Nursing care plan Nursing care plan format Nursing diagnosis plan

1. Shivam Gautam
G.N.M 3rd Year

2. General Patient Introduction
 Student’s Name:-
 Pt. Name:- Father’s name:-
 Age:- Sex:-
 Date of Admission:- to
 Marital status:- Occupation:-
 Address:-
 Clinical Diagnosis:-
 Refer by:- Doctor:-


3. Cont….
 Chief complaint:-

 History of the illness:-

 Past Health History:-

 Medical & Surgical History:-

4. Family History
Family Tree
S.N Name Age Sex Relation Occupation

5. Environment History
 Housing:- Room:-
 Water Supply:- Electricity:-
 Surrounded Area:-

6. Socio-economic status
 Monthly Income:-
 Monthly invest on Health:-
 Total income of head of family:-

7. Physical Examination
 General Appearance:-
Looking:-
Height:-
Weight:-
Skin:-
Pasture:-
Activity:-
 Vital Sign:-
Temp:-
Pulse:-
Resp.:-
B.P:-

8. Cont…
Head to Toe Assessment:-
 HEAD:-
Hair:-
Dandruff:-
Pediculosis:-
 FACE:-
Dullness:-
Facial Expression:-

9. Cont….
 EYEs:-
Eyebrow:-
Sclera:-
Conjunctiva:-
Vision:-
 EARs:-
Any Discharge:-
Hearing Capacity:-
Wax:-
 Nose:-
Size & Shape:-
Any Discharge:-

10. Cont….
 Mouth:-
Lips:-
Teeth:-
Tongue:-
 NECK:-
Lymph Node:-
Range of motion:-

11. Cont….
 CHEST:-
 Size & Shape:-
 Breast:-
 Chest Pain:-
 Breathing Sound:-
 Heart rate:-

12. Cont….
 ABDOMEN:-
 Inspection:-
 Auscultation:-
 Palpation(Liver):-
 (Spleen):-
 Percussion:-
 BACK:-
 Size & Shape:-

13. Cont….
 EXTREMITIES:-
 Upper Extremities:-
 Size & Shape:-
 Movement:-
 Any Congenital Abnormity:-

 Lower Extremities:-
 Size & Shape:-
 Movement:-
 Joint:-

14. Cont….
 GENITAL & PERINEUM:-
 Lymphatic node:-
 Any type node:-
 Infection:-
 Hygiene:-

15. Cont….
 Definition:- about to disease
 Short term Goal
 Long term goal
 Nursing Diagnosis

16. Cont….
Assessm
ent
Diagnosi
s
Goal Planning Impleme
ntation
Rational Evaluati
on
Subjectiv
e data:-
Objective
data:-

17. Cont….
 Health Education