NCP Tarifa

Holy Angel University
School of Nursing and Allied Medical Sciences

NCM-109RLE / Second Semester, SY 2022 – 2023
Name: ____________________ Date:

Section: ___________________ Clinical Instructor: __________________
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Altered tissue After nursing - Identify presence of - Identify factors that After nursing
- Feeling of perfusion related to interventions, the patient high-risk factors or place clients at greater interventions, the
dizziness hypovolemia will: conditions. risk for developing patient:
associated
Objective: (Short term) - Assess skin color, complications. (Short term)
- Alteration in - Verbalize temperature, and - Helps in determining - Verbalized
skin characteristics understanding of risk whether changes are location and type of understanding of risk
- Alteration in factors or condition, widespread or perfusion problem. factors or condition,
motor function therapy regimen, side localized. - Problems with therapy regimen, side
- Hypertension effects of medications, ambulation; effects of medications,
and when to contact - Assess motor and hypersensitivity; or loss and when to contact
healthcare provider. sensory function. of sensation, numbness, healthcare provider.
and tingling are changes
(Long term) - Collaborate in that can indicate (Long term)
- Demonstrate treatment of underlying neurovascular - Demonstrated
increased perfusion as conditions. dysfunction. increased perfusion as
individually appropriate - To maximize systemic individually appropriate.
- Provide intervention to circulation and organ
promote circulation and perfusion.
- To enhance circulation
and promote general
wellbeing.
limit complications
associated with
perfusion.
Name: ____________________ Date:


NURSING CARE PLAN

Risk for injury related After nursing  Provide healthcare After nursing
to side effects of intervention, the within a culture of interventions:
phototherapy. patient will: safety.
 To prevent errors  Verbalized
(Short Term)  Practice hand resulting in client understanding of
 Verbalize hygiene at all injury, promote individual factors
understanding times, and device client safety that contribute to
of individual safety when client behaviors for possibility injury.
factors that has IV lines and clients.
contribute to catheters.  Demonstrated
possibility injury.  To prevent
behaviors,
 Orient or reorient healthcare-
lifestyle changes
(Long Term) client to associated
to reduce risk
 Demonstrate environment, as infections and
factors and
behaviors, needed. potential for
lifestyle bloodborne
changes to pathogens
 Provide proper
reduce risk positioning.
factors and  To provide for
protect self from frequent
 Identify
injury. observation.
interventions and
safety devices.
 To promote safe
environment and
individual safety.
Name: ____________________ Date:

NURSING CARE PLAN

Risk for injury related After nursing  Monitor vital signs,  Hypotension and After nursing
to decreased intervention, the including BP, PR, tachycardia are interventions:
hemoglobin patient will: and RR. initial
secondary for compensatory  Be free of signs
bleeding (Short Term)  Assess skin color mechanisms of active
 Be free of signs and moisture, usually bleeding, such as
of active urinary output, associated with hemoptysis,
bleeding, such level of bleeding. hematuria,
as hemoptysis, consciousness, or hematemesis, or
hematuria, mentation.  Changes in these excessive blood
hematemesis, signs may be loss, as
or excessive  Regulate IVF and indicative of evidenced by
blood loss, as monitor patency of blood loss stable vital signs,
evidenced by vascular access. affecting skin and mucous
stable vital systemic membranes free
signs, skin and  Anticipate the circulation or of pallor, and
mucous need for a platelet local organ usual mentation
membranes free transfusion once function, such as and urinary
of pallor, and the platelet count kidneys or brain. output.
usual mentation drops to a very low  Identified
and urinary value.  Improve longevity individual risks
output. of vascular and engaged in
 Provide access. appropriate
(Long Term) information about behaviors or
 Identify dietary sources of  Platelet lifestyle changes
individual risks iron. replacement may to prevent or
and engage in reduce the

appropriate frequency of
behaviors or be required to bleeding
lifestyle reduce the risk of episodes.
changes to bleeding.
prevent or  Demonstrated
reduce the measures to
 To increase
frequency of prevent bleeding
hemoglobin,
bleeding and recognized
myoglobin.
episodes. signs of bleeding
that need to be
 Demonstrate reported
measures to immediately to a
prevent health care
bleeding and professional.
recognize signs
of bleeding that
need to be
reported
immediately to a
health care
professional.
Name: ____________________ Date:

