CASE STUDY

INTRODUCTION:

PATIENT PROFILE

1. DEMOGRAPHIC PROFILE

 NAME OF THE PATIENT :

 AGE :

 SEX :

 RELIGION :

 MARITAL STATUS :

 EDUCATIONAL STATUS :

 OCCUPATION :

 INCOME :

 I.P NO :

 WARD :

 DATE OF ADMISSION :

 ADDRESS :

 DIAGNOSIS :
2. CHIEF COMPLAINTS :

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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3. HISTORY OF PRESENT ILLNESS:

4. PAST MEDICAL & SURGICAL HISTORY:

5.PRESENT SURGICAL HISTORY IF ANY

6. FAMILY HISTORY

A. Family components

Relationship Health
Name Age Sex Education Occupation
with patient Status

B. Family Genogram:

C. Family health history

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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7. PERSONAL HISTORY

 Habits :

 Life Style :

 Food Habits :

 Hobbies :

8. SOCIO-ECONOMIC HISTORY

 Family Income Rs :

 Bread winner of the family :

 Social Relationship
(Family,Friends,Neighbours)
 Facilities
(Rent/own House with electricity,water,drainage)
9. PHYSICAL EXAMINATION (HEAD TO FOOT ASSESSMENT)
 General Appearance

o Nourishment :

o Body built :

o Activity :

o Health Status :

 Mental Status

Consciousness :

Look :

 Posture

Body Curves :

Movement :

Height :

Weight :

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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 Integumentary System

Inspection :

Palpation

 Head &Face :

 Eyes :

 Ears :

 Nose :

 Throat&Mouth:

 Neck:

 Chest (Respiratory system):

o Inspection-

o Palpation-

o Percussion-

o Auscultation-

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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 Cardiovascular System
o Inspection-

o Palpation-

o Percussion-

o Auscultation-

 Abdomen (Gastrointestinal System)

o Inspection-

o Palpation-

o Percussion-

o Auscultation-

 Extremities (Musculo Skeletal System)

o Upper Extremities

o Lower Extremities

 Back&Spine

 Genetalia&Rectum (Genito urinary System)

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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10. Vital Signs:-

a) T : P: R:
b) BP :

11. Investigations:-

S.NO Name of the Investigation Normal Value Patient Value Remarks

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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12. Medical management

Sl.
Name of the Drug Dose Route Action Indication Side Effect Nursing Responsibility
No

13. Surgical management:

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

 CASE STUDY
14.DISEASE PROFILE
INTRODUCTION

ANATOMY & PHYSIOLOGY OF INVOLVED SYSTEM:

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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I. Definition

II. Incidence &Prevalence

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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COMPARISION BETWEEN PATIENT PROFILE AND BOOK REVIEW

Perticulars Book review Patient profile

III.Etiology

IV.Pathophysiology

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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V.Clinical manifestation

VI.Investigation

VII.Medical
management

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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VIII.Surgical management

IX.Complication

14.Nursing Management

a. List of Nursing Problems based on priority

b. Nursing diagnosis (based on priority) :-

Pre / post operative nursing diagnosis

1.

2.

3.

4.
DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K
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5.

6.

7.

8.

9.

10.

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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c. Nursing Care Plan[-------------------operative nursing care plan]
Sr.no Nsg. Planning with
Assessment Nsg. Diagnosis Goal Implementation Evaluation
Rationale

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

 CASE STUDY

c. Nursing Care Plan [-------------------operative nursing care plan]

Sr.no Nsg. Planning with
Assessment Nsg. Diagnosis Goal Implementation Evaluation
Rationale

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

 CASE STUDY
c. Nursing Care Plan [-------------------operative nursing care plan]
Sr.no Nsg. Planning with
Assessment Nsg. Diagnosis Goal Implementation Evaluation
Rationale

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

 CASE STUDY
c. Nursing Care Plan [-------------------operative nursing care plan]
Sr.no Nsg. Planning with
Assessment Nsg. Diagnosis Goal Implementation Evaluation
Rationale

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

 CASE STUDY
c. Nursing Care Plan [-------------------operative nursing care plan]
Sr.no Nsg. Planning with
Assessment Nsg. Diagnosis Goal Implementation Evaluation
Rationale

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

 CASE STUDY
c. Nursing Care Plan [-------------------operative nursing care plan]
Sr.no Nsg. Planning with
Assessment Nsg. Diagnosis Goal Implementation Evaluation
Rationale

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

 CASE STUDY
c. Nursing Care Plan [-------------------operative nursing care plan]
Sr.no Nsg. Planning with
Assessment Nsg. Diagnosis Goal Implementation Evaluation
Rationale

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

 CASE STUDY
c. Nursing Care Plan [-------------------operative nursing care plan]
Sr.no Nsg. Planning with
Assessment Nsg. Diagnosis Goal Implementation Evaluation
Rationale

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

 CASE STUDY
c. Nursing Care Plan [-------------------operative nursing care plan]
Sr.no Nsg. Planning with
Assessment Nsg. Diagnosis Goal Implementation Evaluation
Rationale

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

 CASE STUDY
c. Nursing Care Plan [-------------------operative nursing care plan]
Sr.no Nsg. Planning with
Assessment Nsg. Diagnosis Goal Implementation Evaluation
Rationale

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

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III. Health Education

 Personal Hygiene

 Diet

 Exercise

 Medication & Follow-up

 Any other specific instruction:

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K

 CASE STUDY
Conclusion

Summary

References:

DEP.OF.MED-SURG-NSG GLOBAL COLLEGE OF NURSING PROF &H.O.D. Mr.G.K