Professional Documents
Culture Documents
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)_____________
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
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 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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