PATIENT/NURSING CARE PLAN

N
C
P
MODULE 7

Diens

Pre-advance level
for S-1 Nursing Students 2008

DEFINITION

A nursing care plan outlines the nursing

care to be provided to a patient.
It is a set of actions the nurse will
implement to resolve nursing problems
identified by assessment.
The creation of the plan is an intermediate
stage of the nursing process.
It guides in the ongoing provision of
nursing care and assists in the evaluation of
that care.

VOCABULARY

PATIENT / NURSING
CARE PLAN (NCP)
ASSESSMENT (n)
DIAGNOSIS (n)
PLANNING (n)
INTERVENTION (n)
EVALUATION (n)

Rencana asuhan
keperawatan (askep)
Pengkajian
Diagnosis
Perencanaan
Intervensi/tindak. kep.
Evaluasi

Characteristics of the nursing care plan

It focuses on actions which are designed to

solve or minimize the existing problem.
It is a product of a deliberate systematic
process.
It relates to the future.
It is based upon identifiable health and
nursing problems.
Its focus is holistic.
It focuses to meet all the needs of the
service user.

Elements of the plan

In the USA, the nursing care plan may

consist of a NANDA nursing diagnosis with
related factors and subjective and
objective data that support the diagnosis,
nursing outcome classifications with
specified outcomes (or goals) to be
achieved including deadlines, and nursing
intervention classifications with specified
interventions.

Nursing Process
Care plans are formed using the nursing process:
1.
2.

3.
4.
5.

ASSESSMENT
DIAGNOSIS
PLASNNING
INTERVENTION
EVALUATION

1. ASSESSMENT

First the nurse collects subjective data and

objective data, then organizes the data into a
systematic pattern, such as Marjory Gordon's
Gordon's functional health patterns.
This step helps identify the areas in which the
client needs nursing care.
Based on this, the nurse makes a nursing
diagnosis

2. DIAGNOSIS
As mentioned above, the full nursing diagnosis also
includes the relating factors and the evidence that
supports the diagnosis. For example, a nurse may give
the following diagnosis to a patient with pneumonia that
has difficulty breathing: Ineffective Airway Clearance
related to tracheobronchial infection (pneumonia) and
excess thick secretions as evidenced by abnormal
breath sounds; crackles, wheezes; change in rate and
depth of respiration; and effective cough with
sputum.(This Nursing Diagnosis is taken from the list of
NANDA's functional health patterns,Disturbed pattern is
"Activity and Exercise pattern")

3. PLANNING
After determining the nursing diagnosis, using
the PES (Problem, Etiology, Signs and
Symptoms) system, the nurse must state the
expected outcomes (goals).
A common method of formulating the expected
outcomes is to reverse the nursing diagnosis,
stating what evidence should be present in the
absence of the problem.
The expected outcomes must also contain a
goal date.
Following the example above, the expected
outcome would be: Effective airway clearance as
evidenced by normal breath sounds; no crackles
or wheezes; respiration rate 14-18/min; and no
cough by 01/01/01.
3

4. INTERVENTION
After the goal is set, the nursing interventions
must be established.
This is the plan of nursing care to be followed to
assist the client in recovery.
The interventions must be specific, noting how
often it is to be performed, so that any nurse or
appropriate faculty can read and understand the
care plan easily and follow the directions exactly.
An example for the patient above would be:
Instruct and assist client to TCDB (turn, cough,
deep breathe) to assist in loosening and
expectoration of mucous every 2 hours.
4

5. EVALUATION
The evaluation is made on the goal date set.
It is stated whether or not the client has met the
goal, the evidence of whether or not the goal
was met, and if the care plan is to be continued,
discontinued or modified.
If the care plan is problem-based and the client
has recovered, the plan would be discontinued.
If the client has not recovered, or if the care plan
was written for a chronic illness or ongoing
problem, it may be continued.
If certain interventions are not helping or other
interventions are to be added, the care plan is
modified and continued.

ASSESSMENT DATA PATTERNS

1.

2.
3.

Gather all data that leads you to a particular nursing

diagnosis and its resolution and divide this information
into two lists, subjective data or objective data.
Remove any information that is NOT directly linked to the
one nursing diagnosis on which you are working.
In the Subjective Data list include relevant :
client complaints
description of the client's support system
behavioural and nonverbal messages
client awareness of her/his own
abilities / disabilities
disease process
prognosis
health care needs
available resources

ASSESSMENT DATA PATTERNS

4. In the objective data list include relevant:
physical assessments including vital signs
observations of the support system in action
judgment of the client's readiness for learning,
her learning potential, and locus of control
chart information including lab and test results

NURSING DIAGNOSES
1. When writing a plan that includes several
diagnoses, write the diagnosis with the
highest priority first.
2. A plan must start with the major issues for
that client. For example, if the client is in
acute distress over one problem, a plan
covering only other minor problems would
show lack of sensitivity on your part.
3. Select only diagnoses that are appropriate
with resolution by actions you can take.

NURSING DIAGNOSES
4. Write out the three parts of the Nursing Diagnosis
(R.E.D.):

The human Response of the client [wellness response /

problem (anxiety)]
Etiology or related events / factors, designated as R/T
Data that is evidence of the diagnosis. You have already
listed this information under Assessment Data Patterns, so
say "as evidenced by the data listed above".

