step is not an afterthought — it is the mechanism through which nursing practice is refined and patient care is improved. A care plan that is never evaluated is a plan that never learns from its outcomes.
Principle underlying evidence-based nursing practice evaluation cycles, reflecting the quality improvement rationale for formal outcome measurement in nursing care planning
If a goal is not met, the nurse must assess why the goal was not met and then modify the plan of care accordingly — revising the diagnosis, changing the outcomes, adjusting the interventions, or all three. The nursing process is genuinely cyclical, not linear.
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, and outcomes (9th ed.). Elsevier — on the iterative nature of care plan evaluation and revision
In evaluation documentation, always reference the outcome criteria you established in the Planning stage. If your outcome stated “patient will report pain ≤3/10 on NRS within 30 minutes of analgesic administration by end of shift,” your evaluation must address exactly that criterion: “Outcome partially met: patient reports pain 4/10 at end of shift, reduced from initial 7/10. Continue current analgesic regimen; reassess comfort measures and consider non-pharmacological adjuncts including repositioning and ice therapy.” This specificity — comparing actual outcome to stated criterion and modifying the plan — is what separates evaluation from a vague summary statement.
APA 7th Edition Formatting for Nursing Care Plans
APA 7th edition (published October 2020) made several changes from the 6th edition that affect nursing care plan papers. The most significant for student papers are the elimination of the running head requirement, the updated title page format, and revised guidance on use of headings. Understanding these changes prevents the most common APA formatting errors in nursing assignments.
APA 7th Edition Formatting Requirements for Student Papers
Title page: Include the paper title (bold, title case, centred), your full name, your institution’s name, course number and name, instructor’s name, and assignment due date. Each element on its own line. No running head required for student papers unless your instructor specifically requests it.
Font and spacing: 12-point Times New Roman, 11-point Calibri, 11-point Arial, or 11-point Georgia. Double-space the entire paper including the title page, headings, body text, block quotations, and reference list. Do not add extra spacing between paragraphs.
Margins: 1-inch (2.54 cm) margins on all sides — top, bottom, left, and right. Page numbers in the top right header, beginning with page 1 on the title page.
Headings: Use APA heading levels consistently. Level 1 headings are bold, centred, title case (e.g., Nursing Diagnoses). Level 2 headings are bold, left-aligned, title case. Level 3 headings are bold, italic, left-aligned. Use as many heading levels as your paper’s structure requires.
Care plan table: If presenting the care plan in table format (many assignments require this), format the table using APA table guidelines: Table number above the table (Table 1), a brief descriptive title in italic below the table number, column headers in bold, and a note below the table explaining any abbreviations.
In-Text Citations and Reference List for Nursing Care Plans
Every claim in your care plan that draws on published knowledge requires an in-text citation. This includes nursing diagnoses (cite the NANDA-I source), interventions and their rationales (cite pharmacology texts, pathophysiology references, or clinical guidelines), and any statistics or clinical evidence you present. The APA 7th edition citation format for nursing uses Author-Date in-text citations and a References page at the end of the document.
In-text citations follow the Author-Date format: (Herdman et al., 2024) for three or more authors from first citation; (Gulanick & Myers, 2022) for two authors. When citing with a signal phrase: “According to Makic and Martinez-Kratz (2023)…” When citing at the end of a sentence: “…as outlined in the NANDA-I taxonomy (Herdman et al., 2024).” For direct quotations, include the page number: (Herdman et al., 2024, p. 86). Block quotations (40 or more words) are indented half an inch, double-spaced, without quotation marks, with the page number after the closing punctuation.
When citing a specific NANDA-I nursing diagnosis in your care plan, you are citing the classification system as a whole, not an individual author of a single diagnosis. The correct citation is the NANDA-I book itself: (Herdman et al., 2024) for the current edition. If you accessed NANDA diagnoses through a secondary source such as Makic and Martinez-Kratz’s nursing diagnosis handbook, cite that source — not NANDA-I directly — unless you are confident you have access to the primary source.
A common error is omitting the NANDA-I citation entirely when writing nursing diagnoses. The nursing diagnosis label, its definition, related factors, and defining characteristics are all intellectual content from the NANDA-I classification system and require attribution. Your care plan must cite the source of every diagnosis you write, just as your analysis essay must cite every theoretical framework you apply. For more on APA citation practice in nursing, see our citation and referencing guide.
Worked Example 1 — Nursing Care Plan for Hypertension (APA Format)
The following is a complete academic nursing care plan for a patient presenting with uncontrolled hypertension. Patient details are fictitious and presented as a case study. This example demonstrates proper NANDA-I diagnosis writing in PES format, SMART outcome construction, NIC interventions with cited rationales, and APA citations throughout.
Mr. R. (all patient information is fictitious for educational purposes) is a 58-year-old male admitted to the medical unit following a blood pressure reading of 178/106 mmHg at a routine GP appointment. He has a two-year history of diagnosed hypertension but reports inconsistent medication adherence because he “feels fine” and dislikes taking medications. He smokes 10 cigarettes daily and reports a sedentary lifestyle with high dietary sodium intake. He expresses confusion about why medication adherence matters when he has no symptoms. Admitting medications include Amlodipine 5 mg daily and Ramipril 5 mg daily, both of which he acknowledges missing “several times a week.”
Nursing Diagnosis 1 (Priority)
Ineffective health management related to insufficient knowledge of hypertension management as evidenced by inconsistent medication adherence, patient-reported belief that symptoms indicate medication necessity, and blood pressure 178/106 mmHg on admission (Herdman et al., 2024)
Short-term: Patient will verbalize the purpose of antihypertensive medication and the risk of untreated hypertension within 24 hours of education session, as demonstrated by accurate oral teach-back.
Long-term: Patient will report taking prescribed antihypertensive medications daily for 7 consecutive days before follow-up appointment, as evidenced by self-reported medication diary and blood pressure reading ≤140/90 mmHg at follow-up (Gulanick & Myers, 2022).
- Assess patient’s current knowledge of hypertension, its complications, and medication purpose using open-ended questions before beginning education. Assessing prior knowledge prevents repetition of already-known content and identifies specific gaps, improving education efficiency and relevance (Hinkle et al., 2022).
- Provide structured patient education covering: the mechanism of hypertensive target organ damage (heart, kidney, brain, vessels); the fact that hypertension is asymptomatic until complications occur; and the importance of adherence even when feeling well. Asymptomatic hypertension is a major adherence barrier; evidence consistently links patient understanding of “silent” target organ damage with improved medication compliance (Hinkle et al., 2022).
- Teach the pharmacological action of prescribed medications: Amlodipine (calcium channel blocker — reduces vascular smooth muscle contraction, lowering peripheral vascular resistance) and Ramipril (ACE inhibitor — inhibits angiotensin-converting enzyme, reducing angiotensin II-mediated vasoconstriction and aldosterone secretion). Patient understanding of how medications work and why benefits occur even without symptoms is associated with significantly improved adherence in chronic disease management (Hinkle et al., 2022).
- Collaborate with the dietitian to provide sodium restriction education (target <2.3 g sodium daily) and dietary modification counselling. Dietary sodium reduction is associated with a mean systolic blood pressure reduction of 5–6 mmHg, directly supporting pharmacological management (Hinkle et al., 2022).
- Use the teach-back method to verify patient understanding at the end of each education session: ask the patient to explain back in their own words what hypertension is, why medication is needed even without symptoms, and how to take each medication correctly. Teach-back is an evidence-based health literacy technique that identifies knowledge gaps more accurately than simple questioning and has been shown to improve patient self-management in chronic disease contexts (Makic & Martinez-Kratz, 2023).
- Monitor blood pressure every 4 hours during admission and document trends. Administer prescribed antihypertensives as ordered and document patient response. Frequent blood pressure monitoring during an acute hypertensive episode allows detection of end-organ stress symptoms and evaluation of medication effectiveness (Hinkle et al., 2022).
Short-term outcome met if patient accurately verbalises purpose of antihypertensives and risks of non-adherence within 24 hours with teach-back confirmation. Long-term outcome met if self-reported diary documents daily administration and blood pressure ≤140/90 mmHg at follow-up. If outcome not met, reassess health literacy level, explore adherence barriers (side effects, cost, access), and modify education approach or engage social work for adherence support.
Nursing Diagnosis 2 (Secondary)
Risk for decreased cardiac tissue perfusion related to hypertension and medication non-adherence (Herdman et al., 2024)
Note: Risk diagnoses use only Problem and Etiology — no “as evidenced by” component because defining characteristics (signs/symptoms) are absent; the problem has not yet occurred.
Patient will maintain blood pressure ≤150/95 mmHg throughout admission as evidenced by recorded vital signs every 4 hours, and will demonstrate no new signs of cardiac compromise (chest pain, dyspnoea, palpitations) during the hospital stay.
