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CHN CASE STUDY AND CAREPLAN BY DR.ANJALATCHI MUTHUKUMARAN.docx
1. ERA COLLEGE OF NURSING
SARFARAZGANJ LUCKNOW 226003
CARE PLAN FORMAT
COMMUNITY HEALTH NURSING
INTRODUCTION:
General information
Name of the client :
House number :
Name of the head of the family :
Type of family :
Size of family :
Religion :
Nationality :
Address :
History of client
Name
Chief complaints
MEDICAL HISTORY
PRESENT HISTORY
PAST HISTORY (general health status, acute infectious diseases, immunization, systemic,
disease, medications, hospitalizations, injuries, blood transfusion)
SURGICAL HISTORY
PRESENT HISTORY
PAST HISTORY (surgery-indications, name of hospital, type of anaesthesia, any complications)
2. BIRTH HISTORY
ANTENATAL HISTORY (regular-antenatal check up, maternal-health status, immunization,
illness, medications)
INTRANATAL HISTORY (mode of delivery with gestation apgar score, resuscitation if any,
complication if any)
POSTNATAL HISTORY (postnatal complications)
DEVELOPMENTAL HISTORY
S. N. Age Milestone Child pictures Remarks
1 6-8 weeks Looks at mother and smile
2 3 Months Holds head erect
3 4-5 Months Recognize mother
4 6-8 Months Sites without support
5 9-10 Months Crawling
6 10-11 months Stand without support
GROWTH AND DEVELOPMENT
Book picture Child's picture
Psychosocial development
Psycho sexual development
Emotional development
ASSESSMENT OF REFLEXES
Book picture Child's picture
Eyes
a) Blinking reflex
b) Capillary reflex
c) Doll's eye reflex
3. Nose
a) Sneezing reflex
b) Glabellar reflex
Mouth and throat
a) Sucking reflex
b) Rooting reflex
c) Extrusion reflex
d) Gag reflex
e) Yawn reflex
Extremities
a) Palmar grasp reflex
b) Plantar grasp reflex
c) Babinski reflex
d) Ankle reflex
e) Placing reflex
f) Stepping reflex
Mass reflexes
a) Dancing reflex
b) startle reflex
c) Tonic neck reflex
d) Trunk incurvation reflex
e) Crawling reflex
IMMUNIZATION STATUS
S. N. AGE Name of vaccine Doses Route Status Remarks
MENSTRUAL HISTORY
Age of attain menarche, duration and intervals of menstrual cycle- menstrual hygiene practices
4. OBSTETRICAL HISTORY (IF FEMALE)
ANTENATAL HISTORY
POSTNATAL HISTORY
FAMILY HISTORY
Type of marriage of parents (consanguineous non consanguineous) hereditary diseases, systemic
illness, psychiatric illness, communicable diseases.
PERSONAL HISTORY
Sleep pattern appetite diet pattern habits hobbies hygiene elimination pattern dressing personality e
allergy type of reactions activity and exercises and relationship with others.
SOCIO ECONOMIC HISTORY
Monthly family income breadwinner of family sources of income financial status type of house on rent
facilities ventilation electricity e drainage lighting water waste disposal and latrine facility availability
of hospital clinics health centre markets temple school and transportation.
Demographic characteristics
S.
N.
Name of
the
family
members
Relationship Age/sex Educational
status
Occupation Income Marital
status
Health
status
1
2
Family tree
Pedigree keys:
Mail
Female
Relationship
5. or Died
or Patient
Environmental conditions
1. ROAD MAP
2. COMMUNITY ENVIRONMENT
Method of disposal
Disposal of waste
Drainage facility
Solid waste
Excreta disposal
Disposal of died
Communication facilities
Transport station facility
Religious resources
Church/Temple/Mosque
Schools/ Colleges
Market /Shops
Post office
Banks
Medical facilities
Private clinics /nursing homes
Recreation facilities
Socio cultural believes
Housing conditions
Floor map of house
Type of house : Pakka/Kaccha/Semi pakka
Ownership: own/ rent
Number of rooms :
o Ventilation :
Natural : Windows /doors
Artificial : Fans/Air condition/Nill
o Source of light
Natural : Adequate /inadequate
Artificial : electricity/ gas pump/kerosene
o Water supply
Source : well/ tap/ hand pump
Adequate /inadequate:
o Kitchen : separate /common
6. Size : adequate/ small
Fuel used : kerosene/ gas/ wood
o Disposal of waste :
o Drainage : closed/ open
o Disposal : dumping/ incineration
o Latrine facility
o Presence of domestic animals: yes/ no (if yes specify)
o Presence of insects :
o Presence of rodents :
o Presence of stay dog/ cats :
o Presence of accidental hazards:
Economic condition
Transportation and communication
Nutritional status
Food habits
Number of males
Staple food
Common vegetables
Use of RAW vegetables
Adequacy of nutrition consumption
Cooking practices
Method of preservation of food
7. PHYSICAL ASSESSMENT AND SYSTEMIC ASSESSMENT
GENERAL APPEARANCE
Consciousness : conscious/ semi conscious/ coma
Orientation : oriented to time place and person
Sign of distress : pain/ Dysnea/ Fatigue
Body built : farm/ muscular /excessively thin
Posture and gait : normal/ coordinated /uncoordinated
Body movement : normal /tremors/ immobility
VITAL SIGNS
Temperature :
Pulse :
Respiration :
Blood pressure :
Impression
ANTHROPOMETRIC MEASUREMENTS
Length /height : Cms
Weight : Kgs
BMI :
Head circumference :
Mid arm circumference :
Impression
HEAD TO FOOT EXAMINATION
SKIN AND NAILS
Colour : Pink/ Brown/ Flushed/Pallor/ Cyanosed/Icterus/ Acrocyanosis/ Pigmentation
Lanugo (Newborn)
Moisture : Moist /Dry /Sweating
Temperature : Cold And Clammy/Worm
Texture : Smooth/ Rough /Thick/ Coarse /Scally
Turgor : Normal clasticity/ Poor elasticity/Wrinkled
Edema : Absent/Present/Dependent/Pitting/pedal/Orbital/Generalized
Integrity : Intact/Lesions/Birth marks/Moles/Scars/Rashes
8. Lesions/Rashes: Present/Absent
Purpuric spots: Present/Absent
Common skin variations: Present/Absent/Milia/Erythema Toxicum/Mangolian
spot/Miliaria/Harlequin color changes/Telangietatc Navi
NAILS : Clean/Smooth/Dry/Brittle/Splinting/Cracling/Clubbibg/Splinter/haemorrh
age/paryncyla
Colour : Pink/Pale/blue
Capillary Refill: Normal/Poor
HEAD AND SCALP
Skull size, Shape, Contour : Normal/Macrocephali/Microcephaly
Symmetrical/Asymmetrical/ Hydrocephalus/Acromegaly/nodules/Masses/Lumps
Scalp : Lesions, Dandruff/Pediculosis
Hair :ColourFine/Thick/Stright/Curly/Shiny/Dry/Brittle/Distribution/Alopecia/Hir
sutism/Hirsutism
Fontanels(If Infant)
Anterior fontanel
o Size Shape:Length/Width/Diameter/Hot/Pulsating/Bulged/Depressed
o Posterior fontanel Width in Cms Triangular/Flat/Hot/Pulsating/Bulged/Depressed
o Sutures: Normal/Widened
o Scalp vein: Visible/Not visi
o Crack pot sign: Present/Absent
Birth injuries: Absent/Caput Succedancum/Cephalic hematoma
FACE: Symmetry/Sensadon asymmetry/Puffy/old man face
EYES:
Vision
Size: Normal/Small/Lar
Space: Normal/Widened
Eyebrows: Symmetrical/Asymmetrical Curved/Straight/Thick/Thin/Sparse
Eye lids: Swollen/Infected/Ptosiss/Ectropion/Chalacian/Sunset sign/Masses
Eye lashes: Long/short/Curved/N
Sclera: White/Red/Pink/Discharges/Blue/red
Color: Gray/Blue/Red/Brown/Brush field spots
Conjunctiva: Pale/Pink/Red/Jaundiced/Sub conjunctival Hemorrhage
Lacrimal Punctum: Normal/Redness/ Excessive tearing
Cornea: Opaque/congenital cataract/Intact
Pupils: PERRLA ( Pupils equally round reacting to light accommodation)
Eye movement: Normal/Week/Nystagmus/Strabismus/estropia/exotropia
Lacrimal gland:Tender/Non Tender/Swollen/Tearing
9. Pupillary reflex:Present/Absent
Corneal Reflex to Touch: Blinking / No response
Corneal reflex to light: Blinking No response
Squint: Yes/No
Vision field: Intact/normal
Vision: Normal 6/6 or 20/20/ Myopia/Presbyopia
EARS
Pinnae Size and shape: Large/ small/ Symmetry/Asymmetry/Flexible Completely
formed/Incompletely formed/Swollen/Pithole
Posistion: Equal to outer canthus of eyes/Low set /High set
Ear canal: Clean/Discharges/Cerumen/Nodules/Foreign objects Disc
