Adventist University of the Philippines

COLLEGE OF NURSING
LEVEL II

NURSING CARE PLAN

STUDENT INFORMATION

Student’s Name:___________________________________ Affiliating Agency:_____________________________________

Clinical Instructor:__________________________________ Date of Actual Patient Care:_____________________________

Clinical Area/Blocking:_______________________________ Shift (Pls. tick mark): AM PM NOC

PATIENT INFORMATION

Name of Patient:___________________________________ Gender: Male Female Age________

Address:__________________________________________ Civil Status: Single Married Annulled

_________________________________________________ Widowed Divorced Not Applicable

Educational Attainment:_____________________________ Date of Admission:___________________________________

Occupation:_______________________________________ Attending Physician:__________________________________

Chief Complaint:________________________________________________________________________________________

Admitting Diagnosis/Impression:_______________________ Final Diagnosis:______________________________________

HISTORY OF PRESENT ILLNESS

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PAST MEDICAL AND /OR OB HISTOR
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FAMILY MEDICAL HISTORY
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FOR PEDIATRIC CLIENTS

Delivery History:
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Feeding History:
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Immunization History:
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Past Childhood Diseases:

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Age-Appropriate Play/Activity:
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 PRINCIPLES/THEORIES OF GROWTH AND DEVELOPMENT
Task/Crisis According to Sigmund Freud (Psychosexual):
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Discussion of Task/Crisis in Relation to the Patient’s Present Condition:

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Book Reference:____________________________________________________________________________________________

Task/Crisis According to Erik Erickson (Psychosocial):

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Discussion of Task/Crisis in Relation to the Patient’s Present Condition:

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Book Reference:____________________________________________________________________________________________

SIMPLE PATHOPHYSIOLOGY OF THE DISEASE PROCESS

Etiology:_______________________________ Predisposing Factor/s:____________________________________________
 DIAGNOSTIC PROCEDURES
1. Procedure:_____________________________________________________________________________________________

NURSING RESPONSIBILITY with RATIONALE

BEFORE DURING AFTER

2. Procedure:______________________________________________________________________________________________

NURSING RESPONSIBILITY with RATIONALE

BEFORE DURING AFTER

3. Procedure:______________________________________________________________________________________________

NURSING RESPONSIBILITY with RATIONALE

BEFORE DURING AFTER

SPECIFIED/SPECIAL DIET (Indication, description, food specification):

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Patient’s Actual Weight:_______ (kg) Patient’s Age Appropriate Weight:_________ (kg)

Patient’s Actual Height:_______ (cm) Patient’s Age Appropriate Height:__________ (cm)

Patient’s BMI:________________ (kg/m2 ) BMI Interpretation:_________________________

 HEALTH ASSESSMENT BASED ON GORDON’S
FUNCTIONAL HEALTH PATTERN
I. Health Maintenance-Perception Pattern
Before Hospitalization During Hospitalization
Cigarette Smoking No Yes Cigarette Consumption : <pack/day Cigarette Smoking No Yes Cigarette Consumption : <pack/day

1-2 pack/day >2 packs/day 1-2 pack/day >2 packs/day

QUIT : Date/year QUIT:____________ QUIT : Date/year QUIT:____________

Alcohol No Yes Type: Beer Hard Liquor Alcohol No Yes Type: Beer Hard Liquor
Other Specify:___________ Other Specify:___________

Therapeutic Drugs No Yes Type of Drug:_______ Purpose:_______ Therapeutic Drugs No Yes Type of Drug:_______ Purpose:_______

Allergies Drugs Food Dyes Others Specify:___________ Allergies Drugs Food Dyes Others Specify:___________

II. Nutritional- Metabolic Pattern

Before Hospitalization During Hospitalization

Special Diet No Yes Specify:___________________ Special Diet No Yes Specify:___________________

Dietary Supplements/Vitamins No Yes Dietary Supplements/Vitamins No Yes

Appetite Normal Increased Decreased Appetite Normal Increased Decreased

Decreased taste sensation Decreased taste sensation

Nausea Vomiting Stomatitis Weight loss/gain______lbs Nausea Vomiting Stomatitis Weight loss/gain______lbs

Swallowing Normal With Difficulty With NGT Swallowing Normal With Difficulty With NGT

Dentures Upper(Partial:____ Full:___) Lower (Partial:____ Full:___) Dentures Upper(Partial:____ Full:___) Lower (Partial:____ Full:___)

III. Elimination Pattern

Before Hospitalization During Hospitalization

Bowel Habits Constipation Diarrhea Bowel Habits Constipation Diarrhea

No. of Bowel Movement ( BM)/day:_____ Date of last BM:_____________ No. of Bowel Movement ( BM)/day:_____ Date of last BM:_____________

