The document is a nursing care plan template for a patient at Raj Nursing Institute, detailing sections for biographic data, medical history, family information, physical examination, vital signs, investigations, medication, and health education. It emphasizes comprehensive patient assessment and documentation for effective nursing care. The template is structured to ensure all necessary information is collected systematically.

1. RAJ NURSING INSTITUTE
ODAR, BHABUA (KAIMUR) – 821108
(Recognized by :- B.N.R.C. Patna)
Subject :- ___________________________________________
Care plan on :- ______________________________________
SUBMITTED TO SUBMITTED BY

2. Biographic Data
Name :-
Father's Name :-
Age :-
Sex :-
Address :-
Education :-
Occupation :-
Religion :-
Marital Status :-
Ward Name :-
Bed No. :-
Date of Admission :-
Date of Discharge :-
Doctor Concerned :-
Chief Complaints :-
Diagonsis :-
Disease Description :-
History of illness
Past medical history :-
Present medical history :-
Past surgical history :-
Present surgical history :-

3. Family history of illness :-
Family Composition
S.No. Name Age Sex Occupation Relation Health Status
Family Key
Family Tree
Nutritional History
:-
Personal History
:-

4. Socio-economic Status
:-
Physical Examination
General appearance
Nourishment :-
Body build :-
Health :-
Activity :-
Mental Status
Consciousness :-
Look :-
Posture
Body Curves :-
Movements :-
Height & Weight :-
Skin condition
Colour :-
Texture :-
Temperature :-
Lesions :-
Head & Face
Shape :-

5. Scalp :-
Face :-
Eyes
Eyebrows :-
Eye lashes :-
Eyelids :-
Eyeballs :-
Conjunctiva :-
Sclera :-
Pupils :-
Vision :-
Ears
External Ear :-
Tympanic membrane :-
Hearing :-
Nose
External Nares :-
Nostrils :-
Mouth & Pharynx
Lips :-
Odour :-
Teeth :-
Gums :-
Tongue :-
Throat & Pharynx :-

6. Neck
Lymph Node :-
Thyroid gland :-
Range of motion :-
Chest
Thorax :-
Breath Sound :-
Heart :-
Breasts :-
Abdomen
Observation :-
Auscultation :-
Palpation :-
Percussion :-
Extermities
Upper extremities :-
Lower extremities :-
Back :-
Genitals & Rectum
Shape & Size :-
Discharge :-
STDs :-

7. Vital Sign Chart
S.No. Vital Name Normal Range Patient Value Remarks
1 Temperature
2 Pulse
3 Respiration
4 B.P.
5 SpO2
Investigation Chart
S.No. Investigation Name Normal Range Patient value Remarks
Medication Chart
S.No. Drug’s Name Dosage Route Frequency Action

8. Nursing Diagonsis
1.
2.
3.
4.
5.

10. Health Education
Nutrition education
:-
:-
:-
Medication Education
:-
:-
:-
Personal Education
:-
:-
:-