NCP: FORMAT, CONTENT SOURCE,

CONTENT CORGANIZATION (FCC)

Format: Confusion Addressed!
Content Source: How to use
NANDA?
Content Organization: How to
Satisfy you Instructors'
Expectations
Defines nurse’s role
Provides direction for individualized care of the client
Continuity of care
Documentation
Serves as guide for assigning a specific staff to a specific client
Defines client’s goals
 ADPIE
Assessment
Diagnosis
Planning
Intervention
Evaluation
Care plans by student nurses are usually required to be handwritten and have
an additional column for “Rationale” or “Scientific Explanation” after the
nursing interventions column.
Two types of sources;
NANDA
-Nursing Diagnosis
Internet
- Nursing Diagnosis
- Nursing Intervention
- Rationale
Helps identify nursing priorities
Helps the formulation of expected outcomes
Provides a common language and forms a basis for
communication and understanding between nursing
professionals and the healthcare team.
For nursing students, nursing diagnoses are an
effective teaching tool to help sharpen their problem-
solving and critical thinking skills.
A nursing diagnosis refers to one of many diagnoses in the classification
system established and approved by NANDA. In this context, a nursing
diagnosis is based upon the response of the patient to the medical condition.
Ex. Anxiety, Fear, and Disturbed Sleep Pattern
A medical diagnosis , on the other hand, is made by the physician or advance
health care practitioner that deals more with the disease, medical condition, or
pathological state only a practitioner can treat.
Ex. Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney
Disease
The four types of NANDA
nursing diagnosis are
Actual (Problem-Focused),
Risk, Health Promotion, and
Syndrome.
Problem-focused diagnosis (also known as actual diagnosis) is a client
problem that is present at the time of the nursing assessment. These
diagnoses are based on the presence of associated signs and symptoms.
Examples:
Anxiety related to stress as evidenced by increased tension, apprehension,
and expression of concern regarding upcoming surgery
Acute Pain related to decreased myocardial flow as evidenced by grimacing,
expression of pain, guarding behavior.
Impaired Skin Integrity related to pressure over bony prominence as
evidenced by pain, bleeding, redness, wound drainage.
The second type of nursing diagnosis is called Risk Nursing Diagnosis . These
are clinical judgment that a problem does not exist, but the presence of risk
factors indicates that a problem is likely to develop unless nurses intervene.
Components of a risk nursing diagnosis include: (1) risk diagnostic label, and
(2) risk factors. Examples of risk nursing diagnosis are:
Risk for Falls as evidenced by muscle weakness
Risk for Injury as evidenced by altered mobility
Risk for Infection as evidenced by immunosuppression
NOTE/CLARIFICATION: RISK DIAGNOSIS HAVE NO SIGNS & SYMPTOMS
INCLUDED IN ITS FORMAT BECAUSE FROM THE WORD "RISK" ITSELF, THE
PROBLEM DO NOT OCCUR YET TO THE PATIENT.
Problem and definition

