Care Plan Builder

Nursing care plan builder

Build a nursing care plan from your assessment. Connect nursing diagnoses, supporting findings, expected outcomes, interventions, and evaluation in one place.

The Care Plan Builder in NurseBrain® Synapse walks you through each part of the plan. You choose every problem, finding, intervention and outcome, so the plan matches your patient.

Start building a care plan See how it works

Start as a guest in your browser. Sign in to export your plan as a PDF.

Care Plan Builder review screen showing the nursing problem Impaired Gas Exchange, its related to and as evidenced by findings, three interventions with activity bullets, the expected outcome, and outcome chips with Improved selected.
The review screen at the end of the builder: one problem with what it is related to and the findings that support it, the interventions with their activities, and the expected outcome. The patient is fictional.

How the builder works

Three screens take you from the problem you found to a plan you can review.

  1. What's the problem?

    Pick the focus area that fits what you assessed, such as respiratory. Choose a nursing problem from the list or write your own. You can add what it is related to and the findings that support it.

  2. What are you going to do?

    Add interventions with an action type and the specific activities you will carry out. Then write the outcome you are aiming for and the direction of change: improved, stabilized or deteriorated.

  3. Review your plan

    Check the finished plan, edit any intervention or the outcome, and add another problem if your patient needs one. Then export it as a PDF or save it to a patient.

Want the full walkthrough with the narrated tutorial? Learn the CCC and ADPIE method

Start building a care plan

What a finished plan looks like

Each problem in your plan reads the way you would write it on a care plan. This example uses the same fictional pneumonia patient as our care plan guide.

Nursing diagnosis
Impaired Gas Exchange
Related to
alveolar inflammation and retained secretions from pneumonia
As evidenced by
dyspnea on exertion, SpO2 90% on room air, crackles in the right lower lobe, productive cough
Interventions
  • Monitor Pulmonary Care
    • Assess breath sounds, RR, effort and SpO2 every 4 hours
    • Note sputum color and amount each shift
  • Perform Oxygen Therapy Care
    • Administer O2 as ordered; titrate to the ordered SpO2 target
    • Check tubing, flow rate and skin under the device
  • Teach Breathing Exercises
    • Teach deep breathing and coughing every 2 hours while awake
    • Coach incentive spirometer use, 10 breaths each hour
Expected outcome
Patient will maintain SpO2 at or above 92% with unlabored breathing at rest by the end of the shift.

On the review screen you can change or remove interventions and their activities, edit the expected outcome, mark how the patient responded or choose to evaluate later, and add or remove problems.

Browse nursing care plan examples

Our condition care plans are reference examples you can read and print. Opening the builder from this page starts a blank plan for your own patient. On any example page, Customize opens that condition plan in the builder, ready to edit.

See all nursing care plan examples

Guest access, saving and export

  • Open the builder in your browser and build a full plan as a guest.
  • To export your plan as a PDF to print or share, sign in or create an account.
  • Already using NurseBrain® Synapse? Save the finished plan to one of your patients.
Start building a care plan

Questions about the builder

Does the builder write the care plan for me?

No. The builder guides you through each part of the plan, and you choose the problem, findings, interventions and outcome. The clinical reasoning stays yours.

Is the Care Plan Builder free?

You can open the builder and build a plan in your browser for free. Exporting a PDF needs an account. The full NurseBrain® Synapse app is a paid subscription that starts with a 7-day free trial.

Which nursing terminology does the builder use?

The builder uses the Clinical Care Classification (CCC) System, a standardized nursing terminology for diagnoses, interventions and outcomes. Our CCC and ADPIE guide explains how the parts fit together.

How is this different from the care plan examples?

The examples are complete reference plans for common conditions. The builder is where you make your own plan for the patient in front of you.

Learn the method behind the plan

New to care plans, or want to see every step with real screenshots? The CCC and ADPIE guide covers the nursing process, related to and as evidenced by, outcomes, and interventions, with a narrated tutorial.

Read the CCC and ADPIE care-plan guide

Build your next care plan

Start building a care plan

Start as a guest in your browser. Sign in to export your plan as a PDF.

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