Sample Care Plan using Case Study
NANDA Nursing Diagnoses NOC Outcomes and Indicators
Risk for infection related to
immunosuppression
secondary to chemotherapy,
inadequate primary defenses
(central venous catheter),
chronic disease (ALL) and
developmental level.
NIC Intervention Label and select nursing activities
0702Immune Status 6550 infection protection
Definition: Natural and acquired appropriately targeted Definition: Prevention and early detection of infection in a patient at risk
resistance to internal and external antigens. Activities:
1=severely compromised thru 5= not compromised Monitor for systemic and localized signs & symptoms of infection
Absolute WBC values WNL(within normal limits) (central line site check every 4 hours.)
1 2 3 4 5 Monitor WBC, and differential results (qod)
Differential WBC values WNL(within normal limits) Follow neutropenic precautions
1 2 3 4 5 Provide a private room
Skin integrity Limit number of visitors
1 2 3 4 5 Screen all visitors for communicable disease
Mucosa integrity Maintain asepsis
1 2 3 4 5 Inspect skin and mucous membranes for redness, extreme warmth or
Body temperature IER( in expected range) drainage (q4 hours)
1 2 3 4 5 Inspect condition of surgical incision
Gastrointestinal function (central line insertion site q 4 hours)
1 2 3 4 5 Obtain cultures, as needed (Blood cultures prn T>38.3 C q 24 hours)
Respiratory Function (Drainage @ Central line site)
1 2 3 4 5 Promote Nutritional intake (1500 kcal per day, Pt likes cereal)
Genitourinary Function Encourage fluid intake (1225 cc per day, Pt likes orange Gatorade)
1 2 3 4 5 Encourage rest (naps daily 1-3 PM, bedtime t 8:30 PM)
1= severe thru 5= None Monitor for change in energy level/malaise
Recurrent Infections Instruct patient to take anti-infective as prescribed
1 2 3 4 5 (Bactrim po BID; Nystatin 5cc,swish & swallow, TID)
Weight Loss Teach Family about s & symptoms of infection and when to report them
1 2 3 4 5 to HCP
Tumors (Immature -Teach patient and family how to avoid infections
WBC’s) (NIC, 2008)
1 2 3 4 5
(NOC, 2008 p.399)
 Sample Blank Careplan
Nursing Diagnosis and Interventions: Choose the highest priority Nursing Diagnosis as indicated on the clinical reasoning web.
Include problem statement (NANDA), related to or risk factors (etiology), and defining characteristics (as evidenced by or AEB) as appropriate.
List all of the appropriate NOC Outcome labels and indicators and NIC intervention labels and nursing activities which will best help your client achieve those outcomes.
List the rationale for each and determine where your client falls on the outcome indicator scale (1-5) at the specified time intervals.
In the final column summarize why you gave your client the indicator scores that were given and any changes in your care plan that should be made.
Briefly describe how the plan of care is helping the patient meet the desired outcomes and any changes that need to be made:
Nanda Nursing Diagnosis NOC Outcome Label(s) Rationale for NOC chosen NIC Intervention label(s) and Rationale for NIC Chosen
and indicators and indictor score nursing activities

Complete NANDA Nursing NOC label and Describe your rationale for NIC label and appropriate activities Describe your rationale for choosing this
Dx Statement including appropriate indicators choosing this NOC label and with individualized information added. NIC label
related or risk factors and and rating on scale with the indicator ratings that you
defining characteristics date (s) chose for this patient.