COMMUNITY HEALTH NURSING
SUBMITTED TO - SUBMITTED BY-
MRS. MALLIKA ROY MR. Deepak P. Gautam
ASSISTANT PROFESSOR MSC NSG 1ST
YEAR
R.D. MEMORIAL COLLEGE OF R.D. MEMORIAL COLLEGE OF
NURSING ,BHOPAL NURSING ,BHOPAL
HEALTH ASSESSMENT
яГШ Name of the Infant :- Mrs. Rakhi Sinde
яГШ Age ( in month) :- 37 year .
яГШ Gender :- Female.
яГШ Educational status :- 8TH
Pass.
яГШ Occupation :- Housewife
яГШ Marital Status :-. Married.
яГШ Type of family :- Nuclear family.
яГШ Income of the family :- 20000 per month.
яГШ Nature of house :- Pucca.
яГШ Address :- Nanakhedi Kalan Bhopal
PRESENT MEDICAL HISTORY:---
яГШ Mrs.Rakhi Sinde has the gas problem since the 2 month due to constipation and loss of
appetite.
яГШ Mrs.Rakhi Sinde has the Anemia and taking the medicine prescribed by the doctors (due
to weakness.).
яГШ Mrs.Rakhi Grandfather has suffer with Skin disorder.
PAST MEDICAL HISTORY:-
яГШ 8 month before the Mrs. Rakhi Sinde take medicine regarding the Abortion.
яГШ 1 year ago Mrs. Rakhi Sinde taketreatment related to the back pain.
PERSONAL HISTORY:-
1.Habit :-She's habbit is chewing chocolate and Tophy .
2. Healthy practice :-Morning walk
3. Diet :-Vegetarian diet
4. Hobbies :-Cooking foods and Singing song.
SOCIO ECONOMICAL HISTORY:-
1) The socio economical history of client is well.
2) Client family member doing the private job.
ENVIRONMENTAL HISTORY:-
1) Client surrounding environment is well.
2) Water facility is available.
3) Electricity are proper available.
4) Waste disposable are proper.
FAMILY HISTORY:-
S.No. Name Of Family Member Age/Sex
Occupatio
n
Relation Healthy Status
1 Mr. Hariram 40y/M Former Husband Healthy
2 Mis. Madhu 12y/F Student Daughter Healthy
3 Mr. Sonu 4y/m -- Son Healthy
Family Tree:-
PHYSICAL EXAMINATION:-
Hariram
Rakhi
Sinde
Madh
u
sonu
яГШ General Appearance:- I observed that the she is looking well and healthy.
яГШ Anthropometric measurements:-
яГШ Height :-155 cm
яГШ Weight :-48 kg
яГШ Dietary history :-Vegetarian diet
яГШ Vital signs :- Temperature -98.6f ,Pulse- 74 /mt , Resp-22 bit/ Min. , B.P -130 / 90 mmhg
яБ╢ PHYSICAL EXAMINATION:-
1) SCALP
яГШ Colour of the hair- Black.
яГШ Anterior fontonellae- Closed.
яГШ Posterior fontonellae- closed.
яГШ Any wounds or birth markings- Scar on face.
2) FACE AND NECK
яГШ Eyes (colour, bitot spots ,foreign body) :-Brownished.
яГШ Ear :-Pinna are normal placed.
яГШ Nose (running, blocked , deviation) :-Normal.
яГШ Mouth ( teeth eruption, odour, any abnormality) :- Yellowish teeth.
яГШ Tongue :-Moisture tungue.
яГШ Throat ( odour , any signs and symptoms of tonsillitis) :-Odour in breath.
яГШ White patches on the check :-No Patches.
яГШ Distensions of the neck veins :-No Distension.
3) CHEST
яГШ Shape of the chest ( barrel pigeon,cylindrical.) :-Barrel Shaped.
яГШ Auscultation ( breath ,sounds, heart sounds ) :-Breath sound
яГШ Percussion(fluid,aircollection) :-No fluid collection
яГШ Sign and symptoms of Pneumonia :- No sign of pnuemonia.
4) ABDOMEN:
яГШ Any distension :-No any distension.
яГШ Auscultation( bowel sounds ) :-Bowel sound present.
