Adult Health Nursing

Nursing Care Plan Adult

Student Name :…………………............ Student ID :…………………..............

Clinical Area / hospital :…………………............ Ward :…………………..............

Instructor Name :…………………............ Date of Submission :…………………..............

EP- F05-07-006, Rev. a

Ref.: 17/47/2019 - 2020
Date: 25/08/2020

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Al-Ahliyya Amman University ‫جامعة عمان األهلية‬

‫كلية التمريض‬

Nursing Admission Data Base (5%)

Client Name: ---------------------------------- Age: --------------------------------------- Sex: ------------------------

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Date of Admission (Transfer):------------------------------------ Via: ------------------------------

Condition on arrival: ---------------------------Walking: ----------------------------Stretcher: --------------------

Source of Data: -------------------------------------------------------------------------------------------

Spoken Language: ---------------------------------------------------------------------------------------

Patient Education: ------------------------------------------------ --------------------------------------- (1 Mark)

Reasons for Hospitalization: --------------------------------------------------------------------------- (0.5 Mark)

Confirmed Diagnosis: ----------------------------------------------------------------------------------- (1 Mark)

Medication taken at home: ----------------------------------------------------------------------------- (0.5 mark)

Past Medical history: ------------------------------------------------------------------------------------ (0.75 Mark)

Past surgical history: ------------------------------------------------------------------------------------ (0.75 Mark)

Family history: ------------------------------------------------------------------------------------------- (0.5 Mark)

EP- F05-07-006, Rev. a

Ref.: 17/47/2019 - 2020
Date: 25/08/2020

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Al-Ahliyya Amman University ‫جامعة عمان األهلية‬

‫كلية التمريض‬

Assessment (Describe): (15%)

1. Health Maintenance_ Perception Pattern. (0.75 Mark)

A: Smoking: ----------------------------------------
B: Alcohol: ------------------------------------------
C: Allergies (Drugs, Food, Tape, Dyes):
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2. Activity/Exercise Pattern(Describe activity, feeding, bathing, dressing, toileting, mobility, and

using assistive devices): (2Mark)

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3. Nutrition/Metabolic Pattern(Describe): (2 Mark)

A: Typical diet at home: -------------------------------------------------------------------------------------------------

Prescribe diet: -------------------------------------------------------------------------------------------------------
B: Appetite: -----------------------------------------------------------------------------------------------------------------
C: Nausea: ------------------------------------------------------------------------------------------------------------------
D: Vomiting: ---------------------------------------------------------------------------------------------------------------
F: Dysphagia: --------------------------------------------------------------------------------------------------------------
G: Weighting changes within last 6 months: ------------------------------------------------------------------------
H: Dentures: ---------------------------------------------------------------------------------------------------------------

4. Elimination Pattern: (2Mark)

EP- F05-07-006, Rev. a

Ref.: 17/47/2019 - 2020
Date: 25/08/2020

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Al-Ahliyya Amman University ‫جامعة عمان األهلية‬

‫كلية التمريض‬

A: Bowel habits, ostomy, bleeding, assistive devices:

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B: Urinary Habits: --------------------------------------------------------------------------------------------------------

5. Sleep/ Rest Pattern: (1.25 Mark)

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6. Cognitive/Conceptual Pattern: (2 mark)

A: Hearing: ----------------------------------------------------------------------
B: Vision: ------------------------------------------------------------------------
C: Vertigo: ----------------------------------------------------------------------
D: Discomfort/ pain: ----------------------------------------------------------

7. Coping stress/ Self Perception Pattern: (1.5 Mark)

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A: Major concerns regarding hospitalization of illness:

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B: Major lose/ change: Yes… No: ------------------------------------

C: Coping mechanisms: -------------------------------------------------------------------------------------------------

8. Value _ Belief Pattern: ( 1 Mark)

A: Religion: ----------------------------------------------------------------------------------------------------------------
B: Spiritual Habits: -------------------------------------------------------------------------------------------------------
9. Role-Relationship Pattern: (1.5 Mark)
A: Occupation: -------------------------------------------------------------------------------------------------------------
B: House-hold members: -------------------------------------------------------------------------------------------------
C: Family concerns regarding hospitalization: ----------------------------------------------------------------------

