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NURSING CARE PLAN

NAME : __________________________________ ID NO : __________________________________ GROUP: __________________________________

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NURSING ASSESSMENT ADULT


MODE OF ADMISSION Walked In Wheelchair Trolley / Bed SOURCE Clinic A&E Ward CONDITION OF ADMISSION Blood Pressure Heart Rate Respiration Rate

PATIENT STICKER
Received Patient Date /Time: _____________ Marital/ Status: Single / Married___________ Occupation: __________________________ Next of Kin: __________________________ Tel Num: __________________________ Accompanied By: ________________________

Temperature Body Weight SPO2

LEVEL OF CONSCIOUSNESS Conscious Semi-conscious Unconscious

MENTAL STATUS Orientated Confused Restless Aggressive

EMOTIONAL STATUS Calm Anxious Depress Irritable

Reason of Admission Surgical / Medical History Family History Current Medication Allergies (Drugs / Food / Environment)

Daily Activities of Living: BODY HYGIENE Assist Dependent DIET Normal Vegetarian

Normal

Abnormal SKIN Colour (Pale, Cyanosed) Temp (Warm, Cold. Moist) Rashes Oedema Urticaria Jaundice Eczema Bedsore Nails (Pale, Cyanosed) www.niche.edu.my

VISION glasses blurring blind cataract

SLEEP snoring insomnia sleep apnea on medication

HEARING deaf tinnitus discharge

DEFECATION constipation diarrhoea bloody/Melina colostomy/ ileostomy

ENT nasal congestion sore throat

MICTURATION incontinence nocturia dysuria polyuria catheter NUTRITION/APPETITE poor nausea vomiting assist SMOKING yes ____ pack per day no

MOUTH dentures ulcers halitosis inflamed NECK lumps pain swelling BREAST lumps pain swelling LUNG chesty wheezing

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PHYSICAL EXAMINATION
Indicate on diagram the following abnormalities : bruises, decubites ulcer,laceration, discoloration

History obtained from :____________________________________________________________ Student Nurse :____________________________________________________________ Date :____________________________________________________________

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NURSING DIAGNOSIS
ACTUAL PROBLEM

1 2 3 4 POTENTIAL PROBLEM

1 2 3 4

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NURSING CARE PLAN NAME:______________________


Date/ time Nursing diagnosis Expected outcome 1. Intervention 1.

MRN:______________________
Rationale evaluation

2.

2.

3.

3.

Subjective data: 4 4.

Objective data:

Date: Time: Sign :

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www.niche.edu.my

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