METRO COLLEGE OF NURSING, GREATER NOIDA, U.P.

FORMAT FOR NURSING CARE PLAN

NURSING CARE PLAN

1. 
   

   Patients Biodata:

   
   
   
   • Name
   
   
   • Address
   
   
   • Age
   
   
   • Sex
   
   
   • Religion
   
   
   • Marital status
   
   
   • Occupation
   
   
   • Source of health care
   
   
   • Date of admission,
   
   
   • Provisional Diagnosis
   
   
   • Date of surgery (if any)
   
   
   

2.Presenting complaints:

Describe the complaints with which the patient has come to the hospital

3.History of illness

• History of present illness onset, symptoms, duration, precipitating/alleviating factors

• History of past illness illnesses, surgeries, allergies, immunizations, medications

• Family history family tree, history of illness in family members, risk factors, congenital problems, psychological problems.

4.Economic status of the family:

• Monthly income & expenditure on health, marital assets (own Pacca house car, two-wheeler, phone, TV etc)

5. Psychological status:

• Ethnic background, (geographical information, cultural information) support system available.

6. Personal habits:

• Consumption of alcohol, smoking, tobacco chewing, sleep, exercise, and work elimination, nutrition.

7. Physical examination with date and time

PHYSICAL EXAMINATION

• General health status:

• Level of consciousness- Conscious/Unconscious

• Height- ..cm

• Weight - ..kg

• Appearance-

• Complexion-

• Head-to-toe assessment

• General Appearance- Observations:

Colour:

Skin:

Vital signs

Head and face

• Size-
  
  
  • Symmetry: Symmetrical/Asymmetrical
  
  
  • Shape:
  
  
  • Color:
  
  
  • Pain:
  
  
  • Tenderness:
  
  
  • Lesion:
  
  
  • Edema:
  
  
  

• Scalp-
  
  
  • Colour:
  
  
  • Texture:
  
  
  • Scales:
  
  
  • Lumps:
  
  
  • Lesions:
  
  
  • Inflammation:
  
  
  

• Hair
  
  
  • Colour:
  
  
  

• Face:
  
  
  • Shape:
  
  
  

• Colour:

• Movement:

• Expression:

• Pigmentation:

• Acne:

• Tics:

• Tremors:

• Scars:

Eyes:

Acuity:

• Glasses:

• Visual loss:

• Diplopia:

• Photophobia:

• Pain burning:

• Eyelids-
  
  
  • Color:
  
  
  • Potosis:
  
  
  • Edema:
  
  
  

• Extra ocular movement-
  
  
  • Position and alignment of eyes: Symmetrical/ Asymmetrical
  
  
  • Strabismus:
  
  
  • Nystagmus:
  
  
  

• Conjunctiva-
  
  
  • Colour:
  
  
  • Discharge:
  
  
  • Vascular changes:
  
  
  

• Iris-
  
  
  • Colour: Ambiguous
  
  
  • Vascularity: Present/Absent
  
  
  • Jaundice: Present/Absent
  
  
  

• Pupils-
  
  
  • Size:
  
  
  • Shape: Normal
  
  
  • Equality: Normal
  
  
  • Reaction to light: Reactive/Not reactive
  
  
  

Ears-

• Acuity
  
  
  • Hearing loss:
  
  
  • Hearing aid:
  
  
  • Pain:
  
  
  • Tinnitus:
  
  
  

• External ear-
  
  
  • Lobe:
  
  
  • Auricle:
  
  
  • Ear canal:
  
  
  

• Inner ear

• Vertigo: Present/Absent

Nose-

• Smell:

• Symmetry: Symmetrical/Asymmetrical

• Flaring:

• Sneezing:

• Deformities:

Mucosa

• Color:

• Edema:

• Exudates:

• Pain tendencies:

• Sinus tenderness:

Mouth and Throat

• Odor:

• Pain:

• Ability to speak:

• Chew:

• Swallow:

• Lips-
  
  
  • Hydration:
  
  
  • Lesions: Present/Absent
  
  
  • Blister: Present/Absent
  
  
  • Swelling: Present/Absent
  
  
  • Numbness: Present/Absent
  
  
  

• Gums-
  
  
  • Colour:
  
  
  • Edema:
  
  
  • Bleeding: Present/Absent
  
  
  

• Teeth-
  
  
  • Number:
  
  
  • Missing:
  
  
  • Caries: Present/Absent
  
  
  

• Tongue-
  
  
  • Symmetry: Symmetrical/Asymmetrical
  
  
  • Color:
  
  
  • Hydration:
  
  
  • Protrusion: Present/Absent
  
  
  • Ulcers: Present/Absent
  
  
  • Swelling: Present/Absent
  
  
  

• Throat-
  
  
  • Gag reflex: Present/Absent
  
  
  • Soreness: Present/Absent
  
  
  • Cough:
  
  
  

• Sputum:

• Haemoptysis: Present/Absent

• Voice-
  
  
  • Hoarseness: Present/Absent
  
  
  • Loss:
  
  
  

• Neck
  
  
  • Symmetry: Symmetrical/Asymmetrical
  
  
  • Movement:
  
  
  • Range of motion: Present/Absent
  
  
  • Masses: Present/Absent
  
  
  • Scars: Present/Absent
  
  
  • Pain: Present/Absent
  
  
  • Stiffness: Present/Absent
  
  
  

