Nursing CASE Study Format PDF

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NURSING CASE STUDY FORMAT

ACKNOWLEDGEMENT Myself _________ student of ___________ in __________ College of Nursing. During my ____________ clinical experience, I came to know about many new things and procedure. During this period, in the ________ward, I make a case study on a patient __________, who is suffering from ________. I am very thankful of my teachers and the ward sisters who help me for the completion of my case study.

INTRODUCTION Myself _______ student of ________ in _______ College of Nursing. During my ________ Clinical Experience, I got a chance to give care to the patient _________ in ________. Through this case study, I explained about the definition, etiology, clinical manifestations, investigations, medical and nursing management of the disease condition. 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

1 2 3 4 

Family Tree:



Personal History:  Dietary habits: vegetarian/ non vegetarian.  Addiction: history of smoking, drug addiction, alcohol consumption, etc.  Socio-economic status:

Lab investigations: S.No. Name of test

 Vital Signs: S. No. Vital signs

Normal value

Normal value

Patient value

Patient’s value

Remarks

Remarks

1 2 3 4 

   

Medications: trade name, pharmacological name, action, route, dose. frequency.

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: ANATOMY AND PHYSIOLOGY: (for e.g. heart)

DISEASE CONDITION: (for e.g.- Aortic stenosis) Definition: Etiology: Pathophysiology:

Clinical Manifestations: Book Picture For e.g. Dizziness, fainting

Patient Picture Present

Diagnostic Tests: Book Picture For e.g. CBC

Patient Picture Done

Management: Medical Management: Book Picture

Patient Picture Given i.e. vancomycin

For e.g. Antibiotics

Surgical Management: Book Picture

Patient Picture Not done

For e.g. Valve replacement Complications: Nursing Process: Day 1 Needs

S. No.

Problems

1 2

Nursing diagnosis: Nursing care plan: Assessment

Nursing diagnosis

S. No. 1 2

Nursing diagnosis:

Goals

Interventions

Nursing Process: Day 2 Needs

Implementations

Rationale

Problems

Evaluation

Nursing care plan: Assessment

Nursing diagnosis

Goals

Interventions

Implementations

Nursing Process: Day 3 Needs

S. No.

Rationale

Evaluation

Problems

1 2

Nursing diagnosis: Nursing care plan: Assessment

  

Nursing diagnosis

Goals

Interventions

Implementations

Rationale

Evaluation

Theory application: Roy’s AdaptationIn this model the person is viewed as an adaptive system; nursing intervention is needed when there is a deficit between the adaptation level and environment demands. The major concepts areRegulator Cognator Adaptive Adaptation is the process of coping with external and internal stimuli. It is determined by the effects of three classes of stimuli- focal, contextual, and residual. Health education: Discharge plan:

Summary:

Bibliography: http://infokreek.blogspot.com/2017/08/nursing-case-study-format.html...