University of Cebu – Banilad

College of Nursing
Cebu City

NURSING CARE PLAN

Patient’s Name : Hospital No. : _

Age : Room No. : _
Impression/Diagnosis: _ Physician : _

CLINICAL PORTRAIT 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 taken during admission

3. Vital signs taken during the nurse’s first contact with the
patient. 5. Laboratory results regardless of findings

NURSING CARE PLAN 1

 NURSING SCIENTIFIC GOAL & OUTCOME NURSING ACTIONS & RATIONALE OF
CUES EVALUATION
DIAGNOSIS BASIS CRITERIA NURSING ORDERS NURSING ORDERS
S– Format: Explains the existence Goal Nursing Actions
 Subjective data of the nursing  general outcome  General Explanations why the nurse Filled out only after
Problem r/t diagnosis.  broad statement Nursing Orders does such functions in detail, care has been given
Etiology Outcome Criteria  Specific except medications because a
 “______ _”  specific separate drug summary Write the following
 use NANDA Write the author  measurable Write in the sequence of the would suffice. statement accordingly:
for the below the statement.  attainable nursing functions:
 “______ _” problem (Brunner & Suddarth,  realistic 1. Independent 1.Goal met:
2001)  time – bounded 2. Dependent
as verbalized by…  2 – 3 outcome criteria for 3. Collaborative ___________
every goal
O– Follow the steps of the nursing 2.Goal partially met:
Format process:
 Objective data 1. Subject 1. Assessment ___________
2. Planning
 Client
 Observations derived 3. Intervention 3.Goal not met:
 Any body part of
from: the client
1. Nurse’s 5 senses Example: ___________
 Some attributes of
2. Laboratory results Independent
the client
3. Diagnostic results A
2. Verb P
 v/s of which must  What the client I
be related to the will do, learn, Dependent
experience A
subjective data
3. Conditions/modifiers P
 Explains the what, I
where, when, how Collaborative
4. Criteria of desired A
performance P
 Standard by which I
the performance is
evaluated

NURSING CARE PLAN 2

CUES NURSING SCIENTIFIC GOAL & OUTCOME NURSING ACTIONS RATIONALE OF EVALUATION
DIAGNOSIS BASIS CRITERIA & NURSING ORDERS NURSING ORDERS
Subjective: Decreased Cardiac Inadequate blood After 4 hours the Client Will: Independent:
------ Output pumped by the heart  Display hemodynamic Determine vital Provides baseline for Goal not met, after 4
to meet the metabolic stability (e.g., blood signs/hemodynamic comparison to follow trends hours of nursing
Objective: demands of the body. pressure, cardiac output, parameters including cognitive and evaluate response to interventions, patient
Lab Results; [In a hypermetabolic renal perfusion/urinary status. Note vital sign interventions. vitals drop to zero
 Creatinine: 9.0 state, although cardiac output, peripheral pulses). response to baseline related to
 BUN: 79.3 output may be within activity/procedures and time septic shock
 BUA: 649 normal range, it may  Report/demonstrate required to return to baseline.
 Sodium: 119.50 still be inadequate to decreased episodes of
 Magnesium: 0.71 meet the needs of the dysrhythmias. Review signs of impending Early detection of changes in
 Albumin: 20.50 body’s tissues. Cardiac failure/shock, noting these parameters promote
 Total Bilirubin: output and tissue  Demonstrate an increase in decreased cognition and timely intervention to limit
89.10 perfusion are activity tolerance unstable/low blood degree of cardiac dysfunction.
interrelated, although pressure/invasive
Vital Signs: there are differences. hemodynamic parameters;
 BP: 120/70 When cardiac output tachypnea; labored
 HR: 107 is decreased, tissue respirations; changes in breath
 RR: 31 perfusion problems sounds (e.g., crackles,
 Temp: 36.9 will develop; however, wheezing); distant or altered
 O2 Sat: 96% tissue perfusion heart sounds (e.g., murmurs,
problems can exist dysrhythmias); and reduced
without decreased urinary output.
cardiac output.
Monitor vital signs frequently To note response to
activities/interventions.

Dependent:
Administer high-flow oxygen To increase oxygen available
via mask or ventilator, as for cardiac function/ tissue
indicated perfusion

To determine therapeutic,
Administer blood/fluid adverse, or toxic effects of
replacement, antibiotics, therapy.
diuretics, inotropic drugs, anti-
dysrhythmics, steroids,
vasopressors, and/or dilators,
NURSING CARE PLAN 3
as indicated.
To maintain body temperature
Alter environment/bed linens in near-normal range.
and administer antipyretics or
NURSING CARE PLAN 4