HISTORY COLLECTION

Name Age Sex Marital status IP No Ward/Bed No Address

: : : : : : :

Religion Education Admission Date Discharge Date Diagnosis Intervention/Operation Date of Intervention/Operation Occupation Monthly Family Income Nursing Alert Sensitivity Weight Height Chief Complaints with Duration History of Present Illness History of Past Illness

: : : : : : : : : : : : : : : in Kgs in cms

Family History Type No of Members Support Person[s] Any Illness : : : :

S.No

Name

Age

Sex

Relationship Education Occupation Health with patient status

Health Facility near Home Type Distance Transportation facility Housing Type No of Rooms Toilet Electricity Drinking Water [Source] Drainage Facility Personal History Personal Hygiene Oral Hygiene Bath Diet : Frequency : : Frequency : : Type of Diet : Agent : Agent : : : : : : : : : : kms

No of Meals/Day: Fluid : Glasses /Day Cups/Day /Day Night:

Tea & Coffee : Elimination : Bowels :

Urine frequency: During Day : Mobility & Exercises : Walking Habits :

Exercise Activity : Sexual & Marital History Spouse Relationship Staying Together No of Children General Health Menstrual History Age at menarche Flow & Rate Age at menopause : : : : General Health : : :1.M : : 2.F : : Occupation:

Handicaps/Deficiency/Impairment/Implants/Fixtures/Aids:

PHYSICAL EXAMINATION Vital Signs Temperature Pulse Respiration Blood Pressure Observation & Assessment General Appearance Nourishment Body Build Health Activity Sensorium Emotional State Foul Body Odour Foul Breath Mental Status Consciousness Look Posture Body Curves Movement Gait Bleeding Discharge : : : : Internal : : External : : : : : : : : : : : : : : : :

Skin Conditions Color Texture Temperature Lesions Head & Face Hair Scalp Face Eyes Eye brows Eye lashes Eye lids Conjunctiva Sclera Cornea and Iris Pupils Lens Vision Ears External eye Tympanic Membrane Hearing Nose Exernal Nares Nostrils : : : : : : : : : : : : : : : : : Pediculosis: : : : :

Mouth & Pharynx Lips Odour of the Mouth Teeth Mucus membrane & Gums Tongue Throat & Pharynx Neck Lymph nodes Thyroid gland Range of motion Chest Inspection Palpation Percussion Auscultation Abdomen Inspection Auscultation Palpation Percussion Extremities Movement of Joints Clubbing of Fingers Ankle Edema Reflexes : : : : : : : : : : : : : : : : : : : : :

Back Spina Bifida Curves Genitals & Rectum Inguinal lymph glands Discharges Presence of STD Hemorrhoids Dependency Level of the patient : : : : : : :

