College of nursing , Pt.
DDU, UHS Karnal,kutail
Case study on
SUBMITTED TO SUBMITTED BY
Date of Submission:-
Introduction
A. General information
House no.------
Name of informer-
Name of the head of the family-
Address- Village-.
Types of the family-
Size of the family-
Religion-
Caste--
Mother tongue-
B. Demographic characteristics
S. Name of the Relation of Age Sex Education Occupation Heath
No member head Status Status status
1.
2.
3.
4.
Family tree:-
C. HISTORY OF THE PATIENT ILLNESS
Past medical history:-
.
Past surgical history :
Present history of illness:-.
PLAN FOR HOME VISIT
Sr No. Name of the Date Needs/problems prevention Short- Long –term goal
beneficiary term goal
1.
E) HOUSING AND ENVIRONMENTAL CONDITION
Type of house
Roof Thatched/thatti /tiled/terraced/others
Floor Mud/tiled/cemented/others
Wall Thatti/mud/brick/cement plastered/others
Housing pattern Pucca/semipucca/kutcha/others
Possession Own house/ rental house/ leased
Area ( square feet) Adequate/ inadequate
Ventilation Natural/artificial
Number of rooms ……
Doors and windows Adequate/ inadequate
Electricity Available/ not available
Mode of light Oil lamp/ kerosene/ electric bulb/others
Water supply Adequate/ inadequate
Mode of water supply Well/ public tap/ hand pump/ others
Latrine Service/ water seal/ open field
Drain Open/ closed/nill
Street light Yes/ no
Street road condition Cement/ tar/ mud/ others
Types of fuel use Firewood/ kerosene/ gas/ cow dung/ biogas
Open space around the Yes/no
house
Garden Yes/no
Water stagnation Yes/no
Disposal of waste Drum/open space/ manure pit/burning/ throwing into
street/ separate
Livestock and poultry Available/not available
if available
Health care facility GH/PHC/SC/ private doctors/others
Medical aids available Doctor/homeo/ sidda/ village vaidyas/others
in the street
Playground in the street Available/ not available
Social institution Bank/ post office/ police station/ market/ transport
Education institution Primary school/ secondary school/ HSS/ College/ Night
school/ Adult school
Religious institution Temple/ church/ mosque/others
Presence of rodents Yes / No
Presence of stray dogs Yes/ No
Presence of domestic Yes/No
animal
Presence of insects Yes/ No
F) ECONOMIC CONDITION
Income:-
Source of income:-
Number of earning members:-
Expenditure:-
Rent:-
Food:-
Heath:-
School:-
Miscellaneous:-
Own properties:-
G) TRANSPORTATION:-
Bus
Auto rickshaw
Four wheelers
Train
Airway
H)COMMUNICATION :-
Face-to-face
Mobile
Telephone
Through latter
Internet
I) PERSONAL HOBBIES
Recreational activity:-
J) NUTRITIONAL STATUS
SL.
No.
1 Dietary pattern
2 Frequency of non- vegetarian
3 Food habit: Number of meals
4 Cooking method
5 Staple food
6 Sources of food
items( vegetables)
7 Storage of food items 1.
8 Usage of processed food items
Amount allotted for nutrition
Use of vegetables:-
Fruits/ vegetable:-
Cereals/pulses/nuts:-
Cooking demonstration:-
K)Maternal and child health
Relation of family members.
Within the family members –
Within the other members of the community- .
With health personal-
L) Vital events:----------
M) General Health of family
1. Personal hygiene :-------
2. Physical health –
N). BENEFICIARY DATA
NAME OF BENEFICIARY:-
AGE:
SEX:
PHYSICAL EXAMINATION
General appearance
Nourishment:-
Body built:-
Health:-
Activity:-
Mental status
Consciousness:-
Look:-
VITAL SIGNS
Vital signs
Temperature Pulse Blood pressure Respiration
ANTHROPOMETRIC MEASUREMENTS
Height or length (cm):- --- cm
Chest circumference (cm):- -----cm
Midarm circumference (cm):----- cm
Body mass index (BMI):-
Skin condition:-
Color:-
Texture:-
Lesion:-
Sensation:-
Weight:- ----- kg
HEAD AND FACE:-
Scalp:-
Face:-
EYES, EARS AND NOSE
Eyes brows:-
Eyelashes:-
Eyelids:-
Eyeballs:-
Conjunctiva:-
Lens:-
Vision:-
Nose
External nose:-
Nasal septum:-
Sinuses:-
Ears
External ear:-
Tympanic membrane:-
Hearing acuity:-
Mouth:-
Lips:-
Odor:-
Teeth:-
Tongue:-
Speech:-
Neck:-
Thyroid gland and lymph:-
Node enlargement:-
CHEST:
Inspection:-
Palpation:-
Percussion:-
Auscultation:-
ABDOMEN:
Inspection:-
Palpation:-
Percussion:-
Auscultation:-
BACK (vertebral column):- mention any abnormal posturing/lordosis/scliosis/ kyphosis:-
GENETALIA:-
INVESTIGATION
History taking
Physical Examination
History of illness
Examination of stool
Hemoglobin test
MEDICATION
Sr. medication Route/ Action Side effect Remarks
No. Amount
1.
2.
3.
4.
5.
6.
BOOK DESCRIPTION OF DISEASE OR LITERATURE
Definition:-
Path physiology:-
Clinical manifestation
In book In patient
,
Nursing diagnosis:
.
NURSING CARE PLAN
ASSESSMEN DIAGNOSIS PLANNING IMPLEMENTATION EVALVATION
T
Subjective Data
Objective data
Health talk on condition
.
Bibliography :
