Outline for case

study/
presentation
College of nursing,IMS,BHU
 I. PATIENT ASSESSMENT
A. Profile of the patient
. Name of the patient ------Age----- Sex------
.Hospital---------------.ward---------Bed.No-------
.Hospital no------------Date of admission---------
.Address---------------------------------
.Education-----------Occupation---------Marital
status
.Income-----------------Religion---------------
.Diagnosis--------------Consultant-------------
.Name of operation if any-------Date of operation
B. FAMILY HISTORY
Family status :- Nuclear/ Joint
No. of family members--------
History of any chronic illness-Yes/ no
Any communicable disease in family------
Any Congenital disease-----------------
Any hereditary disease--------------
Any disability in the family------------
Any marital discord- separation/ divorce
Family tree diagram
C. NUTRITIONAL HISTORY
Vegetarian/Non vegetarian---
No. of meals per day-----------------
No.of glasses of water /day
Tea/ coffee---
Fruit/Juice----
D. PERSONAL HISTORY
1.HYGIENIC HABITS:-
a) Dental care/Oral hygiene------
b) Bath frequency /day-------
c)Skin/Nail/Hair/---------(Clean& healthy)
d) Perineal care- :-yes/no
e) Cleanliness of dress:-----yes/no
2.Health Habits
a) Sleep patterns------Normal: Yes/no

b) Duration of sleep -----

c) Duration of rest at day time------

d) Any sleep Disorders:--

3.Elimination habits
a)Bladder : frequency
amount-----
characteristics
b) Bowel:- Regular/irregular
Frequency------
-Characteristics-(colour, consistency etc)
For female patients-
4. MENSTRUAL CYCLE: regular/irregular
Age at menarche:-
Dysmenorrhoea (if
any)------------
5.Other health habits
a) Smoking: yes/No-/No.per/day----- No.ofyears
b) Alcohol consumption: Daily/occasionally
-No.of years-------
c) Tobacco Chewing- Yes/No No. of years
c) Drug addiction----------
d) Substance use:-
e) Sniff-------
f) Exercises: Regular/irregular
Type: outdoor/indoor
II.HISTORY OF ILLNESS
A. Past Medical or Surgical history
- illness in Childhood:------------
- illness in adulthood-----------
-Any Surgery-------------- nature of illness----
- Any Trauma or injury:------
- Date/month/year of illness
- treatment undergone-yes/no
-duration of treatment-
-Outcome of treatment
B. PRESENT MEDICAL OR SURGICAL HISTORY

Reasons for seeking medical assistance------

Onset of illness-
Precipitating factors---
Effect of the symptom on daily life Activities
Patients Knowledge & understanding of
disease:- Yes/no , Adequate/inadequate
Family members Knowledge & understanding
of disease:- Yes/no , Adequate/inadequate
C. PRESENT COMPLAINTS
----------------------------
----------------------------
---------------------------
-----------------------------
III.PHYSICAL
EXAMINATION
Write Any Deviation from Normal
A. General Appearance: --------------------
B. Vital Sign
Temperature: ------------- Pulse:
-----------------
Respiration: --------------
Blood Pressure:-------------
C. Head and Neck:---------------------------------
D. Eyes, Ear, Nose and Throat:--------------- --
E. Respiratory System:----------------------------
F. Cardiovascular System:------------------------
III.PHYSICAL EXAMINATION
contd.
G. Gastointestinal System:-----------------------
H. Genitourinary System:-------------------------
I. Reproductive System:--------------------------
J. Neurological System:---------------------------
K. Musculoskeletal System:----------------------
L. Integumentary System:------------------------
DESCRIPTION OF
DISEASE
Definition of the Disease
-------------------------------------------------------------

. Related Anatomy and Physiology (With

Diagram)
--------------------------------------------------------
DIAGRAM
Etiology
------------------------------------------------------
Risk Factors/ Precipitating Factors/
Contributing Factors
------------------------------------------------------
Pathophysiology
------------------------------------------------------
CLINICAL
MANIFESTATIONS
In patient In book
DIAGNOSTIC EVALUATION
S.No Name of Date Patient's Normal Remarks
test findings value
MEDICAL MANAGEMENT

S.N Name of doses Rout Action

o the drug e Time/frequen
cy
SURGICAL MANAGEMENT
Name of the operation performed
------------------------------------------

Other surgical options

-------------------------------
NURSING CARE PLAN

Nursing Nursing Nursing Interventi Rationale Evaluatio

assessme Diagnosis goals on n
nt
Subjectiv
e data

Objective
data
COMPLICATIONS IN
PATIENT
If any:-

S.N Complication management

o
PROGRESS/RECOVERY OF THE
PATIENT
-------------------------------------
-------------------------------------
---------------------------------------
--------------------------------------
STUDENTS PERSONAL EXPERIENCE
IN CARING THE PATIENT
-----------------------------------------
----------------------------------------
---------------------------------------
----------------------------------------
 HEALTH
EDUCATION
IN WARD-
--------------------------------------------------
------------------------------------------------

ON DISCHARGE:
------------------------
-----------------------
BIBLIOGRAPHY
Minimum 5 books
S.No Name of the Authors Edition Chapter Page.no
book
 THANK YOU