CARE PLAN

HISTORY COLLECTION

Identification Data
Name-

Age -

Sex –

Address-

Bed No. -

Ward No. -

Marital Status-

Religion-

Education-

Occupation-

Income-

Date of Admission -

Diagnosis-

Name of surgery-

Date of Surgery-

Chief Complains –

History of Illness
Past Medical history-

Past Surgical History-

Present Medical History-

Present Surgical History-

Family History- Total No. of Family members, Type of Family (Nuclear or Joint Family), History of
communicable, congenital and hereditary disease and any disability in family.

Family Folder-

S.No Name of family Age Sex Relation Education Occupation Health

member with Status
Patients

Family Tree-

Socioeconomic and Environmental History –Bread winner of the family, Monthly

Income ,Language type of house (pakka or kuchcha), housing facilities like water, electricity and
presence of mosquitoes.Maintaning Relationship with neighbor.

Personal History –
Habit -

Hobby -

Dietary Habits -

Sleeping Pattern -

Bladder pattern-

Bowel Pattern-

Physical Examination

General Appearance
Consciousness: Conscious/unconscious/Semiconscious/coma……………………..

Orientation: To place/person/time…………………………………………………...

Activity: Active/Dull/Lethargy………………………………………………………

Body Build: Thin/Obese…………………………………………………………….

Anthropometric Measurement
Height………………………………………………………………………………..

Weight………………………………………………………………………………

Vital Sign
Temperature…………………………….. Pulse…………………………………….

Respiration………………………………Blood Pressure…………………………..

Head
Hair: Equally Distributed/Baldhead…………… Color of Hair…………………….

Scalp: Cleanliness/ Dandruff……………………Pediculosis……………………….

Face
Symmetrical/ Asymmetrical………………….Facial puffiness…………………….

Eyes
Eyebrow: Symmetrical/ Asymmetrical/Scaling/lesions……………………………..

Eyelid/Lashes: Redness/Swelling/Discharge/Lesions……………………………….

Eye Ball: Normal /Sunken/Protrusion ………………………………………………

Conjunctiva: Color/Swelling/Lesions……………………………………………….

Sclera: White/Pink/Yellow/ Tenderness/Discharge/Lesions………………………..

Pupil: Size and Shape/Equally Reacting to Light……………………………...........

Eye Discharge………………………Blurred Vision………………………………..

Vision: Normal/ Myopia/Hyperopia…………………………………….………….

Use of Glasses/Contact Lens………………………………………………………...

Ears
Hearing: Normal/ Impaired/Deafness/Aids………………………………………….

Ear Symmetry: Size………………………….Shape………………………………..

Discharge/Swelling/Vertigo/Tinnitus……………………………………………….

Any Ear Surgery…………………………………………………………………….

Nose
Nasal Septum: Normal/ Deviated………………..Nasal polyp……………………..

Nasal Flaring……………Inflammation………….Discharge………………………

Epistaxis……………………………. Any Nose Surgery…………………………...

Mouth and Throat

Buccal Mucosa…………………………….. Voice………………………………..

Number of Teeth………………….. Dentures…………………………………….

Dental Caries…………………….…Halitosis……………………………………..

Gums: Weak /Swollen/Pale/Healthy……………………………………………….

Tongue: Normal/Pale/Dry/Lesion/Sords/Furrows………………………………….

Throat and Pharynx: Normal/ Enlarged/ Redness/ Swelling……………………….

Lips
Lips: Healthy /Cracked/Redness/Swelling …...........................................................

Cleft Lips:…………………………………………………………………………..

Neck
Lymph Nodes…………………………….Thyroid Gland…………………………

Range of Motion: Flexion/Extension/Rotation……………………………………..

Breast
 Male

Symmetry…………… Lump………………….Swelling…………………..

Gynaecomastia………………………………………………………………..

 Female

Symmetry……………………Pain……………………….Lump…………….

