Nursing Care Plan Format

Mr. Shivateerth Hiremath

VMP College of Nursing & Medical Research Institute, Akluj.

 HISTORY COLLECTION
IDENTIFICATION DATA
Name Of the Patient: -
Age: -
Gender: -
Marital Status: -
Educational Status: -
Religion: -
Occupation: -
Date Of Admission: -
OPD No: -
IPD No: -
Ward/Bed No: -
Address: -
Consultant/Doctor Name: -
Provisional Diagnosis: -
Surgical Procedure Name: -
CHIEF COMPLAINTS: -………………………………………….

MEDICAL HISTORY
Present Medical History
Mr./Ms.…………………………. got admitted in ……………………………………hospital. On…………..............with
complaints of………………………………………………….. then She/He is undergone diagnostic evaluation
of…………………………………………………after doctor diagnosed as……………………………Now She/he is
receiving medication………………………………………. finally, His/her health condition is improving.

Past Medical History: There is no significance of Past medical history.

Or
There is a significance of Past medical history ……………………………………….

SURGICAL HISTORY
Present Surgical History: There is no significance of Present surgical history
Or
There is a significance of Present surgical history………………………………………………………

Past Surgical History -There is no significance of Past surgical history.

Or
There is a significance of Present surgical history……………………………………………………….
 FAMILY HISTORY
S.N. Name of Age/ Relation Educational Occupation Marital Health
family Sex with Patient Status status Status
members
1
2
3
4
5

Family history / Pedigree chart

Keys -
Male Female

Deceased/Death Affected Client /individual

FAMILY MEDICAL HISTORY

There is no significance of family medical history of communicable diseases like Tuberculosis,
Hepatitis etc. and Hereditary diseases like Diabetes mellitus/Hypertension/ Heart diseases
/Asthma/ Cancer etc.
Or
There is a significance of family medical history of communicable diseases like Tuberculosis,
Hepatitis etc. and Hereditary diseases like Diabetes mellitus/Hypertension/ Heart diseases
/Asthma/ Cancer etc.

SOCIO ECONOMIC STATUS: -

My Patient Mr./Ms.………………………………………belongs to…………………………. family.
He/she is a……………………. of the family and his monthly income is……………………rupees and
leaving in……………………………… house with……... Rooms, kitchen, latrine and bathroom are
separated.
He /She are having good electricity, water supply and drainage in his house.

PERSONAL HISTORY –

NUTRITIONAL HISTORY-

MENSTRUAL HISTORY (FEMALES): -

 PHYSICAL EXAMINATION
General Appearance:
Nourishment - Well Nourished /Under Nourished
Body build- Thin /Obese
Health- Healthy / Unhealthy
Activity- Active /Dull (Tired)
Habits - Smoking/ alcohol/drug abuse/other

Mental status
Consciousness- Conscious /Unconscious /Delirious/Talking
Look/Behavior - Normal / Relaxed /Anxious/Distressed/Depressed/Withdrawn

Posture
Body curves- Lordosis/ Kyphosis, Scoliosis
Movement- Any Limp
Height-
Weight-
Skin condition
Color- Pallor /Jaundice/Cyanosis, Flushing/ Etc.
Texture- Dryness/Wrinkling/Excessive Moisture
Temperature- Warm/Cold/Clammy
Lesions - Papules/Vesicles/Wounds/Etc.

HEAD:
Hair(color)- Black/White/Etc.
Scalp- Dandruff/Pediculi/Etc.
Face- Pale/Flushed/Puffiness/Fatigue/Pain/Fear/Anxiety
Skull- Shape of the Skull

EYE:
Eye brows - Normal /Absent
Eye lashes - Infection /Sty
Eye lids- Oedema /Lesions/Ectropion(Eversion)/Entropion (Inversion )
Eye balls- Sunken /Protruded
Conjunctiva- Pale /Red/Purulent
Sclera- Jaundiced
Pupils - Dilated /Constricted/Reaction to Light
Lens- Opaque /Transparent
Visual activity- Normal/Myopia/ Hyperopia
Fundus- Congestion /Hemorrhagic Spots
 EARS:
Ear Canal- Normal / Any Discharges
Tympanic membrane - Perforations /Lesions/Bulging
Hearing- Hearing Activity
Bleeding /discharge -Yes/No
NOSE:
External Structure -Crusts /Discharges
Olfactory Sense-Yes/ No
Nostrils- Inflammation of Mucus Membrane / Septal Deviations
Discharge -yes/ no
ORAL CAVITY:
Teeth- Discoloration/ Dental Caries
Lips- Redness /Swelling/Crusts/Cyanosis/Stomatitis
Gums- Ulceration /Bleeding/Swelling/Pus Formation
Breath- Foul Smelling
Taste -Sweet/ Bitter /Sour/ Etc.
NECK:
General Structure - Normal /Abnormal
Lymph node - Enlarged /Palpable
Thyroid Gland- Enlarged
Throat / pharynx -Enlarged Tonsils /Redness/ Pus
Range of motion -Flexion /Extension /Rotation

