SPC Nursing Department

NURSING CARE PLAN

Name of Patient: (Use Code)____________________________ Age: _____ Ward: _________________ Bed#: ____
Chief Complaint: ______________________________________ Diagnosis: ______________________________________________
Physician: (Use Code)__________________________________

Date/ Cues Need Nursing Patient Nursing Implementation Evaluation

Time Diagnosis Outcome Interventions
Write the Write all Use the MENTALLY Identify Formulate List down all Number each Go back to
actual date pertinent Gordon's type of nursing patient appropriate, nursing your patient
and time of assessment Functional diagnosis (problem- outcome using realistic, intervention outcome.
assessment findings Health focused, risk, health the five applicable according to its
Patterns promotion) components of interventions. order of Make a
Subjective outcome performance. judgment
cues (if Write your nursing criterion. Read from whether the
applicable) diagnosis It must be various and For example: goal was
specific, latest sources. Assign number completely
Objective cues Follow format measurable, 1 for your first met, partially
(NANDA I) attainable, Provide nursing met,
Vital signs realistic, time rationale to intervention completely
Provide rationale. bound each performed and unmet.
Laboratory intervention. so on...
results Provide
supporting
Medications data
(objective,
subjective
data)

Affix your
complete
name and
signature