DENTIFICATION DATA

Name

Age/Sex

Father’s name

Ward &unit:
Bed no
Registration number
Mother’s occupation
Father’s occupation
Education
Address
Date of adnission
Income

Gravid

Diagnosis

SUBJECTIVE DATA
1.Admission history :-
2.Personal history :-

3. Medical history:

4. SurgIcal history :-

5 . Family history:

6 . Menstrual history:

7. Obstetrical history:
8. Chief conplaints :-

PHYSICAL EXAMINATION
VITALS:

Temperature -

Pulse -

Respiration -

Blood Pressure

 GENERAL APPEARANCE

 Head, Hair 8 Scalp

 Eye
 Nose

 Ear

 Mouth

 Neck

 Breast

 Chest

 Liver & Spleen

 Upper Extermities

 Abdomen

 Gi system

 Bleeding per vagina

 Urine output
  Lower extermities
S.NO INVESTIGATION VALUE IN PATIENT NORMAL
VALUE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
 LAB INVESTIGATION

NURSING MANAGEMENT
NURSING DIAGNOSIS
NURSING PROCESS :-
1.NURSING DIAGNOSIS :-

SUBJECTIVE DATA OBJECTIVE DATA

DESIRED GOAL / OUTCOME

PLANNING IMPLEMENTATION RATIONALE