URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

NURSING CARE PLAN (NCP)

Name of Student:_________________________________________________ Year Level and Group: _______________

Affiliating Agency/Area: ___________________________________________ Month/Year of Exposure: ________________________

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

(at least 10)

Subjective: Problem, Etiology, Signs Short Term Goal: Independent: Short Term Goal Evaluation
(P.E.S.) format S.M.A.R.T. + Evidence  Assessment
"Laging masakit paa
ko" as verbalized by Acute pain related to After 2 hours of Nursing Establish rapport. - To Gain Cooperation of the After 2hrs of nursing intervention
the patient. inflammatory process as Intervention the patient patient Goal met as the patient
evidenced by swollen will appear calm and verbalized comfortability
joints relaxed Ensure Safety -To avoid accident
Objective:
Facial grimacing Encourage passive ROM exercise -To lessen the stiffness of joint
Restlessness
BP 141/76 Encourage the use of mobility - To compensate impaired
RR: 18 aids function and enhance mobility
HR:100
T:36 Use of Pain Scale - To Monitor changes
WT: 49.2KGS
Pain Scale: 6/10 Dependent:
 Assessment
Administer the medication as - To treat disease condition
prescribed by the doctor

Interdependent/Collaborative
 Assessment

Assist for the procedure - To remove toxins from the

hemodialysis blood and excess water in the
body
Objective: INFERENCE Long Term Goal: Long term Goal Evaluation
(at least 5) Scientific Explanation S.M.A.R.T.+ Evidence
(Diagram Form) After 2 days of nursing
After 4 hours of Nursing intervention Goal met as the
intervention the patient patient report a pain scale of
will verbalize decrease of 2/10.
pain