Kingdom of Saudi Arabia ‫المملكـــــة العربية السعودية‬

Ministry of Higher Education ‫وزارة التعليم العــــــــــــــالي‬

Taibah University ‫جامعة طيبة‬
College of Applied Medical ‫كلية العلوم الطبية التطبيقية‬
Sciences ‫ينبـــــــع‬
Yanbu
Case Study Form
Medical- Surgical Nursing 2
for Student’s 5th level
Student name
Code number
Date
Area of training

Under Supervisor

1442-1443
Sociodemographic data

Special unit…………………..

Patient’s name:……………………………………… Hospital No……………

Date of admission……………………………….. Stay period:…………….

Age:………………. Sex…………………….

Level of education……………………….. Occupation…………….

Marital status………………………… Religious……………….

Present History:

-Diagnosis/ Present illness: ……………………………………………………………….

-Chief complaints on admission: …………………………………………………………

-Associated signs and symptoms: …………………………………………………………

-Onset / Duration / Frequency: ……………………………………………………………

-Predisposing factors: …………………………………………………………………….

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-Reliving measures and its effect: ……………………………………………………….

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Past History:
 Medical:

-Diagnosis / Duration: …………………………………………………………………….

-Diagnosis / Duration: …………………………………………………………………….

 Surgical:

-Name of surgery / Duration:……………………………………………………………..

-Name of surgery / Duration:……………………………………………………………..

 Allergy history:………………………………………………………………………
Family history:
-Diagnosis / Relation:…………………………………………………………………
-Diagnosis / Relation:…………………………………………………………………

Life style habit--------------------------------------------------------------------------

Patient’s physical assessment

1- Respiratory system---------------------------------------------------------------------------

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2-Cardio-vascular system--------------------------------------------------------------------

3-Peripheral vascular ------------------------------------------------------------------------

4-Neurological assessment---------------------------------------------------------------------

5-Gastro-intestinal system-------------------------------------------------------------------

6-Urinary system-----------------------------------------------------------------------------

7-Musculoskeletal system-------------------------------------------------------------------

8- Skin assessment-----------------------------------------------------------------------------

9- Head\hair--------------------------------------------------------------------------------------

10-Eyes-------------------------------------------------------------------------------------------

11-Ears-------------------------------------------------------------------------------------------

12- Nose------------------------------------------------------------------------------------------

13- Mouth----------------------------------------------------------------------------------------

14- Neck------------------------------------------------------------------------------------------

15- Activity and rest--------------------------------------------------------------------------------

Definition of disease --------------------------------------------------------------------
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Path physiology\ types ----------------------------------------------------------------
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Etiology
According to patient According to literature
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Clinical manifestations

According to patient According to literature

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Complications
According to patient According to literature
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Diagnostic measures

Lab investigation:

According to literature According to patient

Normal
Lab Investigation Patient's Results Comment
Range

Radiological examination:

According to literature According to patient

Check for
Type of examination Patient's Results
what done
Medical management according to patient

No. Drug name Route Dose / Frequency Side effect if present

Surgical management

According to patient According to literature

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 Nursing Care Plan
10M 5M 10 M 10 M 5M
Objectives Nursing intervention
Nursing Diagnosis Rational Evaluation
(SMART) Ng implementation Ng standard
 Objectives Nursing intervention
Nursing Diagnosis Rational Evaluation
(SMART) Ng implementation Ng standard
 Objectives Nursing intervention
Nursing Diagnosis Rational Evaluation
(SMART) Ng implementation Ng standard