SPC Nursing Dept

HOW TO MAKE A NURSING CARE PLAN (NCP)

A Step by Step Guide using the SPC Format

1. Perform a thorough head-to-toe assessment.

2. Document all assessment findings.
3. Verify, validate, and double-check data.
4. Cluster the data by writing the cues under its corresponding functional health pattern
(based on Gordon’s) on a separate sheet.

Health Nutritional/ Elimination Activity/

Perception/Health Metabolic Exercise
Management

Cognitive/ Sleep/Rest Self-Perception/Self- Role/Relationship

Perceptual Concept

Sexual/ Coping/Stress Value- Belief

Reproductive Tolerance

5. Establish priority using Maslow’s Hierarchy of Needs. Identify whether the

problem/need is high, medium or low priority.
High-priority problem 1st Immediate life-threatening problems
e.g. Severe fluid & electrolyte loss; Respiratory obstruction
Medium-priority problem 2nd Threats to physiologic or psychologic integrity for which
the person is at high risk
3rd Threats to physiologic or psychologic integrity for which
the person is low-risk
Low-priority problem 4th Health maintenance

6. Write the care plan based on the identified/ prioritized needs using the SPC format:
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

NOTE:
Use long bond paper, landscape in orientation, with one-inch margin on all sides.
Write legibly. Table must be neat and clean.
Submit with correct title page.
Attach the page of clustered cues (step #4). It must be properly stapled.

7. Cite all references used (at least five latest and reliable sources)
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 SPC Nursing Dept

EXAMPLE (for you to practice)

Scenario:

Patient X, 3 years old, female, is admitted to the Holy Child Ward due to fever and
cough for three days. Upon initial assessment, her vitals signs were: T: 38.7 oC, RR:
45cpm, HR: 70bpm. She weighs 13.5kg. Her skin is warm to touch, with good turgor.

The patient’s mother reported that the child seems to have lost her appetite and said
“She consumed only two spoons of rice, one small slice of fried chicken and a half glass
of milk during breakfast.”

When the nurse talked to the patient, she complained, “My head is aching.” She also
complained of pain in the chest when coughing and said, “It’s difficult to breathe.” Her
sputum is yellowish in color. Upon auscultation, the nurse heard crackles. She noted
that the patient is using accessory muscles when breathing. She also noted pallor on
the patient’s lips and nailbeds.

ACTIVITY:
1. List down all the cues and identify the subjective and objective data.
2. Cluster the cues/ group them together using Gordon’s Functional Health Pattern. In your
NCP, this is the Need.
3. Prioritize the identified needs into high, medium or low priority.
4. Formulate the nursing diagnosis.
5. Formulate the patient outcome.
6. List down all applicable nursing interventions.
7. In the Implementation column, assign numbers/rank to your interventions according to
order of performance.
8. Evaluate the care plan whether the goal was completely met, partially met, or
completely unmet.

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