VITALS SIGNS

S.No Parameters 1 2 3 4 Temperature Pulse Respiration Blood pressure

Day 1

Day 2

Day 3

INVESTIGATIONS

S.No

Date

Investigation

Patient value

Normal value

Inference

SPECIFIC INVESTIGATIONS

S.No

Date

Investigation

Impression

TREATMENT

S.No

Drug name

Dose

Route

frequency

S.NO

DRUG NAME

DOSE

ROUTE

FREQUENCY MECHANISM INDICATIONS CONTRA SIDE OF ACTION INDICATIONS EFFECTS

NURSES RESPONSIBILITY

S.NO

DRUG NAME

DOSE

ROUTE

FREQUENCY MECHANISM INDICATIONS CONTRA SIDE OF ACTION INDICATIONS EFFECTS

NURSES RESPONSIBILITY

S.NO

DRUG NAME

DOSE

ROUTE

FREQUENCY MECHANISM INDICATIONS CONTRA SIDE OF ACTION INDICATIONS EFFECTS

NURSES RESPONSIBILITY

S.NO

DRUG NAME

DOSE

ROUTE

FREQUENCY MECHANISM INDICATIONS CONTRA SIDE OF ACTION INDICATIONS EFFECTS

NURSES RESPONSIBILITY

S.NO

DRUG NAME

DOSE

ROUTE

FREQUENCY MECHANISM INDICATIONS CONTRA SIDE OF ACTION INDICATIONS EFFECTS

NURSES RESPONSIBILITY

S.NO

DRUG NAME

DOSE

ROUTE

FREQUENCY MECHANISM INDICATIONS CONTRA SIDE OF ACTION INDICATIONS EFFECTS

NURSES RESPONSIBILITY

S.NO

DRUG NAME

DOSE

ROUTE

FREQUENCY MECHANISM INDICATIONS CONTRA SIDE OF ACTION INDICATIONS EFFECTS

NURSES RESPONSIBILITY

S.NO

DRUG NAME

DOSE

ROUTE

FREQUENCY MECHANISM INDICATIONS CONTRA SIDE OF ACTION INDICATIONS EFFECTS

NURSES RESPONSIBILITY

S.NO

DRUG NAME

DOSE

ROUTE

FREQUENCY MECHANISM INDICATIONS CONTRA SIDE OF ACTION INDICATIONS EFFECTS

NURSES RESPONSIBILITY

S.NO

DRUG NAME

DOSE

ROUTE

FREQUENCY MECHANISM INDICATIONS CONTRA SIDE OF ACTION INDICATIONS EFFECTS

NURSES RESPONSIBILITY

S.NO

DRUG NAME

DOSE

ROUTE

FREQUENCY MECHANISM INDICATIONS CONTRA SIDE OF ACTION INDICATIONS EFFECTS

NURSES RESPONSIBILITY

S.NO

DRUG NAME

DOSE

ROUTE

FREQUENCY MECHANISM INDICATIONS CONTRA SIDE OF ACTION INDICATIONS EFFECTS

NURSES RESPONSIBILITY

COMPARISON OF BOOK PICTURE WITH PATIENT PICTURE BOOK PICTURE PATIENT PICTURE

IDENTIFICATION AND PRIORITIZATION OF NEEDS AND PROBLEMS

S.No 1 2 3 4 5 6 7

Problems

Needs

S.No 1 2 3 4 5 6 7

Problems

Day 1

Day 2

Day 3

LIST OF NURSING DIAGNOSIS

ASSESSMENT

NURSING DIAGNOSIS

GOAL

PLANNING

RATIONALE

IMPLEMENTATION EVALUATION

ASSESSMENT

NURSING DIAGNOSIS

GOAL

PLANNING

RATIONALE

IMPLEMENTATION EVALUATION

ASSESSMENT

NURSING DIAGNOSIS

GOAL

PLANNING

RATIONALE

IMPLEMENTATION EVALUATION

ASSESSMENT

NURSING DIAGNOSIS

GOAL

PLANNING

RATIONALE

IMPLEMENTATION EVALUATION

ASSESSMENT

NURSING DIAGNOSIS

GOAL

PLANNING

RATIONALE

IMPLEMENTATION EVALUATION

ASSESSMENT

NURSING DIAGNOSIS

GOAL

PLANNING

RATIONALE

IMPLEMENTATION EVALUATION

ASSESSMENT

NURSING DIAGNOSIS

GOAL

PLANNING

RATIONALE

IMPLEMENTATION EVALUATION

ASSESSMENT

NURSING DIAGNOSIS

GOAL

PLANNING

RATIONALE

IMPLEMENTATION EVALUATION

ASSESSMENT

NURSING DIAGNOSIS

GOAL

PLANNING

RATIONALE

IMPLEMENTATION EVALUATION

ASSESSMENT

NURSING DIAGNOSIS

GOAL

PLANNING

RATIONALE

IMPLEMENTATION EVALUATION

PROGRESS RECORD

DATE TEMPERATURE PULSE

RESPIRATION

BLOOD PRESSURE

REMARKS

DATE TEMPERATURE PULSE

RESPIRATION

BLOOD PRESSURE

REMARKS

DATE TEMPERATURE PULSE

RESPIRATION

BLOOD PRESSURE

REMARKS

HEALTH EDUCATION

RESEARCH ARTICLES & EVIDENCED BASED PRACTICE

SUMMARY & CONCLUSION

Bibliography