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Description: Example of nursing care plans. These NCP help nursing student or working nurses to make ncp
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Example of nursing diagnosis (NCP)
Name of patient : Ms B
...
Acute pain r
...
e
...
2
...
e
...
3
...
e
...
Date
Nursing
Time
Nursing Action
Evaluation
Problem
3/5/16 @ Acute pain r
...
m
...
e
...
Name
&
Signature
P/t will able to
verbalize
that her pain
level
reduce
within 0-2/10
after 2 hour
...
Position p/t in Semi Fowler’s
position
(relieve abdominal distension
and ensure p/t rest well)
3
...
Diclofenac 50 mg TDS (relieve
pain and swelling)
4
...
Provide emotional support as
non-pharmacological method to
p
...
m
P/t able to
verbalize that her
pain level reduced
to 1/10 after 2
hours
...
Emphasized on deep
breathing and coughing exercise
(minimize pain and pressure on
incision area)
7
...
Document and evaluate the
interventions that being carried
out
...
m
...
e
...
Name
&
Signature
P/t will show
minimal
infection by
reduced
abscess, foulsmelling and
inflammation
on the wound
after 7 days
1
...
(baseline data for better
intervention)
2
...
5
mg TDS ( kill bacterial
infection)
3
...
Emphasized on proper hand
hygiene to p/t and family
members , minimize touching
the area surround wound of
9/5/16 @ 8 a
...
incision site
...
Inspect the drainage( color,
amount, etc ) and sent for
culture and sensitivity (to
identify bacteria, the causing
factor of the infection ; for
medication treatment)
6
...
Document and evaluate the
interventions that being
carried out
...
30 a
...
Nursing
Problem
Anxiety r/t
progress of
disease a
...
b
verbalization
from p/t
stating that
she quite
worry with
what
happening to
her as she
does not know
when it will
heal
...
Assess p/t level of anxiety
(baseline data)
2/5/67 @ 11
...
m
...
2
...
(adequate information
minimize anxiety and promote
confidence to p/t)
3
...
Encourage p/t to talk about
Name &
Signature
RN (nurse
name)
her feeling, her problem,
condition
...
Educate p/t with effective
and appropriate coping
mechanism ; reading, listening
to music, what she like to do,,
eat a well-balanced diet,
talking with family
frequent)
(manage anxiety effectively
using which way she felt
comfortable with)
6
...
Document and evaluate the
interventions that being
carried out
Description: Example of nursing care plans. These NCP help nursing student or working nurses to make ncp