URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

Year Level and Group: BSN 2- Block 1 Month/Year of

NURSING CARE PLAN (NCP)
Exposure:
Name of Student:_Capua,Christianne Dyle P

Affiliating Agency/Area:

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Independent
Subjective: Problem, Etiology, Signs Short Term Goal: Short Term Goal Evaluation
(P.E.S.) format S.M.A.R.T. + Evidence -Assessment
After 8 hours of nursing care,
Acute pain may be related After 8 hours of nursing Respiratory status assessment helps
the goal is partially met as
Monitor respiratory status, gauge the patient's severity and whether
to effect of medications intervention the patient including vital signs breath it's progress. evidenced by clients
possible evidence by will promote good
respiratory function and sounds and skin color participation in breathing and
reports of pain and coughing exercises and ability
treat infection
discomfort may be due to to expectorate sputum upon
Therapeutic
treatments of tuberculosis Promote comfort evaluation. Still they are
-monitor ABG levels and
episodes of dyspnea as claimed
oxygen and oxygen saturation
ABG levels and continuous pulse by the client
oximetry measures the blood's oxygen
content and are good indicators of the
Educative lung's ability to oxygenate the blood
-Teach and encourage deep
breathing and coughing
exercises These exercises hasten the expulsion of
sputum and aids in maintaining airway
patency.
Dependent
-Assessment

Monitor breathing patterns and

breath sounds

It provides baseline data for future

comparison in the evaluation of disease
condition
Objective: Long Term Goal: Long term Goal Evaluation
(at least 5) S.M.A.R.T.+ Evidence

After 3 days of nursing

interventions the After 3 days of nursing care
1. Blood and sputum patient's secretions will intervention the patient
culture collected. be mobilized and airway secretions will be mobilized
will show decreased
and the airway will show
secretions
2. Further cultures decreased insecreations.
taken from the
placenta and
cerebrospinal fluid.

3. Chest x-ray and

computed
tomography with
diffuse micronodular
infiltrative pattern
caused w/ old
granulomatous lung
disease

4. Patient was
tachypneic and
hypoxic

5. Premature labor