Nursing Care Plan Format
I. Biographic data
1. Name :
2. Age : …………………Year
3. Gender : Male / Female
4. Ward :
5. IP No :
6. Marital Status : Single/Married/Separated/
Divorced/Widowed
7. Education : Illiterate/Primary/High School/College
8. Occupation :
9. Income :
10. Religion : Hindu/Muslim/Christian/Others (Specify)
11. Language Known : Hindi/Malayalam/English/Others (Specify)
12. Diagnosis :
13. Date of Admission :
14. Date of Surgery :
15. Name of Surgery :
16. Post O.P. Day :
17. Date of Discharge :
18. Informant :
19. Address :
II. Introduction
III. History of Present Illness
(a) Present Medical History
When the symptoms started
Whether the onset of symptoms was sudden or gradual
How often the problem occurs
Exact location of the distress
Character of the complaint (e.g., intensity of 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
Treatment on admission
(b) Present Surgical History
Date and type of procedure performed, Type of anesthesia, client’s reaction,
events and its outcome.
Surgical Notes
IV. History of Past Illness
(a) Past Medical History
Previous hospitalization (medical/surgical)
Any communicable disease/genetic disorders
On treatment for any disease
Immunization if any
Allergies: H/O any drug allergy
(b) Past Surgical History/Present Surgical History
Name of Surgery
Date of Surgery
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Type of Anaesthesia
V. Family Health History
S. No Name Relationship Age Sex Education Occupation Health
to patient Status
(a) Family Composition
(b) Family Medical History
To ascertain risk factors for certain diseases the ages of siblings, parents, and
grand parents and their current state of health or (if they are deceased) the cause of
death are obtained. Particular attention should be given to disorders such as
Non - Communicable diseases: Heart disease, cancer, obesity, allergies, arthritis, and
any mental health disorders.
Communicable diseases: Tuberculosis
Chronic Diseases like Diabetes, Hypertension
VI. Socio Economic Background
Write whether patient is from a village/town/city. Is he/she living in rented
house or own house/ No. of rooms, doors, windows/water facility/electricity
facility/toilet facility/income of the family/bread winner of the family/drainage
facility, kitchen garden and pet animals.
VII. Personal History
(a) Diet
Vegetarian/Non Vegetarian
Number of meals and snacks/day
Allergies to any food item
Nutritional assessment 24 hours recall and recommended diet plan
(for patients on therapeutic diet)
Likes & Dislikes of food
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(b) Personal Habits
The amount, frequency, and duration of substance use (tobacco
chewing, cigarette smoking, alcohol, coffee, cola, tea)
(c) Sleep/Rest Patterns
Usual daily sleep/number of hours per day & night, wake times, difficulties
sleeping, and remedies used for difficulties.
(d) Activities of daily living
Any difficulties experienced in the basic activities of eating, brushing, bathing,
grooming, dressing, elimination, and locomotion.
(e) Elimination
Bowel habits - Number of times per day
Bladder habits - Number of times during day and night
(f) Hobbies/Interests
Reading books/Watching TV/Playing/Listening to music/Others (Specify)
(g) Menstrual History
1. Puberty attained on :
2. Duration of cycle :
3. Amount of flow :
4. Regular/Irregular :
5. Any abnormalities :
6. Any pain :
(h) Obstetrical History
Number of pregnancy, number of delivery, nature of abortion, still birth,
number of live child, number of death, any complications.
Contraceptive methods, type, Spacing methods.
