FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)

Chapter I - ASSESSMENT
A. Nursing Health History
Adult History
1. Personal data
2. Chief Complaint
3. History of present illness
4. Past Medical History
5. Family Health History
6. Social history

The student t must make her own nursing health history and NOT to copy
from the chart. Each item copied from the chart will be subject to
deduction
 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)

7. Review of Systems (ROS)

§ Adult: Person's Gordon's Approach [Psychological, Elimination, Rest and
Sleep, Safety and Security, Oxygenation, Nutrition] using the
TABULAR FORMAT
§ Pediatrics: In lieu of Review of Systems- Growth and Development
theories following:
§ (Student must briefly discuss theory and relate it adequately to his/her
patient)
§ Psychosocial -- Erik Erickson
§ Psychosexual - Sigmund Freud
§ Cognitive - Jean Piaget
§ Moral - Lawrence Kohlberg
§ Spiritual - James Fowler
NOTE: The Review of Systems must include data before, during, and after
hospitalization. A summary of all areas with problems identified must be
reflected at the end of the Review of Systems
 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)

Review of Systems (ROS) TABLE

Area Before During After Analysis References
and (EBP,
Interpretati Journals,
on and Books)
Psychologic
al
Elimination
Rest and
sleep
Safety and
Security
Oxygenatio
n
Nutrition
 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)

B. Physical Assessment
The report of physical assessment must be in paragraph form
and following the School of Nursing PA format.
§ NOTE: Same rule applies here as mentioned in the
nursing health history. Copying from the chart is NOT
allowed .
§ The use of other tools OB/ Pedia Assessment Tools are
likewise needed if applicable
ž Highlight in RED all abnormal findings seen during
assessments. Students must pay particular attention to signs
that are present and associated to the condition
 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)

C. Diagnostic Procedure
A brief discussion of the following must be included:
1. Name of the diagnostic procedure
2. Definition/description of the procedure
3. Specific indication of the procedure
4. Nursing responsibilities

All diagnostics tests/ procedures must be related by the

student to the specific condition of the client. Students must
emphasize the relation of the tests to their client’s condition
 FORMAT OF THE DIAGNOSTIC PROCEDURES TABLE
NOTE: The table below must be strictly followed in the
presentation of the laboratory and diagnostic tests and relate it
to the specific condition of client. Students must emphasize the
relation of the tests to their client’s condition

Name of Date ordered Normal Values Values Clinical

Procedure (based on Obtained Interpretation
standards of (results of
the hospital) the test)
Example: CBC October 26, Hgb: Hgb: Must
2006 Hct: Hct: scientifically
RBC: RBC: explain why
there is an
increase or
decrease
FORMAT OF THE COMPREHENSIVE NURSING CARE PROCESS
(CNP)
D. Anatomy and Physiology
§ This will involve the discussion of the organ and system
affected. A drawing must be included. This must be drawing
of the student. No downloading and photocopying allowed.
Be sure the drawings are properly labeled.
E. Pathophysiology/ Disease Process
§ This must include a comprehensive definition and
description of the disease. There must also be a schematic
diagram or a pathway from the predisposing and
precipitating factors leading to the signs and symptoms of
the disease condition. The pathophysiology must include
all the signs and symptoms manifested by client and
the findings seen in the physical assessment
 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)
Chapter II - PLANNING

A. List of Prioritize Nursing Diagnoses

There must be a three column table indicating rationale for the
prioritization of the nursing diagnoses
B. Nursing Care Plans
There must be three (3) highly prioritized problems following
the format on the table below

Rank Problem (Complete Diagnostic Statement- Justification

Problem [Nursing Diagnosis] related to [Circulation, Airway,
[Etiology] as evidenced by [Signs and Breathing/ Maslow’s
Symptoms] Hierarchy of Needs]
1
2
3
 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)
CUES NURSING SCIENTIFIC PLANNING IMPLEMENTATION SCIENTIFIC EVALUATION
DIAGNOSIS EXPLANATION RATIONALE