CHEST AND RESPIRATORY SYSTEM:

Thorax - Shape /Symmetry Of Expansion/Posture
Chest shape- Normal/ Flat Chest /Pigeon Chest /Etc
Type of respiration:…………………………….
Breathe sounds – Sigh /Swish/Rustle /Wheezing/Crepitations/Plural Rub /Etc
Breast –Enlarged Lymph Nodes

 INSPECTION :

 PALPATION :-

 PERCUSSION :

 AUSCULTATION :
CARDIO VASCULAR SYSTEM

HEART
Sound:- S1 & S2 Sounds /Murmurs Sounds
Rhythm:-
 INSPECTION:

 PALPATION: -

 PERCUSSION:

 AUSCULTATION:

ABDOMEN
Liver----- Normal/ Abnormal / Enlargement
Spleen ---- Normal/ Abnormal / Enlargement
Kidneys----- Normal/ Abnormal
Bladder------
Hernias-------
 INSPECTION: -Skin Rashes /Scar /Hernia /Ascites /Distension/Pregnancy

 PALPATION: -Tenderness /Enlargement

 PERCUSSION: Presence of Gas/Fluids /Masses

 AUSCULTATION: Bowel Sounds /Fetal Heart Sounds

MUSCULOSKELETAL SYSTEM:
Gait:
Upper extremities: Flexion/Extension/ Rotation
Lower extremities: Flexion/Extension/ Rotation
Deformities: Oedema /Clubbing of Fingers /Varicose Veins
Range of motion: Flexion/Extension/ Rotation
BACK: -
Spina Bifda /Curves
GENITALIA AREA: -

Inguinal lymph glands -Enlarged /Palpable

- Vaginal Discharges
- Presence of Sexually Transmitted Diseases

RECTAL EXAMINATION: -
Hemorrhoids/fistula/piles
 NERVOUS SYSTEM: -
Mental status:
Language :
Motor co-ordination:
Sensory function:
Cranial nerves:
Reflexes: biceps /triceps/patellar/Achilles/planter reflex

FINAL FINDINGS/IMPRESSION

VITAL SIGNS
SL. No Vitals Patient value Normal Value Remarks
1 Temperature 98.6’F
2. Pulse 70-80 beats /minutes
3. Respiration 16-20 breath /minutes
4. Blood pressure 120/80 mm of Hg
5 Oxygen (P02) 90% to 100%

INVESTIGATION
Sl Sample Investigation Patient value Normal Value Remarks/
No Inference
1. BLOOD HB Male 13-17 gm%
Female 12-14gm%
Total R.B.C. M- 4.5-6.5 Mil/ cmm
F- 3.8 - 5.8 Mil/ cmm
Total W.B.C. 4000-11000/ cmm
Neutrophils 40-70%
Lymphocytes 20-45%
Monocytes 2-10%
Eosinophils 1-6%
Basophils 0-1%
Platelets Count 1.5-4.5 Lacs/cmm
2 Urine
3. Sputum
4. Feces
 REPORTS
X-ray-
USG-
CT scan-
MRI scan-
PET scan -
SPECT-
Etc. –

MEDICATION

Sl Drug Name Dosage Route Frequency Mechanism Side Nurses Responsibility

No Of Action Effects
1 Inj. Pantop 40MG IV BID Proton Headache Monitor patient
pump Vomiting condition.
inhibitors Dizziness
Skin Monitor rights of drug
irritation administration

Monitor vital signs

Monitor side
effects/complications

NURSING DIAGNOSIS ACCORDING TO PRIORITY

1. Acute Pain Related to Disease Condition Evidenced By……………
2. Impaired Tissue Integrity Related to Chronic Disease Condition Evidenced
By……………
3. Ineffective Breathing Pattern Related to Disease Condition Evidenced By……………
4. Imbalanced Nutrition, Less Than Body Requirements Regarding Disease
Condition Evidenced By……………
5. Risk For Fluid Volume Deficit R/T Upper G I Hemorrhage, Diseases Condition
Evidenced By……………
6. Activity Intolerance Related to Physical Weakness. Evidenced By……………
7. Ineffective Coping Mechanisms Related to Disease Condition Evidenced
By……………
8. Knowledge Deficit Regarding the Inadequate Information of Medicine and
Nutrition. Evidenced By……………
 NURSING CARE PLAN

Assessment Nursing Objective/ Planning/ Implementation Rationale Evaluation

Diagnosis Goal Intervention
Subjective 1. 1. 1.
data
2. 2. 2.

3. 3. 3.

4. 4. 4.

5. 5. 5.
Objective
6 6. 6.
data
 HEALTH EDUCATION

1. Personal hygiene---------------------------

2. Diet/Nutrition---------------------------------

3. Exercise ---------------------------------------

4. Medication ------------------------------------------

5. follow up/Psychological support----------------------------

NURSES NOTE
SL DATE /TIME NOTE STUDENT TEACHER
.NO SIGNATURE SIGN

CONCLUSION
 CASE STUDY /CASE PRESENTATION/CLINICAL PRESENTATION

History Collection Refer NCP format

Physical examination

Anatomy and Physiology of Disease condition

(Structure and Function describe briefly)

Disease condition

Introduction

Definition

Types /Classification

Incidence

Etiology /Causes (Book Picture and Patient Picture)

Risk factors (Book Picture and Patient Picture)

Pathophysiology

Clinical features /signs and symptoms (Book Picture and Patient Picture)

Investigation (Book Picture and Patient Picture)

Management (Book Picture and Patient Picture)

Medical management Surgical management (If any)

Nursing management (include Nursing care plan/refer NCP format)

Health education (Discharge plan) refer NCP format

Nurses Note

Summery (self-evaluation)

Bibliography
 Nursing Tips
ARTICLES USED FOR PHYSICAL EXAMINATION
SL NO NAME OF EQUIPMENTS PURPOSE
1 THERMOMETER To measure temperature
2 SPHYGMOMANOMETER To measure blood pressure
3 LARYNGOSCOPE To examine the larynx
4 STETHOSCOPE To listen body sounds
5 OPTHALMOSCOPE To examine eye
6 FOETOSCOPE To listen the fetal heart sounds
7 TONGUE DEPRESSOR To examine mouth and throat
8 NASAL SPECULUM To examine the nostrils
9 TUNING FORK To test the hearing
10 VAGINAL SPECULUM To examine the genitals in females
11 PERCUSSION HAMMER To test reflexes
12 PROCTOSCOPE To examine the rectum
13 OTOSCOPE To examine the rectum
14 PHARYNGEAL RETRACTOR To examine the pharynx
15 SALPINGOSCOPY Visualization of fallopian tube
16 DUODENOSCOPY Duodenum
17 PLUEROSCOPY Pleural cavity
18 ARTHROSCOPY Joint
19 CULDOSCOPY Visualization pelvic organ
20 GASTROSCOPY Visualization of stomach
21 URETHROSCOPY Visualization of urethra
22 NEPHROSCOPY Visualization of renal pelvis
23 HYSTEROSCOPY Visualization of uterus
24 CYSTOSCOPY Visualization of urinary bladder
25 LAPROSCOPY Visualization of abdominal organs through
abdominal wall
26 COLONOSCOPY Visualization of colon

MEDICAL ABBREVIATION
SL ABBREVIATION MEANING
NO
1. O. D Once a day
2 B.D Two times in a day
3 T.D.S Three times in a day
4 Q.I.D Four times in a day
5 A.C Before meal
6 P.C After meal
7 A.M Before noon
8 P.M After noon
9 O.M Each morning
10 O.N Each night
11 S.O.S If necessary, in emergency
12 H.S At bed time
13 P.R.N When required
14 STAT Immediately
15 C.M Tomorrow morning
16 H.N Tonight
17 H Hour
18 Q Every
19 C With
20 CC Cubic centimeter
21 CAP Capsule
22 TAB Tablet
23 MEQ Milliequivalent
24 LB Pound
25 IM Intramuscular
26 IV Intravenous
27 ID Intradermal
28 SC Subcutaneous
29 OS Left eye
30 OU Both eye
31 OD Right eye
32 AD Right ear
33 AS Left ear
34 MCG Microgram
35 L Liter
36 ML Milliliter
37 OZ Ounce
38 GIT A drop
39 RX Treatment
40 FL Fluid
41 UNQ Ointment
42 LOT Lotion
43 PIL Pill
44 SYR Syrup
45 TR . Tincture
46 EMPL Plaster
47 MIST. Mixture
48 SP Spirit
49 PULVE Powder
50 AQ. Water
51 DIL . Dilute
 Lab values
TEST NORMAL VALUES
WBC Count 4000 -12000/cmm
DLC (Differential Leucocytes Count) Neutrophils-50-70%
Lymphocytes -20-40%
Monocytes-4-8%
Eosinophils -0-2%
Basophils-3-5%
RBC count 4.5-5.5millian/cmm
Platelet count 1- 3.5lacks/cmm
Hemoglobin ( HB) At birth-18gm%
Adults
MEN- 13 to 16gm/dl
WOMEN -12-15 gm/dl
PCV ( Packed cell volume ) or At birth -44 to 62%
Heamatocrit ADULTS
MEN-40-54%
WOMEN-36-47%
ESR ( Erythrocyte sedimentation MALES-0 to 9mm/1st hour
rate) FEMALE-0 to 20mm/1st hour
Bleeding Time (BT) 1 to 6 minutes in adults
Coagulation Time ( CT) 5 to 18 minutes
Prothrombin Time ( PT ) 60 to 100 % of control blood 12 to 16 seconds
Blood urea 2.5 to 6.5 mmol/l or 20 to 40 mg /dl
3.5 to 5.5 mmol/l or 55 to 110 mg /dl
Blood sugar fasting Post prandial 70 to 140 mg / dl
Total bilirubin 1.7 to 15.4 mol or 0.1 to 1.0mg /dl
Direct bilirubin 0.1 to 0.2 mg/ dl
Indirect bilirubin 0.1 to 0.8 mg/ dl
Cholesterol Below 5.2mmol/L
Triglycerides 0.45-1.69mmol/L
LDL Above 3.36mmol/L
HDL Below 1.55mmol/L
TSH 0.4-5.0mu/L
Serum thyroxine ( T4) 70 to 160 mmol
Tri-iodothyronine (T3) 1.1 to 2.6 mmol/l
Lipase 0.2 to 1.5 units /ml
Amylase 60-180u/l
Lactate 0.6-1.8mmol/l
Uric acid 0.1 to 0.4 mmol/l or 2.5 to 8 mg /dl
Total protein 6 to 8gm /dl
Albumin 3.5 to 5.5 gm /dl
Globulin 1.5 to 3 gm /dl
A/G ratio 1.5/1 to 2.5 /1
SGOT/AST Less than 40n IU/l
SGPT/ALT Less than 40 IU/l
Serum phosphorus 0.8 to 1.4 m mol/lor 2.5 to 4.5 mg /dl
Serum cholesterol 3.5 to 7.8 m mol/l or 100 to 300 mg /dl
Serum sodium 135 to 146 mmol/l or 135 to 146 meq/l
Serum chloride 98 to 108 mmol/ l 98 to 108 meq/l
Serum potassium 3.4 to 5.4 m mol/l
serum creatine 1 to 2 mg /dl
Serum calcium 2.1 to 2.7 mmol/l
Blood PH 7.35 to 7.45
CPK ( Creatinine Phosphokinase ) 15 – 130 IU
Urine normal volume 1200 to 2000ml
Urine specific gravity 1.015 to 1.025

TYPES OF I.V SOLUTIONS

SL TYPE OF SOLUTION TONICITY

NO
1 Normal solution ( 0.9% saline ) Isotonic
2. ½ normal saline ( 0.45%) Hypotonic
3 Ringer lactated solution Isotonic
4 ¼ normal saline (0.225%) Hypotonic solution
5 D5W(5 % dextrose in water ) Isotonic
6 D10 W ( 10% dextrose in solution ) Hypertonic
7 5% normal saline Hypertonic
8 5% dextrose in RL Hypertonic
9 5% dextrose in 0.9% NS Hypertonic
10 5% dextrose in 0.45% NS Hypertonic