Prepared By: Sarah Diana Rise S. Manalili, RN

NCP
Prepared by: Sarah Diana Rise S. Manalili, RN

What is a nursing care plan?
• A nursing care plan (NCP) is a formal process that correctly
identifies existing needs and recognizes potential needs or risks.
• Care plans provide communication among nurses, their patients,
and other healthcare providers to achieve health care outcomes.
• Without the nursing care planning process, the quality and
consistency of patient care would be lost.
Components
• A nursing care plan (NCP) usually includes nursing diagnoses,
client problems, expected outcomes, and nursing interventions
and rationales. These components are elaborated below:
• Client health assessment, medical results, and diagnostic
reports. This is the first measure in order to be able to design a
care plan.
• Information in this area can be subjective and objective.
• Expected client outcomes are outlined. These may be long
and short term.
• Nursing interventions are documented in the care plan.
• Rationale for interventions in order to be evidence-based care.
• Evaluation. This documents the outcome of nursing
interventions.
Goal Unmet, Goal Met and Partially Met ( If only 1 goal was
met for 2 or more goals.)
Writing a Nursing Care Plan
• Step 1: Data Collection or Assessment

• create a client database using assessment techniques and data collection
methods (physical assessment, health history, interview, medical records
review, diagnostic studies).
• CUES
• Step 2: Data Analysis and Organization
• Now that you have information about the client’s health, analyze, cluster,
and organize the data to formulate your nursing diagnosis, priorities, and
desired outcomes.
• Step 3: Formulating Your Nursing Diagnoses
• NANDA nursing diagnoses are a uniform way of identifying, focusing on
and dealing with specific client needs and responses to actual and high-
risk problems.
• Actual or potential health problems that can be prevented or resolved by
independent nursing intervention are termed nursing diagnoses.
NANDA International (NANDA-I)
• NANDA–International earlier known as the

North American Nursing Diagnosis Association (NANDA) is the principal
organization for defining, distribution and integration of standardized
nursing diagnoses worldwide.
Problem-focused nursing diagnoses
• three components:
• (1) nursing diagnosis,
• (2) related factors, and
• (3) defining characteristics. Or Signs and Symptoms
• Acute Pain related to decreased myocardial flow as
evidenced by grimacing, expression of pain, guarding
behavior.
• Impaired Skin Integrity related to pressure over bony

prominence as evidenced by pain, bleeding, redness,
wound drainage.
PE
Problem : Acute Pain

Etiology: related to decreased myocardial flow
PES
Problem :Acute Pain

Etilogy: related to decreased myocardial flow
S/Sx: as evidenced by grimacing, expression of
pain, guarding behavior.
PESS
Problem :Acute Pain

Etilogy: related to decreased myocardial flow
S/Sx: as evidenced by grimacing, expression of
pain, guarding behavior
Secondary to Myocardial Infarction
Risk Nursing Diagnosis
• The second type of nursing diagnosis is called risk nursing diagnosis.

• These are clinical judgments that a problem does not exist, but the
presence of risk factors indicates that a problem is likely to develop unless
nurses intervene.
• There are no etiological factors (related factors) for risk diagnoses.
• Components of a risk nursing diagnosis include (1) risk diagnostic label,
and (2) risk factors.
• Risk for Falls as evidenced by muscle weakness
• Risk for Injury as evidenced by altered mobility
• Risk for Infection as evidenced by immunosuppression
Health Promotion Diagnosis
• Health promotion diagnosis (also known as wellness diagnosis) is a

clinical judgment about motivation and desire to increase well-being.
• Health promotion diagnosis is concerned with the individual, family, or
community transition from a specific level of wellness to a higher level of
wellness.
• Components of a health promotion diagnosis generally include only the
diagnostic label or a one-part statement.
Examples of health promotion diagnosis:
• Readiness for Enhanced Spiritual Well Being
• Readiness for Enhanced Family Coping
• Readiness for Enhanced Parenting
Syndrome Diagnosis
• A syndrome diagnosis is a clinical judgment concerning a cluster of problem or

risk nursing diagnoses that are predicted to present because of a certain situation
or event.
• They, too, are written as a one-part statement requiring only the diagnostic label.
Examples of a syndrome nursing diagnosis are:
• Chronic Pain Syndrome
• Post-trauma Syndrome
• Frail Elderly Syndrome
PE
• Problem
• Hyperthermia
• Etiology
• R/T release of endogenous pyrogens
PES
• Problem
• Hyperthermia
• Etiology
• S/Sx as evidenced by flushed skin, sweating and increase respiratory rate.
P E S Secondary
• Problem
• Hyperthermia
• Etiology
• S/Sx as evidenced by flushed skin, sweating and increase respiratory rate.
Secondary mastitis
SMART
• Specific
• Measurable
• Attainable
• Realistic
• Time bounded
Objective
• That within my 1-2 hours span of care client’s temperature will decrease from a
temperature reading of 38.6 C to a normal body temp range of 36.5 – 37.5 C.
• SMART
• Evaluation
• Goal met clients 9:20 client’s body temp dccreased from 38.6 C to 37C.
• Goal unmet clients 10:25 client’s body temp did not decrease and is still on from
38.6 C.
• Partially met – 1 goal meet for 3 goals
Variations in writing nursing diagnosis
statement formats include the following:
1. Using “secondary to” to divide the etiology into two
parts to make the diagnostic statement more descriptive
and useful. Following the “secondary to” is often a
pathophysiologic or disease process or a medical
diagnosis.
For example, Risk for Decreased Cardiac Output related
to reduced preload secondary to myocardial infarction.
2. Using “complex factors” when there are too many
etiologic factors or when they are too complex to state in
a brief phrase.
• For example, Chronic Low Self-Esteem related to
complex factors.
3. Using “unknown etiology” when the defining
characteristics are present but the nurse does not know
the cause or contributing factors.
For example, Ineffective Coping related to unknown
etiology.
4. Specifying a second part of the general response or
NANDA label to make it more precise.
For example, Impaired Skin Integrity (Right Anterior
Chest) related to disruption of skin surface secondary to
burn injury.
PE
• Problem
• Impaired comfort: Pain
• Etiology
• R/T damaged on hepatocytes
PES
• Problem
• Etiology
• S/Sx as evidenced by facial grimace, elevated liver enzymes,
P E S Secondary
• Problem
• Etiology
• S/Sx as evidenced by facial grimace, elevated liver enzymes,
• Secondary to Liver Cirrhosis

Prepared By: Sarah Diana Rise S. Manalili, RN

Uploaded by

Copyright:

Available Formats

Prepared By: Sarah Diana Rise S. Manalili, RN

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Prepared By: Sarah Diana Rise S. Manalili, RN

Uploaded by

Copyright:

Available Formats

NCP

Prepared by: Sarah Diana Rise S. Manalili, RN

• Step 1: Data Collection or Assessment

• NANDA–International earlier known as the

• Impaired Skin Integrity related to pressure over bony

Problem : Acute Pain

Problem :Acute Pain

Problem :Acute Pain

• The second type of nursing diagnosis is called risk nursing diagnosis.

• Health promotion diagnosis (also known as wellness diagnosis) is a

• A syndrome diagnosis is a clinical judgment concerning a cluster of problem or

You might also like