Comprehensive Nursing Care Plan

:Student name: Student number: Hospital

.Clinical Department/Unit: Instructor's name: Period: from ……….. to …………….. 1
:Assessment sheet
Demographic Data ( 1 )
:Client Name: Date
:Medical diagnosis: Level of consciousness
:Admission Date: Ward
:Bed No: Date of Surgery
:Marital Status: Educational level
:Religion: Blood Group
:Medical insurance: Physical limitations (specify)
:Diet (specify): Allergy
:Specific treatment & frequency (daily dressing, ECG, etc.)

:IV fluid treatment

Medications taken at home: (Generic and trade names, Action, and dose, etc.) ( 2 )

Nursing precautions Action Dose, route, and frequency Medication name

:Communication barriers (specify)

:Health History
: Health perception/ Health management patterns

: Health Related Habits

Smoking : Cigarettes/day
:Alcohol: Exercise Pattern
:Diet
:Rest (Sleeping hours at night, naps, disturbing factors, medications used)
 :Current Health Status
:Chief complaint (Use patient's own words to describe the problem)

:History of present illness

: Current complaint

:Primary assessment
:Airway
:Breathing
:Circulation
:Cervical spine
:Disability
:Vital signs/ CVP

:Ventilator parameters
Mood:……………………………………........... FIO2: …………………………………. Vt: …………………… F:
…………………………………………... PEEP: …………………………….... CPAP:………………….. VE:
….……………………………………:……………………………………………… VC
 Past Health History
:Past health problems ( co-morbidities)

Hospitalizations :( previous admissions to hospital specify the dates & reasons)

:Socio-Economic Status
:Income (average): Occupation
No. of household members
:Job satisfaction / concerns & its relation to present illness

:Family History
Draw a family tree (Grandparents, Parents, Siblings, Children and Grandchildren. Indicate health
:status of each as age and (alive or dead, Cause of death and significant illness or problems)
Physical Assessment
General Survey .1

Integumentary system .2
Head and neck .3

Respiratory system .4

Cardiovascular system .5

Abdomen .6

Urinary system .7

Reproductive system .8

Peripheral vascular system .9

Musculoskeletal system .10

Neurological system .11

:Glasgow Coma Scale (GCS)

: eye opening

: verbal response

: motor response

:Total

:Blood gases analysis

 Total Output Total Date
output intake Intake and
time
urine Drains Stool Vomit Oral Rx NGT Infused Blood IVF (2) IVF (1)

=Balance : Intake – Output

Nursing Care ( 1 )
 Diagnostic Test Sheet (Including blood investigation, CXR, ECG, …etc)

Nursing Abnormal results Normal Value Test Name

Intervention

Date & results Date & results Date & results

 Medication Sheet

Major Nursing Major side effect Indication Classification Dose, Frequency, and Name(Trade And no
Intervention Route Scientific)
Diagnosis: (1)

:Goal

:Intervention
-1
-2
-3
:Rational
-1
-2
-3
:Evaluation(met /not met & Evidence)
Diagnosis: (2)

:Goal

:Intervention
-1
-2
-3
:Rational
-1
-2
-3
:Evaluation(met /not met & Evidence)
Diagnosis: (3)

:Goal

:Intervention
-1
-2
-3
:Rational
-1
-2
-3
:Evaluation(met /not met & Evidence)