COMMUNITY CARE STUDY FORMAT

SELF INTRODUCTION
1. IDENTIFICATION DATA
a. Client Identification
b. Student Identification
2. AREA INTRODUCTION
Name of the area:
Name of the taluk and district:
Main caste group:
Religion:
Occupation:
Method of recording births and deaths:
Facilities available in the area and distance in kilometres:
a. Medical facilities:
Government hospitals:
Private / Mission hospitals:
Health centres:
Indigenous practitioners:
b. Social agencies:
Red Cross/ Lion’s club and their activities:
Education:
Market:
Church, Temple, Mosques:
Recreation:
Communication:
Library:
c. Sanitary facilities:
Latrine:
Refuse disposal:
Disposal of dead bodies:
Water sanitation:
3. AREA MAP:
4. FAMILY INTRODUCTION:
1. Family setup:
2. Pedigree:
3. Property and income in addition to salary/ wages
House:
Land:
Animal:
Other (Specify):
4. Family and Social relationship:
a. Attitude among family members and neighbours:
 b. Attitude towards people of other communities and religion:
5. Description of house and relationship:
a. Roofs:
b. Walls:
c. Floors:
d. No. of rooms:
e. Lighting/ ventilation:
f. Furniture:
g. Storage of food and water:
h. Water supply:
i. Washing place and vessels:
j. Bathing area:
k. Latrine (Location/ Type:
l. Disposal (Waste water, Rubbish and excreta):
6. Surroundings:
a. Neatness and cleanliness:
b. Kitchen garden:
c. Trees and Shrubs where the animal are get:
7. Family health attitude, belief and practices:
A. Disease
a. Cause and spread:
Attitude:
Belief:
Practices:
b. Type and medical health and sought:
Attitude:
Belief:
Practices:
B. Immunization:
Attitude:
Belief:
Practices:
C. Food:
a. Hot and gas forming:
Attitude:
Belief:
Practices:
b. Dushem:
Attitude:
Belief:
Practices:
D. MCH
a. Antenatal care:
Attitude:
 Belief:
Practices:

b. Delivery:
Attitude:
Belief:
Practices:
c. Postpartum care:
Attitude:
Belief:
Practices:
d. Family planning:
Attitude:
Belief:
Practices:
e. New born care
Attitude:
Belief:
Practices:
f. Infant feeding:
Attitude:
Belief:
Practices:
8. Income expenditure:

S.NO ITEMS AMOUNT

Conclusion:
9. Dietary Pattern:
Cooking:
Food Pattern:
10. Past Medical history:
Past Surgical history:
Present Medical history:
Present complaints / needs:
11. Floor Map:

5. PHYSICAL EXAMINATION:
A. Identification data:
 B. Anthropomentric Measurement:
C. Vital Signs:
D. Head to foot assessment
E. Special assessment:
F. Conclusion:
6. NUTRITIONAL ASSESSMENT:
A. Identification data: Name/ Age/ Sex/ Classification
B. Degree of malnutrition:
BMI
(With Normal values)
C. 24 hrs recall:

TIME ITEM AMOUNT

D. 24 hrs recall with nutritive value:

TIME ITEM AMOUNT CHO PRO FAT IRON CAL K.CAL

E. Summary:

NUTRIENT EXPECTED CLIENT REMARKS

VALUE VALUE

F. Conclusion:

7. COOKING DEMOSTRATION:
A. Identification data:
B. Ingredients:
C. Nutrients with value:
D. Preparation:
E. Conclusion:

8. NURSING PROCESS:
A. Complaints or needs / Nursing diagnosis (10)
B. Nursing process (6)
9. VISITS (5)
10. BIBLIOGRAPHY:
11. SELF EVALUATION:
12. TREE PLANTATION:
13. CONCLUSION:

PHYSICAL EXAMINATION
1. IDENTIFICATION DATA:
2. ANTHROPOMRNTRIC MEASUREMENT: (With Normal Values)
Height:
Weight:
Head circumference (New born/ Infant):
Chest circumference (New born/ Infant):
Mid arm circumference (Pre- schooler):
3. VITAL SIGNS: (With Normal Values)
Temperature:
Pulse:
Respiration:
Blood pressure (adolescent/adult/old age):
4. HEAD TO FOOT ASSESSMENT:
1. Hair:
Hair distribution:
Any other:
2. Eyes:
Glasses/ contact lens:
Diplopia:
Inflammation:
Blurring of vision:
Pain:
Watering/ Discharge:
Visual acuity:
3. Ears:
Hearing impairment:
Pain:
Tinnitus:
Hearing Aid:
Discharge:
Loss of balance:
Hearing acuity:
4. Nose:
Discharge:
Allergies:
Polyp:
 Frequency of URI:
Sinusitis:
Bleeding:
5. Mouth and throat:
Dysphagia:
Dental carries:
Halitosis:
Pain:
Inflammation:
Lesions:
Speech disorder:
Lymphadenopathy:
SYSTEMATIC EXAMINATION
6. GI system:
Abdominal pain:
Other:
7. Cardiovascular system:
Heart rate:
Rhythm:
Heart sound:
Pain:
Palpitation:
Numbness:
Syncope:
Any other:
IVP:
Peripheral pulses:
Capillary refill:
8. Respiratory system:
Rate:
Rhythm:
Breath sounds:
Cough:
Dyspnoea:
Pain related to breathing:
Sputum:
Others:
9. Central Nervous system:
Lethargy:
Irritability:
Dizziness:
Headache:
Nausea:
 Vomiting:
Confusion:
Weakness:
Paralysis:
Convulsion:
Memory:
Changes in sensation:
In coordination:
Pain, Gait:
Any other:

10. Musculoskeletal system:

Pain:
Cramps:
Varicose vein:
Swelling:
Posture:
Muscle strength:
Stiffness:
Changes in ADL:
ROM:
Reflexes:
11. Genito -urinary system:
A. Urinary elimination:
Pain in the back
Pain on micturition:
Burning micturition:
Retention of urine:
Incontinence:
Frequency:
Presence of catheters:
Any other:
B. Bowel elimination:
Diarrhoea:
Constipation:
Peristaltic movement:
C. Rectum:
Bleeding, Tissues, Ulcers:
Haemorrhoids:
Any other:
12. Integumentary system:
Temperature:
Texture:
Turgor:
 Colour:
Any other:

13. Reproductive system:

Gyneocological examination:
Cervix – soft / abdominal:
Signs of infection:
Bleeding / discharge:
14. Breast examination:
Size:
Shape:
Any secretion:
Nipple:
5. SPECIAL ASSESSMENT: (ANC/PNC/Reflexes/Milestone/Immunization/Urine
test)
6. CONCLUSION: