Villa College

Faculty of Health Sciences

Male’, Republic of Maldives

PATIENT HISTORY, NURSING ASSESSMENT

FORM, PLAN OF DISCHARGE AND CARE PLAN

(For Pediatric patients)

NURSING PROGRAMS

Student Name:

Student ID No: Date of Care plan:

Checked by
Mentor
Name and Designation:

Care plan checked Date: Sign:

 Villa College
Faculty of Health Sciences
Male’, Republic of Maldives

PATIENT HISTORY FORM

1. PATIENT INFORMATION

Name (Change for confidentiality): ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Age/Gender: ------------------------------ Hospital No: --------------------------------------------- Ward/Bed No: ------------------------------------------------ Admitting Dr. : ---------------------------------------------------------------------------------------------------

2. ADMISSION DATA

Date and Time of Admission: ------------------------------------------------------------------------------------------------------------------------------------ Time of arrival to ward: ----------------------------------------------------------------------------------------------------------------

Accompanied to ward by:  Nurse  Family Other (specify): -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Brought to ward on: Stretcher  Wheelchair  Ambulant

Admission from:  ER OPD  Direct to ward Others(specify): -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

3. General Health Assessment

1. Child’s health in general and today -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

2. What do you do to keep your child well?

a. Nutrition: --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

b. Immunization status: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

c. Opportunities for exercise and play: ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Any regular medication: --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

4. EMERGENCY CONTACT PERSON

Name: ----------------------------------------------------------------------------------------------------------------------------------------------------------- Relationship: --------------------------------------------------------------------------------------------- Contact No: ------------------------------------------------------

5. ALLERGIES

No Known Allergies 
Known Allergies to Food / Medication / Environmental factors: -------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Reaction which occurs: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

6. PERSONAL AND SOCIAL HISTORY

Race: --------------------------------------------------------------------------------------------- Nationality: ------------------------------------------------------------ Religion: ---------------------------------------------------------------------------------------------

Financial Support for treatment:  Self  Welfare  Insurance(specify)

Fluent Languages:  Dhivehi  English  Other(specify)

6. PRESENTING COMPLAINT / ILLNESS

Diagnosis: -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

History of presenting illness (chief complaints the patient presented with):

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 Details of any surgery done during the current admission:
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7. PAST MEDICAL HISTORY

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Has the patient been admitted to the hospital in the past?  No  Yes
If yes, specify the reason for admission, year and ward:
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8. FAMILY HISTORY

Hypertension  No  Yes Heart Disease  No Yes

Diabetes Mellitus  No  Yes Thalassemia  No Yes
Asthma  No Yes

9. DRUG HISTORY (Drug Name / Form / Dose / Route / Frequency)

Regular Medications (Continuous medications) Medications Currently advised

1. 1.

2. 2.

3. 3.

4. 4.

5. 5.

6. 6.

7. 7.

8. 8.

10. DEVELOPMENTAL MILESTONES

INFANCY
Birth weight: -------------------------------------------------------------------------------------------------------------------- Birth length: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Were there any complications with the infant during the first month of life?  Yes  No
If yes, specify: ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

1st month:  Regards. ------------------------------------------------------------------------------------------------------------------------------------------ 7th month:  Sits briefly --------------------------------------------------------------------------------

 Involuntary hand movement -----------------------------------------------------------------------

th
8 month:  Creeps ---------------------------------------------------------------------------------------------

nd
2 month:  Smiles --------------------------------------------------------------------------------------------------------------------------------------------------
th
9 month:  Pulls up. ---------------------------------------------------------------------------------------

3rd month:  Turns head ---------------------------------------------------------------------------------------------------------------------------------- 10th month:  Cruises. -----------------------------------------------------------------------------------------

4th month:  Holds head ---------------------------------------------------------------------------------------------------------------------------------- 11th month:  Walks with support. ------------------------------------------------
5th month:  Roll over ------------------------------------------------------------------------------------------------------------------------------------------ 12th month:  Stands alone. -----------------------------------------------------------------------

th
6 month:  Transfers object from one hand to other. ----------------------------

TODDLER HOOD
13th -18th month:  walk alone --------------------------------------------------------------------------------------------------------------------  jump in place ------------------------------------------------------------------------------------------------------------------

 creeps upstairs -----------------------------------------------------------------------------------------------------  runs but fall -------------------------------------------------------------------------------------------------------------------------

