ANGELES UNIVERSITY FOUNDATION

Angeles City
College of Nursing

NURSING CARE MANAGEMENT 0109-RLE

Second Semester A.Y. 2020- 2021
ACTIVITY INSTRUCTIONS NCP

GENERAL DESCRIPTION:
Nursing care plans provide a means of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes.

In most nursing workplaces, patient care is a team effort. Whether it’s one nurse taking over another’s shift, or a collaboration between different healthcare
professionals, having a consistent care plan is what will ensure that everyone is on the same page.

A nursing care plan contains all of the relevant information about the patient, it includes the following components: Assessment, Diagnosis, Scientific Explanation,
Plan or Objectives, Interventions, Rationale and Expected outcomes

IMPORTANCE OF NCP:

A nursing care plan provides direction on the type of nursing care the individual/family/community may need. The focus of a nursing care plan is to facilitate
standardized, evidence-based and holistic care.

OBJECTIVE: Given a CASE SCENARIO the students will be able:

➢ Formulated a well-constructed Actual and Potential Nursing Diagnosis
➢ Prioritized the formulated Nursing Diagnosis
➢ Apply the nursing process in formulating a patient centered nursing care plan
GENERAL INSTRUCTIONS:
To accomplish the said activity, you will have to follow these guidelines:
1. This is an individual, graded activity. This activity is posted in myClass’ Assignment tab.
2. The presented case scenario on PROPLASE UTERUS is the topic that you are going to work on.
3. Based from the case scenario, as a group formulate 5 ACTUAL, 3 Potential and 3 Health Promotion nursing diagnosis
4. Each group member will work on 1 assigned nursing a diagnosis and formulate an individualized NCP based on the patient’s case. To determine the nursing
diagnosis that you will work on for your NCP, draw lots will be done.
5. Format guidelines: Arial, font size: 10, single-spaced, tabular, legal, landscape, PDF
6. A rubric is provided for reference.
7. Submission of the nursing care plan is scheduled on the 3rd day of the module week via file upload in myClass’ Assignment tab.
8. A feedback is scheduled by your Clinical Instructor.

For your GUIDANCE, an NCP format is attached to this file.

Nursing Care Plan (NCP) Guidelines

Assessment Nursing Diagnosis Scientific Objectives Interventions Rationale Expected Outcome

Explanation

1. Overall appearance 1. The nursing 1. The explanation 1. Objectives should 1. Interventions must 1. The stated rationale 1. The label to be used should be
of the patient should be diagnosis should have should begin with the have both short term include should be scientific EXPECTED OUTCOME and NOT
included as to indicate a problem statement, explanation of the and long term. INDEPENDENT, and should not be evaluation.
relevance to the etiology and signs and disease process and DEPENDENT AND based from opinions.
problem identified. symptoms (P-E-S its relevance to the INTERDEPENDENT.
identified nursing
 format) except for Risk diagnosis as indicative 2. Objectives should be 2. The expected outcome should be
problem (P-E format). of the patient’s relevant to the nursing accurate and complete.
2. Subjective and response to illness. diagnosis. 2. Each intervention 2. The rationale should
objective cues should should be stated be relevant and should
be presented as actual accurately and explain the reason of
and potential 2. The use of medical completely. the needed 3. The use of the phrase “SHALL
manifestations. or surgical condition 2. Explanation should 3. Objectives should be intervention. HAVE” should be made during
should be utilized be scientifically based, stated SPECIFIC, formulation.
appropriately. accurate and MEASURABLE,
complete. ATTAINABLE, And 2. Intervention that is
3. Objective cues REALISTIC and TIME assessment-based 3. The rationale
should be enumerated should be written first provided should be 4. The expected outcome should
3. Related to, as BOUND. have both short term and long term.
in IPPA format if and should be under within the scope of
necessary. evidenced by/ 3. Explanation should independent nursing nursing theory and
manifested by, be patient-based and function. practice.
secondary to should be be properly 4. The given time frame 5. The expected outcome should be
used appropriately as sequenced. for the resolution of the SPECIFIC, MEASURABLE,
4. Objective cues connecting phrases. problem should be
should be enumerated 3. Health teachings 4. Each rationale ATTAINABLE, REALISTIC and
realistic for the nurse to TIME BOUND.
on cephalocaudal perform and for the must also be part of the should correspond to
approach. 4. Explanation should independent nursing every intervention
4. Problem should be be based according to patient to achieve.
functions identified.
stated completely and various concepts of 6. The expected outcome (short
accurately. nursing. term) should address partial
5. Objective and 5. Plans related to
subjective cues should 3. Nursing intervention 5. The rationale stated resolution of the problem while long
provision of health term expected outcome should
be supportive of the teaching should include should make use of should be in complete
identified problem. 5. Problem identified 5. Explanation should present tense during sentence and should address the complete resolution of
should be related to the not be too medical that both verbalization and the problem.
demonstration of health formulation. explain the necessity
cues previously it deviates from the of the intervention
enumerated. nurse’s view of the teachings given.
6. Objective cues within the nurse’s point
disease process. of view. 7. The expected outcome should be
should be stated as 4. Interventions should
manifestations and be stated declaratively. stated that it indicates the
6. Problem should be 6. Long term objectives patient/family/community’s optimal
should NOT be stated should aim to resolve
as medical diagnosis. appropriate to the 6. References must be level of functioning.
patient’s response to included. the main or underlying
illness or treatment. problem and short-term 5. The list of
objectives addressing interventions should be
7. Each manifestation complete to solve the
should be accurately identified problem and
and completely 7. Problem statements to solve partially the to meet the specific
identified and should be based from problem statement. STO and LTO
described. the latest edition of the
North American
Nursing Diagnosis 7. Plan of care should 6. Referral to other
8. Laboratory results Association (NANDA). be directed toward the members of the health
should be included if a resolution of the care should be
problem is etiology of the problem included as to promote
pathophysiologic in statement. collaboration.
nature.