• Trachea-
  
  
  • Deviation: Present/Absent
  
  
  

• Thyroid-
  
  
  • Symmetry: Symmetrical/Asymmetrical
  
  
  • Tenderness: Present/Absent
  
  
  • Enlargement: Present/Absent
  
  
  • Nodules: Palpable/Non-palpable
  
  
  • Scares: Present/Absent
  
  
  

• Lymph nodes-
  
  
  • Size:
  
  
  • Shape:
  
  
  • Mobility: Present/Absent
  
  
  • Tenderness: Present/Absent
  
  
  • Enlargement: Present/Absent
  
  
  

Chest

• Size: Normal

• Symmetry: Symmetrical

• Deformities: Present/Absent

• Pain: Present/Absent

• Tenderness: Present/Absent

• Skin-
  
  
  • Color: Whitish
  
  
  • Rashes: Present/Absent
  
  
  • Scars: Present/Absent
  
  
  • Hair distribution: Regular
  
  
  • Turgor:
  
  
  • Temperature:
  
  
  

Lungs

• Breathing pattern: Regular/Irregular

• Rate:

• Regularity: Regular/Irregular

• Depth:

• Use of accessory muscles: Active/Passive

• Sound:
  
  
  • Cardiac patterns-
    
    
    • Rate:
    
    
    • Regularity: Regular/Irregular
    
    
    • Implanted pacemaker: Present/Absent
    
    
    
  
  
  

Abdomen

• Symmetry: Symmetrical/Asymmetrical

• Muscle tone:

• Turgor:

• Hair distribution:

• Scars:

• Umbilicus:

• Distention:

• Sound:

• Liver border:

Kidney

Genitalia

• Urinary output:

• Amount:

• Colour:

• Frequency:

• Dribbling:

• Incontinence:

• Haematuria:

• Nocturia:

• Male- Penis
  
  
  • Discharge:
  
  
  • Ulceration:
  
  
  • Pain:
  
  
  • Scrotum:
  
  
  • Swelling:
  
  
  • Tenderness:
  
  
  • Testis:
    
    
    • Size:
    
    
    • Shape:
    
    
    • Swelling:
    
    
    • Masses:
    
    
    
  
  
  

Rectum

• Pigmentation:

• Haemorrhoid:

• Rashes:

• Masses:

• Lesions:

• Tenderness:

• Pain:

• Itching:

• Burning sensation:
  
  
  • Back-
    
    
    • Scars:
    
    
    • Edema:
    
    
    • Spiral abnormalities:
    
    
    • Pain:
    
    
    • Tenderness:
    
    
    
  
  
  

Extremities

• Upper extremities-
  
  
  • Symmetry: Symmetrical/Asymmetrical
  
  
  • Joint:
  
  
  • Muscle:
  
  
  • Edema:
  
  
  • Other symptoms:
  
  
  

• Lower extremities-
  
  
  • Symmetry: Symmetrical/Asymmetrical
  
  
  • Joint:
  
  
  • Muscle:
  
  
  • Edema:
  
  
  • Other symptoms:
  
  
  

8. Investigations

9. Treatment

10. Nursing process:

Patient name: Date: Ward:

11. Discharge planning:

It should include health education and discharge planning given to patients.

12. Evaluation of care

Overall evaluation, the problem faced while providing care prognosis of the patient, and conclusion

13. Guideline for writing Nurses Note

METRO COLLEGE OF NURSING, GREATER NOIDA, U.P.

FORMAT FOR CASE PRESENTATION

1. Patients Biodata:

Name, Address, Age, Sex, Religion,

Marital Status Occupation

Source of Health Care Date Of Admission Provisional Diagnosis

2. Presenting complaints:

Describe the complaints with which the patient has come to hospital

3. History of illness

History of present illness onset, symptoms, duration, precipitating/ alleviating

Factors

History of past illness- illnesses, surgeries, allergies, immunizations, medications

4. Economic status:

Monthly income & expenditure on health

5. Psychological status:

Ethnic background, (geographical information, cultural information) support system

available.

6. Personal habits: Consumption of Alcohol Smoking, Tobacco Chewing Sleep, Exercise, Work Elimination, Nutrition.

6. 
   

   Investigation

METRO COLLEGE OF NURSING, GREATER NOIDA, U.P.

FORMAT FOR NURSING CASE STUDY

1. Patients Biodata: Name, Address, Age,

Sex, Religion, Marital Status Occupation

Source of Health Care Date Of Admission Provisional Diagnosis Date Of Surgery (If Any)

2. Presenting complaints:

Describe the complaints with which the patient has come to hospital

3. History of illness

History of present illness onset, symptoms, duration, precipitating/ alleviating

factors

History of past illness- illnesses, surgeries, allergies, immunizations, medications

Family history family tree, history if illness in family members, risk factors, Congenital Problems, Psychological Problems.

4. Economic status:

Monthly income & expenditure on health

5. Psychological status:

Ethnic background, (geographical information, cultural information) support system

available.

6. Personal habits:

Consumption of Alcohol Smoking, Tobacco Chewing Sleep, Exercise, Work Elimination, Nutrition.

7. History to Physical examination with date and time

8. 
   

   Disease condition:

Definition

Anatomy Physiology Incidence

Etiology & Risk Factor