- Perform cardiac assessment every 4 hours: auscultate heart sounds, assess for peripheral oedema, monitor for chest pain, dyspnoea, or headache. Sustained hypertension is associated with left ventricular hypertrophy and increased risk of myocardial ischaemia; early detection of new cardiac symptoms allows prompt intervention (Hinkle et al., 2022).
- Ensure prescribed antihypertensives are administered consistently and on schedule; assess and document blood pressure response to each dose. Calcium channel blockers and ACE inhibitors reduce cardiac afterload and attenuate hypertensive target organ damage; consistent administration maintains therapeutic plasma levels (Hinkle et al., 2022).
- Encourage smoking cessation; provide referral to hospital smoking cessation service. Smoking is an independent cardiovascular risk factor; nicotine causes vasoconstriction and increases heart rate, amplifying hypertensive cardiac stress. Cessation significantly reduces cardiovascular event risk (Hinkle et al., 2022).
Outcome met if blood pressure remains ≤150/95 mmHg throughout admission without new cardiac symptoms documented. Risk diagnosis requires ongoing monitoring and re-evaluation; update priority status if actual symptoms of cardiac compromise emerge, at which point the diagnosis changes to an actual rather than risk diagnosis.
Worked Example 2 — Nursing Care Plan for Type 2 Diabetes Mellitus (APA Format)
Mrs. T. (fictitious for educational purposes) is a 64-year-old woman with a six-year history of type 2 diabetes mellitus, now presenting with blood glucose of 18.4 mmol/L (331 mg/dL) and an HbA1c of 9.2%. She manages her diabetes with Metformin 1000 mg twice daily and reports no regular blood glucose self-monitoring at home. She describes her diet as “I eat the same as everyone else.” Assessment reveals a BMI of 31.2, blood pressure 144/88 mmHg, and a 2 cm superficial wound on her right heel that she states she has not noticed until the nurse’s assessment. She denies pain at the wound site and reports reduced sensation in both feet bilaterally.
Nursing Diagnosis 1 (Priority)
Impaired skin integrity related to peripheral neuropathy and impaired circulation secondary to poorly controlled type 2 diabetes mellitus as evidenced by 2 cm superficial wound on right heel, patient-reported absent wound pain secondary to bilateral peripheral neuropathy, and blood glucose 18.4 mmol/L (Herdman et al., 2024)
Short-term (48 hours): Wound will show no signs of infection (absence of erythema extending beyond wound margins, purulent exudate, or local warmth) and wound size will not increase as assessed by wound measurement at each dressing change.
Long-term (7 days): Wound will demonstrate signs of healing (granulation tissue formation, no necrosis) by Day 7 of treatment, as documented by wound assessment at each dressing change (Gulanick & Myers, 2022).
- Perform wound assessment at each dressing change: measure wound dimensions, document colour, exudate type and amount, tissue type (granulation, slough, necrosis), wound edges, and surrounding skin condition. Systematic wound assessment using a standardised tool provides a comparable baseline and tracks healing trajectory; failure to progress suggests need for advanced wound care referral (Hinkle et al., 2022).
- Perform wound irrigation with normal saline and apply non-adherent moist wound dressing per wound care protocol; handle wound tissue minimally and with aseptic technique throughout dressing change. Moist wound healing environments facilitate granulation tissue formation and epithelialisation, accelerating healing compared to dry wound management; aseptic technique reduces infection risk in immunocompromised patients (Hinkle et al., 2022).
- Maintain blood glucose within prescribed target range through consistent administration of Metformin and prescribed dietary management; monitor blood glucose every 4 hours during admission and document trends. Hyperglycaemia impairs neutrophil function and tissue perfusion, directly inhibiting wound healing; blood glucose control is the single most important intervention for healing in diabetic wounds (Hinkle et al., 2022).
- Offload pressure from the right heel using appropriate positioning aids and specialist diabetic footwear; do not position patient with heels in direct contact with mattress. Pressure offloading is essential for heel wound healing in diabetic patients with peripheral neuropathy, who cannot self-report pressure discomfort; unrelieved pressure impairs local perfusion and prevents healing (Doenges et al., 2019).
- Refer to tissue viability nurse/wound care specialist for formal wound classification and management plan. Diabetic foot wounds carry high risk of osteomyelitis and amputation; specialist review ensures appropriate classification (Wagner grade) and intervention including possible vascular surgery referral (Hinkle et al., 2022).