яГШ Percussion :-Bowel and
яГШ Palpation (liver , other organs of the abdomen) :-Bladder
яГШ Bowel and bladder movements :-Movement present.
5) EXTREMITIES :
яГШ Any Abnormalities seen :-No any abnormalitis.
яГШ Manipulation ( movements of the joints) :-Proper movement of joint.
6) SKIN INFECTION:
яГШ Color of the skin :-Normal skin colour.
яГШ Skin rashes :-No skin rashes.
яГШ Any sign and symptoms of dermatitis :-No any symptom.
яБ╢ ABNORMALITIES DETECTED:-
1) I detected the abnormalities like the rshes in the neck.
2) The gas problems are detected in the patient .
3) The anemia's sign and symptoms are detected in the patient.
яБ╢ MEDICAL HISTORY:-
S.NO NAME OF DRUG DOSE ROUTE FREQUENCY ACTION
1 TAB. Heam up 500MG ORAL BD Vit.-B9
2 SYP. Dexorange 2ML ORAL BD Multi vit.-B12
3 TAB. ACILOC 150 ORAL OD ANTACID
4
яБ╢ INVESTIGATION:-
1. C.B.Cs TEST.
2. ESR TEST
3. THYROID TEST
4. ECG TEST
5. URINE ANALYSIS.
яБ╢ SUGGESTIONS GIVEN:-
1) I suggested to the Mrs. Rakhi Sinde regarding the exercise for well health.
2) I suggested to the Mrs. Rakhi Sinde regarding for the taking the balance diet and take the
iron rich diet like papaya, etc.
3) I suggested to the Mrs. Rakhi Sinde Sharma regarding for a proper personal hygiene.
4) Give advice regarding the take proper iron diet daily.
CARE PLAN
ASSESSMENT NSG.
DIAGNOSIS
GOAL PLANNING IMPLEMENTATION EVALUATION
Subjective data:-
My client says that she has
feel the joint pain, fatigue,
leg pain, weakness, and
uncomfortness.
Objective data:-
I observed that that the my
client are sick. She has ill.
She has suffering from
anemia the weakness.
Impaired
nutrition
level less
than body
requirement
related to
less intake
of food.
To maintain
the nutritional
level.
To assess the general
condition of client.
To check the nutritional level
of client.
To assess the risk of anemia.
To check the nutritional level.
To provide the safety and
security to the client.
To provide the knowledge
regarding the anemia.
General condition of
client are assessed.
the mobility of client
are checked.
Risk of anemia are
checked.
the nutritional level
are checked.
provided the safety
and security to the
client.
provided the
knowledge regarding
the remove of
anemia.
Anemia are
decreased.
Health is
normal.
Nutritional
level
normal.
ASSESSMENT NSG.
DIAGNOSIS
GOAL PLANNING IMPLEMENTATION EVALUATION
Subjective data:-
My client says that she has
feel the joint pain, fatigue,
leg pain, weakness, and
uncomfortness.
Objective data:-
I observed that that the my
client are sick. She has ill.
She has feeling the
weakness.
Impaired
physical
mobility
related to
the joint
pain.
To remove
the leg pain
and joint
pain.
To assess the general
condition of client.
To check the mobility of
client.
To assess the risk of joint
pain.
To check the nutritional level.
To provide the safety and
security to the client.
To provide the knowledge
regarding the remove of joint
pain.
General condition of
client are assessed.
the mobility of client
are checked.
Risk of joint pain are
checked.
the nutritional level
are checked.
provided the safety
and security to the
client.
provided the
knowledge regarding
the remove of joint
pain.
Joint pain
sre
decressed.
Health is
normal.
ASSESSMENT NSG.
DIAGNOSIS
GOAL PLANNING IMPLEMENTATION EVALUATION
Subjective data:-
My client says that she has
feel the joint pain, fatigue,
leg pain, weakness, and
uncomfortness.
Objective data:-
I observed that that the my
client are sick. She has ill.
She has feeling the
weakness.
Impaired
physical
mobility
related to
the joint
pain.
To remove
the leg pain
and joint
pain.
To assess the general
condition of client.
To check the mobility of
client.
To assess the risk of joint
pain.
To check the nutritional level.
To provide the safety and
security to the client.
To provide the knowledge
regarding the remove of joint
pain.
General condition of
client are assessed.
the mobility of client
are checked.
