How To

Make
NCP
PAUL ANDRE A. LUMIGUID RN,MAN,Phd
(Cand.)
Objective:
At the end of this discussion, the students will be able to:

1. Identify what is Nursing Care Plan.

● Type
● Purpose
● Components
2. Understand how to write the Nursing Care Plan
● Data collection or Assessment
● Data Analysis and Organization
● Formulate a Nursing Diagnosis
● Setting Priorities
● Establishing client goals and objective
● Formulating and selecting Nursing Interventions with rationale
● Evaluation
“Every Nurse is
drawn to
Nursing because
of a desire to
care, to serve,
or to help”
- Christina Feist-Heilmeier
 0
1
Nursing Care
Plan
What is Nursing Care Plan?

● A formal process that includes correctly

identifying existing needs, as well as
recognizing potential needs or risks.

● Care plans also provide a means of

communication among nurses, their
patients, and other healthcare providers to
achieve health care outcomes.
 Purpose
● Defines Nurse’s role
● Provides direction for individual care of the
client
● Continuity of care
● Documentation
● Serves as guide for assigning a specific staff
to a specific client
● Serves as guide for reimbursement
● Defines client’s goals
 Components
● Client health assessment (Subjective and Objective
cues), medical results, and diagnostic reports.
● Nursing Diagnosis
● Expected client outcomes (short and long term)
● Nursing Interventions
● Rationale for Interventions
● Evaluation
 0
2
Writing a
Nursing Care
Plan
Step 1: Data Collection or
Assessment
• Physical Assessment
• Health History
• Interview
• Medical records review
• Diagnostic studies
Step 2: Data Analysis and
Organization
• From the collected data about the
client’s health, analyze, cluster and
organize the data to formulate the
nursing diagnosis, priorities and
desired outcomes.
Step 3: Formulating Nursing
Diagnoses
• Diagnosing involves a nurse making
an educated judgment about a
potential or actual health problem
with a patient.
• Types of NANDA Nursing Diagnosis:
 Actual
 Risk
 Health Promotion
 Syndrome
Problem-focused diagnosis
(also known as actual diagnosis) is a client
problem that is present at the time of the
nursing assessment.

• These diagnoses are based on the presence

of associated signs and symptoms.

• Components:
 Nursing diagnosis -> Related factor ->
Defining characteristic

Ex: Ineffective Breathing Pattern

related to pain as evidenced by
pursed-lip breathing, reports of
pain during inhalation, use of
accessory muscles to breathe
Risk Nursing Diagnosis
• These are clinical judgment that a problem
does not exist, but the presence of risk
factors indicates that a problem is likely to
develop unless nurses intervene.

• No etiological factors (related factors) for

risk diagnoses.

• Components:
 Risk Diagnostic level-> Risk factor

Ex: Risk for fall as evidenced by

muscle weakness
Health Promotion Diagnosis
• Also known as wellness diagnosis is a
clinical judgment about motivation and
desire to increase well-being.
• Is concerned in the individual, family, or
community transition from a specific level of
wellness to a higher level of wellness.

• Components: generally include only the

diagnostic label or a one-part-statement.

Ex: * Readiness for Enhanced

Spiritual Well Being
* Readiness for Enhanced
Family Coping
Syndrome Diagnosis
• A clinical judgment concerning with a cluster
of problem or risk nursing diagnoses that are
predicted to present because of a certain
situation or event.

• Components: generally include only the

diagnostic label or a one-part-statement.

Ex: * Chronic Pain Syndrome

* Post-trauma Syndrome
* Frail Elderly Syndrome
Components of a Nursing
Diagnosis
3 typical components:
1. Problem and its definition,
2. Etiology, and
3. Defining characteristics or risk factors (for risk diagnosis).
Components:
Defining
Problem and Characteristic
Etiology s/ Risk Factor
Definition
• Or related factors, • Risk factors are used
• Describes the client’s instead of etiological
• Identifies one or more
health problem or factors for risk nursing
response for which probable causes of the
health problem diagnosis.
nursing therapy is given • Defining
• The conditions involved
as concisely as possible. characteristics are the
• 2 Parts: Qualifier and in the development of
the problem, clusters of signs and
focus of the symptoms that indicate
• Gives direction to the
Diagnosis the presence of a
required nursing
therapy, and enables particular diagnostic
• Examples of label.
Qualifiers: the nurse to
• Identified signs and
- Deficient individualize the client’s
care. symptoms of the client
- Imbalanced • “as evidenced by” or
• “related to”
- Impaired “as manifested by”
- Ineffective
- Risk for
How to Write a Nursing
Diagnosis
How to Write a Nursing
Diagnosis –
PES format
Variations on Basic Statement
Formats
● Using “secondary to” - Risk for Decreased Cardiac Output
related to reduced preload secondary to myocardial
infarction.

