MEDTECH COLLEGE

SCHOOL OF NURSING
CARE PLAN DATA SHEET
NURSING PROCESS
Student Name_____________________________________ Course_________________________________ Date________________________

Assessment

Additional Notes:

1. Client Data Base:

Patient Initials: ________________Age: ______Gender:_____________

_____________________________________________

Cultural/Ethnic: _____________________________________________

_____________________________________________

Language Spoken: __________________________________________

_____________________________________________

2. Medical Data:
Reason for hospitalization: ____________________________________

_____________________________________________

Medical Diagnosis: __________________________________________

_____________________________________________

Other existing problems______________________________________

_____________________________________________

Events leading to hospitalization: _______________________________

_____________________________________________

Summary of present hospitalization: _____________________________

_____________________________________________

Past Medical/Surgical History: _____________________________________________________________________________________

Diagnostic tests/procedures done during this hospitalization and the results:
____________________________________________________________________________________________________________________

Assessment Tool

Nursing Diagnosis

____________________________________________________________________________________________________________________
Laboratory test results only for abnormal results. Please indicate why they are abnormal also indicate the norms and what the norm
results indicate.
Lab Test Performed

Results (Abnormal and the normal ranges)

Why Abnormal

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Use the Assessment Tool in head-to-toe format and record information for both the physical and functional assessment data.
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Data Collection
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Vital Signs
T_______ P_______ R_______ BP_____/____
HT_______WT_______
_____________________________________
Head and Neck:
_____________________________________
Mental Status: ______________________________________________________________________
Scalp:

_____Clear
_________________________________________
_____Dry
_________________________________________
_____Other__________________________________________________________________

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Hair:

_____Clean
_________________________________________
_____Dirty
___________________________________________

Face:

_____Symmetrical
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Assessment Tool

Nursing Diagnosis

_____Asymmetrical
Eyes:
Neck:

_____Clear, no secretions _____Other____________________________________________

_____Smooth, non-tender

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___________________________________________

_____Neck distention
___________________________________________
_____Tender
___________________________________________
_____large palpable lymph nodes
___________________________________________
Ears:

_____No drainage/lesions
___________________________________________

Mouth:
Gums:

_____Moist, pink
___________________________________________
_____Pale
___________________________________________
_____Inflamed
___________________________________________
_____Bleeding
___________________________________________
_____Ulcers
___________________________________________

Tongue: _____Moist, pink

___________________________________________
_____Reddened
___________________________________________
_____Cyanotic

Teeth:

_____Pallor

___________________________________________

_____Lesions present

___________________________________________

_____white patches

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_____Complete _____Color: Clean, white Discolored

_____Loose tooth _____Missing tooth ____Dentures

Mucous membrane: _____Moist

_____Dental Caries
___________________________________________
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Assessment Tool

_____Dry

Self Care:

Nursing Diagnosis

___________________________________________

______________________________________

_____Able to provide self-care (feeding, bathing/hygiene, dressing/grooming, toileting)

___________________________________________

_____Needs assistance with care: __________________________________________

___________________________________________

_____Unable to provide self-care

___________________________________________
___________________________________________

Comfort, Rest, Sleep

_____Has problems falling asleep
___________________________________________
_____Requires sleeping pills
_____Naps sleeps during the day

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_____Pain present_________________________________________________
(Specify level of pain, scale of 1-10)

___________________________________________

What sleep pattern is expected for a patient of this age? ________________________

___________________________________________

What is the actual rest pattern in your patient? _______________________________________

__________________________________________

Self-Perception/Self Concept:
What is expected for a patient of this age? __________________________________________

___________________________________________

What is actual self-concept of your patient? _________________________________________

___________________________________________

Safety: Physical/Mechanical/Microbial/Chemical:

______________________________________

_____Risk for falls: _____History of falls: _____Sensorial deficit

__________________________________________

_____Coordination deficit: _____Effect of narcotics/sedatives

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_____Environmental hazards: clutter in room, poor lighting

__________________________________________

_____Visual deficits

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Assessment Tool

Nursing Diagnosis

_____Presence of infection: ____________________________________________

__________________________________________

Cardiovascular:
Heart Sounds: Clear

Muffled Murmur Thrills Hum

S1

S2

S3

Right Peripheral Pulses: Carotid

Apical Brachial Radial Groin Popliteal Posterior Tibial Pedal

Left Peripheral Pulses: Carotid

Apical Brachial Radial Groin Popliteal Posterior Tibial Pedal

RUE Peripheral Capillary Refill </= 3 secs

>3secs (Amount)

LUE Peripheral Capillary Refill </= 3secs >3secs (Amount)

RLE ________________________ LLE ___________________________________________

__________________________________________

Clubbing or Edema: _____________ Present & Location ________________________________

___________________________________________
Cardiac Rhythm: NSR

Irregular _____________________________________________ ___________________________________________

Tubes/site/location ____________________ Drains/site/location__________________________ ___________________________________________

Respiratory:
Chest Expansion: Symmetrical/ Asymmetrical
R Breath Sounds: Clear Abnormal/Explain L Breath Sounds: Clear Abnormal/Explain:
_____________________________________________________________
Retractions: Mild

