Recommended
More Related Content
What's hot
What's hot (20)
Similar to Case presentation for nursing student
Similar to Case presentation for nursing student (20)
More from Patel Dharmendra
More from Patel Dharmendra (11)
Recently uploaded
Recently uploaded (20)
Case presentation for nursing student
- 1. PATIENT’S IDENTIFICATION DATA Patient’s Name :_______________________________________________________ Father/Husband Name:_________________________________________________ Age:______________________Sex : _______________________________________ Address :_____________________________________________________________ Education : ________________________Occupation:________________________ Income Per Month: __________________Religion :__________________________ Date of Admission : __________________Indoor Number :____________________ Ward :____________________________ Bed No.:___________________________ Marital Status:______________________Diagnosis :_________________________ Doctor’s Name:______________________ Name of Surgry:___________________ Date of Surgery:____________________Date of Data Collection:_______________ Name of Hospital:______________________________________________________ CHIEF COMPLAINTS _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________
- 2. HISTORY OF PRESENT ILLNESS _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ PAST MEDICAL HISTORY _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ PAST SURGICAL HISTORY _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ SOCIO-ECONOMICAL STATUS SocialStatus:__________________________________________________________ _____________________________________________________________________ EconomicaStatus:_____________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________
- 3. HABITS Smoking : __________________________________________________ Tobacco chewing : ___________________________________________ Alcohol Consumption : ________________________________________ Vegetarian : _________________________________________________ Non-vegetarian : _____________________________________________ FAMILY HISTORY Sr. No Name of Family Members Age (Yrs) Sex Relation with patient Education Occupation Marital status Health status
- 4. MENSTRUAL HISTORY _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ DIETETIC HISTORY _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ACTIVITY AND EXERCISE _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ SLEEP / REST _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ELIMINATION _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ COGNITIVE/PERCEPTUAL _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________
- 5. PHYSICAL EXAMINATION General Appearance Level of Consciousness:_________________________ Orientation:-To Place/ Person/Time:_______________ Activity:_____________________________________ Body Built:___________________________________ Anthropometric Measurement Height:_____________________________________ Weight:_____________________________________ Mid upper arm circumference:________________ Vital Signs Temperature:_________________________________ Pulse: ______________________________________ Respiration: _________________________________ Blood Pressure: __________________________ Head Hair:_______________________________________ Colour of Hair:_______________________________ Scalp:_______________________________________ Pediculosis:__________________________________ Face Face:_______________________________________ Facial Puffiness:______________________________ Eyes Eye Brows:__________________________________ Eye Lid/Lashes:______________________________ Eye Ball:__________________________________ Conjunctiva:_______________________________ Sclera:____________________________________
- 6. Puncta:____________________________________ Cornea:____________________________________ Iris:_______________________________________ Pupils:_____________________________________ Nose Nasal Septum:______________________________ Nasal Polyp:________________________________ Nasal Discharge:____________________________ Mouth Number of Teeth:____________________________ Dentures :__________________________________ Dental Carries:______________________________ Odour of Mouth:____________________________ Gums:_____________________________________ Lips Crack/Healthy:______________________________ Cleft Lips:_________________________________ Stomatitis:_________________________________ Ears Size:______________________________________ Shape:_____________________________________ Position And Alignment:______________________ Redness:___________________________________ Discharge:__________________________________ Cerumen:___________________________________ Lesions:____________________________________ Foreign Body:_______________________________ Hearing Acuquity:____________________________ Use of Hearing Aids:__________________________ Tuning Fork Test:_____________________________
- 7. Weber test:__________________________________ Rinne test:___________________________________ SYSTEMIC EXAMINATION Respiratory System __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Cardio Vascular System __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Peripheral Lymphatic System __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
- 8. Digestive System __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Genito Urinary __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Intigumentory System __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ ________________________________________________________________ Musculo Skeletal System __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
- 9. Neurological Assessment ( Glascow Coma Scale) Eye Opening _________ None 1 = To pain 2 = To speech 3 = Spontaneous 4 = Motor Response _________ None 1 = Extension 2 = Flexion response 3 = Withdrawal 4 = Localizes pain 5 = Obeys commands 6 = Verbal Response _________ None 1 = Incomprehensible 2 = Inappropriate 3 = Confused 4 = Oriented 5 = Minimum Score:- 3 Maximum Score:- 15 Patient Score:__________
- 10. LABORATORY INVESTIGATIONS Sr. No. Date Investigation name Normal value Patients value Remark OTHER INVESTIGATION ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
- 11. PRESENT MEDICATION HISTORY Sr. No. Current Medication Dose/Frequency Route Last Dose Taken
- 12. MEDICATION Name of Medication Dose/Route Mechanism of Action Indication Contra-Indication Side-Effects Nurses Responsibility
- 13. Name of Medication Dose/Route Mechanism of Action Indication Contra-Indication Side-Effects Nurses Responsibility
- 14. Name of Medication Dose/Route Mechanism of Action Indication Contra-Indication Side-Effects Nurses Responsibility
- 16. RISK FACTOR Book’s Picture Patient Picture ETIOLOGY /CUASES Book’s Picture Patient Picture
- 17. PATHOPHYSIOLOGY
- 18. CLINICAL MANIFESTATION Book’s Picture Patient Picture DIAGNOSTIC TEST Book’s Picture Patient Picture
- 19. MEDICAL MANAGEMENT Book’s Picture Patient Picture SURGICAL MANAGEMENT Book’s Picture Patient Picture
- 20. LIST OF NURSING DAIGNOSIS ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________
- 21. NURSING CARE PLAN Assessment Diagnosis Expected Outcome Intervention Rational Evaluation
- 22. Assessment Diagnosis Expected Outcome Intervention Rational Evaluation
- 23. Assessment Diagnosis Expected Outcome Intervention Rational Evaluation
- 24. Assessment Diagnosis Expected Outcome Intervention Rational Evaluation
- 25. Assessment Diagnosis Expected Outcome Intervention Rational Evaluation
- 27. NURSES NOTES Date Diet Time Medication Nurses Role