NURSING CARE PLAN (NCP)

Name: (Name of the patient should be kept private and confidential; use initials or a pseudonym: Ex. Patient AML or Patient A)
Age: (You may write the actual age of the patient as these are factors to consider for understanding the case of your patient)
Sex: (You may write the actual sex/gender of the patient as these are factors to consider for understanding the case of your patient)
Medical Diagnosis: (Write the actual diagnosis of the patient: Ex. Pneumonia)
Short Term Goal: (1. This is the GOAL; what you want to achieve in a certain amount of time [within your shift]. 2. Remember this should be SMART. 3. This is based on the
problem of the patient and the cues you have assessed in your patient. 4. This should be written in the future tense. Ex. At the end of my 8-hour shift, the patient will be able to
demonstrate reduction of congestion as evidenced by RR and O2 Sat [within normal range])
Long Term Goal: (1. This is also the GOAL; what you want to achieve in a certain amount of time [with in your rotation]. 2. Remember this should ALSO be SMART. 3. This is
based on the problem of the patient and the cues you have assessed in your patient [but for a longer time frame. 4. This should ALSO be written in the future tense. Ex. At the end
of 3-days of nursing intervention, the patient will be able to maintain airway patency as evidenced by clear breath sounds, noiseless/effortless respirations and improved oxygen
exchange.)

Cues/Data Nursing Diagnosis Rationale Nursing Interventions Rationale Evaluation

Subjective Cues:
(1. This is the problem
verbalized by the patient. 2.
Should be written in how
the patient actually said this
[including language or
vernacular]. 3. This should
be enclosed in “.” Then
write [-as verbalized by the
client]. Ex. “Galisod kog
ginhawa nurse, murag nay
gabara sa akong
ginhawaanan.” -as
verbalized by the client)
[pain]
Problem: [None here] Independent Nursing
(Actual problem of the Interventions:
patient; what the patient (1. These are interventions
actually reports to the that a nurse can do
nurse. Ex. independently without
Difficulty of Breathing) doctor’s orders. 2. State like
you are doing it. Ex.
- Vital Signs Monitoring
[Monitor vital signs every
4hours including breath
sounds and document]
- Encourage increase oral
fluid intake [unless
contraindicated])
(Write a rationale for every
intervention you wrote. Ex.
- To monitor patient’s status
noting for changes and
documenting these changes
- To liquify secretions)
[Evaluation for] Short-term
Goal: (1. Write the
Conclusion + Supporting
Data. 2. Base this on your
GOAL [short term]. 3. See
if the parameters you
included have been met,
partially met, or not met. 4.
This should be stated in the
past tense
Ex.
(C) Goal Met. (SD) After
my 8-hour shift, the patient
was able to demonstrate
reduction of congestion as
evidenced by RR and O2
sat [within normal range])

Objective Cues:
(1. These are the things you
have assessed in your
patient. 2. Emphasize
assessment data that are
Nursing Diagnosis: (This is the definition of Dependent Nursing [Evaluation for] Long-term
(1. Diagnostic Label: base NANDA of the Diagnostic Interventions: Goal: (1. Write the
this on NANDA Nsg. Label Ex. Inability to clear (1. These are interventions (Write a rationale for every Conclusion + Supporting
Diagnosis Handbook. 2. secretions or obstructions the nurse can do only in the intervention you wrote. Ex. Data. 2. Base this on your
PES (3 part statement) Ex. GOAL [long term]. 3. See if
 related to the patient’s (P) Ineffective Airway from the respiratory tract to presence of a doctor’s the parameters you
problem and medical Clearance R/T (E) maintain a clear airway) order. Ex, - to relax smooth included have been met,
diagnosis. 3. Includes vital Retained Secretions (S) as - Administer medications: respiratory musculature, partially met, or not met. 4.
signs and equipments or evidenced by [Expectorants, Mucolytics, reduce airway edema, and This should be stated in the
attachments found on the RR[abnormal], O2 Sat, Anti-Inflammatory and mobilize secretions) past tense
client’s body (IVs, oxygen [abnormal level] and Bronchodilators]) Ex.
cannula, pulse oximeter, productive cough) Goal Met. After 3days of
etc. Ex. [Ineffective Breathing nursing intervention, the
BP: , Pattern], [Pain] patient was able to maintain
PR: , airway patency as
RR: , evidenced by clear breath
Temp: , sounds, effortless
O2 Sat: , respiration, and improved
-Productive cough oxygenation [O2 Sat: ])
-crackles on auscultation
[specify where exactly]
-short and labored
breathing
[pain] )
Collaborative
Interventions:
(1. These are interventions (Write a rationale for every
that a nurse does with intervention you wrote. Ex.
another member of the
health care team. Ex.
- Perform/Assist client in - to mobilize secretions and
doing CPT (postural facilitate drainage.)
drainage and percussion)

[Write all the interventions [Write a rationale for [Depends on your CI, but
you have done (in your EVERY intervention] the important GOAL to be
duty) or you will be doing evaluated is the short term
(if you are working na)] goal]

Prepared By:

______________________________
Student Nurse
BSN (Section) Group (#)