Nursing Care Plan 2013
Student Name :
Clinical Area :
Date :
Clinical Instructor :
Nursing Admission Data Base/
Client: X
Age:
Ward:
Room No.:
Spoken Language:
Date of Admission:
Source of Data:
Condition on arrival:
Walking
Reasons for Hospitalization:
C\o
(5%)
Sex:
Bed No.:
Via:
Wheelchair Stretcher
(0.5 Mark)
(0.5 Mark)
Complain of & chief complain &
symptom
Confirmed Diagnosis:
(1 Mark)
Medication taken at home:
A: Prescribed: No
Yes (specify
(1 Mark)
B: Non– Prescribed: No
Yes (specify)
Past medical history:
(1 Mark)
Past surgical history:
(0.75 Mark)
Family history:
(0.75 Mark)
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Nursing Care Plan 2013
Assessment/ (Subjective Data)
1. Health Maintenance/ Perception Pattern.
(15%)
(2 Mark)
A: Smoking: No
Yes: No. of Cigarettes/ day.
Quit (Date)
B: Alcohol: No
Yes (amount)
C: Allergies (drugs, food, tape, dyes, dust, insects): No
Yes (specify)
2. Nutrition/ Metabolic pattern
(3 Mark)
A: Diet: Typical diet at home:
Prescribe diet:
B: Appetite: Normal
Increased
Decreased
C: Nausea: No
Yes
D: Vomiting: No
Yes (describe)
F:
Dysphagia: No
Yes
G: Weight changes within last 6 months: No
Yes
Kg gained/ lost:
H: Dentures: Upper
Lower
Partial
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Nursing Care Plan 2013
3. Activity/ Exercise pattern
(2 Mark)
Self care ability: (Use codes: 1 = independent, 2 = needs Assistance, 3 = dependent).
Activity
Feeding
Bathing
Dressing/Grooming
Toiling
Mobility
1
2
3
Assistive devices : No
: Yes (specify)
4. Elimination Pattern/
(4 Mark)
A: Bowel habits:
Number of bowel movements/day
Last bowel movement
Constipation
Diarrhea
Distention
Incontinence
Bleeding
Painful defecation
Ostomy
Assistive devices: No
Yes (Specify)
B: Urinary Habits:
Frequency (times/day)
Color
Dysuria
Oliguria
Urgency
Hematuria
Anuria
Nocturia (times/ night)
Retention
Burning
Assistive devices: No
Yes (specify)
folly catheter condom catheter
3 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
5. Sleep/ Rest Pattern
A: Usual number of hours/ night:
AM naps:
PM naps:
B: Use of drugs: No
Yes (specify)
(1.5 Mark)
C: Any change in habits after hospitalization: No
Yes (specify)
6. Cognitive/ Conceptual Pattern
A: Hearing: Impaired (Rt, Lt)
Deaf (Rt, Lt)
Tinnitus
Hearing aids
None
(3 Mark)
B: Vision: Impaired (Rt, Lt)
Glasses
Contact lenses
Blind (Rt, Lt)
None
C: Vertigo: No
Yes
D: Discomfort/ pain: No
Yes (describe)
7. Coping Stress/ Self Perception Pattern
A: Major concerns regarding hospitalization of illness:
(1 Mark)
B: Major loss/ change: No
Yes (specify)
C: Coping mechanisms:
8. Value /Belief Pattern
A: Religion:
B: Spiritual Habits:
(1 Mark)
4 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
9. Role/ Relationship Pattern
A: Occupation:
B: House- ld members: (Specify)
(1.5 Mark)
C: Family concerns regarding hospitalization:
10. Sexual/ Reproductive Pattern
A: Testicular exam: No
Yes
(1 Mark)
Physical Examination/ (Objective Data)
1. General Survey/
(10%)
(1 Mark)
Level of consciousness:
Orientation:
2. Nutritional/ Metabolic pattern
A: Skin:
Color
Symmetrical
Temperature
Turgor
Texture
Moisture
Lesions: No
Yes (describe)
Edema: No
Yes
Pruritus: No
Yes
Tubes: No
Yes (specify)
(4 Mark)
B: Oral Cavity:
Lips (describe)
Gums (describe)
Teeth (describe)
Tongue (describe)
Mucous membrane & adjacent structures (describe)
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Nursing Care Plan 2013
C: Neck:
Symmetrical: Yes
No (specify)
Thyroid
Carotid pulse
Jugular venous pressure
Lymph node enlargement: No
Yes (describe)
D: Abdomen:
Symmetrical: No
Yes
Contour
Umbilicus
Number of bowel sounds / minute
Abnormal sounds: No
Yes (specify)
Masses: No
Yes (specify)
Organomegally: No
Yes (specify)
Tenderness: No
Yes (specify)
Other data:
3. Activity/ Exercise Pattern
A: Lung &Thorax
Respiration: (describe)
(3 Mark)
Symmetrical chest movements: yes
No (specify)
Lung expansion (describe)
B: Cardiovascular:
Blood pressure
Apical pulse (describe)
Peripheral pulses (describe)
Abnormal heart sounds: No
Yes (describe)
6 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
C: Musculoskeletal:
Tempomandibular joint: (describe)
Neck joints: (describe)
Upper extremity joints: (describe)
Lower extremity joints: (describe)
Spine: (describe)
4. Cognitive/ perceptual Pattern
A: Eyes:
B: Ears:
C: Nose:
D: Mental status: able to calculate: Yes
No
Thinking abstractly: Yes
No
Memory: Yes
No (specify)
(2 Mark)
E: Neurological status:
Intact cranial nerves: Yes
No (specify)
Intact sensory function: Yes
No (specify)
Intact motor function: Yes
No (specify)
Deep tendon reflexes (draw a picture)
7 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
Medication / (10%)
Drug's Allergies: No
Yes (Specify)
Drugs and
Classification
For this Patient
Action/indication
Dose/ Route
Frequency
ContraIndications
Expected
Side effects
Nursing Implications
(2 Mark)
(1 Mark)
(3 Mark)
(1 Mark)
(1 Mark)
(2 Mark)
8 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
Diagnostic Evaluation
(Lab results, X-ray, ECG, procedures)
Date
Test Performed
Normal Value
Patient Value
(1 Mark)
(2 Mark)
(2 Mark)
9 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
(10%)
Interpretations &
Nursing Implications
(5 Mark)
Nursing Care Plan 2013
Nursing Care Plan/ (40%)
Functional
Health
Pattern
Nursing
Diagnosis
Evidenced by
/Defining
Characteristics
Short-Term
Goals
Planned
Intervention
(With Rationale)
Actual
Intervention
The Outcome
(With Rationale)
(4 Mark)
(6 Mark)
(6 Mark)
(6 Mark)
(6 Mark)
(6 Mark)
(6 Mark)
10 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
Discharge Care Plan/ (10%)
11 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
Index Key (examples)
Discharge Care Plan/
(10%)
Date &Sign
Plan and Outcome
Target Date:
Nursing Interventions
Date Achieved
(0.5 Mark)
(3 Mark)
(0.5 Mark)
(5.5 Mark)
(0.5 Mark)




The patient/family's discharge planning will
begin on day of admission including
preparation for education and/or equipment.
On the day of discharge, patient/family will
receive verbal and written instructions
concerning:
o Medications
o diet
o Activity
o Treatments
o Follow up appointments
o Signs and symptoms to observe for
(when to contact the doctor)
Care of incisions, wounds, etc.
Other:







12 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Assess needs of patient/family beginning
on the day of admission and continue
assessment during hospitalization.
Anticipated needs/services:
o Respiratory equipment
o Hospital bed
o Wheel char
o Walker
o Home health nurse
o Home PT/OT/ST
Involve the patient/family in the
discharge process.
Discuss with physician the discharge
plan and obtain orders if needed.
Contact appropriate personnel with
orders.
Provide written and verbal instructions
at the patient/family's level of
understanding.
Verbally explain instructions to
patient/family prior to discharge and
provide patient/family with a written
Nursing Care Plan 2013
copy.
 Ascertain that patient has follow-up care
arranged at discharge.
 Provide verbal and written information
on what signs and symptoms to observe
and when to contact the physician.
 Assess if any community resources
should be utilized (i.e.: Home Health
Nurse), and contact appropriate
personnel.
 Document all discharge teaching on
Discharge Instruction Sheet and Nursing
notes.
 Other:________________
________________________
________________________
________________________
13 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
Index Key
(Draw a picture)
+4 = hyperactive
+3 = more than normal
+2 = normal
+1 = low than normal
0 = no response
14 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
Index Key
Family history
-----------------------------------------------------------------------------------------------------
Female
Dead female
Dead male
Male
House hold
---------------------
Abortion
-----------------
The patient
15 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
Guidelines for Review of Body Systems
Use the following format for review of body systems to completes all your assignments:
GENERAL:
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Recent weight changes.
Fever/ chills.
Malaise/ general weakness.
Mood changes
SKIN, HAIR, AND NAILS:
[
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Rashes
Lesions
Itching
Color change
Dryness
Brittle nails
Cracking
Others
[
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Headache
Seizure
Fainting
Head injuries
Dizziness
[
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Changes in vision
Blindness
Cataract
Diplopia
Redness
Pain
Photophobia
Glasses (last exam date and results)
Contact lenses (type)
Glaucoma
Drainage
Infection
others
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Difficulty in hearing/ deafness
Tinnitus
Vertigo
Infection
Discharge
Others
HEAD:
EYES:
EARS:
NOSE AND SINUSES:
[
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Nasal stuffiness
Frequent colds
Hay fever
Nose bleeds
Sinus troubles/ infection
16 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
MOUTH, PHARYNX, AND NECK:
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Bleeding from gums/ teeth
Oral infection
Dental problems
Dentures (last exam, time and results)
Hoarseness
Swelling in neck
Frequent sore throats
Lumps in neck
Dysphagia
Stiffness in neck
other
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Prurutus, pain, lumps
Nipple discharge
Dimpling of skin
Enlargement (gynecosmastia)
Performance of self breast exam
Mammograms (date, results)
Steroids
others
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Shortness of breath
Dyspnea on exertion
Orthopnea
Pain with respiration
Cough
Sputum (color, frequency, quantity)
Hemopteysis
Wheezing
Cyanosis
Pneumonia
Bronchitis
Emphysema
Asthma
TB test ( results and date)
TB exposure
Chest X-ray ( date and results)
others
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Heart troubles
High blood pressure
Heart murmurs
Paroxysmal nocturnal dyspnea
Chest discomfort/ pain
Palpitations
Syncope
Rheumatic fever
Coronary Artery disease
Heart attack
ECG ( results and dates)
Other heart tests
Others
BREASTS:
[
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LUNGS:
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HEART:
[
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17 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
PERIPHERAL VASCULAR:
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Edema
Swelling/ pain calves
Pain/ ulcerations or discoloration of extremities
Cramps
Varicose veins
Others
GASTROINTESTINAL:
[
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Nausea
[
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Vomiting
[
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Hematemesis
[
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Indigestion/ heart burn
[
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Abdominal pain
[
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Jaundice
[
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Hepatitis
[
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Melena
[
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Clay colored stools
[
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Incontinence of stool
[
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Diarrhea
[
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Change in bowel habit
[
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Constipation
[
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Hemorrhoids
[
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Excessive gas
[
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Hernia
[
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Ulcer
[
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Gall bladder stone/ colic
[
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Pancreatic disease
[
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Others
URINARY:
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MALE GENITALIA:
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Frequency
Urgency
Infection
Dysuria
Nocturia
Hematuria
Stream site and force
Hesitancy
Incontinence (stress, urge, dribbling)
Others
Discharge
Genital lesions
Testicular pain/ mass
Syphilis positive serology
Gonorrhea
Sexual problems
Others
FEMALE GENITALIA:
[
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Viginal discharge
[
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Pruritis
[
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Genital lesions
[
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Painful intercourse
[
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Post menstrual bleeding
[
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Post coital bleeding
[
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Pap smear ( results, dates)
[
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Other
18 Department of Nursing \ College of Applied Medical Sciences \Majmaah University
Nursing Care Plan 2013
ENDOCRINE:
[
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HEMATOPOIETIC:
[
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Heat and cold intolerance
Thyroid problems
Neck Surgery
Diabetes
Abnormal bleeding/ bruising
Anemia
Transfusions
Leukemia
Blood type
Others
SPINE AND EXTREMITIES: MUSCOLOSKELETAL
[
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Arthritis
[
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Joint stiffness
[
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Joint swelling
[
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Joint pain
[
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Muscle weakness
[
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Muscle cramps
[
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Backache
[
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Limited ROM
[
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Others
SPINE AND EXTREMITIES: NEUROLOGICAL
[
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Paresthesia/ numbness
[
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Paralysis
[
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Incoordination
[
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Disturbed balance
[
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Fainting (LOC)
[
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Blackouts
[
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Tics
[
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Tremors
[
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Spasms
[
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Others
PSYCHIATRIC (Problems in the following areas):
[
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Spouse
[
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Family
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Peers
[
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Insomnia
[
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Depression (interfering with ADL’s)
[
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Anxiety interfering with ADL’s)
[
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Mood swings
[
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Delusions
[
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Hallucinations
[
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Eating, sleeping, memory problems
[
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Others
19 Department of Nursing \ College of Applied Medical Sciences \Majmaah University