FUTURE TENSE FUTURE TENSE PAST TENSE

Sublective- pt.
verbalization… Patient
states …as verbalized by
the patient or S.O. only if
Necessary
Objective - data gathered
hru observation, interview,
PA & records
-measurable cues
- specific to your nsg. dx
- based on PA presented
in chapter1
- result of diagnostic tests/
lab results
BASED ON PARAGRAPH FORMAT Discharge outcome: Independent COMPREHENSIVE DISCHARGE OUTCOME
PRIORTIZED For Level 1 and 2 Attainable beyond 1 week Done by Nurse’s alone EXPLANATION esp. to ACHIEVED- Mention the
PROBLEMS e.g. : “After 2 wks of nsg. (minimum of 5) prioritized nursing parameter/ indicators
ACTUAL SCHEMATIC DIAGRAM Intervention…” Follow the sequence of action. It must be book PARTIALLY ACHIEVED-
OF THE identifying interventions based Mention what was achieved
NURSING PATHOPHYSIOLOGY ( Long term outcome if 1. Assessment In each intervention , NOT ACHIEVED-
DIAGNOSIS For Level 3 and 4 used in community setting) 2. Nursing indicate your (development of another care
Risk nsg.dx can be Note: Start with the Short term outcome: management rationale plan)
considered as 2nd ETIOLOGY and end with Attainable within hours, ( 3. Health teaching Make sure that the
priority signs and symptoms depends upon the nursing Collaborative: REFERENCE
If the patient is for (indicate the reference, dx Constant is the includes the chapter
discharge, page number and Should contain the 5 Diet and Medications and page it was
wellness dx is chapter) components of outcome Dependent to other health found (BRUNNER /
allowed statements care professionals KOZIER/ PILLITER
- Subject (minimum of 2) I/ WONG/ TAYLOR
- Verb NANDA NOT
- Condition ADVISABLE
- Performance criteria
- Target time Reference must not
exceed five (5) years

Research/ Journal
must likewise be
used in the
intervention-
Evidenced based
nursing practice
 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)

Chapter III - IMPLEMENTATION

B. Medical Management
1. Drug Study
The table below must be followed:

Drug Classificat Dose, Mechanis Contra- Side Nursing

ion/ route and ms of indication effects Responsi
Indication frequency action s bilities

Generic 4 and
Brand above
 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)

2. Treatment
This must include a brief discussion of all prescribed treatments
like blood transfusions, nebulizations, oxygen therapy, NGT, IVF
and other.
3. Diet
To discuss why that particular diet is prescribed to the patient
and samples of the diet must also be included,
 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)

3. Activity/exercise
To included the ordered activity of the patient. Explain why this
particular activity is ordered. Example: ROM exercises,
complete bed rest without bathroom privileges
§ a. Definition, Description
§ b. Specific indication
§ c. Date Ordered
§ d. Date performed/ given
§ e. client's reaction
§ f. Nursing responsibilities
4. Surgical Management (if any)
 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)

C. Nursing Management
These are general interventions related to the specific disease
process
D. Client's Daily Progress Chart
The table below must be followed:
Diagnostic Diet Activity Medications Treatments Surgery
Procedure

Admission

Day 1

Day 2

Discharge
 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)

Chapter IV - EVALUATION

A. Narrative Evaluation of Actual Nursing Problems

B. Discharge Planning Instructions:

 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)
M MEDICATIONS- include those prescribed by the physician to be taken home by the
patient upon discharge
E EXERCISE - In case no particular exercise was ordered by the doctor before Discharge,
the student must base this on his/her review of Related readings/ researches. To include
activities that may be Essential to enhance the patient's faster recovery

T TREATMENT - The treatments prescribed by the doctor like monitoring the Blood
sugar, nebulizations, etc
H HEALTH TEACHINGS - To include those that are highly related and essential to the
case of the patient
O OUT PATIENT DEPARTMENT - Indicate the OPD schedule check up

D DIET - This must be specific to the case of the patient. The student must be able to
mention examples and to explain why the particular foods are important for the client’s
condition. The student can include sample meal plan for the patient
 REFERENCES

ž Students must use proper citation (APA) and

credible references.
ž Evidenced Based Practices (EBP) must be
incorporated in the Nursing Care Plan and the
reference/s for this must be reflected in the
references section of the CNP.
ž All references reflected in the CNP must be
updated (up to maximum of five years
publication date from the current year)
 FORMAT OF THE COMPREHENSIVE NURSING CARE PLAN (CNP)

PRESENTATION

(Includes Over-all output CONTENT, COMPLETENESS,

PRESENTATION, & LEGIBILITY)
FORMAT FOR THE COMPREHENSIVE NURSING PROCESS
LOGBOOK - FRONT COVER (WITH PLASTIC COVER)

CENTRO ESCOLAR UNIVERSITY

SCHOOL OF NURSING
Mendiola, Manila

COMPEHENSIVE NURSING PROCESS

LOGBOOK

Mr. Juan Dela Cruz

BSN2A1
Reminder

Do your CNP well

ALL THE TIME.

Thank you.