Tympanic membrane: Whitish and intact/redness/ulging Perforated
Hearing: Normal(Whisper test, Weber and Rhinne' s test)
Startle Reflex: Present/Absent in response to loud noise
NOSE
Size and Shape : Long /Short Swollen/Flaring of Nostrils
Patency: Patent/Obstructed with mucus/ Discharges/Polyps/Blood/Bony obstruction
Septum: Midline/Deviated/Perforated
Nasal mucosa: Pink/Red/Bluish
Discharges: Watery/Mucoid/Purulent/Blood
Sinuses: Tender/ Non tender
Minor disorders: Absent / Milia
Congenital disorders: Absent /Cleft palate
MOUTH AND PHARYNX:
LIPS
Colour: Pale/Pink/Cyanosed/Red
Shape: Symmetrical/Asymmetrical
Moisture: Smooth/Moist/Dry
Lesions: Absent/Crackles/Figures
Congenital Anomalies: Absent/Cleft lip
TEETH
Natural Teeth: Present/Absent/color
GUMS
Colour: Pink/Pale/Red
Lesions: Absent/Swollen/Bleeding/Gingivitis/Ulcerated/Spongy
10. BUCCAL MUCOSA:
Colour: Pink/Dark Red
Moisture: Dry/Moist
Lesions: Instact/Ulcers/Chancre/Cleft lip and cleft palate
TONGUE
Colour:Pink/White
coated/Thrush(Candidiasis)Giry/Fissure/crackled/Bluish/Microglossia/Macro
glossia/Glossitis/Halitosis
Moisture: Dry
Size: Macroglossia/Microglossia Frenulum of upper lip & Tongue: Midline/Extended upto
lips
Movement: Normal/Tongue Tie
Uvula: Midline/Deviated
Palate: Normal/Cleft palate/Epstein pearls
Gag reflex: Present/Absent
Salivation: Absent/Minimal/Profuse or drooling
Cry: Vigourous Cry/ Weak/ Hoarse/Hight piched/Absent Cry
TONSILS: Enlarged/redness/dysphagia/uvula-mobile/midline/gng refles
NECK
Appearance: Long /Short & thick/Symmetrical/Assymetrical/ Torticollis (Wry Neck) Jugular
vein distension/Carotid bruits
Thyroid: Palpable/Nodules/Tenderness
Trachea: Midline/Deviated
Lymph node: Palpable/Not palpable/Mobile/Hard/Firm
Movements: ROM Possible/Not possible
Neck vein: Distended/ Not distended
CHEST
INSPECTION
Thoracic configuration
o Size: Anterior posterior & lateral diameters are equal/Un equal
o Shape: Normal/ Funnel shaped/ Pigeon shaped
o Chest movement: symmetrical/ Asymptomstic
o Breast: Normal/Red/Tenderness/Enlarged/Supernumerary Nipple/Witch's milk
Respiration
o Rate:
o Rhythm: Regular/Irregular/Periodic breathing
o Depth of respiration: Deep/Shallow
o Quality: Difficult/Labore
11. o Character of breath sounds: Inspiratory stridor/Expiratory Ghunt/Apneic
spells/seesaw respiration
o Retraction: No retraction/Sterna/Intersostals/Supra coastal Visible pulsation
PALPATION
Tendrness: Present/Absent
Abnormality: Absent/Cryst/Crepitus/Trill
AUSCULTATION
Lung sounds: Bilaterally equal/Diminished/Absent/Cracles/Ronchi/Wheeze/Peural
friction/Equal air entry
Adventitious Sounds: Cracies/Wheezes
HEART
Position: Left fifth midclavicular line/Right Sternal boarder
Heart sounds: S1, S2 sounds/Murmurs/Heart rate
Apical Pulse: Normal/Arrhythmias/Dextro cardio
PERCUSSION: Normal resonance/Hyper resonance /Dullness
ABDOMEN
INSPECTION: Symmetrical/Asymmetrical rounded/Flat/Scapoid/Sunken
Abdominal Skin: Taut without wrinkles or creases/Shiny
Peristalic movement: Visible Non visible
Umbilicus: Normal/Infected/Hernias/Flat/Protruding/Green colour /Bleeding
Umbilical cord: 2 arteries & 1 vein/1 artery & I Vein
Visible vein: Present/Absent
Ascites: Present/ Absent
Congenital anomalies: Ompahalocele/Gastroachiaisis/Bladder extrophy
Liver: Palpable/Not palpable
Spleen: Palpable/Non palpable
Palpable mass: Present/ Absent
Bladder: Palpable/Not palpable
AUSCULTAT
Bowel sounds: Metallic clicks & gurgles/ Hyper active/Hypo active
Frequency of bowel sound: 5 sounds per Minute/More/Less
PERCUSSION: Normal/Dullness/Hyper active
BACK
14. MUSCULOSKELETAL SYSTEM
INSPECTION: Size, Symmetry, Shape, edema, Deformity, Prosthesis gait, ROM of Each
joint, Skin colour and characteristics
PALPATION: Muscle tone, Strength (0-5), Bony articulation
REFLEXES:
INTUGUMENTARY SYSTEM
INSPECTION: Skin color/ Integrity/ Redness/Papule/ Blisters/ Shape/ Moisture/ Dry/ Edema
INSPECTION: Type of edema/Tenderness/ Pain
REPRODUCTIVE SYSTEM
FEMALE: Discharges/Lumps/Masses/Menstrual abnormalities/Prolapsed/ Cystocele Rectocele
MALE: Phimosis/Priapisim/ Epispadiasis/ Hypospadiasis /Hydrocele/Hernia
SCORE
CENTRAL NERVOUS SYSTEM:
GLASCO COMA SCALE (GCS) (1-15)
RESPONSE SCORE
EYE OPENING
Spontaneously 4
To command 3
To pain 2
No response 1
MOTOR RESPONSE
Obeys commands 6
Localize pain 5
Flexion withdrawal 4
Flexion 3
Extension 2
No response 1
VERBAL RESPONSE
Oriented 5
Confused 4
In appropriate words 3
In comprehensible sounds 2
No response 1
Total 15
COGNITIVE PERCEPTUAL PATTERN
Mental status: Orientation: Person/place/time
15. Level of Consciousness: Alert/Drowsy/Lethargic/Difficult/Unable to arouse/Other
Memory: Intact/Recent Memory deficit/Remote memory deficit
Thought process: Answers questions appropriately/Answers un reliably
ASSESSMENT OF REFLEXES
Book Picture Clients picture
Superficial and deep
Abdominal
Achilles
Comeal
Biceps
Triceps
Plantar
Babinski
MOTOR FUNCTION: MUSCLE STRENTH AND CO ORDINATION
MUSCLE POWER GRADING
GRADE DESCRIPTION
5/5 Full range of motion against gravity with extreme resistance
4/5 Full range of motion against gravity with some resistance
3/5 Full range of motion against gravity with no resistance
2/5 Full range of motion with gravity eliminated
1/5 Slight contraction visible
0/5 No movements
ASSESSMENT OF CEREBELLAR
Finger to finger test
Finger to nose test
Putting test
Romberg test
Tandom walking test
SENSORY EXAMINATION
Response to touch
Response to pain and temperature
Propioception
CRANIAL NERVE ASSESSMENT
16. Nerve Name of the
cranial nerve
Function Assessment Findings
1 Olfactory Sense of smell Close the eye, occlude
nostril and identify the smell
2 Optic Control visual activity
and visual field
Cover one eye position a
news paper 12-18 inches and
read the letters
3,4,5 Occulomotor,
Trochlear,
Abducens
Control Pupillary
reaction
An object moved
systematically in various
directions
6 Trigemina Control facial sensation
and jaw movement
The patient to close his eyes
then the various parts of the
face is gently touched using
a wisp of cotton
7 Facial Control facial muscles Assessed by having the
patient wrinkle her fore head
smile, showing her teeth
8 Auditory/Vestibule
Choclear
Controls hearing and
sense of balance
Webers test and Rinnes to
evaluate air and bone
conduction
9,10 Hyppoglossall,
Vagus
Controls swallowing,
the gag reflex,
articulation
Instruct the patient to pen his
mouth and say ah. Use the
tip of tongue depressor to
stimulate the back of the
pharynx. Swallowing is
tested by asking the patient
to drink a clear fluid
11 Spinal accessory Controls the trapezius
and sternocleido
mastoid muscle
Instruct the patient to rise
both shoulders and to hold
tightly and apply resistance
to shoulders using both
hands
12 Glosso pharyngeal Controls tongue
movement and strength
Is assessed by having the
patient protrude her tongue
17. SHORT TERM GOALS/LONG TERM GOALS
DISEASE CONDITION
Compare with Books Picture and client picture
Book Picture Patient Picture
DIET PLAN
NUTRITIONAL ASSESSMENT (24 hour Recall) Date
Time Food item Quantity CHO(grams) Protein(grams) Fat(grams) KCAL
Total
Kcal
MENU PLAN Recommended 24 hours dietary plan
Time Food item Quantity CHO(grams) Protein(grams) Fat(grams) KCAL
Total
Kcal
18. COMMUNITY NURSING DIAGNOSIS
1. .
2. .
COMMUNITY NURSING PROCESS
ASSESSM
ENT
NURSIN
G
DIAGN
OSIS
GO
AL
PLANNING/INTER
VETION
RATION
ALE
IMPLIMENT
ATION
EVALUA
TION
Subjective
data
Objective
data
(should be
a
measurabl
e or
observable
data)
BAG TECHNIQUE PROCEDURE
HEALTH EDUCATION
THEORY APPLICATION
RECORDING AND REPORTING
SUMMARY
CONCLUSION