● Using “complex factors” - Chronic Low Self-Esteem related to

complex factors.

● Using “unknown etiology” - Ineffective Coping related to

unknown etiology.

● Specifying a second part of the general response or NANDA label to

make it more precise. - Impaired Skin Integrity (Right Anterior
Chest) related to disruption of skin surface secondary to
burn injury.
Step 4: Setting Priorities
• The process of establishing a
preferential sequence for address
nursing diagnoses and interventions
Maslow’s hierarchy of needs is frequently used
when setting priorities.

• The nurse and the client begin

planning which nursing diagnosis
requires attention first.
Step 5: Establishing Client Goals
and Desired Outcome
• Describe what the nurse hopes to achieve by implementing the nursing
interventions and are derived from the client’s nursing diagnoses.
• SMART – Specific, Measurable, Attainable, Realistic and Time bounded
• It should be client centered
• Goals:
• Serve as criteria for evaluating client progress.
• Enable the client and nurse to determine which problems have been resolved.
• help motivate the client and nurse by providing a sense of achievement.
Short Term and Long Term Goals
● Short-term goal – a statement distinguishing a shift in behavior
that can be completed immediately, usually within a few hours or
days.

● Long-term goal – indicates an objective to be completed over a

longer period, usually over weeks or months.

● Discharge planning – involves naming long-term goals, therefore

promoting continued restorative care and problem resolution through
home health, physical therapy, or various other referral sources.
Components:
● Subject – The client

● Verb- Action the client is to perform

● Condition or Modalities- These are the “what, when, where, or how” that are
added to the verb.

● Criterion of desired performance- Indicates the standard by which a

performance is evaluated or the level at which the client will perform the
specified behavior. Optional.
Step 6: Selecting Nursing
Intervention with Rationale
• Are activities or actions that a nurse performs to achieve
client goals.
• Should focus on eliminating or reducing the etiology of the
nursing diagnosis.
• As for risk nursing diagnoses, interventions should focus on
reducing the client’s risk factors.
• Rationales, also known as scientific explanation, are the
underlying reasons for which the nursing intervention was
chosen for the NCP.
• Rationales do not appear in regular care plans
Types of Nursing Interventions:
● Independent - activities that nurses are licensed to initiate
based on their sound judgment and skills.

● Dependent - activities carried out under the physician’s

orders or supervision.

● Collaborative - actions that the nurse carries out in

collaboration with other health team members.
Independent Dependent Collaborative
• Ongoing Assessment • Medications Collaboration with:
• Emotional Support • IV theraphy • Physicians,
• Providing comfort • Diagnostic Tests • Social workers,
• Teaching • Treatment • Dietitians, and
• Physical care • Diet • Therapists.
• Making referrals • Activity or rest
Characteristic of Nursing Interventions:
● Safe and appropriate for the client’s age, health, and condition.

● Achievable with the resources and time available.

● Inline with the client’s values, culture, and beliefs.

● Inline with other therapies.

● Based on nursing knowledge and experience or knowledge from

relevant sciences.
Step 7: Evaluation

• Evaluating is a planned, ongoing, purposeful activity in which

the client’s progress towards the achievement of goals or
desired outcomes, and the effectiveness of the nursing care
plan (NCP).

• Conclusions drawn from this step determine whether the

nursing intervention should be terminated, continued, or
changed.
THANKS!
Do you have any questions?

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REFERENCES
● Ackley, B. J., & Ladwig, G. B. (2010). Nursing Diagnosis Handbook-E-
Book: An Evidence-Based Guide to Planning Care. Elsevier Health
Sciences.

● Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s
Fundamentals of Nursing: Concepts, process and practice. Boston, MA:
Pearson.

● Herdman, H. T., & Kamitsuru, S. (Eds.). (2017). NANDA International

Nursing Diagnoses: Definitions & Classification 2018-2020. Thieme.

● Vera, M. (December 8, 2020). Nursing Care Plan (NCP): Ultimate Guide

and Database.
[Link]

● MINT Nursing ( Sept. 29, 2018). Nursing Care Plan: Easy and Simple.
 Types of NCP
Informal Formal
Strategy of action that A written or computerized
exists in the nurse‘s mind. guide that organizes
information about the
client’s care.
Subtype:
• Standardized Care
Plan - specify the
nursing care for groups of
clients with everyday
needs.
• Individualized Care
Plan - Tailored to meet
the unique needs of a
specific client or needs