CARE PL

JOSCO COLLEGE F NURSING,NELAMANGALA,BANGALORE

DEMOGRAPHIC DATA
1.

1. Name
2. Age
3. Sex
4. Ward
5. IP No/ OP no
6. Marital status
7. Education
8. Occupation
9 Monthly income
10. Religion
11. Date of admission
12. Address
13. Diagnosis
14. Date of surgery (in surgical cases)
15. Name ofthe surgery
16. Type of anesthesia
17. Post-Operative day
18. Date of discharge
19. Date of care started
20. Date of care ended

II. CHIEF COMPLAINTS (with duration and priorities the complaint)

II. HISTORY OF PRESENT ILLNESS

a. Presentmedical History
When the symptoms started
When the onset of the symptoms were sudden or gradual
. How often the problems occurs
Exact location of the distress
Character of the complaint (eg. Intensity of the pain or quality of
sputum. Emesis or discharge)
Activity in which the client was involved when the problem
occurred.
Phenomena or symptoms associated with the chief complaint.
Factors that aggravate or alleviate the problem.
vital signs during the time of admission
investigations and medications
current status of the patient(improved or worsen)
 surgical History
b. Present condition of the person,
Pre-operative:
with onset and duration,
the patient
Complaint of pre-operative
preparation.
anesthetic check ups details,
-

Intraoperative: name of surgery, type of

procedure performed, events and
Date and type of clients status during the surgery,
anesthesia and other drugs,
its outcomne.

Post-operative:
medications, intake output,
complications,
Client's status after surgery,
bowel and bladder patten.

HISTORY OF PAST ILLNESS

Histor
a. Past MedicalPrevious hospitalization
Any communicable diseases
Chicken Pox, Whooping cough,
Childhood illness (Measles,
Mumps,

etc) diseases.)
Other illnesses, DM.
HT (On treatment for any
Hepatitis
Asthma, CAD,TB
and injuries, blood transfusions.
Allergies, accidents
b. Past Surgical History
Name and type of the surgery

Complications
FAMILY HEALTH HISTORY
V.
a. Family tree with key
b. Family profile
Age sex | Education Occupation Health
Name of the Relationship to
SI status
no family patient
members

c. Family medical history

Family history of DM, HT, TB, Asthma, Heart disease,
cancer etc.
VI. PERSONAL HISTORY
a. Personal habits: - amount, frequency, & duration of substance use (tobacco chewing.
cigarette smoking, alcohol, coffee, cola, tea.
b. Diet (type, meal pattern)
c. Sleep/rest patterns (morning and night)
d. Activities of daily living
e. Elimination (bowel and bladder)
f. Hobbies/ interest
g. Menstrual history
Menarche attained at which age
Duration of cycle
Amount of flow
Regular irregular
Any abnormalities
Any pain (if there, measures)
h. Obstetrical history :- No of pregnancy, no of deliveries, abortion, still birth, no of live
child, no of death, any complications.
VII. SOCIO ECONOMIC STATUS
Breadwinner of the family, Occupation, Income, Education, Family relationship, type of
family, occupational hazards, Exposure to pollutants
VIIL ENVIRONMENTAL HISTORY
House
Water supply
Disposal of excreta
IX. PHYSICAL EXAMINATION

GENERAL SURVEY
a Generalappearance and behavior
Nourishment
Body built
Hygiene & Grooming
Breath odor
Activity
Health
Posture/ gait
Movements
Speech

Mental status
Consciousness
Orientation
Look
Attitude
Affect /mood

Vital signs(normaland patientvalue)

 Temperature
Pulse
Respiration
Blood pressure
Anthropometric measurements
Height
Weight
BMI
b. Headtotoeexamination
Skin
Color
Texture
Temperat e

Lesions
Turgor
Moisture
Discoloration
Edema

Subjective symptoms:
Nails
Nail bed color
Shape
Texture
Capillary refill
Head
Shape
Scalp
Skull
Face
Alopecia/ very
hair/ thin hair/
>Hair - evenly distributed/ thick silky
brittle hair/ excessive oil/ lice/nits/ excessive hair ( hirsutism)
Texture
Color
Grooming
Eyes
Eye brows
Eye lashes
&Eye lids
Eye balls
Conjunctiva
Sclera
Lens
Vision
Lacrimal gland
 Lacrimal sac &naso lacrimal duct
Comea
Iris
Pupils
Color
Size
Shape
PERRLA
Ears
Position
Pinna
Pinna texture & elasticity
Cerumen
Otorrhea
Lesions
Tinnitus/Vertigo
Subjective complains: No complaints/ Otalgia/
Hearing
Response to normal voice tone

