1. 1 University of Jordan - Faculty of Nursing Nursing Care-plan 2015 Student’s name ……………………………….. Evaluator ………………………………….. Clinical Area …………………………….......... Date ………………………………………. ____________________________________________________________________________ Admission Data ( 5% ) ( 1 mark ) Client ……………………………………………………….. Age ………………………….. Gender ……………………. Date of admission ………………………………………… via ……………………………………………. Source of data ………………………………………………………………………………………………………………… Condition on arrival : wheelchair………….. Walking ………… stretcher……………… ( 0.5 ) Reason for hospitalization …………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………….. ( 1 ) Confirmed medical Diagnosis ………………………………………………………………………………………………………………………………………………….. ( 0.2 ) Medication taken at home …………………………………………………………………………………………………………………………………................ ………………………………………………………………………………………………………………………………………………… ( 0.75 ) Past medical History …………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………… ( 0.75 ) Past surgical History …………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………… (0.8) Family History – genogram ( 3 generations) Page 1

2. 2 ASSESSMENT – SUBJECTIVE DATA ( 14 % ) ( 0.75 ) Health maintenance – perception pattern a) Smoker (YES/NO ) ………………………… No. of packs / day ………………………………. Quit-date ………………….. b) Allergies ( drugs, food, tape, dye, etc. ) - Unknown - YES/ Specify………………………………………………………………………………………………………………….. (1.75) Activity - Exercise Pattern a) Assistive devices NO / YES; specify …………………………………………………………………… b) Code of self care ability: 1= independent, 2 = needs assistance, 3 = dependent Feeding ( ) Bathing ( ) Dressing/Grooming ( ) Toileting ( ) Mobility ( ) ( 2 ) Nutrition – Metabolic Pattern a) Special Diet at home ………………………………………………………………………………………………………. Prescribed Diet………………………………………………………………………………………………………………. b) Appetite NO / YES; describe ……………………………………………………………………………………. c) Nausea NO / YES; describe…......................................................................................... d) Vomiting NO / YES; describe ……………………………………………………………………………………………………………………………………… e) Dysphagia NO / YES; describe …………………………………………………………………………………. f) Weight changes within last 6 months / describe ……………………………………………………………………………………………………………………………………… g) Use of Dentures NO / YES; describe ……………………………………………………………………………………………………………………………………… ( 1.5 ) Sleep – Rest Pattern a) Number of sleep hours/ night ……………………………… Naps---------------- b) Use of drugs for sleeping NO / YES---------------- c) Any change of sleep habits after hospitalization NO / YES; describe ……………………………………………………………………………………………. Page 2

3. 3 ( 2 ) Elimination Pattern a) Bowel habits : Number of bowel habits …………/day Last bowel movement ( date ) ………………. Constipation YES / NO Diarrhea NO / YES, describe: ………………….. Distention YES / NO Incontinence NO / YES Bleeding YES / NO Painful defecation YES / NO Ostomy NO / YES, describe: ………………………………………………………………………………………………… assistive devices ( specify ) ………………………………………………………………………………………. b) Urinary habits : Frequency ………… ( times/ day ) Color ……………………………… Dysuria YES / NO Oliguria YES / NO Urgency YES / NO Hematuria YES / NO Anuria YES / NO Incontinence YES / NO Nocturia YES / NO Retention YES / NO Burning YES / NO Assistive devices ( specify ) ……………………………………………………………………………………………. Urine output / shift ………………ml ( 2 ) Cognitive – Perceptual Pattern a) Hearing : Impaired …………………… Deaf ……………………… Tinnitus ………………………. Hearing Aids ……………………………………………… None …………………………… b) Vision : Impaired ………………… Eye Glasses ……………… Contact lenses …………………………. Blind …………………….. None ………………………….. c) Vertigo ( YES / No ) ………………………………………………………………………………………………. d) Pain / Discomfort ( describe ) ………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………............ ………………………………………………………………………………………………………………………………………… Page 3