Note on related factors: Most human responses are

related to several factors. List them all.
For example : anxiety related to
new environment,
separation from usual support system,
big exam in two days

CLIENT GOALS
1.

2.

3.

Number each goal stating the client Goal, the

Tool to measure goal achievement, and the
Time to evaluate (GTT) :
The goal must be stated in terms of client
achievement. ( for example : "The client will
report a reduction in feelings of anxiety")
Each goal must be measurable. You must
indicate how you will measure if the goal has
been achieved. ( for example : "as measured
by the client assessing her/his anxiety as less
on a 10 Point Anxiety Scale. It is now 7 on the
10-point scale.")

CLIENT GOALS
4.

5.

6.

Each goal must state a target date and hour for

evaluation.( The Anxiety Scale will be re administered
in 24 hours : date, hour.)
Write at least one "short term goal" for every Nursing
Diagnosis. This will demonstrate your ability to actually
help a client achieve a goal. To get credit for the
Evaluation section of your Care Plan set a time when
you will be there to evaluate goal achievement. ( for
example :" by noon today")
Some goals that are important for your client are "long
term goals". Write at least one "long term goal" for
each Nursing Care Plan you develop. Your instructors
understand that this kind of goal will have a time
frame for evaluation that goes past the due date for
the Care Plan. See the section on Evaluation on how to
word the Evaluation of any "long term goal".

NURSING INTERVENTIONS
WITH SCIENTIFIC RATIONALE
1.

2.

3.
4.

5.

Immediately following each goal that you write, list specific

nursing actions you used to work toward that goal.
Nursing actions must be specific, not global, appropriate,
and without important omissions. In most cases several
interventions are needed to achieve any one goal.
If your idea to use a nursing action comes from a Care
Plan book or other source, cite the source.
After each nursing action give the scientific rationale for
selecting the action. Cite your source for this rationale.
Sources might include a book, lecture, discussion with a
health professional or media source.
Rationale must be logical and relevant.

EVALUATION OF THE PLAN

1.

2.

3.

4.

5.

State when you evaluated the goal. This should be the same
time you designated in the Goal Statement earlier. (for
example : " At noon 2/15/98")
Use the measures you designated for goal achievement to
state your client's degree of success. (for example : "the
client evaluated her anxiety as 4 on a 10-point scale.")
Draw conclusions on the interventions used related to the
outcome. (for example : "Helping the client to talk about her
feelings reduced her sense of isolation .")
Consider changes or additions to the interventions that might
improve goal achievement. (For example: "Studying with
the client before the next examination should reduce her
anxiety even more.")
For the "long term goal" you write state: "Evaluation of this
goal is set for (state the date & time). The client has made
(no) (some) (significant) progress toward this goal
: (describe any movement toward the goal)."

NCP: CHICKEN POX

ASSESSMENT

SUBJECTIVE:
Nilalagnat ako at may mga butlig ako sa buong
katawan (I have a fever and rashes all over my
body) as verbalized by the patient.
OBJECTIVE:
Warm to touch
Irritability
Petechiae
V/S taken as follows:
T: 37.9 P: 93 R: 21 BP: 120/80

NCP: CHICKEN POX

DIAGNOSIS

Hyperthermia related to viral infection

NCP: CHICKEN POX

INFERENCE

Chickenpox, also known as varicella, is a highly

contagious and self-limited infection that most
commonly affects children between 5-10 years of
age. The disease has a worldwide distribution and is
reported throughout the year in regions of temperate
climate. The peak incident is generally during the
months of March through May. Lifelong immunity
for chickenpox generally follows the disease. If the
patient's immune system does not totally clear the
body of the virus, it may retreat to skin sensory
nerve cell bodies where it is protected from the
patient's immune system. The disease shingles (also
known as "zoster") represents release of these
viruses down the length of the skin nerve fiber and
produces a characteristic painful rash. Shingles is
most commonly a disease of adults

NCP: CHICKEN POX

PLANNING

After 8 hours of nursing interventions, the

patient will demonstrate temperature
within normal range and will experience
no associated complications

NCP: CHICKEN POX

INDEPENDENT:

INTERVENTION

Provide isolation or monitor visitors as indicated.

Wash hands with antibacterial soap before or after care of
the patient.
Encourage patient to cover mouth and nose during coughs
or sneezes.
Monitor patient temperature, degree and pattern.
Observe for chills and profuse diaphoresis.
Monitor environmental temperature.
Provide tepid sponge baths, avoiding the use of alcohol.
Encourage to use calamine lotion.

COLLABORATIVE:
Administer antipyretics as indicated.

NCP: CHICKEN POX

RATIONALE

Body substance isolation should be used for all

infectious patients and patients with diseases
transmitted through air may also need airborne and
droplet precautions.
Reduces the risk of spreading the infection.
Prevents the spread of infection via airborne droplet.
Fever patter aids in the disease process and
diagnosis.
Precede temperature spikes in presence of
generalized infection.
Room temperature should be altered to maintain
near-normal body temperature.
May help reduce the fever.
To help reduce the itchiness.
Used to reduce the fever by its central action on the
hypothalamus.

NCP: CHICKEN POX

EVALUATION

After 8 hours of nursing interventions, the

patient was able to demonstrate
temperature within normal range and
experienced no associated complications.

THANKS for your attention

Practice makes perfect!