DOON INSTITUTE OF MEDICAL SCIENCES, FACULTY OF NURSING

SHANKARPUR,SAHASPUR

SUBJECT:- MEDICAL SURGICAL NURSING-1 (PRACTICAL)

PERFORMA FOR CASE STUDY

PATIENT’S DATA

NAME OF THE PATIENT

AGE

SEX

RELIGION

LANGUAGES

ADMISSION/ IN-PATIENT NO

NAME OF THE WARD

DATE OF ADMISSION

MARITAL STATUS

EDUCATIONAL STATUS

OCCUPATION

DATE OF SURGERY (IF ANY)

DATE OF CARE STARTED

DATE OF CARE ENDED

INFORMANT

CONSULTANT DOCTOR

DIAGNOSIS

CHIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS-

HISTORY OF PAST ILLNESS-

 MEDICAL :
 SURGICAL :

PERSONAL HISTORY

 Habits
 Nutrition
 Appetite
 Personal hygiene
 Sleep pattern
 Elimination pattern

FAMILY HISTORY

Name of the Relationship Age/ Sex Marital Occupation Health Educational

family with patient status status background
member

FAMILY TREE

PSYCHOSOCIAL HISTORY

VITAL SIGNS
PARAMETERS PATIENT VALUE NORMAL VALUE REMARKS
Temperature
Pulse rate
Respiratory rate
Blood pressure
Spo2
PHYSICAL EXAMINATION
General appearance & Behaviour:

Height :
Weight :
Conscious :
Look :
Activity :
Body built :
Posture :
Temperature:
Pulse rate:
Respiration rate:
Blood pressure:

HEAD TO TOE ASSESSMENT

1. Head
 Hair-
 Scalp-
 Forehead –
2. Eyes
 Eyebrows
 Eyelashes
 Eyelids
 Sclera
 Pupil
3. Ear
 External ear
 Tympanic membrane
4. Nose
 External nares
 Nostrils
5. Mouth
 Lips
 Gums
 Tongue
  Teeth
6. Neck
 Lymph node
 Range of motion

SYSTEMIC EXAMINATION
1. Nervous system
2. Cardio vascular system
 Inspection
 Palpation
 Auscultation
 Percussion
3. Respiratory system
 Inspection
 Auscultation
 Palpation
 Percussion
4. Gastro intestinal system
 Inspection
 Auscultation
 Palpation
 Percussion
5. Genitourinary system
6. Musculoskeletal system
 Inspection
 Palpation
7. Integuementary system
8. Endocrine system

INVESTIGATIONS

Date Investigation carried out Patient value Normal values Remarks

DIAGNOSTIC TESTS-

MEDICATION-

SR Name of the Dose / Action Side effect Nursing responsibility

No. drugs route /
time

ANATOMY AND PHYSIOLOGY (OF THE ORGAN INVOLVED WITH DIAGRAM)

DISEASE CONDITION

1. Introduction
2. Definition
3. Etiology

In book In patient

4. Pathophysiology

In book In patient

5. Clinical manifestation

In book In patient

6. Diagnostic evaluation

In book In patient

7. Medical management

In book In patient
 8. Surgical management (if any )

In book In patient

NURSING ASSESSMENT –

NURSING DIAGNOSIS (ACCORDING TO PRIORITY)-

NURSING CARE PLAN –

Assessment Nursing Goal Planning Rationale Implementation Evaluation

diagnosis
1. Subjective
data
2. Objective
data

EVALUATION OF DAILY PROGRESS

DATE & DAY CONDITION OF THE PATIENT

HEALTH EDUCATION:-

CONCLUSION

SUMMARY

BIBLIOGRAPHY