With Ostomy Appliance Self Care With Ostomy Appliance Self Care

Frequency Dysuria Burning Urgency Frequency Dysuria Burning Urgency

Bladder Habits Hematuria Dribbling Nocturia Bladder Habits Hematuria Dribbling Nocturia

Incontinency yes No Daytime Night time Occasional Incontinency yes No Daytime Night time Occasional

Difficulty delaying voiding Difficulty reaching toilet Difficulty delaying voiding Difficulty reaching toilet

Catheterization Retention/Indwelling/Foley Straight Catheterization Retention/Indwelling/Foley Straight

Condom/weebag Cystoclysis Condom/weebag Cystoclysis

Urine Output/Shift:_______cc/ml Urine Color:____________ Urine Output/Shift:_______cc/ml Urine Color:____________

IV. Activity and Exercises

Before Hospitalization
0 1 2 3 4
Self-Care Ability Assistance from Assistance from person Remarks
Independent Assistive Device others and equipment Dependent/Unable
Eating/Drinking
Bathing
Dressing/Grooming

Toileting
Bed Mobility
Transferring
Ambulating
Stair Climbing
Shopping
Cooking
Home Maintenance
Assistive Devices: None Crutches Walker Bedside Commode

Cane Splint/Brace Wheelchair Other Specify:___________

During Hospitalization
0 1 2 3 4
Self-Care Ability Assistance from Assistance from person Remarks
Independent Assistive Device others and equipment Dependent/Unable
Eating/Drinking
Bathing
Dressing/Grooming

Toileting
Bed Mobility
Transferring
Ambulating
Stair Climbing
Shopping
Cooking
Home Maintenance

Assistive Devices: None Crutches Walker Bedside Commode

Cane Splint/Brace Wheelchair Other Specify:___________

V. Sleep/Rest Pattern
Before Hospitalization During Hospitalization

Sleeping Habits: Regular Irregular With AM Nap With PM Nap Sleeping Habits: Regular Irregular With AM Nap With PM Nap

Time of Sleep: _____Time of Arising: ____Total hours of sleep at night: _____ Time of Sleep: _____Time of Arising: ____Total hours of sleep at night: _____
Feeling rested after sleep Feeling inadequately rested after sleep Feeling rested after sleep Feeling inadequately rested after sleep

Problems None Early Walking Insomia Nightmares Problems None Early Walking Insomia Nightmares

VI. Cognitive—Perceptual Pattern

Before Hospitalization During Hospitalization
VI. Cognitive-Perceptual Pattern VI. Cognitive-Perceptual Pattern

Mental Alert Oriented Confused Combative Mental Alert Oriented Confused Combative

Unresponsive Receptive Aphasia Unresponsive Receptive Aphasia

Speech Normal Slurred Garbled Expressive Aphasia Speech Normal Slurred Garbled Expressive Aphasia

Spoken Language:_____________ Interpreter:________________ Spoken Language:_____________ Interpreter:________________

Level of Anxiety Mild Moderate Severe Panic Level of Anxiety Mild Moderate Severe Panic

Hearing Normal Impaired Right ( ) Left ( ) Hearing Normal Impaired Right ( ) Left ( )

Deaf Right( ) Left ( ) Hearing Aid Tinnitus Deaf Right( ) Left ( ) Hearing Aid Tinnitus

Vision Normal Eye glasses Contact Lenses Vertigo Vision Normal Eye glasses Contact Lenses Vertigo

Impaired Right( )Left( ) Blind Right ( ) Left ( ) Impaired Right( )Left( ) Blind Right ( ) Left ( )

Discomfort/Pain None Acute Chronic Description:_________ Discomfort/Pain None Acute Chronic Description:_________

Pain Management: Pain Management:

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VII. Role - Relationship Pattern

Before Hospitalization During Hospitalization
VII. Role-Relationship Pattern VII. Role-Relationship Pattern

Marital Status Single Married Separated Widow/Widower Marital Status Single Married Separated Widow/Widower

Employment Employed Unemployed Employment Employed Unemployed

Short-term/long-term disability Occupation:______________ Short-term/long-term disability Occupation:______________

Support System Spouse Neighbors/Friends None Support System Spouse Neighbors/Friends None

Other Specify:___________________ Other Specify:____________________

Family concerns regarding hospitalization:____________________________ Family concerns regarding hospitalization:____________________________

