NURSING CASE PRESENTATION FORMAT

                                                         

Patient’s profile

1.      Identification Data:

Client name:

Age/sex:

Father/spouse name:

Hospital registration number:

Ward:

Bed No.:

Address:

Education:

Occupation:

Marital status:

Religion:

Date of admission:

Date of discharge:

Diagnosis:

Surgery (if any):

Date of Surgery:

Doctor In-charge:  

2.      History of Illness:

·     Chief complaints: for e.g. complaints of dyspnoea, low blood pressure and cold and clammy skin.

·      Present medical history: for e.g.  complaints of backache, low blood pressure, fever, etc.

·      Present surgical history: any history of surgical procedure.

·  Past medical history: history of any hypertension, Diabetes mellitus, asthma, COPD or other disease.                                                          

·      Past surgical history: history of any surgery in the past.

Family History:

S. No.	Name of family members	Age/sex	Occupation	Relation to family member	Health status	Education

Family Tree:

Personal History:      

·         Dietary habits: vegetarian/ non vegetarian.

·         Addiction: history of smoking, drug addiction, alcohol consumption, etc.

·         Socio-economic status:

Lab investigations:

Name of test	Normal value	Patient value	Remarks

Vital Signs:

S. No.	Vital signs	Normal value	Patient’s value	Remarks

Physical Examination

General Appearance:

·         Body build:

·         Height:

·         Weight:

·         Vital signs: Temperature:

                    Pulse:

                    Respiration:

                    B.P:

·         Colour of skin:

Head:

·         Shape and size of skull:

·         Scalp:

·         Face:

Eyes:

·         Vision:

·         Eye brow and eyelid:

·         Eye ball:

·         Conjunctiva:

·         Sclera:

·         Cornea and iris:

·         Pupil:

·         Lens:

Ear:

·         External ear:

·         Tympanic membrane:

·         Hearing problem:

Nose:

·         External nares:

·         Nostrils:

Mouth and pharynx:

·         Mouth:

·         Teeth:

·         Tongue:

·         Throat and pharynx:

Neck:

·         Thyroid gland:

·         Lymph node:

·         Range of motion:

Chest:

·         Breath sounds:

·         Lungs:

·         Heart:

Abdomen:

·         Inspection:

·         Auscultation:

·         Palpation:

·         Percussion:

Extremities:

·         Upper:

·         Lower:

Back: assess redness, bed sores, etc.

Genital and rectum:

Systematic examination:

·         Central nervous system:

·         Sensory system:

·         Respiratory system:

·         Cardiovascular system:

·         Gastro intestinal system:

·         Musculoskeletal system:

·         Genitourinary system:

·         Integumentary system:

DISEASE CONDITION: (for e.g.- Cardiogenic Shock)

Definition:

Causes:

Sign and Symptoms:

BOOK PICTURE	PATIENT PICTURE

Pathophysiology:

Diagnostic evaluation:

BOOK PICTURE	PATIENT PICTURE

Management-

BOOK PICTURE	PATIENT PICTURE

 

Nursing Process:

Day 1

S. No.	Needs	Problems

Nursing diagnosis:  

    

Nursing care plan:

Assessment	Nursing diagnosis	Goals	Interventions	Implementations	Rationale	Evaluation

                                                          Nursing Process:

                                                                   Day 2

S. No.	Needs	Problems

Nursing diagnosis:

Nursing care plan:

Assessment	Nursing diagnosis	Goals	Interventions	Implementations	Rationale	Evaluation

                                                          Nursing Process:

                                                                  Day 3       

S. No.	Needs	Problems

Nursing diagnosis:

Nursing care plan:

Assessment	Nursing diagnosis	Goals	Interventions	Implementations	Rationale	Evaluation

Theory application:      

For e.g.- Orem’s General Theory of Nursing.

Health education:

Discharge plan:    

Summary:

Bibliography: