Registered Nurse Template

Nursing Care Plan

A professional Registered Nurse template for healthcare professionals.

About this template

The Nursing Care Plan template makes it easy for Registered Nurses to organise patient information, define care priorities, and track outcomes. It guides you through assessment, goal setting, interventions, and evaluation—helping ensure every aspect of care is well-documented and patient-focused. The template streamlines documentation, saving time and improving the accuracy and quality of nursing records.

Preview template

Patient Name: Emily Carter Age: 78 Medical Diagnosis: Pneumonia Assessment: - Patient presents with a productive cough, shortness of breath, and a fever of 38.5°C. - Medical history includes hypertension and a recent fall. Identified Nursing Problem: Impaired gas exchange related to pneumonia. Goals/Outcomes: - Patient will demonstrate improved respiratory function, as evidenced by a respiratory rate within normal limits and oxygen saturation above 90% within 48 hours. - Patient will be afebrile within 72 hours. Interventions: 1. Administer oxygen via nasal cannula at 2L/min, as prescribed. 2. Encourage deep breathing and coughing exercises every 2 hours. 3. Monitor vital signs, including respiratory rate, oxygen saturation, and temperature, every 4 hours. Evaluation: The patient's respiratory rate has decreased from 32 breaths per minute to 24 breaths per minute, and oxygen saturation has improved from 88% to 94% on 2L of oxygen. The patient remains febrile. The goals are partially met. Continue interventions and monitor for further improvement. The patient will be reassessed on 2 November 2024.

Patient Name: [patient's full name] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else include the section heading but omit the placeholder.) Age: [patient’s age] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else include the section heading but omit the placeholder.) Medical Diagnosis: [primary medical diagnosis or condition relevant to the care plan] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else include the section heading but omit the placeholder.) Assessment: - [describe patient’s current condition, symptoms, or nursing concerns] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) - [include relevant medical history, background, or clinical observations] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Identified Nursing Problem: [brief description of the nursing problem or care issue based on assessment findings] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as a single sentence.) Goals/Outcomes: - [measurable, time-bound goal related to the nursing problem] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as bullet points.) - [additional goal if applicable] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as bullet points.) Interventions: 1. [nursing action to address the identified problem and support the goal] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. 2. [additional nursing action if applicable] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) 3. [further nursing action if present] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Evaluation: [assessment of the patient’s progress toward goals and response to nursing interventions, including whether goals were met, partially met, or unmet] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in a paragraph of full sentences.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)

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