4. 4 (1.5) Coping – Stress/ Self- Perception Pattern a) Major concerns regarding hospitalization of illness …………………………………………………………………………………………………………………………………………………….. b) Major loss / change NO / YES ( specify ) …………………………………………………………………………………………………………………………… c) Coping mechanisms ………………………………………………………………………………………………………………. ( 0.6 ) Value – Belief Pattern a) Religion ……………………………….. b) Spiritual habits ……………………………………………………………………………………………………………………… (0.9) Role – Relationship pattern a) Occupation …………………………………………………………… b) House – hold members; patient currently lives with ( specify ) ………………………………………….…………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………… c) Family concerns regarding hospitalization …………………………………………………………………………………………………………………………………………………….. ( 1 ) Sexual – Reproductive Pattern a) Last menstrual period ( date ) ………………………………………………………………….. Menstrual problems NO / YES ( specify ) …………………………………………………………………………… b) Use of contraceptives NO / YES ( specify ) ………………………………………………………………. c) Vaginal bleeding / Discharge NO ………………. YES ( specify ) …………………………………………………………………………………………………………………….. d) Self-Breast exam NO / YES ( specify ) ………………………………………………………………. e) Testicular exam NO / YES ( specify )............................................................................. Page 4

5. 5 PHYSICAL EXAMINATION – OBJECTIVE DATA ( 11% ) ( 1 ) General Survey Level of consciousness …………………………………………………………………………………………………… Orientation …………………………………………………………………………………………………………………….. Height …………………………………………….. Weight ………………………………… Vital Signs Temperature ………………………………….. Respiratory Rate ……………………………………………………. Pulse Rate …………………………………..... Blood Pressure ……………………………………………………… general Appearance ……………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………….. ( 4 ) Nutritional – Metabolic Pattern a) Skin : Color ………………………………………………….…………….. Symmetrical …………………………………………. Temperature ………………………………………………………….. Turgor ………………………………………………... Texture ………………………………………………………. Moisture ………………………………………………………. Lesions /describe ………………………………………………………………………………………………………………… Edema NO / YES; describe …………………………………………………………………………………………. Pruritus NO / YES; describe …………………………………………………………………………………………. Cannula ………………………………………………………………………………………………………………….. Drains NO / YES; describe ………………………………………………………………………………………… b) Oral cavity : Lips/describe………………………………………………………………………………………………………………………….. Gums/describe ……………………………………………………………………………………………………………………….. Teeth/describe …………………………………………………………………………………………………………………………………………………… Tongue/describe ………………………………………………………………………………………………………………….. Mucous Membranes & adjacent structures/describe ……………………………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………………. Page 5

6. 6 c) Neck : Symmetrical YES / NO; describe ……………………………………………………………………… Thyroid …………………………………………………………………………………………………………………………………. Carotid pulse ------------------------------------------------------------------------------------------------------- Jugular venous pressure ---------------------------------------------------------------------------------------- Lymph node Enlargement NO YES/describe …………………………………………………………………………………… d) Abdomen : Symmetrical YES / NO; describe ………………………………………………………………………………… Contour ………………………………………………………………………………………………………………………………. Umbilicus …………………………………………………………………………………………………………………………….. Number of bowel sounds / minute --------------------------------- Abnormal sounds NO / YES; specify ……………………………………………………………….. Masses NO / YES; specify ……………………………………………………………………………………….. Organomegaly NO / YES; specify ……………………………………………………………………………… Tenderness NO …………… YES/specify ……………………………………………………………………………………………………….. ( 4 ) ACTIVITY – EXERCISE PATTERN a) Cardiovascular : Apical Pulse/ describe …………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………….. Peripheral Pulses/ describe …………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………….. Abnormal heart sounds NO / YES; describe ………………………………………………………………………………….. Page 6

7. 7 b) Lung & Thorax : Respiratory Pattern /describe …………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………….. Symmetrical chest movements YES / NO; describe …………………………………………………………………. Lung expansion ; describe ……………………………………………………………………………………………………….. Oxygen therapy No / Yes; describe ……………………………..………………………………………………………. Breathing sounds : c) Musculoskeletal Temporomandibular Joint / describe ………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………….. Neck Joints / describe ……………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………… Upper Extremity’s Joints / describe ………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………… Lower Extremity’s joints / describe ………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………….. Spine / describe …………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………………. Page 7 SoundLocationCharacteristicsAdventitious sound (wheezes, etc…)

8. 8 (2) COGNITIVE – PERCEPTUAL PATTERN a)Eyes …………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………….. b) Ears ………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………. c) Nose ………………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………….............. d) Mental Status : ability to calculate YES / NO; describe …………………………………… Abstract thinking YES / NO; describe ………………………………….. Memory intact YES / NO ; specify …………………………………………………………………………………. e) Neurological Status : Intact Cranial Nerves YES / NO; specify ………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………. Intact Sensory Function YES / NO; specify ………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Intact Motor Function YES / NO; specify ……………………………………………………………………………… ………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………. Deep Tendon Reflexes ( Draw picture with key ) : Page 8