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

15. DISEASE CONDITION INTRODUCTION _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ DEFINITION _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ DIAGRAM

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

26. HEALTH EDUCATION _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ PATIENT PROGRESS DAY-1 DAY-2 DAY-3 DAY-4

27. NURSES NOTES Date Diet Time Medication Nurses Role

28. SUMMARY _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

29. BIBLIOGRAPHY _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Signature of the Student Signature of the Evaluator Date : Date :

Case presentation for nursing student

Case presentation for nursing student

Case presentation for nursing student

Recomendados

Más contenido relacionado

Was ist angesagt?

Was ist angesagt?(20)

Similar a Case presentation for nursing student

Similar a Case presentation for nursing student(20)

Más de Patel Dharmendra

Más de Patel Dharmendra(11)

Último

Último(20)

Case presentation for nursing student