Risk of joint pain are
checked.
the nutritional level
are checked.
provided the safety
and security to the
client.
provided the
knowledge regarding
the remove of joint
pain.
Joint pain
sre
decressed.
Health is
normal.

Care plan family --deepak

  • 1.
    COMMUNITY HEALTH NURSING SUBMITTEDTO - SUBMITTED BY- MRS. MALLIKA ROY MR. Deepak P. Gautam ASSISTANT PROFESSOR MSC NSG 1ST YEAR R.D. MEMORIAL COLLEGE OF R.D. MEMORIAL COLLEGE OF NURSING ,BHOPAL NURSING ,BHOPAL
  • 2.
    HEALTH ASSESSMENT яГШ Nameof the Infant :- Mrs. Rakhi Sinde яГШ Age ( in month) :- 37 year . яГШ Gender :- Female. яГШ Educational status :- 8TH Pass. яГШ Occupation :- Housewife яГШ Marital Status :-. Married. яГШ Type of family :- Nuclear family. яГШ Income of the family :- 20000 per month. яГШ Nature of house :- Pucca. яГШ Address :- Nanakhedi Kalan Bhopal PRESENT MEDICAL HISTORY:--- яГШ Mrs.Rakhi Sinde has the gas problem since the 2 month due to constipation and loss of appetite. яГШ Mrs.Rakhi Sinde has the Anemia and taking the medicine prescribed by the doctors (due to weakness.). яГШ Mrs.Rakhi Grandfather has suffer with Skin disorder. PAST MEDICAL HISTORY:- яГШ 8 month before the Mrs. Rakhi Sinde take medicine regarding the Abortion. яГШ 1 year ago Mrs. Rakhi Sinde taketreatment related to the back pain. PERSONAL HISTORY:- 1.Habit :-She's habbit is chewing chocolate and Tophy .
  • 3.
    2. Healthy practice:-Morning walk 3. Diet :-Vegetarian diet 4. Hobbies :-Cooking foods and Singing song. SOCIO ECONOMICAL HISTORY:- 1) The socio economical history of client is well. 2) Client family member doing the private job. ENVIRONMENTAL HISTORY:- 1) Client surrounding environment is well. 2) Water facility is available. 3) Electricity are proper available. 4) Waste disposable are proper. FAMILY HISTORY:- S.No. Name Of Family Member Age/Sex Occupatio n Relation Healthy Status 1 Mr. Hariram 40y/M Former Husband Healthy 2 Mis. Madhu 12y/F Student Daughter Healthy 3 Mr. Sonu 4y/m -- Son Healthy Family Tree:- PHYSICAL EXAMINATION:- Hariram Rakhi Sinde Madh u sonu
  • 4.
    яГШ General Appearance:-I observed that the she is looking well and healthy. яГШ Anthropometric measurements:- яГШ Height :-155 cm яГШ Weight :-48 kg яГШ Dietary history :-Vegetarian diet яГШ Vital signs :- Temperature -98.6f ,Pulse- 74 /mt , Resp-22 bit/ Min. , B.P -130 / 90 mmhg яБ╢ PHYSICAL EXAMINATION:- 1) SCALP яГШ Colour of the hair- Black. яГШ Anterior fontonellae- Closed. яГШ Posterior fontonellae- closed. яГШ Any wounds or birth markings- Scar on face. 2) FACE AND NECK яГШ Eyes (colour, bitot spots ,foreign body) :-Brownished. яГШ Ear :-Pinna are normal placed. яГШ Nose (running, blocked , deviation) :-Normal. яГШ Mouth ( teeth eruption, odour, any abnormality) :- Yellowish teeth. яГШ Tongue :-Moisture tungue. яГШ Throat ( odour , any signs and symptoms of tonsillitis) :-Odour in breath. яГШ White patches on the check :-No Patches. яГШ Distensions of the neck veins :-No Distension. 3) CHEST яГШ Shape of the chest ( barrel pigeon,cylindrical.) :-Barrel Shaped.
  • 5.