Discharge…………………….. Breast Surgery………………………………

Respiratory System
Thoracic Cage Shape: Normal/ Barrel Chest/ Scoliosis/Kyphosis………………….

Chest Expansion: Symmetry/Asymmetry…………………………………………...

Breathing Sounds: Broncho/ BronchoVesicular/ Vesicular…………………………

Adventitious Sound: Crackles/ Wheeze/ Rhonchi…………………………………..

Respiratory pattern: Normal /Tachypnea/ Bradypnea/Cheyne Stokes………………

Cough…………………Sputum: Productive/Non Productive………………………

Dyspnea…………………….. Hemoptysis………………………………………..

Cardiovascular System
Pulse: Normal/ Tachycardia/Bradycardia……………………………………………

Bloodpressure: Normal/ Hypertension/ Hypotension……………………………….

Chest pain…………......Palpitation……………Tingling Sensation………………..

Edema…………………………………… Numbness………………………………

Syncope/ Dizziness……………..Paroxysmal Noctural Dyspnea…………………..

Heart Sound: S1 and S2 Heard…………… Abnormal Heart Sound……………….

Digestive System
Abdominal Girth…………………….Diarrhea/ Constipation………………………

Nausea………………………………..Vomiting……………………………………

Malena……………………………………………………………………………….

 Inspection

Size: Flat/ Rounded/Scaphoid/Protuberant………………………………………….

Symmetry: Bulges/ masses/ Hernia…………………Scar/ Lesion………………….

 Palpation

Tenderness………………………. Fluid Collection………………………………...

 Percussion

Ascites/Peritonitis: Gas/Fluid Collection……………………………………………

  Auscultation

Bowel Sounds……………………………………………………………………….

Genitourinary System
Urination: Frequency……………….Amount………………Color ………………..

Urinary pattern: Normal/ Urgency/Retention/Dysuria/Anuria………………………

Hematuria….............................................Urethral Discharge………………………

Catheter Present……………………………………………………………………..

Reproductive System
 Male

Testis………………………… Scrotum……………………………………..

Prostate Gland………………………Perineal Area………………………….

 Female

No. of pregnancies…………………..Nature of delivery…………………….

Abortion…………………………….Pain……………………………………

Vaginal Bleeding………………..Vaginal Discharge………………………...

Integumentary System
Color: pallor/ Jaundice/ Cyanosis……………………………………………...……

Texture: Dryness/Wrinkling/ Excessive moisture/Flaking…………………………

Skin Turgidity…………..……Temperature: Warm/Cold/Clammy………………..

Allergies/Dermatitis/Lesions/Pigmentation/Sores………………………………….

Musculoskeletal System
General appearance: Body Symmetry………….Gait………….Posture……………

Coordination……………..Joint Range of Motion……..……Movement…………..

Immobility………………………….Joint Pain/ Swelling……………….………….

Changes in ADL…………………………Physical Deformity………. …………….

Paralysis/Contracture…………………………………………… ……………… ….
Spinal Curvature………………………..Muscle Tone……………………………...

Muscle Mass……………………………Muscle Strength…………………………..

Neurological System
Level of Consciousness (GCS)………………………..Orientation…………………

Headache………………….Confusion………………………Convulsion………….

Paralysis…………………………….In coordination: Memory…………………….

Tingling and Numbness……………………Paresthesia……………………………

Sensation…………………………..Judgement……………………………………..

Reflexes: Cranial Nerve Functions………………………………………………….

Investigation
S.No Name Of Investigation Normal Value Patient Value Remark

Medication

S.No Name of Dose Route Frequency Action Side Nurses

Medication effect Responsibility
Nursing Management

 Assessment

 Nursing Diagnosis

 Nursing Care Plan

Assessment Nursing Goal/ Expected Nursing Rational Nursing Evaluation

Diagnosis Outcomes intervention implementatio
Subjective Goal n
data
Objective
data

 Health Education

 Patient progres

 Nurses Notes

HOD

Medical Surgical Nursing