Nursing Diagnosis 2
Ineffective health management related to insufficient knowledge of diabetes self-monitoring and dietary management as evidenced by absence of home blood glucose monitoring, patient-reported unrestricted diet, HbA1c 9.2%, and blood glucose 18.4 mmol/L (Herdman et al., 2024)
Patient will independently demonstrate correct blood glucose monitoring technique using her glucometer in two consecutive supervised attempts before discharge, and will verbalize target blood glucose ranges and the action to take when readings are outside target range (Makic & Martinez-Kratz, 2023).
- Assess patient’s current understanding of blood glucose monitoring, target ranges, and dietary carbohydrate management before beginning education. Prior knowledge assessment prevents redundant teaching and tailors education to actual knowledge gaps, improving retention and relevance (Makic & Martinez-Kratz, 2023).
- Teach and supervise blood glucose monitoring technique: calibration, lancing, sample collection, reading interpretation, and recording; have patient perform return demonstration. Self-monitoring of blood glucose enables patients to detect hypoglycaemia, assess dietary impact, and adjust management; validated self-monitoring technique ensures accurate readings that support safe self-management decisions (Hinkle et al., 2022).
- Refer to the diabetes specialist nurse and dietitian for structured diabetes education and meal planning guidance appropriate to patient’s cultural context and food preferences. Structured diabetes education programmes significantly improve HbA1c, self-management behaviours, and quality of life compared to standard care alone (Hinkle et al., 2022).
- Educate patient on daily diabetic foot inspection technique: visual and tactile assessment of all surfaces of both feet; when and how to report changes to a healthcare provider. Patients with peripheral neuropathy cannot rely on pain to detect early foot injury; daily self-inspection is the evidence-based compensatory strategy for early wound identification in this population (Doenges et al., 2019).
Worked Example 3 — Nursing Care Plan for Post-Surgical Acute Pain (APA Format)
Mr. K. (fictitious for educational purposes) is a 45-year-old male on Day 1 following an open appendectomy performed under general anaesthesia. He is alert and oriented, reports pain at the surgical site rated 7/10 on the Numerical Rating Scale (NRS), and is reluctant to take deep breaths because “it pulls.” He is guarding his abdomen and resisting ambulation. Observations: respiratory rate 20 bpm with shallow breathing; surgical wound intact with minimal serosanguineous drainage; prescribed regular paracetamol 1000 mg QDS, ibuprofen 400 mg TDS with food, and PRN opioid (Oxycodone 5 mg oral) for breakthrough pain. Patient has not yet received his first dose of PRN opioid and states he is “trying not to take it.”
Nursing Diagnosis 1 (Priority)
Acute pain related to surgical tissue disruption (open appendectomy) as evidenced by patient-reported pain score 7/10 on NRS, guarding behaviour, facial grimacing, reluctance to deep breathe, and refusal to mobilise (Herdman et al., 2024)
Short-term (30–60 minutes): Patient will report pain score ≤4/10 on NRS within 30 minutes of scheduled analgesic administration as documented in the pain assessment record.
Long-term (end of shift): Patient will take a minimum of three deep breaths on request and perform a supervised 5-minute assisted ambulation to the chair without pain score exceeding 5/10 on NRS by end of shift (Gulanick & Myers, 2022).
- Perform comprehensive pain assessment using the NRS every 2 hours and following any analgesic administration: assess location, character, radiation, timing, aggravating and relieving factors, and impact on function. Systematic pain assessment using a validated scale enables objective measurement of pain severity and analgesic effectiveness, guiding titration of the analgesic regimen (Hinkle et al., 2022).
- Administer prescribed analgesia on schedule: Paracetamol 1000 mg QDS and Ibuprofen 400 mg TDS (with food) as regularly scheduled. Educate patient that regular analgesic administration maintains therapeutic plasma levels and prevents pain escalation more effectively than PRN-only dosing. Paracetamol acts centrally via the endocannabinoid system and descending serotoninergic pathways to reduce pain perception; ibuprofen (NSAID) inhibits COX-1/COX-2 enzymes, reducing prostaglandin synthesis at the surgical site, reducing peripheral sensitisation (Hinkle et al., 2022). Regular multimodal analgesia is associated with superior pain control and reduced opioid requirements (Doenges et al., 2019).
