Format of Nursing Care Plan Based on Nursing Process

i)Identification data

Name : ...................................................................................................

Age : ...................................................................................................

Sex : ...................................................................................................

Religion : ...................................................................................................

Marital Status : ...................................................................................................

Educational Background : ...................................................................................................

Occupation : ...................................................................................................

Date of Admission : ...................................................................................................

M.R.D. No. : ...................................................................................................

Diagnosis : ...................................................................................................

Ward : ...................................................................................................

Bed No. : ...................................................................................................

Address : ...................................................................................................
...................................................................................................
Date of Discharge : ...................................................................................................

Date of Planning : ...................................................................................................

ii) Brief Socio-Eeconomic History

1) Family history

2)Development of Nursing Care Plan Using

Nursing Process

a) Type of family ----- Nuclear/joint

b) Numbers of family members

c) Any specific disease in members

d) Health status of family members

e) Total Income

f) Dietary habits

g) Housing condition ---- Own/Rental/Water/Electricity Supply etc.

h) I.P.R. Among Family Members

Personal history

- - Hygine and grooming

- - Any H/O Allergy

- - H/O smoking, alcohol, tobacco, drinking etc.

- - Life style flabits--exercises-drugs etc.

3) Hisotry of fast illness

4) History of present illness ---- Present complaints

5) Examination by doctor (from casesheet)

6) Investigations:
 

 7) Doctors Ordes:

 

8)Name of Investigation

Assessment:

a) Subjective Assessment:

b) Objective Assessment :

vital signs

Head to foot examination

9)Nursing Care Plan

10) Health Teachings

11) Progress Notes ---- (Day wise)

12) Activity

a) Write three nursing care plans using nursing process.

Select patient from anyone of the following setting

• OPD
• Medical/surgical ward
• ICU, CCU, RR, Neuro ICU

b) Discuss nursing process with your supervisor?

c) Write five objective and subjective data?