UNIVERSITY OF CEBU at PARDO and TALISAY,Inc.

BULACAO, CEBU CITY

TEL. NO. 272-8475 / 272-2985
College of Nursing

Patient”s Name: Hospital No. :

Age: Room No. :
Impression/ Diagnosis Physician :
Nurse’s Name & Signature

CLINICAL PORTRAIT PERTINENT DATA

1. Assessment ( General impression from head to toe ) 1. History of Present illness

2. Significant Findings 2. Chief Complaints

3. Vital signs taken during the Nurses’ first contact with the patient 3. Health History Relevant to present illness

4. Vital signs taken during admission

5. Laboratory results regardless of findings

UNIVERSITY OF CEBU at PARDO and TALISAY,Inc.

 BULACAO, CEBU CITY
TEL. NO. 272-8475 / 272-2985
College of Nursing
NURSING CARE PLAN

Name of patient: (use Ms. x or Mr. x for anonymity)

Age:

Diagnosis:

CUES NURSING DIAGNOSIS SCIENTIFIC BASIS GOAL AND OUTCOME CRITERIA NURSING ACTIONS & NURSING RATIONALE OF NURSING EVALUATION
ORDERS ORDERS

Subjective data: Can be: Risk or actual; use Explains the existence Goal: Nursing Actions – General (Why the intervention is Filled out only after
PES format of the nursing -general outcome carried out.) care has been given.
-as verbalized by the diagnosis - broad statement Nursing Orders – Specific
patient
Write the author Outcome criteria:
Problem r/t Etiology below the statement -specific Explanations why the nurse Write the following
( e.g. Bruner and -measurable Write in the sequence of the does each functions in detail, statement accordingly:
Objective data: Suddarth, 2021) - attainable nursing functions: except medications because
- realistic 1. Goal met:
a separate drug summary
-observations derived Use NANDA for the - time bounded 1. Independent
- 2-3 outcome criteria for every 2. Dependent would suffice
from problem 2. Goal partially
goal 3. Collaborative met:
1. nurse’s 5 senses
3. Goal not met:
2. laboratory results FORMAT: Follow the steps of the Nursing
Process:
3.diagnosis 1. Subject
- Client 1. Assessment
v/s which must be - Any body part of the 2. Planning
related to the subjective client 3. Intervention
data - Some attributes of
the client EXAMPLE:
2. Verb
- What the client will INDEPENDENT:
do, learn, experience A
3. Conditions/modifiers P
- Explain the what, I
where, when, how
4. Criterion of desired DEPENDENT:
performance standard by A
which the performance is P
evaluated I
-time
-Speed COLLABORATIVE:
-Quantity A
-quality P
I