NURSING CARE PLANS (NCPs)
Format:
• Assessment
• Nursing Diagnosis
• Goal
• Intervention (with Rationale)
• Evaluation
🌡 1.
Pyrexia (Fever)
Assessment:
• Elevated body temperature (>37.5°C oral)
• Flushed skin, warm to touch
• Increased heart rate, shivering
Nursing Diagnosis:
• Hyperthermia related to infection as evidenced by temperature of 39.2°C and flushed skin
Goal:
• Patient will maintain normal body temperature (36.5–37.5°C) within 48 hours
Interventions with Rationale:
1. Monitor temperature every 4 hours – Helps assess response to treatment
2. Encourage fluid intake (2–3L/day) – Prevents dehydration
3. Administer antipyretics as prescribed – Reduces fever (e.g., paracetamol)
4. Provide tepid sponge bath – Aids heat loss through conduction
5. Remove excess clothing and blankets – Facilitates cooling
Evaluation:
• Temperature reduced to 37.2°C; patient reports feeling more comfortable
💩 2.
Diarrhea
Assessment:
• Frequent loose stools
• Dehydration signs: dry mucosa, low urine output
• Cramping abdominal pain
Nursing Diagnosis:
• Diarrhea related to intestinal infection as evidenced by 5 loose stools/day and abdominal
cramps
Goal:
• Patient will have formed stools and maintain hydration within 3 days
Interventions with Rationale:
1. Monitor frequency and consistency of stools – Assesses severity and progress
2. Encourage oral rehydration (ORS) – Replenishes fluids and electrolytes
3. Maintain perianal hygiene – Prevents skin breakdown
4. Administer prescribed antimotility agents – Reduces intestinal motility
5. Educate on hand hygiene – Prevents spread of infection
Evaluation:
• Stool frequency decreased to 1–2/day; hydration status normal
🫁 3.
Pneumonia
Assessment:
• Productive cough, fever, dyspnea
• Decreased breath sounds on auscultation
• Chest X-ray showing consolidation
Nursing Diagnosis:
• Ineffective airway clearance related to increased secretions as evidenced by crackles and
productive cough
Goal:
• Patient will maintain clear airway with normal breath sounds within 72 hours
Interventions with Rationale:
1. Monitor respiratory rate and SpO₂ – Detects hypoxia (normal SpO₂: 95–100%)
2. Encourage coughing and deep breathing – Mobilizes secretions
3. Provide chest physiotherapy – Facilitates mucus clearance
4. Administer antibiotics and expectorants – Treats infection and thins secretions
5. Ensure adequate hydration – Loosens mucus
Evaluation:
• Breath sounds improved; SpO₂ maintained at 96% on room air
🦴 4.
Fracture
Assessment:
• Pain and swelling at injury site
• Deformity and limited mobility
• X-ray confirmation
Nursing Diagnosis:
• Acute pain related to musculoskeletal injury as evidenced by guarding and pain score of
7/10
Goal:
• Patient will report pain relief within 24 hours and maintain limb alignment
Interventions with Rationale:
1. Assess pain level regularly – Evaluates effectiveness of treatment
2. Elevate affected limb – Reduces edema
3. Apply ice packs – Minimizes inflammation
4. Administer analgesics as prescribed – Relieves pain
5. Monitor neurovascular status (capillary refill < 2 sec, pulse, color) – Prevents complications
like compartment syndrome
Evaluation:
• Pain score reduced to 2/10; limb alignment maintained
🔥 5.
Burns
Assessment:
• Red, blistered skin
• Severe pain (superficial burns)
• Risk of fluid loss (hypovolemia)
Nursing Diagnosis:
• Risk for infection related to loss of skin barrier as evidenced by open burn wounds
Goal:
• Patient’s burn wound will remain free from infection during hospital stay
Interventions with Rationale:
1. Maintain strict aseptic technique during dressing – Prevents contamination
2. Administer prescribed antibiotics – Controls/prevents infection
3. Monitor WBC count (normal: 4,000–11,000/mm³) – Detects infection
4. Educate on wound care and hygiene – Promotes recovery and self-care
5. Ensure nutritional support (high protein, high calorie) – Aids tissue healing
Evaluation:
• Wound shows signs of healing; no fever or WBC elevation
🚫 6.
Constipation
Assessment:
• No bowel movement for 3 days
• Abdominal distention, straining
• Hard, dry stool
Nursing Diagnosis:
• Constipation related to inadequate fluid intake and immobility as evidenced by hard stool
and infrequent bowel movement
Goal:
• Patient will have a soft, regular bowel movement within 48 hours
Interventions with Rationale:
1. Monitor bowel movement frequency and consistency – Evaluates progress
2. Encourage high-fiber diet (fruits, vegetables, whole grains) – Increases stool bulk
3. Increase fluid intake (1.5–2L/day unless contraindicated) – Softens stool
4. Encourage ambulation – Stimulates peristalsis
5. Administer stool softeners or laxatives as prescribed – Facilitates defecation
Evaluation:
• Patient passed soft stool without straining; abdominal discomfort resolved
💧 7.
Urinary Tract Infection (UTI)
Assessment:
• Dysuria, frequency, urgency
• Foul-smelling urine
• Low-grade fever
Nursing Diagnosis:
• Impaired urinary elimination related to infection as evidenced by burning sensation and
frequent urination
Goal:
• Patient will be free from UTI symptoms within 5 days
Interventions with Rationale:
1. Monitor urine output and characteristics – Detects progress and complications
2. Encourage fluid intake (2–3L/day) – Flushes bacteria from urinary tract
3. Administer prescribed antibiotics – Eradicates infection
4. Teach perineal hygiene (wipe front to back) – Prevents recurrence
5. Encourage urination every 2–3 hours – Reduces urine stasis
Evaluation:
• Dysuria resolved; urine clear and odorless; afebrile
💓 8.
Hypertension
Assessment:
• BP reading >140/90 mmHg
• Headache, dizziness
• History of HTN
Nursing Diagnosis:
• Risk for decreased cardiac output related to increased vascular resistance
Goal:
• Patient’s BP will remain within normal limits (<120/80 mmHg) during hospitalization
Interventions with Rationale:
1. Monitor BP every 4–6 hours – Tracks control and treatment effect
2. Administer antihypertensive meds as prescribed – Lowers BP
3. Encourage DASH diet (low sodium, high potassium) – Helps BP control
4. Encourage stress-reducing techniques – Reduces sympathetic stimulation
5. Educate on medication adherence – Prevents complications like stroke
Evaluation:
• BP controlled at 124/78 mmHg; no dizziness or headache reported
🍬 9.
Diabetes Mellitus
Assessment:
• Elevated blood glucose levels (>126 mg/dL fasting)
• Polyuria, polydipsia, fatigue
• History of diabetes
Nursing Diagnosis:
• Ineffective health management related to lack of knowledge as evidenced by high blood
sugar and poor dietary habits
Goal:
• Patient will demonstrate effective glucose control within 5 days
Interventions with Rationale:
1. Monitor blood glucose before meals and at bedtime – Assesses glycemic control (normal
fasting: 70–100 mg/dL)
2. Administer insulin/oral hypoglycemics as prescribed – Lowers glucose
3. Educate on diabetic diet (low sugar, high fiber) – Promotes stable glucose levels
4. Encourage daily exercise – Enhances insulin sensitivity
5. Teach self-monitoring and foot care – Prevents long-term complications
Evaluation:
• Fasting glucose reduced to 105 mg/dL; patient verbalizes understanding of diabetes care
🦠 10.
Appendicitis
Assessment:
• RLQ pain (McBurney’s point), fever, nausea
• Rebound tenderness
• Elevated WBC count
Nursing Diagnosis:
• Acute pain related to inflammation of appendix as evidenced by verbal report of 8/10 pain
and guarding behavior
Goal:
• Patient will report reduced pain and avoid complications (e.g., perforation) within 24 hours
Interventions with Rationale:
1. Assess pain level and characteristics – Monitors inflammation progression
2. Keep patient NPO (nothing by mouth) – Prepares for surgery, prevents perforation
3. Administer analgesics and IV fluids as prescribed – Manages pain and dehydration
4. Prepare for surgery (appendectomy) – Definitive treatment
5. Monitor for signs of rupture (sudden pain relief followed by worsened condition) – Early
detection of complication
Evaluation:
• Pain reduced to 2/10 post-op; patient recovering without signs of rupture