VIII. Sexuality - Reproductive Pattern
Before Hospitalization During Hospitalization
VIII. Sexuality—Reproductive Pattern VIII. Sexuality—Reproductive Pattern
SUBJECTIVE (REPORTS) SUBJECTIVE (REPORTS)
Sexually active:___________________ Use of condoms:____________ Sexually active:___________________ Use of condoms:____________
Birth control method:____________________________________________ Birth control method:____________________________________________
Sexual concerns/difficulties:_______________________________________ Sexual concerns/difficulties:_______________________________________
Recent change in frequency/interest:________________________________ Recent change in frequency/interest:________________________________

Female: Subjective (Reports) Female: Subjective (Reports)

Age at menarche:_________________ Length of cycle:_____________ Age at menarche:_________________ Length of cycle:_____________
Duration:_____________ No. of pads used/day:_________________ Duration:_____________ No. of pads used/day:_________________
Last menstrual period:____________ Pregnant now:______________ Last menstrual period:____________ Pregnant now:______________
Bleeding between periods:________________________________________ Bleeding between periods:________________________________________
Menopause:____________________ Vaginal lubrication:__________ Menopause:____________________ Vaginal lubrication:__________
Surgeries:______________________________________________________ Surgeries:______________________________________________________
Hormonal therapy/calcium use:____________________________________ Hormonal therapy/calcium use:____________________________________
Practices breast self-examination:__________________________________ Practices breast self-examination:__________________________________
Last mammogram:__________________ Pap smear:_________________ Last mammogram:__________________ Pap smear:_________________

Objective (Exhibits) Objective (Exhibits)

Breast examination:_____________________________________________ Breast examination:_____________________________________________
Genital warts/lesions:_____________ Vaginal Discharge:_______________ Genital warts/lesions:_____________ Vaginal Discharge:_______________

Male: Subjective (Reports) Male: Subjective (Reports)

Penile discharge:_________________ Prostate disorder:___________ Penile discharge:_________________ Prostate disorder:___________
Circumcised:_____________________ Vasectomy:_________________ Circumcised:_____________________ Vasectomy:_________________
Practice self-examination: Breast:_________ Testicles:_________________ Practice self-examination: Breast:_________ Testicles:_________________

Objective (Exhibits) Objective (Exhibits)

Breast:___________ Penis:____________ Testicles:__________________ Breast:___________ Penis:____________ Testicles:__________________
Genital warts/lesions:_________________ Discharge:_________________ Genital warts/lesions:_________________ Discharge:_________________

IX. Coping - Stress Tolerance/ Self-Perception/Self-Concept

Before Hospitalization During Hospitalization

IX. Coping- Stress Tolerance/ Self-Perception /Self-Concept IX. Coping- Stress Tolerance/ Self-Perception /Self-Concept

Major concerns regarding hospitalization or illness (Financial, self-care):
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Major loss/crisis/change in past year/s: Yes No
Specify:______________________________________________________
Fear of Violence Yes No Who/Specify:________________
Outlook on Future:________ (rate 1-poor to 10- very optimistic)
Describe:
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Major concerns regarding hospitalization or illness (Financial, self-care):
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Major loss/crisis/change in past year/s: Yes No
Specify:______________________________________________________
Fear of Violence Yes No Who/Specify:________________
Outlook on Future:________ (rate 1-poor to 10- very optimistic)
Describe:
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X. Value — Belief Pattern

Religion: Religious Restrictions:

Request Chaplain Visitation: Yes No Time:_____________

OTHER INFORMATION
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 Nursing Diagnosis and Goals and Objectives NI Rationale with Evaluation
Problem Nursing Interventions
Rationale References
NOC: NIC:
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Nursing Diagnosis:
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No.__:______________
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Cues Independent:
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Subjective Data:
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Rationale:
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Objective/s:
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Cues
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Objective Data:
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Dependent:
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Reference:
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 Nursing Diagnosis and Goals and Objectives NI Rationale with Evaluation
Problem Nursing Interventions
Rationale References
NOC: NIC:
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Nursing Diagnosis:
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No.__:______________
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Cues Independent:
Goal/s:
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Subjective Data:
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Rationale:
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Objective/s:
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Cues
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Objective Data:
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Dependent:
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Reference:
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 Nursing Diagnosis and Goals and Objectives NI Rationale with Evaluation
Problem Nursing Interventions
Rationale References
NOC: NIC:
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Nursing Diagnosis:
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Cues Independent:
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Subjective Data:
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Rationale:
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Objective/s:
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Cues
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Objective Data:
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Dependent:
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Reference:
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 Nursing Diagnosis and Goals and Objectives NI Rationale with Evaluation
Problem Nursing Interventions
Rationale References
NOC: NIC:
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Nursing Diagnosis:
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No.__:______________
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Cues Independent:
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Subjective Data:
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Rationale:
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Objective/s:
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Cues
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Objective Data:
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Dependent:
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Reference:
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