Nursing Care Plan

STEPHANIE BONIFACIO LADERO, RN,MSN, JDc

▪ A nursing care plan (NCP) is a formal process that includes correctly
identifying existing needs, as well as recognizing potential needs or
risks. Care plans also provide a means of communication among
nurses, their patients, and other healthcare providers to achieve
health care outcomes. Without the nursing care planning process,
quality and consistency in patient care would be lost.
ASSESSMENT

▪ Assessment is the first step of the

ADPIE process.
▪ During the assessment phase
medical professionals will attempt
to identify the problem and
establish a data base by
interviewing the individual and/or
family members, observing their
behavior and performing
examinations.
▪ This step focuses heavily on
collecting/recording data, validating
information and listing any
abnormalities in the data.
▪ Assessment data can be collecting in
one of two ways, subjective or
objective.
Subjective Data

▪ Subjective data is data that can

not be measured directly.
▪ This can include verbal
information such as asking
questions, obtaining verbal
feedback, interviewing other
individuals and collecting/
gathering information on a
patients health history.
▪ Subjective data is often referred
to as symptomatic as it can not
be measured or observed directly.
▪ Objective data is data that is measurable
and can be seen, heard, felt or smelt.
▪ This can include performing an examination
to measure a patients weight, blood
pressure, heart rate and body temperature.
▪ Because objective data is measurable they
are often referred to as signs.
▪ During the assessment phase it is important
to gather as much data as possible and
identify if the data is accurate, concise,
consistent and clear.
▪ Once you’ve gathered enough accurate data
you can form a conclusion about the
patients condition and move into the next
phase, which is diagnosis.
Diagnosis

▪ The diagnosis phase of

the process is the phase where the
medical professional develops a
theory or hypothesis about the
individuals situation based on the
information that has been collected
while performing an assessment.
▪ While nurses are unable to form a
professional diagnosis they are able
to develop their critical thinking and
communicate their clinical
judgments to their team members.
▪ In fact nurses have a standardized
language for communicating their
clinical judgments, which comes
from NANDA international.
▪ While a professional diagnosis may
not be given by a nurse these
medical professionals are able to
identity actual or potential medical /
health risks.
▪ Once a diagnosis has been
performed any potential risks that
may cause complications or harm to
the individual should be placed in
order with the highest risk listed as
the top priority (life-threatening)
and lower risks being addressed
later in the list (non life-threatening /
minor / future well-being).
▪ After the problems have been
identified and prioritized the phase
of the process is planning.
Nursing Diagnosis in P.E.S. Format

Problem:

The main problem or the priority problem of the patient

sometimes it can be gathered using the chief complain.
NOTE: Priority Problem

Qualifiers

1. Acute/chronic

2. Impaired

3. Imbalanced

4. Ineffective

5. Activity intolerance

6. Altered

7. Decreased/ Increased
Etiology:
The probalble cause of the problem.
The origin or the determinant

Ex: (Related to)

Acute pain related to tissue
ischemia
Ineffective airway clearance related
to viscous secretions on lungs
Signs:
These are the signs or symptoms that supports
the main problem.
Ex:
Acute pain related to tissue ischemia as
manifested by immobility on the lower
extremities
Ineffective airway clearance related to viscous
secretions on lungs as evidence by productive
cough
Imbalance Nutrition less than body
requirements related to decrease appetite and
nausea as showed by decrease body weight.
Nursing Diagnosis: Inference

Scientific Explanation
This is a brief clarification or a
short pathophysiology on how
the main problem occur. NOTE:
in a diagram form.
Ex:
Planning

▪ Planning is the process of developing a plan

and establishing SMART goals in order to
achieve a desired outcome such as reducing
pain or improving cardiovascular function.
▪ SMART goals stand for specific, measurable,
attainable, realistic/relevant and time
restricted.
▪ SMART goals are developed to provide the
individual with a focused set of activities that
are designed to improve their condition.
▪ They also provide medical professionals with
a plan in which they can measure and
evaluate the individuals improvements.
▪ After the care plan, interventions and SMART
goals have been established it needs to be
implemented.
2 Types:
▪ Short-term goal – a statement
distinguishing a shift in
behavior that can be
completed immediately,
usually within a few hours.
▪ Long-term goal – indicates an
objective to be completed over
a longer period, usually over
days weeks or months.
Intervention

This are actions, a nurse takes to

implement their patient care plan it
includes treatments, procedures or
teaching moments intended to
improve the patient’s comfort and
health
NOTE: it should focus based on the
planning phase
NOTE: it should be written in a past
tense format. (documentation is
always at the end of every
procedure, consider it done)
Examples of Intervention

▪ Note:
Assessment
Therapeutic
Educative
Rationale

In every intervention there is a

rationale
A stated purpose for carrying out
nursing intervention.

Ex: Positioned the patient in a

semi fowlers position.
Rationale: to promote lung
expansion and ease breathing
pattern.
Evaluation

▪ The last phase of the process is

the evaluation phase.
▪ This is the part where the medical
professionals assess and evaluate
the success of the planning and
implementation processes to
ensure that the individual is
making progress towards his/her
goals and is achieving the desired
outcome.
▪ If the process is not working
reassess it and determine
whether it needs to be modifying
or eliminated.
SAMPLE NCP
NURSES NOTE

▪ A nursing note is a medical note into

a medical or health record made by a
nurse that can provide an accurate
reflection of nursing assessments,
changes in patient conditions, care
provided and relevant information to
support the clinical team to deliver
excellent care.
▪ Complete and accurate nursing notes
are crucial to make good decisions
for patient care. Nursing notes
should provide a clear and accurate
picture of the patient while under the
care of the healthcare team.
FDAR FORMAT
Focus Charting

▪ Date and Time

▪ Focus (the problem)
▪ Data
▪ Action (interventions)
▪ Response
NOTE:

▪ Write a line on every spaces

▪ Write your full name with
signature above
▪ If an written error occurred
(put a single straight line
indicate error and initial
signature)
▪ Past tense Format
NOTE:

▪ Always include interventions initiated and the patient

response when documenting an acute abnormality
found during assessment

▪ Always elaborate when documenting a body system

abnormality with each assessment

▪ Always include if an assessment was visual, audible, and/

or tactile

▪ Reconcile mismatched objective and subjective

assessment findings

▪ Document the patient’s baseline mental status

▪ Always assess the patient at the time of discharge or

transfer.

▪ Use quantifiable data with descriptions. Reference to

common objects, such as a quarter or soda can, to
describe the size or shape of wounds may be useful with
awkward shapes or when there isn’t access to a
measurement device.
DRUG STUDY

MEDICATION
▪ A medication is a substance that is taken
into or placed on the body that does one of C CURE
the following things:
▪ Most medications are used to cure a disease
or condition. For example, antibiotics are T TREAT
given to cure an infection.
CUTE
▪ Medications are also given to treat a medical PARIN
Condition. For example, anti-depressants R
are given to treat depression. PREVENT
▪ Medications are also given to relieve
symptoms of an illness. For example, pain
relievers are given to reduce pain. P RELIEVE
▪ Vaccinations are given to prevent diseases.
For example, the Flu Vaccine helps to
prevent the person from complications of
having the flu.
DRUG STUDY

▪ Generic name: Chemical make up

▪ Brand name: Manufacturer/
Company
▪ Dosage: mg, cc/ml
▪ Route: oral, nasal, buccal,
sublingual, intravenous,
intramuscular, subcutaneous, eye
drops, ear drops, transdermal,
topical,
▪ Frequency: OD, BID, TID, q4, q8,
q12, RTC
DRUG STUDY

▪ Classification: Medications and other ▪ Side effects: Or undesirable secondary

compounds that have similar chemical effect which occurs in addition to its desired
structures, the same mechanism of action a therapeutic effect
related mode of actin and or used to treat
the same disease. ▪ Adverse Effect: Unwanted or harmful
reaction experienced following the
▪ Mechanism of Action Refers to the specific administration of a drug. Discontinue or
biochemical through which drug substance dose reduced.
produces it pharmacological effect.
▪ Indications: Valid reasons for the use of
medication.
▪ Contraindication: Drug should not be used
because it may harm the person.
2 TYPES
▪ Relative contraindication: Drug to Drug
interaction
▪ Absolute contraindication: Could cause life
threatening situation
NURSING RESPONSIBILITY
10 Rights of Drug Administration

1. Right drug 7. Right drug approach and

right to refuse
2. Right patient
8. Right drug to drug
3. Right route interaction and evaluation
4. Right dose 9. Right education and
5. Right time and frequency information

6. Right history and assessment 10. Right documentation

Panyang