8. The tense of the 7. Interventions should

9. Normal findings verb used in the be directed to both
should NOT be construction of the patient and his or her
included under objectives should be family.
assessment. future.

10. Risk problems

should have cues that
indicate the presence of
a risk problem while
actual problem should
have cues indicating
the presence of an
actual problem.

11. The use of (+) or (-)

should be applied only
to special body signs
12. Objective cues that
may be manifested by
the client are presented
 ANGELES UNIVERSITY FOUNDATION
Angeles City
College of Nursing

NURSING CARE PLAN’S CRITICAL APPRAISAL RUBRIC

(30 points)

CRITERIA EXEMPLARY ACCOMPLISHED DEVELOPING BEGINNING LAUNCHING SCORE

Assessment Utilized all data sources Majority of the identified The identified assessment There is a very limited None is
(subjective and objective cues) assessment findings findings (subjective and identification of assessment presented
identifies clear, specific and (Subjective and objective cues) objective cues) provide a weak findings (subjective and
relevant cues clustered to support the nursing problem support to the nursing problem objective cues) that they fail to
provide a complete and strong while a few cues are unrelated because majority of the represent the nursing problem.
Assigned support on the nursing to the nursing problem. identified cues are unrelated.
Weight: problem.
5 Points 3.75 Points
2.5 Points 0 point
1.25 Points
5 Points
Nursing The nursing diagnosis is The nursing diagnosis is The nursing diagnosis is The nursing diagnosis is not None is
Diagnosis NANDA- approved and follows NANDA- approved but either NANDA- approved but fails to NANDA- approved with presented
the ProblemEtiology-Signs and fails to follow the format or follow required format and has inappropriate format and with
Symptoms (PES) format for makes use of inappropriate inappropriate connecting wrong use of connecting
actual nursing diagnosis; and connecting phrases. phrases. phrases or: a nursing
PE format for risk nursing diagnosis that is not NANDA-
diagnosis with appropriate use approved even if with an
of connecting phrases (related appropriate format and
to from problem to etiology and connecting phrases.
as evidenced/ manifested by
Assigned from etiology to signs and
Weight: symptoms).
4 Points
4 Points 0 point
3 Points 2 Points 1 Point
 Scientific Comprehensively discusses Explanation lack 1-2 of the Explanation lack 3-4 of the Explanation lack 5-6 of the None is
Explanation with the following criteria: stated criteria stated criteria stated criteria discussed
1. Should begin with the
explanation of the disease
process and its relevance to
the identified nursing
Assigned diagnosis
Weight: 2. Explanation should be
4 Points scientifically based,
accurate and complete.
3. Explanation should be
patientbased and be
properly sequenced.
4. Explanation should be
based according to various
concepts of nursing.
5. Explanation should not be
too medical that it deviates
from the nurse’s view of the
disease process.
6. References must be
included.

