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Case study format (Nursing)
1. 1
HISTORY COLLECTION
PATIENT PROFILE
I. History Collection:
Name :
Age :
Sex :
Education :
Occupation :
Religion :
Marital Status :
Husband’s Name :
Wife’s Name :
Address :
Date of Admission :
Diagnosis :
Ward Name :
I.P. No :
Bed No. :
III. Chief complaints :
IV. History of Health status:
(a) Present Medical History :
(b) Past Medical History :
(c) Present Surgical History :
(d) Past Surgical History :
2. 2
V. Family History :
(a) Family Tree :
S.
No
Name of family
Member
Age Sex Relationship Occupation
Health
status
Remarks
VI. Personal History :
(a) Habits :
(b) Sleep :
(c) Nutrition :
(d) Elimination Pattern :
VII. Socio Economic Status :
(a) Housing :
(b) Ventilation :
(c) Electricity :
(d) Water supply :
3. 3
PHYSICAL ASSESSMENT/EXAMINATION
Vital signs:
Temperature :
Pulse :
Resp. Rate :
B.P. :
General Appearance :
Nourishment :
Body build :
Health :
Activity :
Consciousness :
Look :
Body curves :
Movement :
Height :
Weight :
Skin :
Colour :
Texture :
Temperature :
Lesions :
Rashes :
Lumps :
Itching :
Dryness :
Moles :
Head :
Size :
Shape :
Hair & Scalp/ Skull/ face :
Colour :
Distribution :
Hair loss :
Dandruff :
Lice :
Healthy :
Eyes :
Vision/Visual Acuity :
11. 11
INTAKE AND OUTPUT RECORD
Name: Hospital No. Age: Sex:
Date Time Oral
Fluids
Naso
Gastric
Intra
Venous
Other
Routs
Total Urine Vomitus Aspirations Other Total
12. 12
Kardex form
Date Medications Dose Time Date Nursing care plan Time
Date Treatment Dose Time
Religion
Age Sex Bath T.P.R B.P Diet
Name of the patient Bed
no
Diagnosis Doctor name IPNO
22. 22
Summary:
Mr/Ms/Mrs. x was admitted in …….. Hospital on ………(date) with chief
complaints of ………………………………… and he/she was diagnosed as
………………… and he/she was given the treatment like
………………………………. . he/she was now better than during the time of
admission.
23. 23
Discharge plan:
Mr/Ms/Mrs. x was admitted with chief complaints of ………………………….
And diagnosed as ………………….. he/she was given the quality care for his
improvement of health status and he was better now and doing all his activities of
daily living and health education also given to the patient and their family
members . He/she was planned to discharge within 3days as per the condition of
the patient and orders of the physician.
24. 24
Conclusion:
If I got a chance of taking care of the patient with chief complaints
of…………………….. & diagnosed as …………………….. & I will able to take
care of the patient independently with quality of care & for better outcome &
improvement of the patient’s health status.