Name: ________________________ Date: ________

Section: ___________

ACTIVITY 8

Developing a Nursing Care Plan

Interview someone who will act as your client and develop a Nursing care Plan (NCP).

Name of Client: _________________________ Age: ____________ Gender: ____

Present Weight: __________________ Height: __________________

BMI = ________________ BMI Classification = __________________________

Waist/ Hip Ratio

ASSESSMENT

1. Make a diet history for 2 days

(What has your patient been eating for 2 days?) (Breakfast, Lunch, Dinner)

DETAILED RECORD OF FOOD EATEN

DATE/ TIME AMOUNT FOOD/ drinks (all intake)
EXAMPLE:
8AM 1 cup (200ml) Coffee
1 slice White loaf bread
2. How is your patient’s appetite? ________________________________
3. Is this diet typical? ____________ If NOT, explain why? ___________________
4. Foods that your client liked best:
________________________________________________________________
5. Foods disliked or avoided: ___________________________________________
6. Other observations: (unusual attitude, relationship)
7. History:
 Any recent illness, clinic consultation, or hospitalization? ____________
 If YES, what was the cause or the diagnosis? ____________________________
 Any recent medications your client has taken? (specify, if
any)_______________________________________________________
 Any laboratory tests done to your client? (specify, if any)____________________

8. Ask your client if there are problems with eating or digestion (example: constipation,
diarrhea, vomiting) that he/ she has experienced lately? What are her / his thoughts
about the cause of the condition?
______________________________________________________________________
______________________________________________________________________
_____________________________________________
9. Try to identify the Nursing Diagnosis out of the gathered assessments
 ___________________________________________________________________

(nursing problem) + (cause / etiology) + (manifestations)

You can list the Nursing Interventions below that are appropriate or applicable to the
case of the patient. As much as possible, know why these interventions should be done
(write as the rationale for each intervention)

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________