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VIII. Physical Assessment
Physical Assessment Format
I. General Appearance
Nourishment : Well nourished/Moderately Nourished/Malnourished
Body Build : Thin/Moderate/Obese
Hygiene and
Grooming : Clean and Neat/Dirty/Unkempt (not combed properly)
Activity : Active/Dull
Health : Healthy/Unhealthy
Posture : Normal posture/Lordosis/Kyphosis/Scoliosis
Movement : Coordinated movement/Tremors/Uncoordinated
movement
Mental Status :
Consciousness : Conscious/Semiconscious/Unconscious
Behaviour :
Look : Anxious/Depressed/Happy/Pleasant/Sad/Alert
/Tired/Fearful
Attitude : Cooperative/Withdrawn/Hostile
Affect/Mood : Appropriate to situation/Inappropriate to situation
Speech : Clear/Rapid/Slow/Slurring/Stammering/Relevant/
Irrelevant/Aphasia
Orientation : Oriented to time place and person
Vital Signs
Temperature : …………..oC/………….oF
Pulse : ………………beats/minute
Respiration : ………………breaths/minute
Blood pressure : ………………mm of Hg
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Height and Weight
Height : ……………….cms
Weight : ……………….kgs
A. Head
Shape : Normal/macrocephalic/ hydrocephalic
/micro cephalic
Scalp : Clean/presence of dandruff/pediculi
Face : Pale/flushed/puffiness/fear/anxiety/enlargement
of parotid Glands/ symmetric
Subjective Symptoms :
B. Hair : Evenly distributed/thick silky hair/alopecia/very
thin hair/ Brittle hair/excessive
oily/lice/nits/excessive hairness
(Hirsutism)
Texture : Normal/dry
Colour : Black/brown/red/gray etc
Grooming : Not groomed/well groomed
Subjective Symptoms :
C. Eyes
Eye brows : Hair equally distributed/symmetrical/
asymmetrical/scanty etc
Eye lashes : Equally distributed/unequal
Eye lids : Skin intact/edema lesion/etropion
(eversion)/entropion (inversion)/
Redness/lids closed symmetrically
/asymmetrically/ incompletely/painful
/ptosis (drooping of eyelids)
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Eye balls : Sunken/protruded
Pupils :
Colour : Black/cloudiness
Size : 3 – 7 mm in diameter
Shape : Round/Oval/Irregular/pinpointed etc
Reaction to light : PERLA->Pupils equally reacting to light and
accommodation
Corneal reflex : Present/absent
Conjunctiva : Pale/normal/yellowish/purulent/conjunctivitis
Sclera : White/jaundiced (yellow)/reddish etc
Lens : Opaque/transparent
Vision : Client can see objects/myopia (short sight)
hyperopia(Long sight)
Extra ocular muscle test : Normal/nystagmus/cross eye or squint
Subjective Symptoms : No complaints/pain/itching/increased or
decreased production of tears etc
D. Ear
Position : Normal/placed/low set ear
Cerumen : Absent/present
Otorrhoea : Absent/purulent/serous/blood
Subjective Symptoms : No complaints/otalgia/tinnitus/vertigo
Hearing :
Response to Normal voice tone : Normal voice tone audible/not
audible
Watch tick test (2cm – 3cm distance : Able to hear ticking in both ears
(weber negative)/not audible
Turning fork test (weber test) : Sound is heard in both ears/sound
is heard better in impaired ear
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Rinne test : Sound heard better in ear with out
a problem
Subjective Symptoms :
E. Nose
External Nose : Symmetric & symmetric/discharge
(present/ not present)/crusts
Nasal Septum : Midline/deviated
Patency of Nasal Cavity : Air moves freely as the client breaths
through the nares/obstructed
/nasal polyp
Frontal & maxillary sinuses : Normal/painful/render/sinusitis
Smell : Normal/absent(anosmia)
Rhinorrhoea : Absent/watery/purulent/mucoid/epistaxis
etc
Subjective Symptoms :
F. Mouth and Pharynx :
Outer lips : Pink/pale/ability to purse
lips/asymmetry/symmetry/ soft/
moist/smooth texture/or scales
Inner lips : Pink(freckled brown pigmentaion in dark
skinned client)/moist/smooth/
soft/excessive dryness/pale/
leukoplakia(with patches)/ulcerations
Teeth : Smooth/shiny tooth enamel/32
teeth(adult)/missing teeth/yellowish/
stains/ill fitting denture/brown/black
white/dental caries/tooth ache/plague
Gums : Pink/bleeding swelling/pus
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Tongue : Central position/deviated from
center/pink colour/
moist/slightly/rough/thin/whitish
coating/smooth red tongue/dry tongue/
lesions/ulcerations
Movement : Moves freely/no tenderness/restricted
mobility
Palate : Light pink/smooth soft palate/lighter pink
hard palate/discoloration
Uvula : Positioned in midline of soft
palate/deviation to one side from tumor
or trauma/immobility
Tonsils : Smooth/pink/pale/painful/enlarged/not
enlarge
Odour of mouth : Foul smelling
Pharynx : Gag reflex(present/absent) sore
throat/infections/ dysphagia,
odynophagia,
throat pain etc
Voice : Clear/harsh/aphonia/dysphonia
Subjective Symptoms :
G. Neck :
Range of motion : Possible/painful/absent etc
Thyroid gland : Enlarged/not enlarged/removed etc
Trachea : Midline/displaced etc
Lymphnodes : Palpable/not palpable/painful etc
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Jugular Veins : Distended/not distended
H. Chest : Barrel chest/pigeon chest/funnel
chest/transverse diameter is twice
the anterior posterior diameter/
symmetrical/asymmetrical/flat/etc
Expansion of the chest : Symmetry/asymmetry/delayed/shallow
/etc
Palpation :
Tactile fremitus : Symmetry/asymmetry/decreased/
increased
Thoracic excursion : Resonance/hyper resonance
Auscultation :
Apical pulse : ………. beats/mt
Breath sounds : Normal vesicular sound/normal bronchial
sound/ normal broncho vesicular
sound/crackles/stridor/ rhonchi/
wheezing/pleural friction
rub/bronchophony egophony/
whispered pectoriloguy
Cough : Absent/if present(dry/whooping/
productive/ aggravating/factors etc
Sputum : Absent/if present(bad odour/frothy/
mucoid/rusty/
sticky/purulent/green/yellow/blood
stained etc
Subjective Symptoms : No complaints/diaphoresis/breathless/
giddiness/palpitations/chest pain/shoulder
pain/exercise intolerance etc
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Heart : S1, S2 heard/murmur/gallop sounds
I. Breast & Axilla :
Symmetry : Symmetrical/asymmetrical
Areola & nipple : Colour/retracted/inverted/dimpling/erect
etc
Discharge : Absent/milky/yellowish/purulent etc
Lesions/masses : Absent/ulcerations/nodes/swelling/moving/
painful/tender etc
Auxiliary nodes : Not palpable/palpable/moving/painful etc.
Hair distribution : Well distributed/scanty etc
J. Abdomen :
Inspection : Skin rashes/scar/hernia/ascites/flat/abdominal
pulsation seen/linea nigra/umbilicus
clean/infected/ everted etc.
Palpation : Liver/(Palpable/not palpable)/spleen
(palpable/not palpable)/tenderness/soft/masses
etc
Percussion : Presence of gas/presence of fluid/mass
/detected/not detected.
Auscultation : Bowel sounds heard/not heard
Abdominal girth : ……….cms
Inguinal Lymph nodes : Not enlarged/enlarged/movable/painful etc
Appetite : Normal/anorexia/bulimia nervosa/anorexia
nervous
Subjective Symptoms : No complaints/nausea/vomiting/heart burn/
abdominal pain/abdominal cramps/flatulence/
polyphagia etc.
K. Skin :
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Colour : Fair/brown/dark in complexion
Texture : Dryness/wrinkling/excessive moisture/normal
Temperature : Warm/cold and clammy/hot
Lesions : Macules/papules/vesicles/wounds
Turgor : Normal/decreased
Discoloration : Absent/yellowish/cyanosis/pallor/increased
pigmentation
L. Upper extremities :
Symmetry : Symmetrical/asymmetrical
Range of motion : Possible/if impossible (specify)
Peripheral pulses : Brachial, radial pulses (normal rate, rhythm,
volume)
Reflexes : Biceps, triceps, brachio radialis normal if
abnormal...
Oedema/Swelling : Absent/if present (specify area)
Cyanosis : Absent/if present (specify area)
Joints : Stiffness/swelling/tenderness/crepitus etc/absent
Deformity : Absent/if present (specify)
Lower extremities :
Symmetry : Symmetry/asymmetry
Toe nails : Capillary refill …..sec
Range of motion : Possible/not possible (specify)
Peripheral pulses : Dorsalis pedis, posterior tibial artery, popilitial
artery(normal rate, rhythm, volume) if
abnormal…………
Reflexes : Patellar, ankle jerk, planter (normal) (kneejerk)
if abnormal
Oedema/ Swelling : Absent/ if present (specify area)
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Cyanosis : Absent/ if present (specify area)
Joints : Stiffness/ Swelling/ Tenderness/ Crepitus/ etc.
Deformity : Talipes equino varus/ Talipes equino valfum/
bow legs/etc/ absent
Subjective symptoms : No complaints/pain while walking or doing
daily activities/musclecramps/myalgia/problems
with flexion, extension, abduction, adduction,
external and internal rotation etc.
M. Nails
Shape : Convex curve (schamroth’s window test)/
spoon shape (Koilonychia)/ Clubbing
Texture : Smooth/excessive thickness/ excessive thinness/
presence of grooves or furrows/ Beau’s line
(Transverse white lines or grooves on nail may result
from severe injury or illness
Nail bed color : Pink/ cyanosed/ pale etc
Tissues surrounding nails: Intact epidermis/ hang nails/ paronychia
(inflammation of the tissues surrounding a nail)
Capillary refill : (Blanch test) …………..seconds
N. Genitals and Rectum
IX. Investigations:
S.No Name of the Patient Value Normal Value Remarks
Investigation
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X. Medications:
S.No Name of the Dosage, Route Action Side effects Nursing
Drug and Time Responsibilit
y
XI. List of Nursing Diagnosis
XII. Nursing Process:
Assessment Diagnosis Goal Planning Rational Implementation Evaluatio
e n
XIII. Nursing Health Education:
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