Watch tick test (2cm-3cm)

Weber test
Ear
Rinne test
Nose & Sinuses
External nose
Nasal septum
Patency of nasal cavity
Rhinorrhea
Frontal & maxillary sinuses

Smell
Mouth & Pharynx
Lips
Teeth
G u m s & buccal mucosa

Tongue
Palate
Uvula
Tonsils
Salivary glands
Odour of mouth
Pharynx
Voice
Neck
Range of motion
Neck of muscles
Carotid artery
Thyroid gland
Trachea
 Lymph nodes
Jugular veins

Thorax (Anterior & posterior)

Inspection:- Shape & symmetry , skeletal
abnormalities, Symmetry of expansion, breathing
pattern, Rate & Rhythm, Visible pulsations, Exaggerated
lifts
Palpation: -
Chest excursion, / Expansion, Tactile
fremitus, tenderness, mass, apical impulse, abnormal
pulsations, Thrill.
Percussion:- Resonance, Hyper resonance, Dullness,
Flatness
Auscultation: - Breath sounds- normal/ Adventitious.
Heart sounds& Murmurs.
>Breast & Axilla
Symmetry
Areola & nipple
Discharge
Lesions/ masses
Axillary, subclavian & supra clavicular nodes
Abdomen
Inspection
Contour& symmetry
Abdominal movement
Auscultation
Percussion

Palpation
Abdominal girth
Inguinal lymph node
Rectum & Anus
Hemorrhoids
Anus& surrounding tissue: Color, Integrity, lesions
Palpate rectum & anal sphincter: Normal tone/ hypertonic/
hypotonic/ hypotonicity
Extremities
Upper extremities
Symmetry
Range of motion
Peripheral pulses
Edema
Cyanosis
Joints
 Deformities
Lower extremities
Sym etr
Range of motion
Peripheral pulses
Toe nails
Edema
Cyanosis
Joints
Deformities
Genitalia
lesions,
Female: excessive foul smelling discharge,
Hemorthoids
M a l e : - lesion, redness, swelling. discharges, difficult in voiding

SYSTEM WISE EXAMINATION

X.
a System
Central NervousLevel o f consciousness

Orientation
Cranial nerves
Sensory function

Motor function
Reflexes
Glasgow coma scale

if productive: color,
b. Respiratory System productive/ nonproductive, duration, frequency,
H/O cough mucoid, rusty, sticky/
consistency of sputum (bad odour, frothy,
amount, chest pain, dyspnea, and tachypnea.
yellow/ blood stained),
purulent/ green/ shape and symmetry,
rate, rhythm & quality,
Inspection:- respiratory muscles
use of accessory
symmetry of expansion, tactile fremitus, tenderness,
chest excursion, expansion,
Palpation:
-

subeutaneous emphysema.
tracheal position, presence of
mass, flatness.
r e s o n a n c e , dullness,
Percussion: -resonance, hyper
sound/
Auscultation sound/ normal brochial
normal vesicular
Breath sounds: crackles/ stridor
ronchi/
brocho-vesicular sound
normal egophony.
friction nub/ bronchophony/
wheezing/ pleural
Cardiovascular System on exertion, Dizzness,
Palpitation, syncope
Distension of
H/O chest pain, Dyspnea Exaggerated lifts/ Heaves,
-Visible pulsations,
Inspection:
Neck veins.
Pallor
Skin color: -Cyanosis,
-Present/ Absent
Clubbing of fingers: which type)
absent(if present
Edema: -Present/
Varicose vein: -Present/Absent
 Endocrine:- Thyroid problems, Excessive sweating. Excessive thirst, Polyuria

XI. INVESTIGATIONS(all investigations)

Date Investigations Patient's value Normal value Remarks

XII. PHARMACOLOGICAL & NON PHARMACOLOGICAL

SI Trade Action Side Nurses

Pharmacological Dose/Frequency
n o name name /Route effects responsibility

XIII. LIST OF NURSING PROBLEM

XIV. NURSING CARE PLAN

Plan of Rationale | Implementation Evaluation
Assessment Nursing Objective
Diagnosis action
| Subjective
data

Objective
data

XV. NURSE RECORD

With date nurses record should want to write
XVI. CONCLUSION
XVII. BIBILIOGRAPHY