24th months:  walk steadily -------------------------------------------------------------------------------------------------------------  kicks ball forward ------------------------------------------------------------------------------------------------------

 picks up object without falling ---------------------------------------------------  undress self -------------------------------------------------------------------------------------------------------------------------

 build a tower of 6-7 blocks ---------------------------------------------------------------  vocabulary of about 300 words ---------------------------------------------------------

th
30 month:  walks on tiptoes -------------------------------------------------------------------------------------------------  throw ball 3-4 feet ---------------------------------------------------------------------------------------------------

 imitates lines and circles ----------------------------------------------------------------------

36th month:  rides a tricycle --------------------------------------------------------------------------------------------------------  balances on foot for few seconds ---------------------------------------------------

PRESCHOOL AGE
 Skip --------------------------  hop ---------------------------  jump ----------------------  play catch and throw games --------------------------------------------------------------------

 button and unbutton shirts --------------------------------------------------------------------  can put on the shoes --------------------------------------------------------------------------------------------

 Talk in sentences ------------------------------------------------------------------------------------------------------  able to describe small incidents --------------------------------------------------------

SCHOOL AGE
 Take part in outdoor games like football ----------------------------  swimming. --------------------------------------------------------------------------------------------------------------------------------

 Learns refine drawing, painting, writing skills ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

11. NURSING PRECAUTIONS

 Not Applicable  Measles  Hepatitis  AIDS  TB  Specify: ---------------------------------------------------------------------

Isolation Required:  Yes  No If Yes, Specify:  Standard  Universal Precautions

12. INFECTION CONTROL

Notified to relevant authorities:  No  Yes (specify):  QID  Nursing Dept  MOH

 HPA Details of action taken (if any): ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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13. SPECIAL INSTRUCTIONS (Regarding feeding, mobility etc.)

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14. ORIENTATION TO WARD

 Not given  Given  Patient  Family  Other (specify): -----------------------------------------------------------------------------------------------------------------------------------

Has the admitting doctor been informed of the admission:  No  Yes - if yes, date of most recent consultation? ---------------------------------------------------------------
 Villa College
Faculty of Health Sciences
Male’, Republic of Maldives

NURSING ASSESSMENT FORM

1. PATIENT INFORMATION
Name (Change for confidentiality): -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Age/Sex: ------------------------------------------------------------------------------------------------ Hospital No: -------------------------------------------------------------- Ward: ---------------------------------------------------------------------------

2. VITAL SIGNS, HEIGHT & WEIGHT

Pulse: ---------------------------------------------------------- Blood Pressure: ------------------------------------------------- Height: ----------------------------------------. Weight: -------------------------------------------------------------
Respiration: ------------------------------------------ Temperature: ------------------------------------------------------ Head Circumference: -----------------------------------------------------------------------------------------
Chest Circumference: ------------------------- MUAC: ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Remarks: -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

3. RESPIRATION

Breathing:  Regular  Irregular

Presence of:  Cough  Wheeze  Dyspnea  Crackles  SOB Orthopnea

 Cyanosis  No abnormality detected

Sputum:  Non-Productive  Productive (Colour: White /  Yellow /  Greenish)

Oxygen Use:  Continuous  Intermittent (Rate: …………..……….. ) Not on Oxygen
Remarks: -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

4. CIRCULATION
Pulse:  Regular  Irregular
Presence of:  Oedema  Calf pain  Chest pain
Remarks: -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

5. NEUROLOGICAL / COGNITIVE LEVEL

Level of consciousness:  Alert  Altered  No response
Responds to:  Verbal commands  Pain  Moves to command
Mood:  Calm  Anxious  Confused  Agitated  Aggressive
Speech:  Normal  Slurred  Aphasic  Incoherent
History of:  Seizures  Fainting  Tremors  Paralysis
Pupils Size:  Equal  Unequal Reaction to light:  Brisk  Sluggish  No reaction
Remarks: -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

6. INTEGUMENTARY

 Skin intact  Normal Colour

Presence of:  Lesion  Rash  Ulcer  Pediculosis
 Discoloration ( Pale /  Jaundice)
Turgor:  Elastic  Non elastic
Remarks: -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

7. ORAL CAVITY
 No reported concerns
Presence of:  Difficulty swallowing Difficulty chewing  Ulcers  Dental caries
 Halitosis  Coated tongue  Loose tooth  Dentures (Upper/  Lower)
Remarks: -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

8. VISION & HEARING

 No reported vision impairment  No hearing loss
Presence of:  Blindness  Blurred vision  Tinnitus  Deaf
 Partially impaired hearing  Other: -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Use of:  Spectacles  Contact Lens  Lens implanted  Hearing device

Remarks: -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

9. NUTRITIONAL
Infant feeding:
Type of feeding: ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

When complimentary feeding was started? --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

