University of Cebu – Banilad

College of Nursing
Cebu City

NURSING CARE PLAN

Patient’s Name : Hospital No. :

Age : Room No. :
Impression/Diagnosis: Physician :

CLINICAL PORTRAIT PERTINENT DATA

1. Assessment (general impression from head to toe) 1. History of present illness

2. Chief complaints

2. Significant findings
3. Health history relevant to present illness

3. Vital signs taken during the nurse’s first contact with the 4. Vital signs taken during admission
patient

5. Laboratory results regardless of findings

 RATIONALE
NURSING
NURSING SCIENTIFIC OF
CUES GOAL & OUTCOME CRITERIA ACTIONS & EVALUATION
DIAGNOSIS BASIS NURSING
NURSING ORDERS
ORDERS
S– Format: Explains the Goal Nursing Actions
existence of the  general outcome • general Explanations Filled out only
 Subjective data Problem r/t nursing diagnosis.  broad statement Nursing Orders why the nurse after care has
Etiology Outcome Criteria • specific does such been given
 " “  specific functions in
 use
Write the author  measurable Write in the sequence of detail, except Write the
below the  attainable the nursing functions: medications following
NANDA statement. 1. Independent because a statement
 " “, for the (Brunner  realistic
&  time – bounded 2. Dependent separate drug accordingly:
proble Suddarth, 2001) 3. Collaborative summary would
as verbalized by …  2 – 3 outcome criteria for every
m suffice. 1.Goal met:
goal Follow the steps of the
nursing process:
Format: 1. Assessment
O– 1. Subject 2. Planning 2.Goal partially met:
 Client 3. Intervention
 Objective data  Any body part of the
client Example:
 Observations derived  Some attributes of the Independent 3.Goal not met:
from: client A
1. Nurse’s 5 senses 2. Verb P
2. Laboratory results  What the client will do, I
3. Diagnostic results learn, experience Dependent
3. Conditions/modifiers A
 v/s of which must be  Explains the what, P
related to the where, when, how I
subjective data 4. Criteria of desired performance Collaborative
 Standard by which the A
performance is P
evaluated I
 NURSING RATIONALE
NURSING SCIENTIFIC ACTIONS & OF
CUES GOAL & OUTCOME CRITERIA EVALUATION
DIAGNOSIS BASIS NURSING NURSING
ORDERS ORDERS