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	Normal Value	Remarks

Medical treatment of the patient/Medications

Sr. No.	Name of Drug	Pharmacological name	Dose	Route	Frequency	Action

NURSING CARE PLAN

Nursing assessment:

List of nursing diagnosis:

Short term goals:

Long term goals:

Nursing Process:

Sr. No.	Asses-sment	Nursing Diagnosis	Objectives /Goal	Planning	Rationale	Implementation	Evaluation
	Subjective data: Objective data:

Health Education