NURSING CARE PLAN
IDENTIFICATION DATA
Name of the patient:
Age:
Sex:
Marital Status:
Religion:
Education:
Occupation:
Address:
I P no.:
Bed no:
Ward:
Date of Admission:
Medical Diagnosis:
Surgical Diagnosis:
CHIEF COMPLAINTS:
Mr.----------, was admitted to hospital on ……….., with the complaints of……….
PRESENT MEDICAL HISTORY
Mr.----------,was admitted to hospital on ............. , with the complaints of……Investigation are
done and its diagnosed as .......... he is under medication
PAST MEDICAL HISTORY
Mr.-----------, has no significant past medical history/ Mr ----------- , was diagnosed with
hypertension 15 days ago, he is under medication.
PRESENT SURGICAL HISTORY
Mr.-----------,has no significance present surgical history/ Mr.-----------, Mr ....... is underwent
………. On .......... he is under observation
PAST SURGICAL HISTORY
Mr.-----------, has no significant past surgical history / Mr ...... underwent appendectomy 2 years
ago
FAMILY HISTORY:
Mr ----------- , family has no history of communicable diseases, hereditary and congenital
abnormalities.
FAMILY PROFILE:
NAME OF Age in Gender RELATIONS OCCUPATI Health
SL. THE year HIP with ON Status
NO. FAMILY patient
MEMBERS
[Link] 54 M *******
01
FAMILY TREE: KEY TERM
Mr _ Mrs
Age Age
PERSONAL HISTORY
Diet –
Bowel and Bladder Pattern -
Sleep Pattern -
Habits -
SOCIO ECONOMIC STATUS:
Mr…. is the bread winner of the family, Type of house, ventilation, water, electrical facilities,
latrine facilities.
PHYSICAL EXAMINATION.
VITAL SIGNS
Vital signs Patient value Normal value remarks
Temperature
Pulse
Respiration
Blood pressure
HEAD TO FOOT EXAMINATION.
General Appearance
Nourishment: well-nourished/undernourished
Body builds: obese/thin
Health: healthy/unhealthy
Activity: active/dull
Height :
Weight:
Mental Status
Consciousness: conscious/unconscious
Look: anxious/worried/depressed
Posture
Body curve: Normal/Abnormal
Movement: limb movement
Skin Condition
Colour: pallor,cyanosis
Temperature: warm, cold, clammy
Texture: dryness, wrinkling,
Itching: absent or present
Head
Hair :-
Color:
Texture: smooth, rough
Distribution: even distribution,
Dandruff: present/absent
Lice: present/absent
Face
Facial expression: Happy/ Sad/ Anxious
Facial edema: Present/ Absent
EYE
Vision: Normal/ Abnormal
Eyebrows: normal/abnormal
Eye lashes: Normal/Abnormal
Eye lids: edema/normal
Eye balls: Normal/sunken/protruded
Sclera: normal/yellow/ red/ bluish/
Conjunctiva: normal/pale/red
Pupils: dilated/constricted /reactive to light
NOSE
Appearance:Symmetry/Asym
Discharge: Absent /not present
Epistaxis: present/absent
Nasal septum: Normal/ DNS
Nostril: normal/dry/nose flaring’s
MOUTH
Gum: normal/bleeding/gingivitis
Teeth: normal/dental caries/discoloration
LIPS
Color :normal/ bluish color/pale
TONGUE
Colour : any white, yellow, gray
Ulceration : present/absent
Surface : normal/coating present
EARS
Hearing activity : normal/impaierd
Discharge : Present/Absent
Wax : Present/Absent
NECK
Range of motion:normal/ abnormal(specify)
Lymph nodes : normal/enlarged
THROAT:
Sore : present/absent
Enlarged Tonsil : present/absent
CHEST
Inspection:-
Symmetry : Symmetrical/Asymmetrical
Breathing pattern : normal/abnormal
Respiratory rate : Mention the Rate
Palpation:
Chest wall : Normal/ Scar present
Tenderness/swelling: present/absent
Percussion:
Thorax : normal/ abnormal (specify)
Auscultation:
Heart sound : S1, S2 heard
Breath sound : normal/abnormal
FEMALECLIENT BREASTEXAMINATION
Inspection :
Breast :
Shape: normal/abnormal
Symmetry: symmetrical/ asymmetrical
Skin : colour, pigmentation , vascularity
Areola : colour , any pigmentation
Nipple : discharge, lesion
Palpation :
Breast and axillae : normal/abnormal (lymph node, tenderness, bleeding ulcer)
ABDOMEN
Inspection :-
Skin appearance : scar, color changes,
Abdominal distention: Present/Absent
Palpation :
Liver enlargement :present/absent
Appendix:Normal/ Abnormal
Hernia : Present/Absent
Percussion :
Ascities : absent/ present
Auscultation
Bowel sound : normal/abnormal
LOWER LIMB
Movements of joints : normal/abnormal
BACK /SPINE
Scoliosis, kyphosis,lordosis : present/absent
GENITALIA AND RECTUM (As per Gender)
Male
Discharge: present/absent
Incontinence and retention of urine: present/absent
Penis and scrotum: normal/ pain/ swelling or enlargement
Female
Incontinence and retention of urine : present/absent
STD (sexual transmitted disease) infection : present/absent
Unusual bleeding/Discharge : Present/Absent
Rectum( Common for both gender )
Hemorrhoids : present/absent
Bleeding : present/absent
INVESTIGATION
Sl NO Type/Name of Investigation Patient Value Normal Value Remarks
MEDICATION
Nurses
Sl Name of thedrug Dosage & Side Contra- responsibility
Action Route Indication
NO frequency effect indication
NURSING DIAGNOSIS
1)
2)
3)
4)
5)
NURSING PROCESS
Sl Assessment Diagnosis Expected Planning Rationale Implementation Evaluation
No Out Come
HEALTH EDUCATION:
CONCLUSION:
BIBLIOGRAPHY: