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School of Nursing, Rangsit University

Health assessment and Nursing care plan

Student name ID:

Assigned Date Ward

1. Personal Information

Bed No HN AN Age

Gender Education Nationality

Religion Marital status Occupational

Admission date Number of admissions

Diagnosis Operation

Health assessment

2.1 Chief complaint

2.2 Present illness

1.3 Past history

2.4 Family medical history

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2.5 Family genogram and family medical history

2.6 Patient condition and ongoing assessment (including current bio-psycho-social data of patient)

BW kg Height cm.
BMI Kg/m2 Nutritional Status
Vital signs (Admitted date
T=……….C P=………. beat/min. R=……. beat/min. BP=………mm.Hg

Vital signs (Assigned date

T=……….C P=………. beat/min. R=……. beat/min. BP=…….mm.Hg.

2.7 General Appearance

Physical Examination (Head to Toe)

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Neurological Genitourinary
Level of Conscious (LOC): Urine elimination:
__alert; __ lethargic; _unresponsive __independent void;
Orientation: __oriented; _forgetful; __incontinent: _diapers; __ stress
_disoriented Foley: _no; _yes; _size; _
Extremity movement: _full; _limited; _none date inserted _
Grip _firm; _weak; _absent; _numbness Urine color: __ light; __ dark; __ BRP,
Comments: __ not noted
Comments:
Cardiovascular Safety
Pulses: Apical: rate; rhythm ____arm band on;___ call light within
Radial: __strong and regular reach
Pedal:___ present and strong;__ weak ____allergy band on
Other__________________________ ____bed in lowest position; ___wheels
Chest pain: denies;at rest;
Pulmonary locked bed rails up: _1;__2;__3;_4
Musculoskeletal
____on
Resp: __ exertion
no distress; ___ dyspnea; ___ cyanosis Histry of falls?:__no;___
Ambulation: yes restricted
independent;
Monitor: ___on;_________
Cough: __none; rhythm;____
__ productive; none
__ hemoptysis yes: risk assessment
If restricted explain
Peripheral edema:___clear;
Breath sounds: ____absent;
___wheezes; results:___________
__ crakles present_____________ Extra safety
Sequential
Location; compression device in use:
___R;_ __L;__bilat;__ __yes;
base;__mid; measures:_________________
___ apex ___no Fall
of precautions
arms and legs.
Compression
Oxygen support:stocking in use: yes;__ no explained:___pt;___family
Equipment: none; specify
Comments:
type_______; ______liters; _____sats Restraint order in__independent;
Bed mobility: place? ___no;____
_ _assistant
Chest tube: site(s)__________; type_________ yesComment:
Suction______cm.; ________water seal; If yes: type; expires________
______no air leaks Comments:
Comments: Psychosocial
Gastrointestinal Skin
Affect: __responsive;___little expression;
Abdomen:___soft;____tender;_____distended Family__race
Color:_ at bedside: ___ no; ____ yes
Bowel sounds: Comment:
appropriate;__pale;__jaundice__warm;
___present,____quads;___absent ___cool;_ _dry;_
Date last BM: ________; usual pattern: _____ __moist;___diaphoretic
GI tubes: no;___yes: specify____________ IV: __no;__yes,
If yes:___gravity;___suction;____clamped
Site appearance; __no redness, swelling or
Drainage:____no;___yes:
_____color; other________ pain __tender;__red;___swollen
Method of nutrition: ____NPO;____oral:_ Incision: _no; __yes:
__independent; ____feed____NG/G-tube location
Comments: If yes, length; describe

.
Edges approximated: __no; _ _yes
Wounds:__no;_ _yes (if yes, explain
more in comments)

Comments:
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2.9. Lab & Investigation Result

3.Pathology of Disease
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4.Treatment during admission

4.1 Order for continuation (Medication & Treatment)

Medication Treatment
Date Medication Dose Route Time off Date Treatment Time off
.
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4.2 Order for one day & Order for Continue

Date/time Order for one day Order for Continue
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5.Conclusion for Nursing Diagnosis

Setting the nursing priorities of caring to the patient as follows:
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6. Nursing Care Plan

Nursing Diagnosis / Objective & Nursing Intervention Rational Evaluation
Nursing Expected outcome
Problem with data support
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7. Medication
Name / Route / Time Action Side effect Nursing Care
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8.Discharge Plan [D-METHOD]

9. Remark: Reflects on the ethical and moral principle within the case assigned.