clinical care plan format of nursing students

1. 1
PATIENT’S IDENTIFICATION DATA
Patient’s Name :_______________________________________________________
Father/Husband Name:_________________________________________________
Age:______________________Sex : _______________________________________
Address :_____________________________________________________________
Education : ________________________Occupation:________________________
Income Per Month: __________________Religion :__________________________
Date of Admission : __________________Indoor Number :____________________
Ward :____________________________ Bed No.:___________________________
Marital Status:______________________Diagnosis :_________________________
Doctor’s Name:______________________ Name of Surgry:___________________
Date of Surgery:____________________Date of Data Collection:_______________
Name of Hospital:______________________________________________________
CHIEF COMPLAINTS
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2. 2
HISTORY OF PRESENT ILLNESS
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PAST MEDICAL HISTORY
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PAST SURGICAL HISTORY
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SOCIO-ECONOMICAL STATUS
SocialStatus:________________________________________________
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EconomicaStatus:____________________________________________
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3. 3
HABITS
Smoking : __________________________________________________
Tobacco chewing : ___________________________________________
Alcohol Consumption : ________________________________________
Vegetarian : _________________________________________________
Non-vegetarian : _____________________________________________
FAMILY HISTORY
Sr.
No
Name of Family
Members
Age
(Yrs)
Sex
Relation
with patient
Education Occupation
Marital
status
Health
status

4. 4
MENSTRUAL HISTORY
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DIETETIC HISTORY
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ACTIVITY AND EXERCISE
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SLEEP / REST
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ELIMINATION
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COGNITIVE/PERCEPTUAL
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5. 5
PRESENT MEDICATION HISTORY
Sr.
No.
Current Medication Dose/Frequency Route Last Dose Taken
LABORATORY INVESTIGATIONS
Sr.
No.
Date Investigation name Normal value Patients value Remark

6. 6
PHYSICAL EXAMINATION
General Appearance
 Level of Consciousness:________________________________
 Orientation:-To Place/ Person/Time:_______________________
 Activity:_____________________________________________
 Body Built:___________________________________________
Anthropometric Measurement
 Height:_____________________________________
 Weight:_____________________________________
 Mid upper arm circumference:________________
Vital Signs
 Temperature:_________________________________
 Pulse: ______________________________________
 Respiration: _________________________________
 Blood Pressure: __________________________
Head
 Hair:_______________________________________
 Colour of Hair:_______________________________
 Scalp:_______________________________________
 Pediculosis:__________________________________
Face
 Face:_______________________________________
 Facial Puffiness:______________________________
Eyes
 Eye Brows:__________________________________
 Eye Lid/Lashes:______________________________
 Eye Ball:__________________________________
 Conjunctiva:_______________________________
 Sclera:____________________________________

7. 7
 Puncta:____________________________________
 Cornea:____________________________________
 Iris:_______________________________________
 Pupils:_____________________________________
Nose
 Nasal Septum:______________________________
 Nasal Polyp:________________________________
 Nasal Discharge:____________________________
Mouth
 Number of Teeth:____________________________
 Dentures :__________________________________
 Dental Carries:______________________________
 Odour of Mouth:____________________________
 Gums:_____________________________________
Lips
 Crack/Healthy:______________________________
 Cleft Lips:_________________________________
 Stomatitis:_________________________________
Ears
 Size:______________________________________
 Shape:_____________________________________
 Position And Alignment:______________________
 Redness:___________________________________
 Discharge:__________________________________
 Cerumen:___________________________________
 Lesions:____________________________________
 Foreign Body:_______________________________
 Hearing Acuquity:____________________________
 Use of Hearing Aids:__________________________
 Tuning Fork Test:_____________________________

8. 8
 Weber test:__________________________________
 Rinne test:___________________________________
Respiratory System
 Respiratory Rate:______________________________
Inspect the Chest
 Thoracic Cage –Shape:__________________________
 Skin Colour and Condition:______________________
 Chest Expansion:_______________________________
Percussion
 Lung Field:___________________________________
 Resonance:___________________________________
 Diaphragmatic Excursion:_______________________
Auscultation
 Breathing Sound:_______________________________
 Adventitious Sound:____________________________
 Respiratory Pattern:_____________________________
Cardio Vascular System
 Blood Pressure:________________________________
 Pulse:________________________________________
 Heart Sound:______________________________________
 Abnormal Heart Sound:______________________________
 Murmurs:_________________________________________
 Carotid Pulse Rate:__________________________________
Peripheral Lymphatic System
 Inspect and Palpate The Leg:___________________________
 Allen Test :_________________________________________
 Edema:____________________________________________
 Type of Edema:_____________________________________
 Lymph Edema:______________________________________

9. 9
 Varicose Veins:______________________________________
 Venous Ulcer:_______________________________________
Digestive System
 Abdominal Girth:____________________________________
Inspection:
 Size:_______________________________________________
 Scar:_______________________________________________
 Lesions:____________________________________________
 Redness:____________________________________________
Palpation
 Tenderness:__________________________________________
 Fluid Collection:______________________________________
 Mass / Soft:__________________________________________
Percussion
 ____________________________________________________
Auscultation
 Bowel Sounds :______________________________________
Genito Urinary
 Frequency of Urination:______________________________
 Urine Last Voided:_________________________________
 Colour:____________________________________________
 Catheter Present:__________________________________
 Urethral Discharge:__________________________________
Intigumentory System
 Skin Colour:_______________________________________
 Dermatitis:_________________________________________
 Allergies:__________________________________________
 Lesions/Abrasions:___________________________________
 Tenderness /Redness:_________________________________

10. 10
Musculo Skeletal System
 Range of Motion:____________________________________
 Joint Swelling :_______________________________________________
 Weakness / Paralysis / Contracture :______________________________

11. 11
LIST OF NURSING DAIGNOSIS
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12. 12
NURSING CARE PLAN
Assessment Diagnosis Expected Outcome Intervention Rational Evaluation

13. 13
Assessment Diagnosis Expected Outcome Intervention Rational Evaluation

14. 14
Assessment Diagnosis Expected Outcome Intervention Rational Evaluation

15. 15
Assessment Diagnosis Expected Outcome Intervention Rational Evaluation

16. 16
Assessment Diagnosis Expected Outcome Intervention Rational Evaluation

17. 17
SUMMARY
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18. 18
BIBLIOGRAPHY
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Signature of the Student Signature of the Evaluator
Date : Date :