    яГШ Auscultation (breath ,sounds, heart sounds ) :-Breath sound яГШ Percussion(fluid,aircollection) :-No fluid collection яГШ Sign and symptoms of Pneumonia :- No sign of pnuemonia. 4) ABDOMEN: яГШ Any distension :-No any distension. яГШ Auscultation( bowel sounds ) :-Bowel sound present. яГШ Percussion :-Bowel and яГШ Palpation (liver , other organs of the abdomen) :-Bladder яГШ Bowel and bladder movements :-Movement present. 5) EXTREMITIES : яГШ Any Abnormalities seen :-No any abnormalitis. яГШ Manipulation ( movements of the joints) :-Proper movement of joint. 6) SKIN INFECTION: яГШ Color of the skin :-Normal skin colour. яГШ Skin rashes :-No skin rashes. яГШ Any sign and symptoms of dermatitis :-No any symptom. яБ╢ ABNORMALITIES DETECTED:- 1) I detected the abnormalities like the rshes in the neck. 2) The gas problems are detected in the patient . 3) The anemia's sign and symptoms are detected in the patient. яБ╢ MEDICAL HISTORY:- S.NO NAME OF DRUG DOSE ROUTE FREQUENCY ACTION 1 TAB. Heam up 500MG ORAL BD Vit.-B9
  • 6.
    2 SYP. Dexorange2ML ORAL BD Multi vit.-B12 3 TAB. ACILOC 150 ORAL OD ANTACID 4 яБ╢ INVESTIGATION:- 1. C.B.Cs TEST. 2. ESR TEST 3. THYROID TEST 4. ECG TEST 5. URINE ANALYSIS. яБ╢ SUGGESTIONS GIVEN:- 1) I suggested to the Mrs. Rakhi Sinde regarding the exercise for well health. 2) I suggested to the Mrs. Rakhi Sinde regarding for the taking the balance diet and take the iron rich diet like papaya, etc. 3) I suggested to the Mrs. Rakhi Sinde Sharma regarding for a proper personal hygiene. 4) Give advice regarding the take proper iron diet daily.
  • 8.
    CARE PLAN ASSESSMENT NSG. DIAGNOSIS GOALPLANNING IMPLEMENTATION EVALUATION Subjective data:- My client says that she has feel the joint pain, fatigue, leg pain, weakness, and uncomfortness. Objective data:- I observed that that the my client are sick. She has ill. She has suffering from anemia the weakness. Impaired nutrition level less than body requirement related to less intake of food. To maintain the nutritional level. To assess the general condition of client. To check the nutritional level of client. To assess the risk of anemia. To check the nutritional level. To provide the safety and security to the client. To provide the knowledge regarding the anemia. General condition of client are assessed. the mobility of client are checked. Risk of anemia are checked. the nutritional level are checked. provided the safety and security to the client. provided the knowledge regarding the remove of anemia. Anemia are decreased. Health is normal. Nutritional level normal.
  • 9.
    ASSESSMENT NSG. DIAGNOSIS GOAL PLANNINGIMPLEMENTATION EVALUATION Subjective data:- My client says that she has feel the joint pain, fatigue, leg pain, weakness, and uncomfortness. Objective data:- I observed that that the my client are sick. She has ill. She has feeling the weakness. Impaired physical mobility related to the joint pain. To remove the leg pain and joint pain. To assess the general condition of client. To check the mobility of client. To assess the risk of joint pain. To check the nutritional level. To provide the safety and security to the client. To provide the knowledge regarding the remove of joint pain. General condition of client are assessed. the mobility of client are checked. Risk of joint pain are checked. the nutritional level are checked. provided the safety and security to the client. provided the knowledge regarding the remove of joint pain. Joint pain sre decressed. Health is normal.
  • 10.
    ASSESSMENT NSG. DIAGNOSIS GOAL PLANNINGIMPLEMENTATION EVALUATION Subjective data:- My client says that she has feel the joint pain, fatigue, leg pain, weakness, and uncomfortness. Objective data:- I observed that that the my client are sick. She has ill. She has feeling the weakness. Impaired physical mobility related to the joint pain. To remove the leg pain and joint pain. To assess the general condition of client. To check the mobility of client. To assess the risk of joint pain. To check the nutritional level. To provide the safety and security to the client. To provide the knowledge regarding the remove of joint pain. General condition of client are assessed. the mobility of client are checked. Risk of joint pain are checked. the nutritional level are checked. provided the safety and security to the client. provided the knowledge regarding the remove of joint pain. Joint pain sre decressed. Health is normal.