NURSING CARE PLAN

Subjective: Acute pain After nursing intervention,  Monitor vital After nursing interventions:
 Self-report related to the patient will: signs, including
of intensity tissue trauma temperature  Identify precipitating  Reported pain is
using secondary to (Short Term) BP, PR, RR, or aggravating and relieved or
standardize surgery  Report pain is and skin color. relieving factors to controlled.
d pain scale. relieved or control.  Obtain clients fully understand  Verbalized
 Proxy report  Verbalize assessment of client’s pain nonpharmacological
of pain nonpharmacological pain to include symptoms. methods that
behavior methods that location,  To demonstrate provide relief.
activity provide relief. characteristics, improvement in  Verbalized sense of
changes.  Verbalize sense of onset, duration, status or to identify control of response
control of response frequency, worsening of to acute situation
Objectives to acute situation quality, and underlying and positive outlook
 Change in and positive outlook intensity. condition/developing for the future.
physiologica for the future.  Perform pain complications.  Demonstrated use
l parameter. assessment  It reduces muscle of relaxation skills
 Distraction (Long Term) each time pain tensions and and diversional
behavior,  Demonstrate use of occurs. fatigue. activities, as
expressive relaxation skills and Document and  To maintain an indicated, for
behavior. diversional investigate acceptable level of individual situations.
 Facial activities, as changes from pain.
expression indicated, for previous
of pain. individual situations. reports and
 Guarding evaluate
behavior, results of pain
interventions.
protective
 Assist in
behavior,
positioning different
to ease positions like
pain. sitting and side
lying position.
 Self-
 Administer
focused,
narrowed analgesics to
focus reduce pain.
Name: ____________________ Date:

NURSING CARE PLAN

Subjective Knowledge deficit After nursing  Determine the  The individual After nursing
 Insufficient regarding condition, intervention, the client’s ability, may not be interventions:
knowledge. prognosis, and patient will: readiness, and physically,
treatment needs. barriers to emotionally, or  Participated in
Objectives (Short Term) learning. mentally capable learning process.
 Inaccurate  Participate in at this time.  Identify
 Assess the level of
follow- learning interferences to
the client’s  The client or
through of process. learning and
capabilities and caregivers may
instruction or  Identify specific actions
the possibilities of need help to
performance interferences to to deal with them.
the situation. learn.
on a test or learning and  Verbalized
 Review with  Validates current
procedure specific actions understanding of
patient/SO level of
 Inappropriate to deal with condition,
understanding if understanding,
behavior. them. disease process,
specific diagnosis, identifies learning
 Verbalize and treatment.
treatment needs, and
understanding alternatives, and provides
of condition,  Performed
future knowledge base
disease necessary
expectations. from which
process, and procedures
treatment. patient can make correctly and
informed explained
(Long Term) decisions. reasons for the
 Perform actions.
necessary  Initiated
procedures necessary
correctly and lifestyle changes
explain reasons and participate in
for the actions. treatment
 Initiate regimen.
necessary
lifestyle
changes and
participate in
treatment
regimen.
Name: ____________________ Date:

NURSING CARE PLAN

Fluid volume deficit After nursing  Monitor and After nursing

related to fluid shifting intervention, the document vital interventions:
out of the vascular patient will: signs, especially
compartment BP and HR.  Patient explained
(edema) (Short Term)  Assess skin turgor  A decrease in measures that
 Patient explains and oral mucous circulating blood can be taken to
measures that membranes for can cause treat or prevent
can be taken to signs of hypotension and fluid volume loss.
treat or prevent dehydration. tachycardia.  Patient
fluid volume  Assess color and  To identify signs verbalized
loss. amount of urine. of dehydration awareness of
 Patient are also detected causative factors
 Monitor and
verbalize through the skin. and behaviors
document
awareness of temperature.  Normal urine essential to
causative output is correct fluid
 Monitor fluid status
factors and considered deficit.
in relation to
behaviors normal, not less  Patients
dietary intake.
essential to than 30ml/hour. demonstrated
 Note the presence
correct fluid Concentrated lifestyle changes
of nausea,
deficit. urine denotes to avoid
vomiting, and
fluid deficit. progression of
fever.
(Long Term)  To identify dehydration.
 Patients insensible water  Patient described
demonstrate loss symptoms that
lifestyle  To verify if the indicate the need
changes to patient is on a to consult with
avoid fluid restraint is health care
progression of necessary. provider.
dehydration.  These factors

 Patient influence intake,
describes fluid needs, and
symptoms that route of
indicate the replacement.
need to consult
with health care
provider.

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Holy Angel University

School of Nursing and Allied Medical Sciences

Name: ____________________ Date:

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Name: ____________________ Date:

Section: _ Clinical Instructor:

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Name: ____________________ Date:

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

and engage in reduce the

Name: ____________________ Date:

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Name: ____________________ Date:

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Name: ____________________ Date:

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Fluid volume deficit After nursing  Monitor and After nursing

dehydration.  These factors

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