NARAYANA COLLEGEOF NURSING

CHINTAREDDYPALEM NELLORE

M.SC NURSING

NURSING CARE PLAN FORMAT

PATIENT PROFILE :

Name :

Age :

Sex

Education

Occupation

Income

Marital status

Religion

Nationality

I p no:

Ward

Diagnosis

Date of admission :

Date of Surgery:

I. HEALTH PERCEPTIONS HEALTH MANAGEMENT PATTERN :

a. Reason for seeking health care /chief complaints:
b. How was illness treated at home (include alternative /complementary therapies):
c. Past medical history (date):
d. Past surgical history (date):
e. Allergies :
f. Life style risk factors :
g. Familial risk factors :
 II. NUTRITIONAL METABOLISM PATTERN:
a. Height
b. Weight
c. Body mass index:
d. Type of diet in hospital and home :
e. Problems eating/digesting foods : difficulty swallowing/nausea/vomiting /abdominal
pain /antacid use :
f. Dentition : condition-------- dentures : upper/lower
g. Oral mucosa: intact /pink/moist/dry/lesions
h. Appetite :normal/ increased/decreased
i. Taste sensation :normal/impaired

HOME BLOOD GLUCOSE MONITORING :

Tube feeding

Type of feeding

Total parenteral nutrition :

Type of IV access(s):

Intake and out put chart :

DRAINS:

Site

Colour

NAILS:

Colour

Shape

Condition

Others

GENERAL SKIN COLOUR/TEXTURE

Skin

Edema: no/yes grading (0-4+)--------,site/explain

Skin turgor : no tenting/supple, delayed return/tents

Identify and describe any skin lesions on the figure:

III. ELIMINATION PATTERN:

a. Presences of bowel sounds:
b. Usual bowel habits: normal pattern / frequency----last bowel movement
c. Bowel elimination :no problem diarrhea, constipation
d. Stool : colour ---consistency
e. Ostomy : colostomy/Ileosotomy
f. Rectum: no problem/rashes/lesions/hemorriods/others
g. Bladder function:no problem/continent /incontinent/urgency/frequency/dribblingpain/
folycatheter/supra pubic catheter.
h. Urine :clear/yellow/cloudy/sediment blader distension: no/yes anuria no/yes
i. Dialysis :Hemo ,peritoneal, dialysis access site :

IV. ACTIVITY EXERCISE PATTERN:

Vital Date Temperature Pulse Respiration Blood Pulse

signs pressure ox/fio2

Apical rhythm
Capillary refill
Supplementary oxygen: No /Yes Nasal Cannula/L/min---------- Mask O2%----------
Respiratory depth :Shallow/Normal/Deep
Difficulty in breathing : No Yes /At rest /------------With exertion of
Cough: No /Yes/Non productive/ Productive/ Sputum Colour---------------Sputum
consistency------------ Sputum amount-----------------
Breath sounds : document location
Suctioning : No/ Yes/ how often----------- Colour/ amount
Artificial airway: No/ Yes type----------size/appearance
Chest tube:Right/Left Drainage Colour/amount
ACTIVITIES OF DAILY LIVING /SELF CARE ABILITY :
O=independent /requires no assistance
1= requires use of an assistive device ;
2=requires one person assistance
3= requires one person assistance and an assistive device
4= requires two person assistance ;dependent
 Score Score Score
Eating Bathing Dressing
/drinking
Toileting Bed mobility Transferring
Ambulating
Response to activities of daily living :
MUSCULO SKELETAL :
Gait: Steady/ unsteady/ posture---------
Upper extremities: strength : equal/ unequal/Strong/ moderate/ weak ,
ROM: full/ limited, explain------------
Lower extremities : equal , unequal , strong , moderate, weak
ROM : full , limited, explain
Assistive devices used : walker ,cane .wheel chair, crutches , prosthesis
V. SLEEP REST PATTERN:
a. Typical home sleep pattern : hrs/ night naps times/day
b. Typical hospital sleep pattern : : hrs/ night naps times/day
c. Sleep difficulties :
Sleep apnea , other, sleep aids
VI. SEXUALITY REPRODUCTIVE PATTERN :
Breasts : Variation
Genitalia : discharge lesions bleeding explain
History of STDS : no/yes sexually active: no/yes
contraceptive use: no/yes pregnant : no/yes
VII. COGNITIVE PERCEPTUAL PATTERN :
Mental status : orientation : person place time
Level of consciousness : alert, drowsy/lethargic , difficult/unable to arouse , other
Memory : intact , recent memory deficit , remote memory deficit
Thought processes: Answers questions appropriately
Answers unreliably
Poor historian
Explain
Restraints : indications for use
Restraints alternatives : bed alarm , sitter , frequent observations, side rails ,others ,
Pupils : PERRLA yes /no , explain :
Vision : normal , glasses, contacts , explain:
Hearing : normal , impaired, aid used, explain :
PAIN LASTING LONGER THAN SIX MONTHS ? no/yes
Aggravating factors
Alleviating factors
Desired pain score (0-10)
ROLE RELATIONSHIPS PATTERN
Retired or current occupation
Support systems : marital status : married , widowed , divorced , single , life partner
Identified support systems/individuals
Socialization : receives phone calls, visitors, cards , other
Changes in life roles/relation ships
Verbalized fear of violence : no /yes
SELF PERCEPTION /SELF CONCEPT PATTERN :
Erickson’s age related development stage
Clients development stage
Verbalized identification with a particular cultural group: no/ yes
Indicators of culture : culture cues evidence in communication style, family patterns,
space orientation, time orientation and nutritional patterns
Identified /verbalized major losses or life changes : no /yes
Emotional /behavioural state : calm , happy , sad, depressed, agitated, combative , angry,
anxious, other/explain.
COPING STRESS TOLERANCE PATTERN :
Behaviors/statements indicating adjustment to stressors /illness:
Behaviors/ statements indicating impaired adjustment to stressors /illness:
Home use of drugs and/or alcohol for coping : no/yes explain:
VALUES BELIEF PATTERN :
Verbalization of the which is most valued in life :
Verbalization of self as a spiritual or religious person : no/yes explain:
Request for spiritual support while hospitalized : no/ yes
NEUROLOGICAL ASSESSMENT
GCS (0-15)
RESPONSE SCORE
EYE OPENING Spontaneously 4
To command 3
To pain 2
No response 1
MOTOR RESPONSE Obeys commands 6
Localizes pain 5
Flexion withdrawal 4
Flexion 3
Extension 2
No response 1
VERBAL RESPONSE Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
TOTAL 15
 Higher mental function: orientation, insight, judgement, intelligence, behavior changes,
speech
 CRANIAL NERVE ASSESSMENT:
CRANIAL NAME FUNCTION HOW TO TEST
NERVES
1 Olfactary Sense of smell Close the eyes, occlude
one nostril and identify
the odour
2 Optic Control visual activity Instruct the patient to
and visual field cover one eye, position a
news paper 12 – 18
inches from patient and
ask him to read
3,4,6 Occulomotor, Controls pupilary Ask the patient to follow
trochlear, abducens reaction an object moved
systematically in various
directions
5 Trigeminal Control facial sensation Ask the patient to close
and jaw movements his eyes then the various
parts of the face is gently
touched using a wisp of
cotton.
7 Facial Control the facial Assessed by having the
muscles patient wrinkle her fore
head, smile, showing her
teeth.
8 Auditory/vestibule Controls hearing and webers test and rinnes
cochlear sense of balance test to evaluate air and
bone conduction.
9, 10 Hypoglossal, vagus Controls swallowing, Instruct the patient to
the gag reflex, pen his mouth and say
articulation ah. Use the tip of tongue
depressor to stimulate
the back of the pharynx.
Swallowing is tested by
asking the patient to
drink a clear fluid
11 Spinal accessory Controls the trapezius Instruct the patient to
and sternocleido rise both shoulders and
mastoid muscle to hold tightly and apply
resistance to shoulders
using both hands.
12 Glosso pharyngeal Controls tongue Is assessed by having the
movement and strength patient protrude her
tongue
  Sensory examination
 Response to touch
 Response to pain and temperature
 propioception
 MOTOR EXAMINATION
MUSCLE POWER GRADING

GRADE DESCRIPTION
5/5 Full range of motion against gravity with extreme resistance
4/5 Full range of motion against gravity with some resistance
3/5 Full range of motion against gravity with no resistance
2/5 Full range of motion with gravity eliminated
1/5 Slight contraction visible
0/5 No movements
ASSESSMENT OF CEREBELLAR FUNCTIONS

 Finger to finger test

 Finger to nose test
 Patting test
 Romberg test
 Tandom walking test
Reflexes:superficial &deep (abdominal, Achilles, corneal, biceps, triceps, patellar,
plantar, babinski reflex)

SYSTEMIC EXAMINATION
FUTURE HEALTH CARE NEEDS /DISCHARGE PLANS :
Nurse anticipated future health care plans : home ,ECF, live with relative ,rehabilitation,
others:
Anticipated discharge needs :
Nursing /nurse aids :
Dietary /nutrition :
Equipment /medications :
Medical:
MEDICATIONS CURRENTLY PRESCRIBED:
INVESTIGATIONS
NANDA NURSING DIAGNOSIS
NURSING PROCESS
THEORY APPLICATION
DIET PLAN
HEALTH EDUCATION
RECORDING AND REPORTING