10. Sexual/Reproductive Pattern: (1Mark)

A: Female patients: --------------------------------------------------------------

*Menstruation: ----------------------------------------------------------------
EP- F05-07-006, Rev. a
Ref.: 17/47/2019 - 2020
Date: 25/08/2020

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Al-Ahliyya Amman University ‫جامعة عمان األهلية‬

‫كلية التمريض‬

*Use of contraceptives: ------------------------------------------------------

*Vaginal bleeding: ------------------------------------------------------------
*Vaginal discharge: ----------------------------------------------------------
*Self-Breast Exam: -----------------------------------------------------------

B: Male patients:
*Testicular exam: ------------------------------------------------------------

PHYSICAL EXAMINATION (OBJECTIVE DATA): (10%)

1. General Survey: (1.25 Mark)

A: Level of consciousness: -------------------------------------------------

B: Orientation: ---------------------------------------------------------------

C: High: ---------- Weight: -------------- Temperature: -----------

D: General Appearance: ---------------------------------------------------

2. Nutritional Metabolic Pattern (Describe): (4Mark)

A: Skin: -----------------------------------------------------------------------

B: Oral cavity: --------------------------------------------------------------

C: Neck: ----------------------------------------------------------------------

D: Abdomen: ----------------------------------------------------------------

EP- F05-07-006, Rev. a

Ref.: 17/47/2019 - 2020
Date: 25/08/2020

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Al-Ahliyya Amman University ‫جامعة عمان األهلية‬

‫كلية التمريض‬

3. Activity Exercise Pattern: (3 Mark)

A: Lung and Thorax: -----------------------------------------------------

B: Cardiovascular: --------------------------------------------------------

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C: Musculoskeletal: ----------------------------------------------------------------------------------------------
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4. Cognitive- Perceptual Pattern: (1.75 Mark)

A: Mental status :( able to calculate, thinking abstractly, memory)

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B: Neurological status:

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MEDICATION PROFILE (10%)

EP- F05-07-006, Rev. a

Ref.: 17/47/2019 - 2020
Date: 25/08/2020

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Al-Ahliyya Amman University ‫جامعة عمان األهلية‬

‫كلية التمريض‬

Allergies: ……………………………………………………………..

Contra- Nursing
Drugs and Indication Dose/ Route/ Expected
indication implication
Classification Frequency Side effects
(1 Mark) (2 Mark) (1Mark) (2 Mark)
(1 Mark) (3 Mark)

References:

EP- F05-07-006, Rev. a

Ref.: 17/47/2019 - 2020
Date: 25/08/2020

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Al-Ahliyya Amman University ‫جامعة عمان األهلية‬

‫كلية التمريض‬

INTAKE AND OUTPUT (5%)

INTAKE OUTPUT
TOTAL Total
BLOOD INTAKE output
IVF(1) IVF(2) ORAL NGT Urine stool Drain Vomit
PRODUCT

Balance: ----------------------------------------------------------------------------------------------------

Diagnostic Test (5%)

Test Name Normal Value Result Nursing Intervention

EP- F05-07-006, Rev. a

Ref.: 17/47/2019 - 2020
Date: 25/08/2020

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 Al-Ahliyya Amman University ‫جامعة عمان األهلية‬

‫كلية التمريض‬

Nursing Process (50%)

Planned Actual Actual The Outcome

Evidence BY/ Short –Term Intervention
Nursing Goals Intervention Intervention (with
Defining (5 Mark)
Diagnosis (10Mark) (with Rationale)
Characteristic
(10 Mark) Rationale) (5 Mark)
(10 Mark)
(15 Mark (5 Marks)
1.

2.

3.

EP- F05-07-006, Rev. a

Ref.: 17/47/2019 - 2020
Date: 25/08/2020

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