- Educate patient that PRN opioid (Oxycodone 5 mg) is prescribed specifically for breakthrough pain and that taking it as needed does not indicate weakness or addiction — explain mechanism and purpose. Patient misconceptions about opioid use are a significant barrier to adequate post-operative pain management; uncontrolled post-surgical pain impairs respiratory effort, increases atelectasis risk, delays mobilisation, and slows recovery (Hinkle et al., 2022).
- Teach and encourage pillow splinting technique for deep breathing exercises and coughing: patient hugs a pillow firmly against the surgical site to support the incision, reducing pain during deep breathing. Pillow splinting reduces incisional tension during inspiration and expiration, decreasing pain associated with respiratory effort and enabling more effective deep breathing, which reduces post-operative atelectasis risk (Hinkle et al., 2022).
- Implement non-pharmacological pain adjuncts: comfortable positioning (semi-recumbent, supported with pillows under the knees to reduce abdominal muscle tension), ice pack application to surgical site per protocol, and distraction techniques. Non-pharmacological interventions provide additive pain relief through distinct mechanisms (cold therapy reduces local inflammatory mediators; positioning reduces tissue tension) without systemic side effects, supporting multimodal analgesia principles (Doenges et al., 2019).
- Plan for first supervised ambulation 30 minutes after analgesic administration when pain score is ≤4/10; provide full assistance and reassurance; increase ambulation distance progressively. Early ambulation reduces deep vein thrombosis risk, promotes respiratory function, and accelerates post-operative recovery; timing ambulation to coincide with peak analgesic effect reduces pain barrier to mobilisation (Hinkle et al., 2022).
Short-term outcome met if pain score ≤4/10 documented at 30-minute post-analgesia assessment. Long-term outcome met if deep breathing performed on request and assisted ambulation to chair completed with pain ≤5/10 by end of shift. If outcomes not met, reassess analgesic timing and effectiveness, consider contacting prescriber for analgesic review, increase non-pharmacological measures, and reassess patient education about the importance of pain management for recovery.
Nursing Diagnosis 2 (Secondary)
Risk for ineffective breathing pattern related to pain-limited respiratory effort, general anaesthesia effects, and abdominal surgical incision (Herdman et al., 2024)
Patient will maintain SpO₂ ≥95% on room air, respiratory rate 12–20 bpm, and will perform incentive spirometer use 10 repetitions per hour while awake by Day 2 post-operatively, as documented in respiratory assessment records (Gulanick & Myers, 2022).
- Monitor respiratory rate, depth, and oxygen saturation (SpO₂) every 2 hours; assess for signs of respiratory compromise (increased respiratory rate, reduced SpO₂, use of accessory muscles, cyanosis). Post-operative atelectasis is a leading cause of fever and respiratory compromise in the first 48 hours following abdominal surgery; early detection enables prompt intervention before hypoxaemia develops (Hinkle et al., 2022).
- Teach and supervise incentive spirometer use: technique, frequency (10 repetitions per hour while awake), and expected sensations; document actual use and performance. Incentive spirometry promotes maximal sustained inspiration, opening collapsed alveoli and preventing progressive atelectasis; research supports its use in post-abdominal surgery patients to reduce pulmonary complications (Hinkle et al., 2022).
- Administer prescribed analgesia on schedule to facilitate deep breathing (see Diagnosis 1 interventions); plan respiratory exercises during peak analgesic effect periods. Effective analgesia enables deeper inspiratory effort, directly supporting incentive spirometry performance and deep breathing exercise outcomes (Doenges et al., 2019).
Common Mistakes in Nursing Care Plans and How to Avoid Every One
Nursing care plan errors cluster consistently around the same problems across student cohorts and clinical settings. Understanding them in advance — rather than discovering them in feedback — changes the quality of every care plan you write from your first submission.
Writing medical diagnoses instead of nursing diagnoses
The most common and most heavily penalised care plan error. “Hypertension,” “Pneumonia,” and “Post-appendectomy” are medical diagnoses. The nursing diagnosis must be a NANDA-I-approved label describing the patient’s human response — “Ineffective health management,” “Impaired gas exchange,” “Acute pain.” Every diagnosis you write should be verifiable against the current NANDA-I taxonomy (Herdman et al., 2024). If it is not there, it is not a nursing diagnosis.
