MEDICAL CARE PLAN - I

IDENTIFICATION DATA:-
Name of the Patient :

Age :

Gender :

Ward :

I.P.D. No. :

Date of Admission :

Educational Status :

Occupation :

Family Income :

Religion :

Marital Status :

Present Complaints :

Diagnosis :

Address :

CHIEF COMPLAINTS:

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FAMILY HISTORY:

FAMILY MEMBERS’ DETAILS:

S. no. Name Age Qualification/ Relation to the Health status

Occupation client
1.
2.
3.
4.
5.
6.
7.

FAMILY TREE:

SOCIO- ECONOMIC STATUS:

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Housing:

Medical
Facility:

Economic
status:

PERSONAL HISTORY
Habits:
Diet:
Sleeping
habits:
Bowel &
Bladder
habits:
Exercise:
Belief:
Relationship:
Hobby:
Allergy:

PAST MEDICAL HISTORY:

.
PAST SURGICAL HISTORY:

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PRESENT MEDICAL HISTORY:

PRESENT SURGICAL HISTORY:

PHYSICAL EXAMINATION

General appearance:

Facial Appearance:

Mood and affect:

Personal hygiene:

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 Communication:

Mobility:

Position:

Nutrition / body built:

Height and weight:-

Height :

Weight :

BMI :

Vital signs:-

Temperature :

Pulse :

Respiration :

Blood Pressure:

HEAD TO FOOT EXAMINATION:-

Head:

Hair:

Movement:

Scalp:

Eyes:

Eye brows and eye lids:

Lacrimation:

Conjunctiva:

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Sclera:

Cornea:

Pupil:

Others:

Ears:

Appearance:

Discharge/ wax:

Hearing tests: Webbers test:

Rinnies test:

Nose:

Appearance:

Discharge:

Patency:

Sense of smell:

Mouth and throat:

Lips:

Tongue:

Teeth:

Gums:

Buccal mucosa:

Taste:

Tonsils:

Uvula:

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Neck:

Inspection:

Lymph nodes:

Palpation: Trachea:

Thyroid gland:

Chest:

Respiratory

Inspection:

Palpation:

Percussion:

Auscultation:

Cardiac

Inspection:

Palpation:

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Percussion:

Auscultation:

Abdomen:

Inspection:

Abdominal girth - ______cm.

Auscultation:

Percussion:

Liver span – ______cm.

Palpation: Light palpation –

Deep palpation –

Special sign’s/test:

Genitourinary:

Male:

Inspection:

Female:

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Inspection:

Upper and lower extremities and spine:

Inspection:

Palpation:

ROM:

Nervous system:

GCS:

Cranial nerves:

Muscles:

Reflexes:

Skin:

Color:

Temperature:

Moisture:

Texture:

Thickness:

Edema:

Turgor:

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FINAL IMPRESSION :-

LABORATORY / OTHER INVESTIGATION:-

Date Investigations Name Normal Findings Patient’s Remarks

Findings

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Others if any :- X- ray, USG, Endoscopy, CT, MRI, PFT

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 MEDICATION

Drug name Dose / Mechanism of Indications Contra- Side Effects Nurses Responsibilities
/pharmacolog Route/ Action Indications
ical name Frequency

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Drug name Dose/ Mechanism of Indications Contra- Side-Effects Nurses Responsibilities
/pharmacolog Route/ Action Indications
ical name Frequency

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Drug name Dose/ Mechanism of Indications Contra- Side-Effects Nurses Responsibilities
/pharmacologi Route/ Action Indications
cal name Frequency

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Drug name Dose/ Mechanism of Indications Contra- Side-Effects Nurses Responsibilities
/pharmacologi Route Action Indications
cal name

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NURSING PROCESS:-

Problems identified:

1.

2.

3.

4.

5.

6.

7.

8.

Nursing diagnosis:

1.

2.

3.

4.

5.

6.

7.

8.

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 NURSING CARE PLAN
Nursing Nursing Expected
Planning Rationale Implementation Evaluation
Assessment Diagnosis Outcome
Short
Sub. term
Data goal

Obj.
Data Long
Term
goal

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 Nursing Nursing Expected Planning
Rationale Implementation Evaluation
Assessment Diagnosis Outcome

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 Nursing Nursing Expected
Planning Rationale implementation Evaluation
Assessment Diagnosis Outcome

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 Nursing Nursing Expected
Planning Rationale Implementation Evaluation
Assessment Diagnosis Outcome

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 Nursing Nursing
Expected Outcome Planning Rationale Implementation Evaluation
Assessment Diagnosis

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 Nursing Nursing Expected
Planning Rationale Implementation Evaluation
Assessment Diagnosis Outcome

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 Nursing Nursing Expected
Planning Rationale Implementation Evaluation
Assessment Diagnosis Outcome

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Health Teaching:-

Progress of Patient:-

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Summary:-

Conclusion:-

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Bibliography:-

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Signature of the student Signature of the Eval uator

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