 Introduction:

 Demographic data:

o Name of the patient:

o Age:
o Sex:
o MRD.no:
o Ward:
o Address:
o Mother tongue:
o Education:
o Occupation:
o Income:
o Religion:
o Marital status:
o D.O.A:
o D.O.S:
o Type of anesthesia:
o Diagnosis:
o Date of care started:
o Date of care ended:
o D.O.D:
 Socio-economic history:
o Family history:

o Total income:
o Dietary habits:

o Housing condition:

o Interpersonal relation:

 Chief complaints:
 Personal history:
o Personal hygiene:
o History of allergy:
o Present medical history:

o Present surgical history:

o Past medical history:

o Past surgical history:

o Family history:
 Demographic data:
S.n Name of the family Age sex Relationship Education Occupatio Health
o member with patient n status

 Family tree:
 Physical examination:
 Vital signs:
S.n Vital signs Patient’s value Normal value Remarks
o
Temperature 98.6 F OR 37 C

Pulse 60-100
beats/minute
Respiration 16-24
breaths/minute
Blood pressure 120/80 mmHg

 Anthropometric measurement:
o Height:
o Weight:
o BMI:

 General appearance:
o Consciousness:
o Orientation:
o Nourishment:
o Bodies build:
o Activity:
o Look:
o Speech:
 Head to toe assessment:
 Skin:
o Color:
o Texture:
o Skin turgor:
o Lesions:
o Hydration:
 Nails:
o Color:
o Clubbing:
o Shape:
 Hair:
o Color:
o Texture:
o Grooming:
o Distribution:
 Head:
o Shape:
o Scalp:
 Eyes:
o Eye brows:
o Eye lashes:
o Eye lids:
o Papillary reflex:
o Pupil shape:
o Sclera:
 o Sense of vision:
 Ears:
o Pinna:
o Cerumen:
o Oltorhea:
o Sense of hearing:
 Nose:
o Nasal septum:
o Nostrils:
o Sense of smell:
 Mouth and pharynx:
o Lips:
o Color of lips:
o Lesion of lips:
o Gums:
o Tongue:
o Sense of taste:
o Teeth:
o Color of teeth:
o Mucous membrane:
o Halitosis:
o Tonsils:
o Voice:
 Neck:
o Size:
o Range of motion (ROM):
 o Position of trachea:
o Thyroid gland:
o Jugular vein:
o Lymph nodes:

Cardio-pulmonary system:
o Thorax:
o Thorax expansion:
o Heart sound:
o Breathe sound:
 Breasts:
o Size:
o Palpation:
o Discharge:
o Lesion:
 Abdomen:
o Inspection:

o Auscultation:

o Percussion:

o Palpation:

 Back:
o Spine:
 o Movement:
o Tenderness:
 Genitalia and rectum:
o Lesion:
o Infection:
o Voiding:
o Color of urine:
o Rectum and anus:

 Extremities:
o Deformities:
o Range of motion (ROM):
o Edema:
 Nervous system:
o Level of consciousness:
o Response:
o Intellectual capability:
 Cranial function:
o Sensory:

o Motor:

o Reflexes:
 Investigations:
S.no Investigation Patient’s value Normal value Remarks
Hematology
Hemoglobin
RBC
WBC
Platelet count
Biochemistry
Sodium(Na )
Potassium(K
)
Chloride(Cl )
Blood urea

 Medications:
S.no Name of the Dose Rout Frequency Action Side effects Nurse’s
drug e responsibility
 Anatomy and physiology:
 Disease condition:

 Definition:
 Pathophysiology:
 Clinical manifestations:
S.no Book picture Patient picture

 Diagnostic evaluation:
 Management:
o Pre operative nursing diagnosis:
o Post operative nursing diagnosis:
 Health education:
 Diet:

 Personal hygiene:

 Exercise:
 Rest and sleep:

 Medication:

 Follow up:
 Progress notes:
 Day 01:

Vitals:
S.n Vital signs Patient’s value Normal value
o
Temperature 98.6 F OR 37 C
Pulse 60-100 beats/minute
Respiration 16-24 breaths/minute
Blood pressure 120/80 mmHg
 Day 02:

Vitals:
S.n Vital signs Patient’s value Normal value
o
Temperature 98.6 F OR 37 C
Pulse 60-100 beats/minute
  Day 03:

Vitals:
S.n Vital signs Patient’s value Normal value
o
Temperature 98.6 F OR 37 C
Pulse 60-100 beats/minute
Respiration 16-24 breaths/minute
Blood pressure 120/80 mmHg
 Day 04:

Vitals:
S.n Vital signs Patient’s value Normal value
o
Temperature 98.6 F OR 37 C
Pulse 60-100 beats/minute
Respiration 16-24 breaths/minute
 Conclusion:
Bibliography: