NOOTAN COLLEGE OF NURSING

B.SC NURSING THIRD YEAR STUDENTS

PERFORMA FOR CARE PLAN
CHILD HEALTH NURSING
Name of the student -
Placement -

Sr. No Content Maximum Obtained

marks marks
1 History Taking 08
2 Physical Examination 06
3 Medication 06
4 Diagnostic Test 06

5 Growth And Development 08

6 Nursing Care plan 12

7 Reference 04

Total 50

Remarks:-

Signature of Student Signature of Supervisor

 CARE PLAN -I (MEDICAL)

IDENTIFICATION DATA:-

Name of the Patient :

Age :

Sex :

Ward :

I.P.D. No. :

Educational Status :

Occupation :

Family Income :

Religion :

Date of Admission :

Diagnosis :

Present Complaints :

Address :

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PRESENT MEDICAL HISTORY:-

PAST MEDICAL HISTORY:-

PAST SURGICAL HISTORY:-

FAMILY HISTORY:-

Family Tree:-

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 HEALTH
NO. NAME AGE RELATION EDUCATION OCCUPATION
STATUS

SOCIO ECONOMIC STATUS:-

IMMUNIZATION HISTORY

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 FUNCTIONAL HEALTH PATTERN

Hygiene:-

Activity / Exercises:-

Rest / Sleep:-

Elimination Pattern :-

Cognitive / Perceptual :-

Self perception / self concept pattern:-

Coping Stress Tolerance:-

Personal Habits:-

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 PHYSICAL ASSESSMENT
General Appearance:


Level of Consciousness: - Conscious / Un / Semi / Coma

Orientation: - To Place / Person / Time

Activity: - Active / Dull / Lethargy

Body Built: - Mild / Moderate / Thin / Obese

Anthropometric Measurement:

1. Height - 2. Weight - 3. Mid Upper Arm Circumference -

Vital Signs:

1. Temperature - 2. Pulse - 3. Respiration -

Head:


Hair - Equally Distributed / Baldhead

Colour of Hair - Gray / White / Black

Scalp - Clean / No Dandruff

Pediculosis - Present / Absent

Face:

 Face - Symmetrical/Asymmetrical
 Facial Puffiness - Present /Absent
Eyes:


Eye Brows - Symmetrical / Asymmetrical / Scaling /
Lesions

Eye Lid/Lashes - Redness / Swelling / Discharge / Lesions
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 
Conjunctiva - Color / Swelling / Lesions

Sclera - White / blue / Yellow / Tenderness / Discharge /

Cornea - Regular / Irregular Ridges

Iris - Flat / Irregular Shape

Pupils - Size/ Reacting/ Dilated –

Nose:
 
 Nasal Septum – Deviated / Central
 
 Nasal Polyps – Present / Absent
 
Nasal Discharge – Present / Absent

Mouth:
 
 Number of Teeth -
 
 Dentures – Present / Absent
 
 Dental Carries - Present / Absent
 
 Odor of Mouth - Foul Smell / Acetone Smell / Others
 
Gums –Weak / Swollen / Pale Colour / Healthy

Lips :
 
 Crack / Healthy
 
 Cleft Lips – Unilateral / Bilateral/ Absent
 
Stomatitis - Present / Absent

Ears :
 
 Redness – Present / Absent
 
 Lesions - Present / Absent
 
 Hearing Acuity -
 
Use of Hearing Aids – Yes / No

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 SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM:


Respiratory Rate –

Inspect the Chest:

 
 Skin Color and Condition – Normal / Cyanosis / Pallor
 
 Chest Expansion – Symmetric / Asymmetric
 
Rhonchi / Crepitus

Respiratory Pattern – Normal / Tachypnea / Bradypnea / Cheyne Stokes

Hypo / Hyper Ventilation / Bitot’s

Percussion:
 
 Lung Field – Clear : Yes / No
 
Resonance- Hyper resonance / Dull

Auscultation:
 
 Breathing Sound - Broncho / Broncho Vesicular/ Vesicular
 
Adventitious Sound - Crackles / Wheeze

Palpation:

CARDIO VASCULAR SYSTEM:

 
 Pulse :
 
 Heart Sound – S1 ,S2 Heard :
 
 Abnormal Heart Sound – S3 or S4 – Present / Absent :
 
 Murmurs – Present / Absent :
 
 Carotid Pulse Rate :
 
Blood Pressure :

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PERIPHERAL LYMPHATIC SYSTEM:
 Inspect and Palpate The Leg – Cyanosis / Uni /Bilateral Edema
 Dorsalis Pedis Pulse – Rt. Lt.
 
 Edema – Present / Absent
 
 Type of Edema – Pitting / Pretibial Generalized
 
Lymph Edema – Present / Absent

DIGESTIVE SYSTEM:

ABDOMEN


Abdominal Girth

Inspection:
 
 Size- Scaphoid / Protuberant Flat / Rounded
 
 Symmetry – Bulges / Masses / Hernia.
 
 Scar -
 
Lesions -

Palpation:

Tenderness -
 
 Mass / Soft
 
 Organomegally -
 
 Pain -

Percussion : 
 
 Ascitis / Peritonitis
 
 No Gas / Fluid Collection

Auscultation: 
 
Bowel Sounds - Normal / Borborygmus / Absent
21
GENITO URINARY:

Frequency of Urination -

Urine Last Voided -

Colour -

Normal / Anuria / Hematuria / Dysuria / Incontinence / Any Other :

Catheter Present : Yes / No

Urethral Discharge :

INTEGUMENTORY SYSTEM :


Skin Colour -

Dermatitis -

Allergies -

Lesions / Abrasions -

Tenderness / Redness -

MUSCULO SKELETAL SYSTEM

 
 Range of Motion
 
 Joint Swelling / Pain / Others
 
Weakness / Paralysis / Contracture
22

NEUROLOGICAL ASSESSMENT :
Level of consciousness

GCS (Glasgow coma scale)

Normal
content Patient score
score

Eye opening response

Spontaneous 4

To Voice 3

To pain 2

No response 1

Best motor response

Obeys verbal command 6

Localize pain 5

Withdraws 4

Flexion abnormal 3

Extension abnormal 2

No response 1

Best verbal response

Oriented to place & person 5

Conversation with confused 4

Inappropriate words 3

Incomprehensive Sounds 2

No response 1

TOTAL 15

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 Notes:
 
 Record if eyes closed by swelling - C
 
 Record if Endotracheal tube in place - E
 
Record if Tracheotomy tube is placed - T


 
 MOTOR FUNCTION :
 
Reflexes

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LABORATORY / OTHER INVESTIGATION:-
Investigations Normal Patient’s
Date Remarks
Name Findings Findings

X-ray:-

ECG :-

ECHO:-
25
Others if any:-

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 MEDICATION

Dose / Contra-
Pharmacolo Mechanism of action Indications Side-effects Nurses responsibilities
gical Name/ Route indications
Trade Name

27
 Dose / Contra-
Pharmacolo Mechanism of action Indications Side-effects Nurses responsibilities
gical Name/ Route indications
Trade Name

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 NURSING CARE PLAN

List of nursing diagnosis:-

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 NURSING CARE PLAN

Nursing Nursing Expected Planning Implementation Rational Evaluation

assessment Diagnosis out come

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 Nursing Nursing Expected Planning Implementaion Rational Evaluation
assessment Diagnosis out come

31
 Nursing Expected out
assessment Nursing Diagnosis come Planning Implementation Rational Evaluation

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 Nursing
Nursing Diagnosis Expected out come Planning Implementation Rational Evaluation
assessment

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 NURSES NOTES
Name of the Patient - Diagnosis -

Age / Sex - Dr. Incharge

Date of Admission -

Ward / Bed No. - -

Date Diet Medication Time Nursing Observation Nursing care Remarks Sign.

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Date Diet Medication Time Nursing Observation Nursing care Remarks Sign.

35
Date Diet Medication Time Nursing Observation Nursing care Remarks Sign.

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Summary:-

Bibliography:-

Signature of Student Signature of Supervisor