‫وزارة العالي‬

Ministry of Education
JAZAN UNIVERSITY
‫التعليم العالي‬ ‫وزارة‬
‫جازان‬ ‫جامعة‬
College of Nursing ‫جامعة جازان‬
‫كلية التمريض‬
Date: Nursing Care Plan (Case Study) ‫الصحية المساعدة‬Total
‫العلوم‬Points:
‫التمريض و‬
30 ‫كلية‬

ent Name: Academic No.: Level:

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1- Biographical Information: (1 point)

Client Name: File number:

Department: Room: Bed:
Age: Sex: Date of Admission:
Medical Diagnosis:

2- Chief Complaint: (Reasons for seeking health care) (1 point)

3- Present Illness: (The signs & symptoms experienced by the client including the; onset,location ,
intensity ,duration ,quality ,progress & effect of therapy) (1 point)

4- Past Health History: (Previous major illnesses ,hospitalizations ,operations ,injuries ,

including dates….& Allergies to food ,drugs , etc…….) (1 point)

5- Family History: (Family Tree/ Genogram) (2 points)

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6- Psychosocial History: (Marital status ,number of children ,occupation ,financial status,
 activities of daily living ,habits ,hobbies ,…….) (1 point)

7- Physical Examination Findings: (By the doctor on admission) (3 points)

***Give special attention to organ or system involved in the disease process***

General:

Skin:

Head:

Eyes, Ear, Nose ,Mouth, &Throat:

Neck:

Chest:

Lungs:

Heart:

Abdomen:

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Musculoskeletal
 Genitourinary:

Neurologic:

8- Laboratory & Other Diagnostic Procedures Results : ( The relevant tests & the normal values)
(2 points)

9- Current Medications: (Drug name ,dose ,frequency ,route ,& Classification) (3 points)
Drug name Dose Frequency Route Classification Side-effects

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