The document outlines a comprehensive patient assessment and care plan, detailing the collection of patient history, physical examinations, diagnostic tests, and nursing responsibilities. It includes sections on vital signs, health status, medical histories, and systematic evaluations across various bodily systems. Additionally, it describes the nursing care plan, discharge planning, and the conclusion reflecting on patient care quality and outcomes.

1. 1
HISTORY COLLECTION
PATIENT PROFILE
I. History Collection:
Name :
Age :
Sex :
Education :
Occupation :
Religion :
Marital Status :
Husband’s Name :
Wife’s Name :
Address :
Date of Admission :
Diagnosis :
Ward Name :
I.P. No :
Bed No. :
III. Chief complaints :
IV. History of Health status:
(a) Present Medical History :
(b) Past Medical History :
(c) Present Surgical History :
(d) Past Surgical History :

2. 2
V. Family History :
(a) Family Tree :
S.
No
Name of family
Member
Age Sex Relationship Occupation
Health
status
Remarks
VI. Personal History :
(a) Habits :
(b) Sleep :
(c) Nutrition :
(d) Elimination Pattern :
VII. Socio Economic Status :
(a) Housing :
(b) Ventilation :
(c) Electricity :
(d) Water supply :

3. 3
PHYSICAL ASSESSMENT/EXAMINATION
Vital signs:
Temperature :
Pulse :
Resp. Rate :
B.P. :
General Appearance :
Nourishment :
Body build :
Health :
Activity :
Consciousness :
Look :
Body curves :
Movement :
Height :
Weight :
Skin :
Colour :
Texture :
Temperature :
Lesions :
Rashes :
Lumps :
Itching :
Dryness :
Moles :
Head :
Size :
Shape :
Hair & Scalp/ Skull/ face :
Colour :
Distribution :
Hair loss :
Dandruff :
Lice :
Healthy :
Eyes :
Vision/Visual Acuity :

4. 4
Eyeballs :
Conjunctiva :
Sclera :
Cornea and Iris :
Pupils :
Fundus :
Eye muscles :
Eye brows :
Eye lashes :
Lens :
Glasses :
Discharge :
Pain :
Itching :
Ears :
Hearing :
Ear Canals :
Ear Drum :
External Ear :
Tymphanic Membrane :
Pain :
Itching :
Ringing :
Vertigo :
Nose & Sinuses :
Deviated nasal septum :
External Nares :
Nostrils :`
Discharge :
Allergies :
Frequent colds :
Obstruction :
Pain :
Epistaxis :
Mouth & throat :
Tongue :
Lesions :
Lips :
Bleeding :
Tooth decay :
Dental care :
Odour :
Throat & Pharynx :
Mucus Membrane :
Gums :

5. 5
Neck :
Stiffness :
Limited motion :
Lymph nodes :
Swelling :
Pain :
Thyroid Gland :
Swallowing Reflex :
Cervical Spine :
Muscles of Back(Neck) :
I. Respiratory System :
H/O Smoking :
Sputum (Colour) :
Asthma :
Wheezing :
Haemoptysis :
Cough :
Shortness of Breath :
Inspection :
Palpation :
Percussion :
Auscultation :
II. Cardio Vascular System :
H/O Hypertension :
Varicose veins :
Dyspnea :
Orthopnea :
Chest pain :
Palpitation :
Claudication :
Heart sound :
Pulse :
Heart beat :
Inspection :
Palpation :

6. 6
Percussion :
Auscultation :
III. Gastro Intestinal System :
Shape & Symmetry :
Abdominal girth :
Pain :
Abdominal distension :
Artificial Openings :
Anorexia :
Diarrhea :
Nausea :
Constipation :
Vomiting :
Hemetemesis :
Food intolerance :
Bowel sounds :
Abdomen :
Soft & Tender :
Inspection :
Palpation :
Percussion :
Auscultation :
IV. Genito urinary system :
Nocturia :
Dysuria :
Incontinence :
Infection :
Frequency :
H/O Illness (or) surgery :
Inspection :

7. 7
Palpation :
Percussion :
Auscultation :
V. Genito Reproductive system:
Female :
Menses :
Menarche :
Cycle :
Duration :
No. of Pregnancies :
Menopause :
Vaginal Discharge :
H/O STD :
Male :
Pain :
Soreness :
Discharge :
H/O STD’s :
Swelling :
VI. Musculo-skeletal system :
Posture :
Muscular pain/cramps :
Pain :
Swelling :
Upper extremities :
Range of motion :
Colour of extremities :
Any deformities :
Lower extremities :
Range of motion :
Colour of extremities :
Any deformities :
Inspection :

8. 8
Palpation :
Percussion :
Auscultation :
VII. Integumentary system :
Color :
Texture :
Moisture :
Dryness :
Bleeding :
Discharge :
Infection :
VIII. Hematological System :
Hb% :
Bleeding tendencies :
Any blood transfusions :
IX. Neurological system :
Level of consciousness :
Activity :
Dizziness :
Posture & gait :
Tremors (or) seizures :
Sensation of pain :
Mental status :
Motor function :
Sensory function :
Cranial nerves :

9. 9
GCS :
Reflexes :
INVESTIGATIONS:
S.No Name of Investigations Patient Value Normal Value Remarks

10. 10
MEDICATION CHART
S.
No
Name of the drug Dose Route Frequency Action
Side
Effects
Nurse’s
responsibility

11. 11
INTAKE AND OUTPUT RECORD
Name: Hospital No. Age: Sex:
Date Time Oral
Fluids
Naso
Gastric
Intra
Venous
Other
Routs
Total Urine Vomitus Aspirations Other Total

12. 12
Kardex form
Date Medications Dose Time Date Nursing care plan Time
Date Treatment Dose Time
Religion
Age Sex Bath T.P.R B.P Diet
Name of the patient Bed
no
Diagnosis Doctor name IPNO

13. 13
NURSES NOTES
Name: I.P.No:
Age: Ward:
Sex: Diagnosis:
Bed No: Doctor Name:
TIME DIET MEDICATIONS NURSING CARE PLAN

14. 14
Theory application: ( For Msc level)

15. 15
NUTRITIONAL ASSESSMENT:
S.No Time Food item k.calories

16. 16
Anatomy and physiology: ( with diagram)

17. 17
Diseasecondition:
Book picture Patient picture

18. 18
NURSING DIAGNOSIS:(5days)
Day-1:
Day-2:
Day-3:
Day-4:
Day-5:

19. 19
Nursing Care Plan:( 5days )
Assessment Diagnosis Goal Planning Rationale Implementation Evaluation

20. 20
Health Education:(5days)
Day-1:
Day-2:
Day-3:
Day-4:
Day-5:

21. 21
Recording and Reporting:(5days)
Day-1:
Day-2:
Day-3:
Day-4:
Day-5:

22. 22
Summary:
Mr/Ms/Mrs. x was admitted in …….. Hospital on ………(date) with chief
complaints of ………………………………… and he/she was diagnosed as
………………… and he/she was given the treatment like
………………………………. . he/she was now better than during the time of
admission.

23. 23
Discharge plan:
Mr/Ms/Mrs. x was admitted with chief complaints of ………………………….
And diagnosed as ………………….. he/she was given the quality care for his
improvement of health status and he was better now and doing all his activities of
daily living and health education also given to the patient and their family
members . He/she was planned to discharge within 3days as per the condition of
the patient and orders of the physician.

24. 24
Conclusion:
If I got a chance of taking care of the patient with chief complaints
of…………………….. & diagnosed as …………………….. & I will able to take
care of the patient independently with quality of care & for better outcome &
improvement of the patient’s health status.

25. 25
Bibliography:
Book references:
Journal references:
Web references: