Nursing Care Plan - Its a format PDF

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NURSING CARE PLAN FORMAT

OUTLINE/FORMAT FOR NURSING CARE PLAN STUDENTS DATA Name of student: _____________ Year of study: _______________ Hospital: ___________________ IDENTIFICATION DATA OF PATIENT Name of patient: Age: Gender: Male/Female Marital Status: Married/Single/Widow/Divorced Hospital registration number: Ward: Bed No.: Address: Telephone No.: Religion: Hindu/Muslim/Christian/Sikh/Other Education: Illiterate/Primary/Secondary/Graduate or Above Date of Admission: Date of Discharge: Diagnosis: Surgery (If any): Date of Surgery: Occupation: Monthly family income: Name of Doctor in-charge/ Surgeon: Nursing Alert: Sensitivity/Allergy/Precaution Weight: _______in Kg Height: _______feet, inch, etc. Chief Complaints with duration: _____________________ History of present illness: Onset/Treatment taken Present Medical History: Present Surgical History: History of past illness: Illness/Medication/Any restriction Past Medical History: Past Surgical History: Family history: Type: Joint/Nuclear No. of family members: Support person(s): Any Illness: Tuberculosis/Diabetes Mellitus/Hypertension/Heredity Illness/Any other Family tree: Health facility near home: Type: PHC/CHC/Hospital/Any other If any other (specify):

Transport facility: Yes/No Housing: Type: Kuccha/Pukka No. of rooms: Toilet: Indian/western/temporary/open Electricity: Yes/No Drinking Water (Source): Tap/Well/Pond/Hand pump/Other Personal History: Personal hygiene Oral hygiene: Frequency: ___________ Agent: __________ Bath per day: Frequency: ___________ Agent: __________ Diet: Veg./Non veg. No. of meals per day: Food preference: Fluid: __________Glasses/ml/litres/day Tea/Coffee: _______cups/ml/day Sleep & rest: _____hrs/day Uninterrupted/interrupted, Explain: _______ Elimination Pattern: Bowel per day: Regular/constipation Frequency: ______ Urine frequency: During day: __________During Night: _________ Mobility & Exercises: Walking habits: Yes/No If Yes: Regular/Irregular Joints: Normal/Pain/Discomfort/Restriction. Specify: _____ Menstrual History: Regular/Irregular If regular: Normal/Scanty/Heavy cycle LMP: _____ Any other problem: _______ Sexual and Marital History: Spouse: General Health: Good/Fair/Bad Spouse Occupation: Relationship: Satisfactory/Unsatisfactory Staying together: Yes/No No. of children: Male ______ Female _______ General health: Any addiction: Yes/No, If Yes, specify: ___________

OBSERVATION AND ASSESSMENT General appearance: ____________ Sensorium: Conscious/Unconscious/Alert/Oriented/Confused Emotional Status: __________ Foul body odour: Yes/No Foul Breath: Yes/No PHYSICAL EXAMINATION Temperature _____________ Pulse ____________ Respiration _____________ BP _____________ Skin Colour: Normal/Pale/Flushed/Cyanosed Posture: Normal/Kyphosis/Lordosis/Scoliosis Gait: Normal/Abnormal Bleeding: No/Internal/External, If Yes Specify: ____________ Discharge: Yes/No Hair & scalp: Clean/Not clean Pediculosis: Yes/No Skin: Hydrated/Dry/Intact/Broken/Pigmentation/Any other, Specify: _______ Eyes: Symmetry: ______________ Vision: __________ If any discharge, Specify: ____________ Nose: Symmetry: _______ Septal Deviation: Yes/No Any Discharge: Yes/No, If Yes, Specify: _______ Ears: Symmetry: _______ Any Discharge: Yes/No, If Yes, Specify: _______ Mouth & Pharynx: Teeth & Gums: No. of teeth/Dentures Present or Not. Gums: Healthy/Swollen/Bleeding/Any other, Specify: __________ Oral Mucosa: Tongue: Normal/Coated Lips: Normal/Cracks Odour: Neck: Lymph node enlargement: Yes/No Chest: Shape, Symmetry, Movement If any abnormality, Specify____________ Abdomen: Size: ______ Fluid: ______ Shape: ______ Girth: _____ Scar: _____ Herniation: _______ Pigmentation: _______ Distension: _______ Extremities/Limbs: Shape/Size/Movements

Dependency level of the patient: Independent/Partially dependent/Completely dependent Laboratory investigation Sr. No. Name of Investigation

Patient’s Value

Medical treatment of the patient/Medications Sr. No. Name of Drug Pharmacological name

Dose

Normal Value

Remarks

Route Frequency

Action

Implementatio n

Evaluatio n

NURSING CARE PLAN Nursing assessment: List of nursing diagnosis: Short term goals: Long term goals: Nursing Process: Sr. AssesNursing No sment Diagnosi . s

Objective s /Goal

Plannin g

Rational e

Subjectiv e data: Objective data:

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