Nursing Care Plan (NCP)

An official procedure known as a nursing care plan (NCP) accurately identifies current needs and recognizes prospective requirements or concerns. To accomplish health care results, care plans facilitate communication between nurses, their patients, and other healthcare professionals. The practice of nurse care planning is essential to maintaining the caliber and consistency of patient care.  Nursing care planning starts when a client is accepted to the agency and is regularly updated when the client's health changes, and goal attainment is assessed. Excellence in nursing practice is based on the planning and provision of customized or patient-centered care.

 

Steps in writing NCP

The Steps involves in nursing care plan are as follow;

    • Assessment
    • Diagnosis
    • Planning
    • Interventions
    • Evaluation

Based on the above steps, we will now make an NCP for patients.

 

Examples of NCP.

Following are some of the examples and template for NCP. You can copy paste the and place them in your own template or you can download the document also. Just edit your name on that and can submit that as your assignment.

 

NCP for Cholecystitis

Assessment

Patient Amjad Khan comes with complaint of pain in the upper right abdomen. He also has complaints of less desire to eat.

 

Diagnosis

1.     Pain related to disease process.

2.     Imbalanced Nutrition: less than body requirements related to decreased desire to eat secondary to cholecystitis.

3.     Disturb Body Image related to change in appearance Secondary to disease process.

 

Planning

1.     At the end of my shift, the pt will relief at a level less than 4 on a scale from 0 to 10.

 

2.     At the end of my shift, the patient will have a desire to eat and verbalize method to free from nutrition deficiency.

3.     At the end of my shift, the pt will implement new coping patterns and acceptance of appearance.

 

Intervention 

  • Monitor Vital Sign. 
  • Perform pain assessment every time when pain occurs.
  • Deep breath exercise technique. 
  • Administer Pain Killer.

 

  • Monitor food/fluid ingested and calculate daily caloric intake as appropriate. 
  • Encourage healthier food choices. 
  • Adding supplements to the diet of client. 
  • Administer Appetizer. 
  • Advice such food intake that has high calories. 
  • Provide oral care before meals.

 

  •  Support verbalization of positive or negative feelings about the actual or perceived loss.  
  • Encourage the pt to express feelings about body changes. 
  • Encourage the pt about his perception of rejection by others. 
  • Teach the pt about how to care for the change body part or function.

 

 

Evaluation

1.     Patient Pain was reduced to 3/10 as verbalized by the patient on pain scale.

 

2.     The patient became desire to eat after the administer of the appetizer. Also verbalize methods to free from nutritional deficiency.

 

3.     The patient verbalized methods of coping and he accepted her new appearance.

 

 

NCP on cholecystitis

 

 

NCP for Inflamed Ear

 

Assessment

A 20-year-old patient has come with High grade fever and pain on his right ear. He has also Complain of loss of appetite, Nausea and discharge of fluid and pus from ear.

 

Diagnosis

1.     Acute pain related to disease process

2.     Hyperthermia related to high metabolic rate/ illness.

3.     Discharge of Pus related to infection.

 

Planning

1.     At the end of my shift, the pt will relief at a level less than 5 on a scale from 0 to 10.

2.     At the end of my shift, the pt temperature will decrease from 102 to 98.6 F.

3.     At the end of my shift, the pt will have no exudation.

 

Interventions

1.    Monitor Vital Sign.

Perform pain assessment every time when pain occurs.

Deep breath exercise technique.

 

 

2.     Administer antibiotics. 

        Cold therapy. 

        Wash hands with anti-bacterial soap before and after each care of activity and encourage proper     hygiene.

 

 

3.    Clean ear canal

Administer acidic drops

Antibiotics

Topical acetic acid

Corticosteroid

 

Evaluation

1.    Patient Pain was reduced to 3/10 as verbalized by the patient on pain scale.

The goal was partially met. Temperature come to 99F

The patient’s ear canal was cleaned at the end and had no exudation.

 

NCP example