CARE PLAN FORMAT

PATIENT PROFILE
Name
Age
Gender
Religion
Marital status
Education
Occupation
Income
I.P number
Diagnosis
Name of surgery
Chief present complaints
Present medical history
Past medical history
Present surgical history
Past surgical history
Family history and family tree
Personal history
Socioeconomic history

PHYSICAL EXAMINATION

General examination
Consciousness : Conscious/semi conscious/unconscious
Orientation: Oriented to time, place & person /not oriented
Nourishment: well nourished/moderately nourished/mal nourished
Body built: Thin/moderate/obese
Look: Happy/sad/depressed
Hygiene: Good/bad
Height:--________cm
Weight: _________kg

VITAL SIGNS
PARAMETER PATIENT VALUE NORMAL VALUE INFERENCE
Temperature
Pulse
Respiration
Blood pressure
SKIN
Colour: Fair/dark complexion
Texture: normal/dry/moist
Hydration: good/dehydrated
Discoloration: absent/yellowish/cyanosis/pallor
Lesions: absent/wound
HEAD
Scalp: Clean/dandruff/pediculosis
Hair colour: Black/brown/grey
Grooming : well groomed/not groomed
Distribution : Normal/alopecia
EYES
Eyebrows: equally distributed/asymmetric
Eye lashes: Infected/not infected
Eye lids: Normal/edematous
Sclera: white/reddish/yellow
Conjunctiva: Pink/pale/yellowish
EARS
Pinna: Normally placed/swelling
Hearing: Normal/decreased
NOSE
Nasal septum: Midline/deviated
Sense of smell: present /absent
Rhinnorrhea: present/absent
MOUTH AND PHARYNX
Lips: dry/cracked
Colour of lips: pink/pale
Gums bleeding : present/absent
Tongue: dry /coated
Teeth: dental caries-present/absent
dentures- present/absent
NECK
Range of motion: Possible/not possible
Thyroid gland: enlarged/normal
Lymph nodes: enlarged /normal
RESPIRATORY SYSTEM
Inspection: thorax expansion:equal/unequal
Palpation: tenderness: present/absent
masses: present/absent
Auscultation: normal sounds :present/absent
Abnormal sounds: present/absent
CARDIOVASCULAR SYSTEM
Inspection: Bulging-present/absent
Palpation: masses-present/absent
Percussion: Dullness-present/absent
Auscultation: S1 &S2 heard
murmurs- present/absent
ABDOMEN
Inspection: Flat/distended/scar
Auscultation: Bowel sounds present/absent
Palpation: Tenderness-present/absent
Mass-present/absent
Percussion: tympanic sounds-present/absent
UPPER EXTREMITY
Symmetry: symmetric/asymmetric
Range of motion: possible/not possible
LOWER EXTREMITY
Symmetry: symmetric/asymmetric
Range of motion: possible/not possible
GENITO URINARY SYSTEM
Discharge-present/absent
Voiding –normal/catheterized
INVESTIGATIONS
Investigation PATIENT VALUE NORMAL VALUE INFERENCE

PLAN OF TREATMENT
Drug name Generic Dosage Route Frequency Action
name

IV FLUIDS:
PROBLEMS IDENTIFIED
NURSING CARE PLAN
NURSING DIAGNOSIS -5
SHORT TERM GOALS -5
LONG TERM GOALS -5
ASSESSMEN NURSING GOAL PLAN OF RATIONAL IMPLEMENTATIO EVLUATION
T DIAGNOSIS ACTION E N

HEALTH EDUCATION
DIET PERSONAL HYGIENE
EXERCISE MEDICATION & FOLLOW UP
CONCLUSION
 HEALTH EDUCATION FORMAT

BASELINE DATA
Name of the topic:
Place:
Date:
Time:
Name of the student:
Method of teaching:
AV aids:

GENERAL OBJECTIVES
After completion of health education, the patient and family members will be able to gain
knowledge regarding____________

SPECIFIC OBJECTIVES
After completion of this health education the patient will be able to
Define__________
Explain__________

Sl.no Time Specific Content Teaching/ AV Evaluation

objectives learning aids
activity
1 _ min Lecture Flash What is?
cum cards What are?
discussion

CONCLUSION
BIBLIOGRAPHY