Vague or non-SMART outcomes
“Patient will improve” is not an evaluable outcome. Every outcome must be measurable, time-bound, and stated from the patient’s perspective. If you cannot determine whether the outcome was met or not met at the specified time point, using the specified criterion, it is not SMART enough. Rewrite every outcome that lacks a number, scale, observable behaviour, or deadline.
Interventions without clinical rationales
Every nursing intervention in an academic care plan requires a cited rationale explaining the mechanism by which the intervention addresses the patient’s problem. “Monitor vital signs” is an intervention without a rationale. “Monitor blood pressure every 4 hours to detect end-organ changes associated with acute hypertensive episodes and to evaluate antihypertensive medication effectiveness (Hinkle et al., 2022)” is an intervention with a rationale. Rationale-less interventions typically lose 30–50% of their available marks.
Incorrect PES format — missing components
Actual diagnoses require all three PES components: Problem, Etiology (related to), and Signs/Symptoms (as evidenced by). Missing the “as evidenced by” component turns an actual diagnosis into an incomplete, unsubstantiated statement. Risk diagnoses use only P and E — adding “as evidenced by” to a risk diagnosis is the opposite error, suggesting defining characteristics that by definition do not yet exist. Know which type of diagnosis you are writing and format it accordingly.
Missing or incorrect APA citations
No nursing diagnosis, intervention, or rationale in an academic care plan is self-evidently true — all require source attribution. The most frequently missing citations are the NANDA-I source for diagnoses, pharmacology references for medication interventions, and evidence-based practice citations for specific clinical decisions. A care plan without citations is like a research paper without references: the work may be clinically accurate but is academically incomplete, and will be graded accordingly.
APA formatting errors — title page, running head, references
APA 7th edition student papers do not require a running head unless the instructor specifically requests one — including one is a 6th edition habit that signals unfamiliarity with the current standard. Title pages must include all five required elements (paper title, student name, institution, course, instructor, due date). References require hanging indents, double-spacing, alphabetical order, and either DOI or URL for every electronic source. These formatting requirements are mechanical — they require attention, not expertise — and losing marks on them is entirely avoidable.
APA Title Page and Heading Structure for a Nursing Care Plan Paper
The APA 7th edition title page for a student nursing care plan paper must include five elements: the paper title (centred, bold, using title case), your full name, your institution’s name, the course number and name, the instructor’s name, and the assignment due date. Each element appears on its own line. The page number appears in the top-right header beginning with page 1. There is no running head required for student papers.
Within the paper body, use APA heading levels consistently. For a nursing care plan paper, a typical heading structure might be: Level 1 (centred, bold, title case) for major sections like “Patient Assessment,” “Nursing Diagnoses,” and “References.” Level 2 (left-aligned, bold, title case) for sub-sections within each major section, such as the individual nursing diagnoses. This hierarchy helps markers navigate the document and demonstrates your understanding of APA structure. Always check your specific assignment instructions, as some nursing programmes use institution-specific heading requirements that may differ slightly from the APA default.
The 7th edition (2020) introduced important changes for student nursing papers
Running head eliminated for student papers. Title page updated with course and instructor information. Heading styles refined. DOI format changed to hyperlink. “et al.” now used for three or more authors from first citation (previously from sixth citation). Race and ethnicity terms updated. These changes catch students who learned formatting under the 6th edition — check your edition before submitting.
The NNN Linkage Framework — Using NANDA-I, NOC, and NIC Together
The NNN linkage framework connects NANDA-I, NOC, and NIC as an integrated system for nursing documentation. The three systems are designed to work together: a NANDA-I diagnosis identifies the patient problem; a NOC outcome specifies the measurable change required; a NIC intervention identifies the nursing action to produce that change. This linkage is what produces a coherent, evidence-based care plan rather than a disconnected list of diagnoses, goals, and actions.
