Scribd
Upload
20 views7 pages

Comprehensive Nursing Care Plan

The document outlines a comprehensive nursing care plan that includes baseline data, patient history, physical examination findings, and nursing diagnoses. It details various aspects of the patient's health, including medical history, family history, socio-economic status, and specific assessments of different body systems. The plan also includes sections for lab investigations, nursing goals, implementation strategies, and health education.

Uploaded by

shikhaonline88
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
20 views7 pages

Comprehensive Nursing Care Plan

The document outlines a comprehensive nursing care plan that includes baseline data, patient history, physical examination findings, and nursing diagnoses. It details various aspects of the patient's health, including medical history, family history, socio-economic status, and specific assessments of different body systems. The plan also includes sections for lab investigations, nursing goals, implementation strategies, and health education.

Uploaded by

shikhaonline88
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

NURSING CARE PLAN

Introduction-

Baseline data
Name of the patient -

Age / sex -

Opd / ipd no. -

Date of admission -

Date of birth -

Provisional diagnosis –

Diagnosis -

Religion -

Address -

Bed no -

Present chief complaints


History of client –

Present medical history

Birth History
 Prenatal history-

Prenatal visits -

Gestational age -

Immunization of mother -
 Natal history-

Type of delivery -

Immediate cry -

Apgar score -

Birth weight -

Initiation of breast feeding -.

 Post natal history-

Immunization history
Age Vaccine taken

Family history
[Link] Name of Age Sex Relation Occupation Education Health
family with status
member patient
1

Family medical history


Family Tree

Keys
Socio economic history
Type of family -
Housing -
Income -

Sources of income -
Waste disposal -

Water supply -

Total family member -

Personal history
Personal hygiene -

Bowel & bladder pattern –

Sleep & rest pattern -

Nutritional history

Head to the examination to detect signs of nutritional deficiency states

 General appearance-
 Hair-
 Face-
 Eyes-
 Lips-
 Tongue-
 Teeth-
 Gums-
 Glands-
 Skin-
 Nails-
 Edema-
 Rachitic changes-
 Internal systems-

Physical examination
Vital signs

 Temperature –
 Pulse -
 Respiration -
 Blood pressure-

Anthropometric measurement

 Weight-
 Head circumference-
 Chest circumference-
 Mid arm circumference-

General appearance

 Irritability-
 Activity -
 Lethargy-
 Dullness-
 Health-

Skin

 Complexion -
 Lesion -
 Lanugo-
 Nails-
 Rashes-

Head

 Circumference-
 Shape-
 Fontanel-
 Moulding-
 Birth trauma -
 Facial symmetry-
 Caput succedenum-
 Cephalohematoma-
 Eye
 Eye fixed downward[sundowning sign]-
 Sclera –

 Conjunctiva -

 Pupil –
 Eye brow –
 Any discharge-

Ear

 Position-
 Pinna –
 Cartilage –
 Any discharge-
 Size –

Nose

 Patency-
 Flaring-
 Flat nasal bridge –
 Any discharge-

Mouth\thorat

 Lips -
 Symmetrical facial movement-
 Palate-
 Tongue –
 Cleft lip / palate -
 Secretion-

Neck

 Webbing-
 Masses-
 Range of motion-
 Enlargement of thyroid gland -
 Enlargement of lymph nodes -

Cardiovascular system

Inspection -

 Cyanosis-

Palpation-
Auscultation -

 Heart murmur-
 Heart sound-
 Pulse rate-
 Blood pressure-

Respiratory system

Inspection

 Chest movement-
 Shape of chest-
 Breathing pattern-

palpation

 any lymphnode-absent
 abnormal growth mass-absent
 injury- absent

auscultation

 breath sound-low pitched sound


 respiratory rate-56br\min
 chest retraction- absent

Gastro intestinal system

Inspection -

 Size- normal
 Shape-round
 Skin rashes-absent
 Abdominal distension-absent
 Umbilical cord- normal
 Redness-absent
 Bleeding from cord absent
 Umbilical hernia- absent
 Percussion - no evidence of fluid collection.
 Palpation - no palpable mass [Link] and spleen are not palpable.
 Auscultation -
 Ascities-absent

Genitourinary system[female]

 Urination-6 times in a day


 Abnormalties- absent
 Musculoskeletal system
 Upper \lower extremities- normal symmetry
 Muscle tone- dull
 Muscle \joint- normal

Central nervous system

 Moro reflex-
 Tonic-
 Swallowing reflex-
 Sucking reflex-

Back

 Spinal deformities -
 Spina bifida –

Extremities

 Polydactyly -
 Syndactyly -
 Nail -
 Knocked knee –
Growth And Development (Neurological reflexes)

Lab Investigation
Test In patient Normal

[Link]. Assessment Nursing Goal Planning Implementation Rational Evaluation


diagnosi
s
Nursing care plan

Complication
Prognosis:-
Health education
Conclusion-
Bibliography

You might also like