UNIVERSITY OF CEBU - BANILAD

College of Nursing

NURSING CARE PLAN

Patient's Name: Hospital No.:
Age: Room No.:
Impression/Diagnosis: Physician:
Nurse's Name & Signature:

CLINICAL REPORT 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

4. Vital signs taking during admission

3. Vital signs taking during the nurse's first contact with the patient 5. Laboratory results regardless of findings
 NURSING SCIENTIFIC GOAL & OUTCOME NURSING ACTIONS & RATIONALE OF
CUES EVALUATION
DIAGNOSIS BASIS CRITERIA NURSING ORDERS NURSING ORDERS

S -- Format: Explain the existence Goal Nursing Actions Explanations why the nurse Filled out only after care has
 Subjective of the nursing  General outcome  General does such functions in been given
data Problem r/t diagnosis.  Broad statement detail, except medications
 “ ” Etiology Nursing Orders because a separate drug Write the following statement
 “ ” Write the author below Outcome Criteria  Specific summary would suffice. accordingly:
 Use NANDA the statement.  Specific
Verbalized by for the (Brunner and  Measurable 1. Goal met:
…… problem Suddarth, 2011)  Attainable Write in the sequence of
 Realistic the nursing functions:
O --  Time-bounded
 Objective data  2-3 outcome criteria for 1. Independent
 Observations every goal 2. Dependent
derived from: 3. Collaborative 2. Goal partially met:
1. Nurse’s 5 Format
senses 1. Subject Follow the steps of the
2. Laboratory  Client nursing process:
results  Anybody part of the
3. Diagnostic 1. Assessment
client
results 2. Planning
 Some attributes of 3. Goal not met:
 V/S of which 3. Intervention
the client
must be 2. Verb
related to the Example:
 What the client will
subjective do, learn,
data Independent
experience. A
3. Conditions/modifiers
 Explains the what, P
where, when, how I
4. Criterion of desired
performance Dependent
 Standard by which A
the performance is
evaluated P
I
Collaborative
A

P
I
 NURSING SCIENTIFIC GOAL & OUTCOME NURSING ACTIONS & RATIONALE OF
CUES EVALUATION
DIAGNOSIS BASIS CRITERIA NURSING ORDERS NURSING ORDERS

Subjective Data: Impaired Vehicular Short term goal: Dependent:  .Rationale: for After 8 hours of nursing
“ Maglisod ko ug physical accident, In 2-3 hours of nursing   Instruct the patient to postion changes or intervention to
lihok” mobility r/t injuries of face interventions the client will use assistive device like transfer maintain or increase
verbalized by musculoskel and be able to maintain or siderails or  Rationale: to strength and function
patient. etal extremities, increase strength and wheelchair maintain position of affected body parts
Objective Data: impairment inflammation, function of affected body   Support affected function and reduced risk were met as evidenced
> Slowed as impaired parts as evidenced by: body of pressure ulcer by:
movement of evidenced physical 1. Verbalized understaning parts or joint using  Ability to move the
both upper and by decrease movement the situation and pillow, rolls and T affected body parts
lower extremities. muscle individual treatment support. without discomfort
> Difficulty tuning. strength regimen and safety  Verbalized
> Limited range measures. understanding the
of motion both 2. Ability to move the situation and
upper and lower affected body parts individual
extremities without discomfort. treatment regimen
3. Demonstrate technique safety measures
or behaviors that enable