Comprehensive Nursing Process (CNP) Format

CUES	NURSING DIAGNOSIS	SCIENTIFIC  EXPLANATION	PLANNING	IMPLEMENTATION	SCIENTIFIC RATIONALE	EVALUATION
Sublective- pt. verbalization… Patient states …as verbalized by the patient or S.O. only if Necessary Objective - data gathered hru observation, interview, PA & records -measurable cues - specific to your nsg. dx - based  on PA presented  in chapter1 - result of diagnostic tests/ lab results	For NCM 102-    PRIORITIZED 2 ACTUAL  NURSING DIAGNOSIS Risk nsg.dx can be considered as  2nd priority If the patient is for discharge, wellness dx is allowed	SCHEMATIC DIAGRAM OF THE PATHOPHYSIOLOGY Note: Start with the ETIOLOGY and end with signs and symptoms  (indicate the reference, page number and chapter)	Discharge outcome: Attainable beyond 1 week e.g. : “After 2 wks of nsg. Intervention…” ( Long term outcome if used in community setting) Short term outcome: Attainable  within hours, shift,  days or within a week ( depends upon the nursing dx Should contain the 5 components of outcome statements -        Subject -        Verb -        Condition -        Performance criteria -        Target time	PRESENT TENSE Independent Done by Nurse’s alone (minimum of 4) Follow the sequence of identifying interventions 1.      Assessment 2.      Nursing management 3.      Health teaching Collaborative: Constant is the Diet and Medications Dependent to other health care professionals (minimum of 2)	COMPREHENSIVE EXPLANATION esp. to prioritized nursing action. It must be book based In each intervention , indicate your rationale Make sure that the  REFERENCE includes  the chapter and page it was found (BRUNNER  /  KOZIER/ PILLITER I/ WONG/ TAYLOR NANDA NOT ADVISABLE	DISCHARGE OUTCOME ACHIEVED- Mention the parameter/ indicators PARTIALLY ACHIEVED- Mention what  was achieved NOT ACHIEVED- (development of another care plan)