How long at each feeding? ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Number of feedings in 24 hours? --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Diet:  normal  others (specify): ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Appetite:  good  poor

 weight loss  weight gain  no change
 difficulty chewing  difficulty swallowing  nausea  vomiting  heartburn

Approximate amounts at each meal: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Vitamins and /or supplements does the child take? …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Child’s special food likes and dislikes? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

How much candy, other sweets, processed snack foods, and soda does your child eat/drink? ……………………………………………………………………………………………………………

What, if any, concerns do you have about your child’s appetite, feeding behavior, or diet? ………………………………………………………………………………………………………………………

Remarks: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

10. GENITAL / URINARY SYSTEM

Is the child toilet-trained? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

At what age the attainment take place:

Day: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Night: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Urinary  Burning  Dribbling  Bladder distension

 Frequency  Urgency  Haematuria  Hesitancy  Oliguria
Stoma for urinary drainage-describe routine of care: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Nighttime  incontinence  NAD

Remarks: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Bowel
How many stools does your child have daily? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
What is the color, amount, and consistency? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Does the child ever need laxatives, and or suppositories? How often? How do you decide that one of the above
is necessary?
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What is the usual colostomy/ileostomy care? (If applicable) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Usual bowel habits: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Last bowel movements: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Presence of:  diarrhoea  constipation  incontinence  NAD

Remarks: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

11. REPRODUCTIVE (if applicable only)

Age at which menarche was attained: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Presence of secondary sexual characteristics:  Yes  No

Remarks: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

12. MUSCULOSKELETAL SYSTEM

History of fall in the past:  No  Yes

Fall risk level assessment done  Yes  No
Remarks: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

13.MENTAL STATE BEHAVIOUR

How is the child’s school achievement? -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

For school-age and adolescent child:

How does your illness (injury) make you feel? ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

What are you most concerned about? ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Remarks: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

14.REST / SLEEP / ACTIVITIES OF DAILY LIVING (S=self, A=assist, T= total care)

Usual hours (night): -------------------------------------------------------------------------------------------------------------------------- Naps (time of day/length): ----------------------------------------------------------------------------------------------------------------------------------

Child’s usual sleep time routine: Bed time: -------------------------- Nap time ---------------------- Rituals (stories, drink, and so forth): -----------------------------------------------

Are there any problems related to sleep: Night mares /Night terrors: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Difficulty falling asleep: -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Refusal at bedtime: --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Waking up during night: -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Activities of Daily Living:  independent  needs assistance

 difficulty walking  pain  limitation of R.O.M
 seizures  muscle weakness  paralysis
 impaired coordination  NAD
Self-care ability
How independent is your child in self-feeding? Describe the help needed, if any. -------------------------------------------------------------------------------------------------------------------------------------

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How much help does your child need with toileting? --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Does child use diapers, a potty chair, or toilet? ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

How much help does your child needs in dressing? -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

How much help does your child need in hygiene practice? ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Remarks: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
 PLAN FOR DISCHARGE
PATIENT INFORMATION

Name (Change for confidentiality): ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Age/Gender: ------------------------------ Hospital No: --------------------------------------------- Ward/Bed No: ------------------------------------------------ Admitting Dr. : ------------------------------------------------------------------------------------------------

DETAILS OF DISCHARGE

Date of Discharge: ----------------------------------------------------------------------------------------------- Time of Discharge: -------------------------------------------------------------------------------------------------------------

Plan for discharge explained by the doctor:  No  Yes ( To patient /  To guardian)

Reason for Discharge:  Recovery  Referral  On request

Destination:  Home  Island  Abroad

Mode of transport:  Arranged by patient party Ambulance

Accompanied by Nurse:  No  Yes

Procedure for discharge explained:  No  Yes

COMPLETED DOCUMENTATION

Billing:  Yes  No Ambulance Memo:  Yes  No Prescription:  Yes  No

Follow up Appointment made:  Yes  No
Medical certificate Issued:  Yes  No
Documents handed over:

 Discharge Summary  Prescriptions  X-ray/CT films

 Reports ( Lab results /  ECG /  CT /  EEG /  Echo)

EXPLAINED PROCESSES

 Advise on discharge  Medications  Dressing Diet  Exercise  Date of follow up

 Others: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Special instructions:
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 PLAN OF CARE
Outcome evaluation and
Assessment Findings Nursing Diagnosis Goals Nursing Interventions Rationale Implemented Care
Re-planning
 PLAN OF CARE
Outcome evaluation and
Assessment Findings Nursing Diagnosis Goals Nursing Interventions Rationale Implemented Care
Re-planning
 PLAN OF CARE
Outcome evaluation and
Assessment Findings Nursing Diagnosis Goals Nursing Interventions Rationale Implemented Care
Re-planning