Student Name:

Student #: Jordan University of Science and Technology

(JUST)
Faculty of Nursing
Department of Maternal and Child Health

Biographical Data

Patient Name: ___________________________ Patient Age: ___________Hospital/ ward:___________

Medical Diagnosis: ____________________Date Received: __________Date of Admission: ___________
Patient birth weight: ____________ Patient current weight: ___________

(1 point) - Written in clear hand writing with correct spelling

- The care plan is applicable to the patient need and age, and reflect student understanding to
the medical condition of the patient

Chief Complain
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Present History: (0.5 point)
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Past History: (0.5 point)
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Family pedigree (Family Tree- Three Generations )

Assessment
Subjective data (1.5 points): (describe today's complain OPQRS, activity, diet, sleep, elimination,
pt./family knowledge of condition/management/prevention)
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Objective data (1 point):

* (general appearance, V/S, growth and development, pain assessment)
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---------------------------------------------------------------------------------------------------------------- *Fluid intake
and output during shift

Time Type of fluid Amount Time Type of output Amount

Intake (oral/IV) (urine/vomit/stool/other)
……am ……am
9 am 9 am
……am ……am
……am ……am
……am ……am
……am ……am
……pm ……pm
……pm ……pm
2:30 pm 2:30 pm
Nursing DX(s) (WRITE ALL DXs according to priority) (1 point)
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Planning (conduct nursing process for the Most prioritized two DX (1 point)
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Interventions and Rational: (2 points)

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- Evaluation (0.5 point):
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