Moderate

Severe Intercostal

Subcostal

__________________________________________
Sternal Substernal

Breathing Pattern: Regular/ Irregular, Unlabored/Labored, Shallow/Deep

Dyspnea/Orthopnea/Apnea/Tachypnea

Cough: None/Non Productive/Productive & Color of expectorant, Amt: Scant,

moderate,

Assistive Device(s): Airway/type/size

Tubes/site/location

Nasal Flaring

heavy

Drains/site/location (circle)

Integumentary:
Skin: Intactness

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Assessment Tool

Nursing Diagnosis

Lesions: Macule, vesicle, nodules, pustule, papule, wheal, tumor (circle)

Texture, Temperature, Moisture:

_____Smooth and soft

_____Rough, thick, scaly

_____Warm and dry

_____Extremely cool or warm/hot diaphoretic
Turgor and elasticity: _____________

_________________________________________
_________________________________________
_________________________________________

_____Pinched-up skin returns immediately to original position, elastic _____Pinched-up skin takes >=30 seconds to return to original position, inelastic
Infestations:
_____None

_________________________________________
_____Present____________________

Nails:

_________________________________________
_________________________________________

_____Round, firm, smooth edges, pinkish 160 degree nail base

_________________________________________

_____Clubbing: 180 degree or more nail base

_________________________________________

_____Pale, cyanotic, splintered nails

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_____Other: ___________________________________________________________

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Digestive/Gastrointestinal/Nutrition:
Size and contour of abdomen:

_____________________________________
_____________________________________

_____Flat/soft/firm

_____Distended

_____Enlarged

_____Tender

_________________________________________

______________________________________
Bowel sounds on auscultation in all 4 quadrants (for up to 5 minutes in each quadrant)
Frequency and characteristics: _____________

__________________________________________

_____Audible all 4 quadrants, high pitched, irregular gurgles 5 to 35 times/minutes

__________________________________________

_____Hypoactive_____________________________quadrant____________________

__________________________________________

_____Absent________________________________quadrant____________________

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Bowel Movement: _____ Regular _____Irregular

Date of last bowel movement: _________________

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Assessment Tool

Nursing Diagnosis

Characteristics of stools: _________________________________________________

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Abdominal girth (if appropriate) ____________________________________________

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Diet: _______________%Eaten______________Snacks_____No_______Yes______

___________________________________________

Food allergy: _____None______Yes________________________________________

___________________________________________

Factors that may alter nutritional intake less or more than body requirements:

___________________________________________

_____________________________________________________________________
Specify factors

___________________________________________
___________________________________________

Weight in relation to height________________________________________________

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Signs of nutritional deficit (list) _________, _________, _________, _________, _____
___________________________________________
Fluid intake in 24 hours (amount):
___________________________________________
P.O._________________________________________________________________
___________________________________________
Parenteral: IV_________________________________________________________
___________________________________________
Rate of administration (CCs/hr) ___________________________________________
___________________________________________
Signs of fluid volume deficit/excess (specify below):
___________________________________________
Skin turgor_____________________Mucous membranes______________________
Edema_____________________Urine characteristics_________________________

___________________________________________

Feeding tube to be used: ______None ______Gastrostomy T. ______Jejunostomy T.

___________________________________________

Drainage tube: ______N.G. ______Cecostomy ______Ileostomy ______Colostomy

___________________________________________

Family Dynamics: Describe family interactions you observed:

_________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Assessment Tool

Nursing Diagnosis

MedTech College School of Nursing

Nursing Care Plan
Prioritized Nursing Diagnosis

Goal/Expect Patient Outcome

(Short-term goal, By end of shift,
objective, measurable criteria) Include
date and time

Nursing Interventions and

Rationale
Nursing actions and frequency done
during your care) Reasons for your
actions

Evaluation/Recommendation
Did patient reach goal? How do you
know? What do you recommend for
the next nursing shift?

1.

Related to:

Evidenced by:

Assessment Tool

Nursing Diagnosis

MedTech College School of Nursing

Nursing Care Plan
Prioritized Nursing Diagnosis

Goal/Expect Patient Outcome

(Short-term goal, By end of shift,
objective, measurable criteria) Include
date and time

Nursing Interventions and

Rationale
Nursing actions and frequency done
during your care) Reasons for your
actions

Evaluation/Recommendation
Did patient reach goal? How do you
know? What do you recommend for
the next nursing shift?

2.

Related to:

Evidenced by:

Assessment Tool

Nursing Diagnosis

MedTech College School of Nursing

Nursing Care Plan
Prioritized Nursing Diagnosis

Goal/Expect Patient Outcome

(Short-term goal, By end of shift,
objective, measurable criteria) Include
date and time

Nursing Interventions and

Rationale
Nursing actions and frequency done
during your care) Reasons for your
actions

Evaluation/Recommendation
Did patient reach goal? How do you
know? What do you recommend for
the next nursing shift?

3.

Related to:

Evidenced by:

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Assessment Tool

Nursing Diagnosis

MedTech College School of Nursing

Drug Sheet
Medicine-Drug

Dosage and
Frequency of
Administration

Classification

Common Side-Effects

Rationale for Use by

Client

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Assessment Tool

Nursing Diagnosis

MedTech College School of Nursing

Clinical Skills Expectation Summary
Student Name______________________ Date__________________________________
Clinical Skill Expectation

Instructor Signature

Date Observed

Care Plan # Completed_____________________

Write in skillexample, Communication /Patient
education
Write in skill
Write in skill
Write in skill
Write in skill
Write in skill
Write in skill
Comments:

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Assessment Tool

Nursing Diagnosis

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