| NANDA-I Diagnosis | NOC Outcome | NIC Intervention | Clinical Rationale Basis |
|---|---|---|---|
| Acute pain r/t surgical tissue disruption aeb pain 7/10 | Pain Level: patient reports ≤4/10 within 30 min of analgesia | Pain Management: administer multimodal analgesia on schedule; reassess 30 min post-dose | Pharmacology texts; evidence-based multimodal analgesia guidelines (Hinkle et al., 2022) |
| Ineffective health management r/t knowledge deficit aeb missed antihypertensives | Health-Promoting Behavior: patient verbalises medication purpose via teach-back within 24 hours | Teaching: Disease Process; Teaching: Prescribed Medication | Evidence-based patient education; health literacy interventions (Makic & Martinez-Kratz, 2023) |
| Impaired skin integrity r/t peripheral neuropathy aeb 2 cm heel wound | Wound Healing: Primary Intention — no wound size increase at 48 hours; granulation by Day 7 | Wound Care; Infection Protection; Teaching: Foot Care | Diabetic wound care guidelines; evidence-based moist wound healing (Hinkle et al., 2022) |
| Risk for ineffective breathing pattern r/t post-surgical pain and anaesthesia | Respiratory Status: SpO₂ ≥95% on room air; incentive spirometry 10×/hour by Day 2 | Respiratory Monitoring; Incentive Spirometry; Airway Management | Post-surgical atelectasis prevention protocols; evidence for incentive spirometry (Hinkle et al., 2022) |
| Deficient knowledge r/t diabetes self-monitoring aeb no home BGM, HbA1c 9.2% | Knowledge: Diabetes Management — demonstrated BGM technique before discharge | Teaching: Disease Process; Teaching: Prescribed Medication; Teaching: Psychomotor Skill (BGM) | Diabetes education evidence base; structured patient education outcomes (Gulanick & Myers, 2022) |
Need Help Writing Your Nursing Care Plan?
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Priority Setting in Nursing Care Plans — Maslow and ABC
When a care plan includes multiple nursing diagnoses, the order in which they are addressed is not arbitrary — it reflects the clinical priority of each patient problem relative to others. Two frameworks guide nursing diagnosis prioritisation: Maslow’s Hierarchy of Needs and the ABC framework (Airway, Breathing, Circulation).
Airway (Highest Priority)
Any diagnosis involving airway compromise or risk of airway obstruction is the immediate first priority. Ineffective airway clearance, risk for aspiration, impaired spontaneous ventilation — these diagnoses precede all others. A patient cannot benefit from any other intervention without a patent airway.
Breathing (Second Priority)
Respiratory diagnoses — ineffective breathing pattern, impaired gas exchange — take second priority after airway. These diagnoses threaten oxygenation and therefore all organ function. In the post-surgical pain example, Risk for Ineffective Breathing Pattern takes priority as a secondary diagnosis for this reason.
Circulation (Third Priority)
Cardiovascular and perfusion diagnoses — decreased cardiac output, risk for decreased cardiac tissue perfusion, excess fluid volume — follow. These diagnoses threaten circulatory integrity and therefore tissue oxygenation and organ function.
All Other Diagnoses
Safety diagnoses (risk for infection, risk for falls), then physiological comfort (acute pain), then psychological diagnoses (anxiety, ineffective coping), then knowledge and health management diagnoses. Maslow’s full hierarchy guides prioritisation within these categories.
Documenting your prioritisation rationale — even briefly — in the care plan demonstrates clinical reasoning that markers assess directly. “This diagnosis is prioritised first because it addresses physiological safety needs per Maslow’s Hierarchy of Needs (Maslow, 1943), specifically the risk of circulatory compromise secondary to uncontrolled hypertension” is a one-sentence rationale that shows deliberate clinical thinking rather than arbitrary ordering.
How to Format the Care Plan Table in APA Style
Many nursing care plan assignments require a tabular format in addition to or instead of a narrative format. APA 7th edition provides specific guidance for table formatting that applies to care plan tables within an academic paper.
- Table number: Above the table, bold, left-aligned (Table 1, Table 2, etc.)
- Table title: On the line below the table number, italic, left-aligned, title case. Example: Nursing Care Plan for Patient With Uncontrolled Hypertension
- Column headers: Bold, centred within each column. Use standard care plan headers: Nursing Diagnosis, Expected Outcomes, Nursing Interventions, Rationale, Evaluation
- Table body: Left-aligned text within cells. Use sentence case for cell content (not all caps). Double-space within cells for readability if required by your institution, or use 1.5 spacing within cells while maintaining double-spacing between rows
- Table note: Below the table, “Note.” in italic followed by a period. Use for defining abbreviations (e.g., Note. NRS = Numerical Rating Scale; r/t = related to; aeb = as evidenced by; PRN = as needed)
- Borders: APA recommends no vertical lines in tables. Use horizontal lines above and below column headers and at the bottom of the table. Avoid grid-style borders throughout the table body
- Citations within the table: Include (Author, Year) in-text citations within the Rationale column for each cited source. The full reference appears in the References page, not within the table itself
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Frequently Asked Questions About Nursing Care Plans in APA Format
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