3 Points 2 Points 1 Point 0 point

4 Points
Objectives Both identified short-term and The short-term and long-term One of the objectives (either Both short-term and long-term None is
longterm objectives are objectives are appropriately short or long-term) is not objectives are not SMARTly identified
SMARTly stated stated but show minimal lack SMARTly stated. One of the stated. Both short-term and
(Specific, (lacking at least 2 out of 5 objectives (either short or long- long-term objectives are not
Measurable, Attainable, parameters) of a SMARTly term) is not related to the related to the
Realistic, Time-bound: 5 stated objective.) nursing diagnosis nursing diagnosis
parameters). All objectives are clearly related
Assigned The objectives are clearly to the nursing diagnosis.
Weight: related to the nursing diagnosis.
3 Points
2.25 Points 0 Point
1.5 Points 0.75 Point
3 Points
 Nursing All interventions are completely Majority of identified There is an adequate number Majority of the interventions are None is
Interventions identified and are appropriate Interventions are appropriate to of appropriately identified irrelevant to the nursing identified
to address the identified address the nursing problem interventions to address the problem and NO intervention
nursing problem, easily linked and to the attainment of the problem and to the attainment was given to address the
to the planned objectives (short and of the planned objectives (short attainment of the planned
attainment of the planned long term) but the interventions and long term) but the problem objectives (short and long term)
objectives (short and long term) are not clustered appropriately lies with improper clustering (even if with proper clustering of
and are clustered accordingly OR some interventions show and lack of relevance of other interventions) failing to address
Assigned (Independent, Dependent and lack of relevance to the nursing interventions to the nursing the nursing problem.
Weight: Interdependent/ collaborative). problem. problem.
4 Points
4 Points 3 Points 1 Point
2 Points 0 point
Rationale The rationale provides a Majority of the nursing Most of the nursing The rationale fails to provide None is
comprehensive and complete interventions are well supported interventions have justification for all nursing provided
justification for all identified by scientific rationale. inappropriate or incomplete interventions.
nursing interventions. presentation of rationale.
Assigned
Weight:
4 Points 4 Points 3 Points 1 Point 0 point
2 Points
Expected The expected outcomes The expected outcomes are One of the expected outcomes Both expected outcomes are None is
Outcome resemble a SMARTly stated appropriate but show evidence (either short or long term) is not not SMARTly stated. provided
short-term and longterm of minimal lack of parameters of SMARTly stated.
objective with appropriate SMARTly stated objectives
usage of “shall have.” (atleast 2 out of 5 parameters).
Assigned
Weight:
3 Points 2.25 Points
1.5 Points 0.75 Point 0 point
3 Points
Format Shows full compliance on Shows moderate compliance Shows fair compliance on Shows poor compliance on Very poor
Compliance required format (e.g. font, on required format (e.g. font, required format (e.g. font, required format (e.g. font, compliance
size, spacing, margin) size, spacing, margin) size, spacing, margin) size, spacing, margin) on
Assigned required
Weight: format
1 Point 1 point 0.75 point 0.5 point 0.25 point
0 point
Grammar Displays competent grammar Displays minor grammatical Displays noticeable Displays several and major No data
Usage use errors grammatical errors grammatical errors coherence
owing to
grave
grammatical
Assigned
errors
Weight:
1 Point

1 point 0.75 point 0.5 point 0.25 point 0 point

Timeliness Submits the requirement on Submits the requirement a day Submits the requirement two Submits the requirement three Submits the
time after (2) days after the scheduled (3) requirement
the scheduled submission date submission date after the scheduled submission for more
date than three
(3) days
after the
scheduled
submission
date
Assigned
Weight:
1 Point

1 point 0.75 point 0.5 point 0.25 point 0 point

Computation Guidelines:

1. There are ten (10) criteria on this rubric. Each criterion carries a specific weight reflective of its relative importance to the other criteria.
2. Similarly, there is a pre-assigned weight or point on each category (e.g. exemplary, developing) of a given criterion. You CANNOT assign a
score that is between categories.
3. The highest possible score on this activity is 30 points.
Prepared by:
NADINE VICTORIA L. LISING RN, MAN
Alfredo Z. Feliciano, RN, PhD
Joan Russel D. Feliciano, RN, MN
Faculty, College of Nursing

Reviewed by:

Angela P. Apostol, RN, MN

Level III RLE Coordinator, College of Nursing

Brenda B. Policarpio, RN, RM, MN

Level II RLE Coordinator, College of Nursing

Doroteo S. Dizon, RN, MAN

Research Coordinator, College of Nursing

Approved by:

Zenaida S. Fernandez, RN, PhD

Dean, College of Nursing