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    Case Study

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    Subhalaxmi Sahu
    This document contains a case study of a patient including identification data, history of present illness, past medical history, family history, physical examination findings, disease description, management, and nursing care plan. The case study collects extensive information on the patient's condition, treatment, and nursing needs for care.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Case Study

    Uploaded by

    Subhalaxmi Sahu
    268 views31 pages
    This document contains a case study of a patient including identification data, history of present illness, past medical history, family history, physical examination findings, disease description, management, and nursing care plan. The case study collects extensive information on the patient's condition, treatment, and nursing needs for care.

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    © © All Rights Reserved

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    DOCX, PDF, TXT or read online from Scribd

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    This document contains a case study of a patient including identification data, history of present illness, past medical history, family history, physical examination findings, disease description, management, and nursing care plan. The case study collects extensive information on the patient's condition, treatment, and nursing needs for care.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    268 views31 pages

    Case Study

    Uploaded by

    Subhalaxmi Sahu
    This document contains a case study of a patient including identification data, history of present illness, past medical history, family history, physical examination findings, disease description, management, and nursing care plan. The case study collects extensive information on the patient's condition, treatment, and nursing needs for care.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 31

    CASE STUDY

    IDENTIFICATION DATA OF PATIENT

     Name of patient :
     Age :
     Gender : 
     Marital Status : 
     IPD Number :
     Ward :
     Bed No :
     Address :

     Religion : 
     Education :
     Date of Admission :
     Date of Discharge :
     Diagnosis :
     Surgery (If any) :
     Occupation :

     Chief Complaints with duration:

     History of present illness: 

     History of past illness:

     Past medical history:

     Past surgical history:


     Family history:
     Type :
     No. of family members:
     Any Illness :

     Family Composition:
    Sl Name of the Family Age Relation Education Occupation Health
    No Members With Status
    . Patient
    1.

    2.

    3.

    4.

    5.

     Family tree:

     History of any Illness:

     Socio-Economic Status:
     Family income :
     Enviornmental hygiene:
     Type of house:

     Personal History:
     Personal hygiene:
     Oral hygiene :
     Bath per day :
     Diet : 
     No. of meals per day :
     Food preference :
     Tea/Coffee :
     Sleep & rest :

     Elimination Pattern:
     Bowel :
     Frequency :
     Urine frequency
     During day:
     During Night:

     Habits:
     Alcohol :
     Smoking :
     Tobacco :
     Exercises :

    PHYSICAL EXAMINATION
     General Appearance:
     Level of Consciousness :
     Speech :
     Height :
     Weight :
     Body Built :
     Personal Hygiene :
     Vital Signs:
    Date Time Pulse Respiration BP Temperature
     Head:
     Size :
     Hair Colour :
     Scalp :
     Face :
     Facial Symmetry :
     Ears:
     External Ear :
     Tympanic Membrane :
     Hearing activity :
     Webber test :
     Nose:
     External Nose :
     Nostrils :
     Sinusitis ;
     Sense of smell :
     Eyes:
     Eyes Brows :
     Eye Lashes :
     Eye Lids :
     Eye Balls :
     Conjunctiva :
     Sclera :
     Pupils :
     Vision :
     Mouth and Pharynx:
     Lips :
     Odour :
     Teeth :
     Denture :
     Buccal mucosa :
     Tongue :
     Tonsils :
     Neck:
     Lymph Nodes :
     Thyroid Gland :
     Range of Motion :
     Cardio-Respiratory System:
     Chest expansion :
     Shape :
     Any deformities :
     Breathing sound :
     Respiratory pattern :
     Respiratory rate :
     Heart :
     Heart sound :
     Murmur sound :
     Diaphragmatic excursion :
     Varicose vein :

     Abdomen:
     Inspection :
     Colour of skin :
     Presence of scar :
     Assess for lesions :
     Palpation :
     Percussion :
     Ascites :
     Auscultation :

     Bowel sound :

     Genito-urinary system:
     Urinary frequency :
     Burning micturation :
     Hematuria :
     Urethral discharge :
     Bladder tenderness :
     Musculo-skeletal system:
     Gait :
     Posture :
     Range of motion :
     Spine :
     Weakness :
     Integumentary system:
     Skin colour :
     Skin texture :
     Skin integrity :
     Lesions :
     Cyanosis :
     Edema :
     Clubbing of nail :
     Neurological Test:
     Co-Ordination Test:

     Equilibrium Test:

    DISEASE DESCRIPTION
     Etiology:

    According to book According to patient


     Risk Factors:

    Book Picture Patient Picture

     Pathophysiology:
    Clinical Manifestations:

    Book Picture Patient Picture

     Diagnostic Evaluation:

    Book Picture Patient Picture


    Date Investigations Normal value Patient’s Value
     Management:

    Book Picture Patient Picture


    DATE Name of the drug Dosage Route Time
    Nursing Care Plan

    Date Problems Needs Nursing diagnosis according


    to priority basis
    Date Problems Needs Nursing diagnosis according
    to priority basis
    Date Nursing Assessment Nursing Diagnosis Goal Planning Intervention Rationale Evaluation
    Time
    Date Nursing Assessment Nursing Diagnosis Goal Planning Intervention Rationale Evaluation
    Time
    Date Nursing Assessment Nursing Diagnosis Goal Planning Intervention Rationale Evaluation
    Time
    Date Nursing Assessment Nursing Diagnosis Goal Planning Intervention Rationale Evaluation
    Time
    Date Nursing Assessment Nursing Diagnosis Goal Planning Intervention Rationale Evaluation
    Time
    Date Nursing Assessment Nursing Diagnosis Goal Planning Intervention Rationale Evaluation
    Time
    Date Nursing Assessment Nursing Diagnosis Goal Planning Intervention Rationale Evaluation
    Time
    Date Nursing Assessment Nursing Diagnosis Goal Planning Intervention Rationale Evaluation
    Time
    Date Nursing Assessment Nursing Diagnosis Goal Planning Intervention Rationale Evaluation
    Time
    Date Nursing Assessment Nursing Diagnosis Goal Planning Intervention Rationale Evaluation
    Time
    Date Nursing Assessment Nursing Diagnosis Goal Planning Intervention Rationale Evaluation
    Time
    Date Nursing Assessment Nursing Diagnosis Goal Planning Intervention Rationale Evaluation
    Time
     Health education:
     Progress note:

     Summarization:

     Conclusion:
     Bibliography:

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