Nursing Care Plan

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

Identification Data Chief Complaints/Presenting Problem History ---Medical & Surgical , Present & Past Family History ----I) Family Pedigree II) Family Relationship/chart III) Family History of Disease Communicable , Non- communicable & Genetic disorder Psychological health statusConsciousness , OrientationTime, place & Person, Memory . Socio-Economic status Personal Habits :--- I) ADLs II) Sleep III) Rest IV) Hobbies V) Smoking & Drinking Nutritional Status Physical Examination ----Head to toe or System wise Investigation Medications Nursing Process ---- List out nursing diagnosis as per client problems , both present & potential Nursing Care Plan Health Education ---Diet , Medications, Exercises, Personal Hygiene, Follow Up Care Summary/Evaluation Conclusion Bibliography Developmental, Menstrual, Immunization