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Case Study Formate

The document outlines a comprehensive case plan format for patient identification, medical history, family history, personal history, socio-economic status, laboratory investigations, medication history, physical examination, nursing diagnosis, nursing care plan, health education, follow-up, prognosis, and summary. It includes detailed sections for various assessments and evaluations related to the patient's health and treatment. This structured format is designed to ensure thorough documentation and care management for patients.

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ajkumar250980
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5 views16 pages

Case Study Formate

The document outlines a comprehensive case plan format for patient identification, medical history, family history, personal history, socio-economic status, laboratory investigations, medication history, physical examination, nursing diagnosis, nursing care plan, health education, follow-up, prognosis, and summary. It includes detailed sections for various assessments and evaluations related to the patient's health and treatment. This structured format is designed to ensure thorough documentation and care management for patients.

Uploaded by

ajkumar250980
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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FORMATE FOR

CASE PLAN
PATIENT IDENTIFICATION DATA

Patient's Name:
Father/Husband Name:
Age:
Sex:
Address:
Education:
Occupation:
Income Per Month:
Religion:
Date of Admission:
IPD no.
Ward :
Bed no:
Marital Status:
Diagnosis:
Doctor’s Name:
Name of Surgery:
Date of Surgery:
Date of Data Collection:
Name of Hospital:
Date of discharge:
CHIEF COMPLAINTS

PRESENT MEDICAL HISTORY:

PRESENT SURGICAL HISTORY:

PAST MEDICAL HISTORY:

PAST SURGICAL HISTORY:


FAMILY HISTORY

Sr. No Name of Age Sex Relation Education Occupation Marital Health


family (yrs) with status status
members patient

PEDIGREE CHART/ FAMILY CHART

PERSONAL HISTORY
 Nutrition
 Hygiene:
 Rest/sleep
 Bowel and bladder:
 Habits:
 Exercise:
 Allergies

MENSTRUAL HISTORY :( if female patient )


 Age of menarche
 Cycle
 Amount of bleeding
 Menstrual disorder
 Treatment taken---------------------
MARITAL HISRORY
 Age of marriage
 Year of marriage
 Contraceptive history
 Primary infertility
 Secondary infertility

SOCIO-ECONOMICAL STATUS
 Income:
 Housing:
 Ventilation:
 Electricity:
 Drainage:
 Water supply

LABORATORY INVESTIGATIONS
Sr. Date Investigation name Normal Patients Remark
No. value value

OTHER INVESTIGATIONS
MEDICATION HISTORY

Sr. no. Medication name Dose/ frequency route action


PHYSICAL EXAMINATION
General Appearance
 Level of Consciousness:
 Orientation:-To Place/ Person/Time:
 Activity:,
 Body Built:
 Hygiene:

REMARK: -

Anthropometric Measurement
 Height:
 Weight:
 BMI
Vital Signs
 Temperature:
 Pulse:
 Respiration:
 Blood Pressure:
Head and Face
 head circumference
 size and shape of the skull
 apperence of face
 hair
 colour of hair
 scalp
 pediculosis:
 facial symmetry:
 facial puffiness:

Eyes
 Vision
 Eyebrows:
 Eye Lid
 Lashes:
 Eye Ball:
 Conjunctiva:
 Sclera:
 Cornea:
 Iris:
 Pupils:
 Inflammation:

Nose
 symmetry
 deformity
 plarring
 inflammation
 discharge
 pattency of nostril
 epistaxin any nose surgery
 nasal septum:
 nasal polyp:
 Sinuses:
 Nasal Discharge:

Mouth
 Number of Teeth:
 Dentures :
 Dental Carries:
 Odour of Mouth:
 Gums:
 Pharynx
 Togue
 Voice:
 Halitosis
 Thyroid glands
 Oral Hygiene
 Buccal Mucosa
 Lips:

Ears
 Size:
 Ear wax
 Shape
 Position And Alignment:,
 Redness:
 Discharge:
 Cerumen:
 Lesions:
 Vertigo
 Foreign Body:
 Hearing Acuity:
 Use of Hearing Aids:
 Any ear surgey

Respiratory System
 Chest posture
 Shape and symmetry
 Respiration rate
 Rhythem
 Cough
 Sputum
 Amount and colour of sputum
 Hemophysis
 Lung expansion
CARDIOVASCULAR SYSTEM

 pulse rate
 rhythem
 peripheral pulse
 blood pressure
 hyper/hypotension
 colour of skin
 cynosis numbness
 tingling
 edema
 palpitataion

GASTROINTESTINAL SYSTEM

 skin integrity
 appetide
 digestion
 peristalsis
 bowel sound
 nausea and vomiting
 abdominal pain
 constipation
 diarrhea
 melena

GENITOURINARY SYSTEM

urination (frequency ,amount and colour )


 characterstic :-
 urinary pattern :- ( urgency , retension)
 dysuria
 buring micturation
 hematuria
 bladder tenderness
 epididymis
 prostate gland
 perineal area

NEUROLOGICAL SYSTEM

 level of conciousness
 oriented
 headache
 incordination
 paresthesia
 tingling and numbness
 paralysis
 memory
Musculo Setal System

 general appearance
 Body symmetry
 Gait
 Pattern
 Muscle tone
 Joint pain
 Posture
 Range of Motion:
 Joint Swelling :
 Weakness / Paralysis / Contracture :
 Immobility
 Coordination
 Changes of daily activity

INTEGUMENTARY SYSTEM

 overall appearance
 colour
 skin texture
 skin temperature
 skin integriy
 tutor
 lesion
 rashes
 sores
 blewish discoleration
 pigmentation
NURSING DIAGNOSIS
NURSING CARE PLAN

Assessment Nursing Goal Planning Rational Implementation Evaluation


Diagnosis

Assessment Nursing Goal Planning Rational Implementation Evaluation


Diagnosis

Assessment Nursing Goal Planning Rational Implementation Evaluation


Diagnosis
Assessment Nursing Goal Planning Rational Implementation Evaluation
Diagnosis

Assessment Nursing Goal Planning Rational Implementation Evaluation


Diagnosis
HEALTH EDUCATION

REGARDING NUTRIOTION:

REGARDING HYGIENE:

REGARDING EXERCISE:

REGARDING REST AND SLEEP

FOLLOW UP:
PROGNOSIS

DAY-1

DAY-2

DAY-3

DAY-4

DAY-5
SUMMARY

BIBLIOGRAPHY

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