The nursing care plan is a written document that outlines how a patient will be cared for. A typical nursing care plan includes nursing diagnoses, expected outcomes, interventions, rationales and an evaluation. A nursing rationale is a stated purpose for carrying out a nursing intervention. Nursing interventions are actions that nurses perform to help patients achieve specified health goals. A nursing rationale is written next to each nursing intervention in the nursing care plan.

Write the nursing diagnosis. The nursing diagnosis is a statement of an actual observed risk or potential problem of the patient. "Body image, disturbed," Ineffective coping" and "Nutrition imbalanced: less than body requirements" are examples of nursing diagnoses. Generally the care plan will include multiple diagnoses. Rate the importance of each nursing diagnosis, from 1 for highest priority to 3 for lowest.

Identify expected outcomes for each nursing diagnosis and write them in the plan. Expected outcomes are stated goals for the patient. "The patient will walk steadily without assistance," "The patient will be pain-free" and "The patient will have clear lung sounds" are examples of expected outcomes. Expected outcomes should be stated with a definite time frame attached to them.

Write nursing interventions next to the expected outcomes. Ask: "What do I need to do to help this patient achieve this goal?" For example, if the expected outcome is "The patient will be pain-free," a nursing intervention might be, "Administer pain medication as needed or as ordered."

Write the nursing rationale next to each nursing intervention in the plan. The rationale is the "why" of the nursing care plan. It is the explanation you provide for performing a duty such as administering medications, irrigating a wound or orienting a patient to time and place. For example, if the nursing intervention is "administer pain medication as needed," the rationale could be, "Maximum pain control will help Mrs. X participate in physical therapy exercises and improve her quality of life."