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. Asses- Nursing Objectives Planning Rationale Implementation Evaluation
No. sment Diagnosis /Goal

Subjective
data:

Objective
data:

Health Education