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    Nursing Care Plan Format

    Uploaded by

    Prasann Roy
    This document contains a template for collecting a child patient's medical history and examination findings. It includes sections for identification data, chief complaints, past medical history, physical examination, milestones/growth assessment, investigations, and urine test results. The goal is to gather relevant information to inform the child's diagnosis, treatment, and care.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Nursing Care Plan Format

    Uploaded by

    Prasann Roy
    4K views7 pages
    This document contains a template for collecting a child patient's medical history and examination findings. It includes sections for identification data, chief complaints, past medical history, physical examination, milestones/growth assessment, investigations, and urine test results. The goal is to gather relevant information to inform the child's diagnosis, treatment, and care.

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    nursing care plan format

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    This document contains a template for collecting a child patient's medical history and examination findings. It includes sections for identification data, chief complaints, past medical history, physical examination, milestones/growth assessment, investigations, and urine test results. The goal is to gather relevant information to inform the child's diagnosis, treatment, and care.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    4K views7 pages

    Nursing Care Plan Format

    Uploaded by

    Prasann Roy
    This document contains a template for collecting a child patient's medical history and examination findings. It includes sections for identification data, chief complaints, past medical history, physical examination, milestones/growth assessment, investigations, and urine test results. The goal is to gather relevant information to inform the child's diagnosis, treatment, and care.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 7

    IDENTIFICATION DATA-

     Name of the Child –


     Age/Sex –
     Ward / Bed No.-
     Admission No.-
     OPD No.-
     Date of admission/ Time –
     Address –
     Educational Level of child –
     Religion –
     Father / Mother Name-
     Parent’s education-
     Parent’s Occupation –
     Family Income –
     Diagnosis –
     Consent doctor –

     CHIEF COMPLAINS –

     PRESENT MEDICAL HISTORY –

     PAST MEDICAL HISTORY –

     PAST SURGICAL HISTORY –

     SOCIO ECONOMIC STATUS (HISTORY) –


     PERSONAL HISTORY –

     FAMILY HISTORY OF ANY ILLNESS –

    S. Name of the family members Relationship Age/Sex Health Status


    No.
    1.
    2.
    3.
    4

     FAMILY TREE-

     BIRTH HISTORY-
     Antenatal History –
     Natal History –

     Immediate Post Natal History –

     FEEDING HISTORY –

     IMMUNIZATION STATUS –

     FUNCTIONAL HEALTH PATTERNS-


     Hygiene –

     Dietetic History –

     Activity exercise –

     Sleep & Rest –

     Cognitive / Perceptual –

     Coping stress tolerance –


     Values & Beliefs –

     PHYSICAL EXAMINATION-
     General Appearance –

     Physical assessment (Anthropometry)-


     Height –
     Weight –
     Mid arm circumference –
     Head circumference –
     Chest circumference –

     Vital Signs-
    Temperature -
    Pulse -
    Respiration –
    Blood Pressure –
    Heart rate-

     Head –

     Eyes –

     Ears –

     Nose –

     Oral Cavity –

     Neck –
     Chest & Respiratory System –

     Abdomen & Inguinal Areas –

     Upper & Lower Extremities –

     Nervous System –

     Genital & Rectal Examination –

     Skin –

     SYSTEMIC EXAMINATION-

     MILESTONES / GROWTH & DEVELOPMENT-


     Physical and Biological Development –
    Weight-

    Height-

     Vital Signs-
     Temperature –
     Pulse -
     Respiration –
     Blood Pressure -
     Gross motor development-

     Fine motor development-

     Social /cognitive milestone-

     Language milestone-

     Play-

     INVESTIGATION-

    S.no Investigation Patient Value Normal Value Remarks


    1
    2
    3

    4
    5

    6
    7

     URINE ROUTEINE MICROSCOPY-

    S.no. Parameters Pt.’s value Normal value


    1
    2
    3
    4
    5
     OTHER INVESTIGATIONS-

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