NOOTAN COLLEGE OF NURSING, VISNAGAR
THIRD YEAR B.SC NURSING
EVALUATION FORM FOR CASE PRESENTATION
NAME OF STUDENT:
SUBJECT:
AREA OF HOSPITAL EXPERIENCE:
PERIOD OF EXPERIENCE:
Sr. No. Content Total Obtained
marks marks
1 History taking & physical
examination 04
2 Medication 04
3 Diagnostic test 04
4 Disease condition 14
5 Nursing care plan 10
6 Growth And Development 06
7 Health education & progress 06
notes
8 Reference 02
50
TOTAL MARKS OBTAINED:
REMARKS:
SIGNATURE OF GUIDE SIGNATURE OF STUDENT
CASE PRESENTATION ON (HIGH RISK NEW BORN)
HISTORY TAKING
IDENTIFICATION DATA:
NAME :
AGE :
SEX :
ADDRESS :
DATE OF ADMISSION :
TIME OF ADMISSION :
NAME OF CONSULTANT :
O.P.D. NO. :
INDOOR NO. :
WARD NO. :
BED NO. :
M.L.C. : YES/NO
DIAGNOSIS :
PROCEDURE / SURGERY :
DONE
DATE OF SURGERY :
NAME OF THE SURGERY
101
PRESENT MEDICAL HISTORY:
PAST MEDICAL HISTORY:
PAST SURGICAL HISTORY
FAMILY HISTORY:
FAMILY TREE:
102
FAMILY HISTORY:
HEALTH
NO. NAME AGE RELATION EDUCATION OCCUPATION
STATUS
SOCIO ECONOMIC DATA:-
IMMUNIZATION HISTORY
103
FUNCTIONAL HEALTH PATTERN
Hygiene
Activity/Exercises:-
Rest/Sleep
Elimination Pattern:-
Cognitive / Perceptual:-
Self perception / self concept pattern:-
Coping stress tolerance:-
Personal habits:-
104
GROWTH &DEVELOPMENT:
VITAL SIGN:
TEMPERATURE:
PULSE:
RESPIRATION:
B.P.:
ANTHROPOIMETRIC MEASUREMENT
Sr.No. Measurement Patient’s value Normal Value Remarks
1 Height
2 Weight
3 Head Circumference
4 Chest Circumference
5 Mid Arms Circumference
GROSS MOTOR
FINE MOTOR
SENSORY
105
PSYCHOLOGICAL
INTELECTUAL
SPEECH & LANGUAGE
PLAY
NUTRITION
106
PHYSICAL EXAMINATION
GENERAL INFORMATION:
NOURISHMENT:
BODY BUILT:
SKIN CONDITION:
COLOUR:
TEXTURE:
LESIONS:
HEAD & FACE:
LESIONS
SCAR
HAIR DISTRIBUTION
HAIR COLOUR:
EYE:
EYE BROWS:
EYELASHES:
EYE LIDS:
EYE BALLS:
CONJUNCTIVA:
SCLERA:
CORNEA & IRIS:
PUPIL:
LENS:
EARS:
EXTERNAL NARES:
NOSTRILS:
107
MOUTH & PHARYNX:
LIPS:
Cleft lips/palate;
TEETH:
MUCUS MEMBRANE& GUMS:
TONGUE:
THROAT &
PHARYNX: NECK:
CHEST:
THORAX:
BREATH SOUNDS:
HEART:
BREAST:
ABDOMEN:
INSPECTION:
AUSCULTATION:
PALPATION:
PERCUSSION:
EXTREMITIES:
MOVEMENT OF JOINTS:
TREMORS:
CLUMBING OF FINGERS:
OEDEMA:
BACK & SPINE:
CURVES:
MOVEMENT:
108
GENITALS & RECTUM:
INGUINAL LYMPH GLANDS:
PATENCY OF URINARY MEATUS & RECTUM(IN INFANT):
DESCENT OF TESTES (IN INFANT):
VAGINAL DISCHARGE:
PRESENCE OF STDs:
NEUROLOGICAL TESTS:
REFLEXES:
109
SYSTEMIC EXAMINATION:
CENTRAL NERVOUS SYSTEM:
CARDIO-VASCULAR SYSTEM:
RESPIRATORY SYSTEM
MUSCULO-SKELETAL SYSTEM:
110
DIGESTIVE SYSTEM:
GENITO-URINARY SYSTEM:
INVESTIGATION
NAMEOF NORMAL
DATE PATIENT VALUE REMARK
INVESTIGATIONS VALUE
111
OTHERS
112
MEDICATION
Pharmacological
Dose/ Mechanism of
Name/ Trade Indication Contra- Indications Side-Effects Nurses responsibility
Route Action
Name
113
MEDICATION
Pharmacological
Dose/ Mechanism of
Name/ Trade Indication Contra- Indications Side-Effects Nurses responsibility
Route Action
Name
114
Anatomy and physiology:-
115
DISEASE CONDITION
Introduction:-
Definition;-
Etiology
116
Pathophysiology
117
Clinical Manifestations:-
Book Picture Patient picture
118
Diagnostic Tests:-
Book Picture Patient picture
119
MANAGEMENT:-
Medical Management:-
Book Picture Patient picture
120
12
1
Surgical Management:-
Book Picture Patient picture
122
Dietary Management:-
Book Picture Patient Picture
Other Management:-
123
Complication:-
NURSING PROCESS:-
List of Nursing Diagnosis:
124
NURSING CARE PLAN
Nursing Nursing Expected
Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come
125
Nursing Nursing Expected
Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come
126
Nursing Nursing Expected
Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come
127
Nursing Nursing Expected
Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come
128
NURSES NOTES
Name of the patients:- Diagnosis;-
Age/Sex: - Name of Surgery:-
Date of Admission; - Date of Surgery:-
Ward/Bed no.:- Dr. In charge:-
Nursing
Date Diet Medication Time Nursing Care Remarks Sign
Observation
129
Nursing
Date Diet Medication Time Nursing Care Remarks Sign
Observation
130
Nursing
Date Diet Medication Time Nursing Care Remarks Sign
Observation
131
HEALTH TEACHING:
PROGRESS OF PATIENT:-
132
SUMMARY:-
CONCLUSION:-
133
BIBLIOGRAPHY:-
SIGNATURE OF EVALUATOR SIGNATURE OF
STUDENT
134
