Nursing Care plan ( History collection format )

The care plan is a written document (either electronic or paper-based) that is used and altered constantly throughout the day. It’s based on a ‘template’ which defines the areas the care plan covers. Some templates are very simple and focus on the essentials of care – nutrition, mobility, sleeping, positioning, oral care and personal hygiene, for instance – while others can be very detailed and might include sections on issues like falls prevention, psychological needs, recording of clinical signs, communication and information.

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. :

II. Chief complaints :





III. History of Health status:

(a) Present Medical History :



(b) Past Medical History :



(c) Present Surgical History :



(d) Past Surgical History :

2. 2


IV. Family History :
(a) Family Tree :
















S.
No
Name of family
Member
Age Sex Relationship Occupation
Health
status
Remarks










V. Personal History :
(a) Habits :
(b) Sleep :
(c) Nutrition :
(d) Elimination Pattern :

VI. 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 :

4. 4


Eyes :
Vision/Visual Acuity :
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 :
Epitaxis :


Mouth & throat :
Tongue :
Lesions :
Lips :
Bleeding :
Tooth decay :
Dental care :
Odour :
Throat & Pharynx :

5. 5

Mucus Membrane :
Gums :

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 :

6. 6

Palpation :



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 :

7. 7

Inspection :


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 :

Palpation :

8. 8



Percussion :

Auscultation :


VII. Integumentory system :

Colour :
Texture :
Moisture :

Dryness :
Bleeding :
Discharge :
Infection :

VIII. Haematological 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 :


GCS :



Reflexes :

9. 9



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 Vomitys Aspirations Other Total

12. 12

NURSES NOTES

Name: I.P.No:
Age: Ward:
Sex: Diagnosis:
Bed No: Doctor Name:

IME DIET MEDICATIONS NURSING CARE PLAN

13. 13

NURSING DIAGNOSIS:

14. 14

Nursing Care Plan:
Assessment Diagnosis Goal Planning Rationale Implementation Evaluation

15. 15

Health Education:











Bibliography: