‫المملكة العربية السعودية‬

KINGDOM OF SAUDI ARABIA ‫وزارة التعليم العالي‬

Ministry of Higher Education ‫جامـعـة حـائل‬
University of Hail ‫كلية التمريض‬
College of Nursing

SAMPLE NCP
Subject; Fundamentals of Nursing Practice 1

A 21-year-old male patient confined in Male Surgical Ward (MSW) Room 2 who had cholecystectomy 5 hours ago, is arching and moaning and
verbalized “I have pain on my abdomen”. The nurse performs assessment with the following observation. Temperature is 37.5ºC, the wound dressing is
intact but patient holds abdomen in a guarded and protective behavior. Formulate Nursing Care Plan based on the given scenario.

ASSESSMENT NURSING DIAGNOSIS OBJECTIVES NURSING RATIONALE EVALUATION

(.5%) (Prioritized) (1%) INTERVENTIONS (1%) (.5%)
(1%) (1%)

Subjective Data (1%) Problem (2%): Specific Objective: (SMART) a) Independent Goal met
Nursing Action evidenced by pain
Client verbalized: Acute Pain After 30 mins of nursing (2%) is reduced from
interventions, patient will  Assess location,  Assessment is scale of 8 to 2
“ I have pain on my Etiology (2%): verbalize that pain reduced duration, the first step
abdomen from scale of 8 to 2 frequency and in managing
Related to severity of pain pain. It helps Or
ensure that Goal is partially
Surgical incision (operative the patient met evidenced by
site) receives pain scale is
effective pain reduced from 8 to
relief. 5
Objective Data (4%)  Obtain Vital Signs  Vital Signs Or
are usually Goal is unmet
 Surgical incision with As evidenced by (Major affected when evidenced by pain
dressing – (post Sign/Symptom (1%) pain is present score is still 8,
surgery 5 hours ago)
 Provide a quiet  Additional patient is moaning
 Crying and moaning
 Pain Score- 7/10
environment stressors can and crying
 Holds abdomen with Patient’s report of pain, increase pain
guarded and protective crying and moaning  Non  To divert
bahavior PS 7/10 pharmacological attention and
Pain Relief Method is more safe
Ex. breathing and effective
exercise, music
therapy

b) Dependent Nursing
Action (1%)
 Give pain relieve  Pain reliever
medication as reduces pain
doctor’s order
 KINGDOM OF SAUDI ARABIA ‫المملكة العربية السعودية‬
Ministry of Higher Education ‫وزارة التعليم العالي‬
University of Ha’il ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Name of Student: ___________________________________ Date: ______________________

ASSESSMENT NURSING DIAGNOSIS OBJECTIVES NURSING RATIONALE EVALUATION

(.5%) (Prioritized) (1%) INTERVENTIONS (1%) (.5%)
(1%) (1%)

Subjective Data (1%) Problem (2%): Specific Objective: (SMART) a) Independent

________________________ Nursing Action
Client verbalized: ________________________ (2%)
_ ________________________
______________________
________________________ ________________________
______________________ _
________________________

Objective Data (4%)

Etiology (2%):
b) Dependent Nursing
Related to Action (1%)

________________________
_

________________________
_

As evidenced by (Major
Sign/Symptom (1%)

________________________
_

________________________
_