Defining Characteristics/signs
and symptoms
Related Factors/Etiology
Associated condition
Can be put on nursing Dx as etiology/related
factor
The problem statement describes the client’s health problem or response for which nursing
therapy is given as concisely as possible.
The etiology/related factors , component of a nursing diagnosis label identifies one or more
probable causes of the health problem, are the conditions involved in the development of the
problem.
Risk factors are written following the phrase “as evidenced by” in the diagnostic statement.
A 25 year old female in admitted to your floor due to extreme nausea followed by
some vomiting. The patient had a chemotherapy treatment 24 hours ago. She is
getting chemotherapy due to having stage 4 cervical cancer. This was her first
chemotherapy treatment. The patient is lying on her side with her arms around her
stomach. The patient intermittently moans out in discomfort. A vomit basin is at
the bedside. The patient says she's extremely nauseous. Upon assessment patient
V/S are HR 101, BP 120/80, Temperature 37.3, RR 20, oxygen saturation 98% on
room air. H of appendectomy and c-section.
Subjective Data:
Patient says she's extremely nauseous
Objective Data:
25 year old female
Patient had a chemotherapy treatment 24 hours ago
Patient is lying on her side with her arms around her stomach
Patient intermittently moans out in discomfort
A vomit basin is at the bedside
V/S
HR: 101 RR: 20
BP: 120/80 O2 Sat 98%
Temp: 37.3
Nausea related to effects of
chemotherapy as evidence by patient
reporting nausea followed by some
vomiting and chemotherapy treatment
Step 1. Read the Case Scenario
Step 2. Data Collection or Assessment
2.1. Subjective Data - As verbalized by the patient
2.2. Objective Data- Something you can prove,
something measurable, what you see as a nurse. V/S
and Lab results
Step 3. Data Analysis and Organization
Step 4. Formulating a Nursing Diagnosis
Step 4.1. 3 Parts of a Nursing Dx
P roblem
R elated to
A s Evidenced by
NANDA - North American Nursing Diagnosis
Association
- Make sure that your diagnosis fits the
definition of the problem
Step 5. Setting Priorities
the process of establishing a preferential sequence for address nursing
diagnoses and interventions. In this step, the nurse and the client begin
planning which nursing diagnosis requires attention first. Diagnoses
can be ranked and grouped as having a high, medium, or low priority.
Life-threatening problems should be given high priority.
Culture and Sensitivity Test
Step 6. Planning/ Establishing Client Goals and Desired Outcomes
Goals or desired outcomes describe what the nurse hopes to achieve by
implementing the nursing interventions derived from the client’s
nursing diagnoses
S- SPECIFIC
M - MEASURABLE
A - ATTAINABLE
R - REALISTIC
T - TIMELY
GOALS AND EXPECTED OUTCOMES MUST BE MEASURABLE AND CLIENT-CENTERED.
Step 6.1 2 Types of Goals
Goals are constructed by focusing on problem prevention, resolution,
and rehabilitation.

Goals can be short-term or long-term. Most goals are short-term in an

acute care setting since much of the nurse’s time is spent on the
client’s immediate needs. Long-term goals are often used for clients
who have chronic health problems or live at home, in nursing homes, or
in extended-care facilities.
Step 6.2 Components of Goals and Desired Outcomes
Goals or desired outcome statements usually have four components: a
subject, a verb, conditions or modifiers, and criterion of desired
performance.
Step 7. Selecting Nursing Interventions
Nursing interventions are activities or actions that a nurse performs to
achieve client goals. Interventions chosen should focus on eliminating
or reducing the etiology of the nursing diagnosis.
Step 8. Providing Rationale
Rationales, also known as scientific explanations, explain why the
nursing intervention was chosen for the NCP. Rationales do not appear
in regular care plans. They are included to assist nursing students.
Step 9. Evaluation
Evaluating is a planned, ongoing, purposeful activity in which the
client’s progress towards achieving goals or desired outcomes and the
effectiveness of the nursing care plan (NCP). Evaluation is an essential
aspect of the nursing process because conclusions drawn from this
step determine whether the nursing intervention should be terminated,
continued, or changed.
CASE SCENARIO
ASSESSMENT
Subjective Data:
Patient states she is experiencing constipation and has been unable to have a bowel
movement for 5 days
Patient says she has been “straining” and she is having difficulty passing stool and
when she does it is a very hard small “ball”.
Patient says she feels ” a lot of pressure” in her rectum and she is having pain from
hemorrhoids
Patient states she is afraid to have a bowel movement because of the pain caused by
the hemorrhoids
Objective Data:
26 year old female
On her day 3 of postpartum care from delivering a baby via c-section
NURSING DIAGNOSIS
Constipation related to pain on defecation
secondary to hemorrhoids as evidence by the
patient reporting she has not had a bowel
movement for 5 days, hard stool, rectum
pressure, and painful hemorrhoids.
GOALS/DESIRED OUTCOMES
The patient will have a bowel
movement before discharge.
The patient will report decreased
pain in rectum from hemorrhoids.
The patient will verbalize 3
techniques on how to keep bowel
movements regular.
The patient will verbalize how to take
prescribed medication regime to
prevent constipation.
NURSING INTERVENTIONS
The nurse will administer per MD orders
Miralax and Colace as prescribed to help
assist patient with bowel movement.
The nurse will assess and document
when patient has had a bowel movement
daily.
The nurse will provide the patient with a
sitz bath and hemorrhoid cream as
prescribed to help with hemorrhoid pain.
The nurse will educate the patient on 3
techniques on how to keep bowl
movements regular by discharge.
NURSING INTERVENTIONS
The nurse will administer per MD orders
Miralax and Colace as prescribed to help
assist patient with bowel movement.
The nurse will assess and document when
patient has had a bowel movement daily.
The nurse will provide the patient with a
sitz bath and hemorrhoid cream as
prescribed to help with hemorrhoid pain.
The nurse will educate the patient on 3
techniques on how to keep bowl
movements regular by discharge.
RATIONALE
- Miralax and Colace , as prescribed to help assist
patient with bowel movement.This medication is
used to treat occasional constipation. Stool
softeners such as docusate are often the first
method used for preventing and treating this type
of constipation.
A sitz bath is a relaxing way to naturally relieve a
variety of hemorrhoid symptoms. Hemorrhoids cream
is used to temporarily relieve swelling, burning, pain,
and itching caused by hemorrhoids.
To help the patient have a more comfortable bowel
movement
Patient education leads to better patient
satisfaction with providers and their overall care.
Educational plans can reduce provider's liability.
GOALS/DESIRED OUTCOMES
The patient will have a bowel
movement before discharge.
The patient will report decreased
pain in rectum from hemorrhoids.
The patient will verbalize 3
techniques on how to keep bowel
movements regular.
The patient will verbalize how to take
prescribed medication regime to
prevent constipation.
EVALUATION
Goal Met
Patient had a bowel movement before
discharge.
Patient had reported decreased pain in
rectum from hemorrhoids.
Patient verbalized 3 techniques on how to
keep bowel movements regular.
Patient verbalized how to take prescribed
medication regime to prevent
constipation.
Patient showed signs of relief from
constipation
DO'S DON'TS
1. Write goals and outcomes in terms of client 1. Nursing interventions should be specific and clearly
responses and not as activities of the nurse. Begin stated, beginning with an action verb indicating what
each goal with “Client will […]” help focus the goal the nurse is expected to do.
on client behavior and responses.
2. Action verb starts the intervention and must be
2. Avoid writing goals on what the nurse hopes to precise. Qualifiers of how, when, where, time,
accomplish, and focus on what the client will do. frequency, and amount provide the content of the
planned activity. For example: “Educate parents on how
3. Ensure that each goal is derived from only one to take temperature and notify of any changes,” or
nursing diagnosis. Keeping it this way facilitates “Assess urine for color, amount, odor, and turbidity.”
evaluation of care by ensuring that planned nursing
interventions are clearly related to the diagnosis set. 3. Do not ever put a medical diagnosis on the first part
of the nursing Dx (problem/diagnosis)
4. Lastly, make sure that the client considers the goals
important and values them to ensure cooperation.
 RegisteredNurseRN.com. Nursing Care Plan. https://www.registerednursern.com/?
s=nursing+care+plan
Nurseslabs.com. Nursing Care Plan. hhttps://nurseslabs.com/nursing-care-
plans/#step_9_putting_it_on_paper
T. Heather Herdman, PhD, RN, FNI, Shigemi Kamitsuru, PhD, RN, FNI. (2018). Nausea
.NANDA International, Inc. Nursing Diagnoses Definitions and Classification
T. Heather Herdman, PhD, RN, FNI, Shigemi Kamitsuru, PhD, RN, FNI. (2018). Constipation
.NANDA International, Inc. Nursing Diagnoses Definitions and Classification

YOUTUBE CHANNELS ABOUT NURSING SCHOOL

RegisteredNurseRN
Level Up RN
That Nursing Prof
Simple Nursing
Armando Hasudungan
You ARE
CAPABLE
of

-Spartan League of Nurses