Formulating A Nursing Care Plan: S++aint Paul University Philippines

S++aint Paul University Philippines
Tuguegarao City, Cagayan 3500
School of Nursing and Allied Health Sciences

College of Nursing
FORMULATING A NURSING CARE PLAN

Name of Student: Date:
Section: ID Number:
Instructions:
1. From the given scenarios, formulate one priority nursing care plan.
2. Develop a complete plan of care for the patient from ASSESMENT TO EVALUATION with rationales (EBP) of the nursing interventions
3. Submission on or before October 24, 2020
4. Use filename format: NCP (complete name of student)
5. Use the NCP format below.
6. It is expected that students EXERT ACADEMIC EFFORT IN COMING UP WITH AN HONEST, INDIVIDUAL AND PROFESSIONAL
OUTPUT.
SCENARIO 1:
A 20 year old nursing student was seen at the Out-
Patient Department of Saint Paul Hospital due to
complaints of difficulty in sleeping for the past 5
days. She said: “I cannot sleep because I worried
about my exams next week.” She used to sleep 8
hours but now, she barely sleeps for 4 hours, she
keeps thinking. Her conjunctivae are pale, with
dark circles around the eyes. She also complained
of dizziness and feeling tired all the time.
SCENARIO 2:
A 35-year-old female patient is admitted in

the ward. She is very weak, and she has low
hemoglobin level of 9.1 g/dL. She is a known
case of chronic iron deficiency anemia. She
looks pale, thin and complains of breathing
difficulty and dizziness whenever she
performs activity. She wants to take a bath,
but she feels very tired and her breathing
becomes difficult.
NURSING CARE PLAN
Name of Student:
Name of Patient: Civil Status:
Diagnosis or Clinical Impression: Age: Sex:
Date:
ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING EVALUATION

CUES DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTONS
AND RATIONALE
SUBJECTIVE: Sleep Sleep deprivation NOC: Sleep NIC: Sleep The patient was
-”I cannot sleep deprivation related to Enhancement able to adjust her
because I worried related to anxiousness. The Goal: The patient sleeping pattern
about my exam anxiousness as state in which an will be able to INDEPENDENT: from 4 hours to
next week” as evidence by individual adjust her 7-8 hours within
stated by the paleness of experience a sleeping pattern -Assure the client that 2-3 days.
client. conjunctivae disruption in from 4 hours to 7- occasional sleepless
-Dizziness and and dark circle amount and 8 hours within 2-3 should not threaten The goal was
feeling tired. around the quality of sleep days. health. met.
eyes. that impairs -Worrying about not
OBJECTIVE: functioning. Objective:The sleeping can
-Conjunctivae are patient will: perpetuate or
pale. A. Increased exacerbate the
-Dark circles sense of well- problem.
around the eyes. being and feeling -Assist the client to
rested. develop individual
B. Improvement in program of relaxation.
sleep-rest pattern. -Methods that
C. Identify reduce sympathetic
individually response and
appropriate decrease stress can
interventions to help induce sleep.
promote sleep. -Encourage
participation in
regular exercise
program during the
day.
-To aid in stress
control and release
of energy.
-Recommend
inclusion of bedtime
snack.
-To reduce sleep
interference from
hunger or
hypoglycemia.
INTERDEPENDENT
-Refer to sleep
specialist, as
indicated or desired.
-Follow up
evaluation or
intervention may be
needed when
insomnia is
seriously impacting
the client’s quality
of life, productivity
and safety.
-Participate in a
program to “reset” the
body’s sleep clock
(chronotherapy)
-When the client has
delayed-sleep-onset
insomnia.
ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING EVALUATION

CUES DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTONS
AND RATIONALE
SUBJECTIVE: Activity Activity NOC: Activity NIC: Energy The patient was
-Complains of intolerance Intolerance. A Intolerance Management able to
breathing difficulty related to state where in a productively
and dizziness fatigue, difficulty person is Goal: The patient INDEPENDENT: perform her daily
whenever she of breathing and susceptible to will productively activities within 2-
performs activity. weakness. experience perform her daily -Evaluate the clients 3 days.
-Weak insufficient activities within actual and perceive
physiological or 2-3 days. limitations and The goal was
OBJECTIVE: psychological severity of deficit in met.
-Pale, thin energy to endure Objective: The light of usual status
-Low hemoglobin or complete patient will: -this provides a
level of 9.1 g/dL required or desired A. Identify comparative
daily activities negative factors baseline and
which may affecting activity information about
compromise tolerance and needed education
health. eliminate or or intervention
reduce their regarding quality of
effects when life.
possible -Assist client with
B. Use identified planning for changes
techniques to that may become
enhance activity necessary such as
tolerance use of supplemental
C. Participate oxygen.
willingly in -to improve the
necessary clients ability to
activities and participate in
report desired activities
measurable -Plan for progressive
increase in increase of activity
activity tolerance. level/participation and
exercise training as
tolerated by client.
-both activity
tolerance and health
status may improve
with progressive
training.
INTERDEPENDENT
-Refer to appropriate
resources for
assistance and
equipment, as
needed.
-to sustain activity
level.

Formulating A Nursing Care Plan: S++aint Paul University Philippines

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S++aint Paul University Philippines

Tuguegarao City, Cagayan 3500

School of Nursing and Allied Health Sciences

FORMULATING A NURSING CARE PLAN

A 35-year-old female patient is admitted in

ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING EVALUATION

ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING EVALUATION

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