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The document outlines a comprehensive patient assessment form that includes sections for medication, vital signs, physical assessment, family health history, and nursing history. It provides a structured approach for documenting patient conditions, interventions, and findings across various body systems. Additionally, it includes patient demographic information and objectives for the nursing case study.

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yaduvanshishivii1107
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8 views20 pages

Adobe Scan Feb 28, 2022

The document outlines a comprehensive patient assessment form that includes sections for medication, vital signs, physical assessment, family health history, and nursing history. It provides a structured approach for documenting patient conditions, interventions, and findings across various body systems. Additionally, it includes patient demographic information and objectives for the nursing case study.

Uploaded by

yaduvanshishivii1107
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

1R

S.No Name.of Drug


Action
MEDICATION CHARI DATE:
ose Roul Frequenc Nursing intervention Side effect
-
te

ACCORDING TO
S. NO. CONTENT ACCORDING TO
SUBJECT MATiER
PATIENTCONDITION
DISEASE DISCRIPTION
ACCORDING TO
S. NO. CONTENT ACCORDING rO SUBJECT MATT ER PATIENT CONDITION
LABORATORYINVESTIGAT
REMARKK
NORmAL VALUES
S. No. NAME OF INVESTIGATION R6SULTS
20. UPPER EXTREMITIES
RANGE OF MOTION

ANY CONGENITAL

MALFOLMATION

. ANY OTHER

21. LowER EXTREMITIES

AUSCU1.TATION RANGE
OF MOTOON

ANY CONGENITAL

MALFORMATION

ANY OTIER
22. OTHER:

VITALSIGNS

S.No. VITALS NORMAL DAY PAT ENT REMARK


VALUE FIND NGS

1. TEMPERATURE

PULSE RATE

RESPIRATORY
RATE

BILOOD
PRESSURE
15. CARDIO VASCUIAR

SYSTEM:
INSPECTION

PALPATION

PERCUSSiON

AUSCULTATION

16. NERVOUS SYSTEM:

FHiGIER FUNCTION
REFLEXES

17. ABDOMEN

INSPECTION

PALPATION

PERCUSSiON
AUSCULTAITON

18. BACK:

SPINE AND CURVATURE

MOvEMENT

INSPECTION

PALPATION

PERCUsSION

AUSCULTATION

19, GENITUURINARY
ExTERNAL GENITALIA

ANY DISCHARGE
ANY SIGN/sYMPTOMS

OF INFFCTION
11. MoUTH AND THROAT: -

LIPS,
TONGUE

TEETH

GUMS

BUCCAL MUCOSA

TASTEB

12. NECK:

LYMPH NODES
THYROID GLAND

VENOUS DILATION

ARTERIAL PULSATION

ANY CYSTS OR

TUMOURS

13. BREAST:

ANY TENDERNESS

LUMP
ANY DISCHARGE

14. CHEST AND RESPIRATORY

SYSTEM:
INSPECTION

PALPATION

PERCUSSION

AUSCULTATION
FACE

SYMMETRY

EXPRESSION

DEFORMITY
ANY OTHER

8. EYES:

EYE sYMMETRY
EYE BROWS
EYELIDS

EYELASHES
LACHRYMAL GLAND
CONJUNCTIVA

BLINKING SYMMETRY

9 EARS
APPEARANCE

HEARING

DIsCHARGE

10. NoSE:

APPEARANCE
SYMMETRY

DIsCHARGE
PATENCY

NASAL SEPTUM
MucosA & CILIA

SENSE OF SMELL
PHYSICALASSESSMENT
SIGNIFICANCE
ASSESSMENT AREAS FINDINGS
1. GENERAL APPEARANCE

cOLOR

BODY BUILT
NOURISHMENT

2. MENTAL STATUS AND SPEECH

3. ANTHROPOMETRIC
MEASUREMENTS
HIGHT

WEIGHT

4. PoSTURE

BODY CURVES

MoVEMENTS

SKIN AND Mucous


MEMBRANE
COLOUR OF SKIN

EDEMA

.MoiSTURE&
TEMPERATURE

.TURGOR

ANY OTHER CHANGES

6. HEAD:

SCALP

HAIR

FOREHEAD

ANY SCAR
3)FAMILY HEALTH HISTORY

4) FAMILY TREE
5) SOCIO-ECONOMICAL STATUS

6) PERSONAL HISTORY
NUTRITIONAL METABOLIC PATTERN

ELIMINATION

ACTIVITY AND EXERCISE

REST AND SILEEP PAITERN

RELIGIOUS/CULTURALBELIEE

OCCUPATIONAL HISTORY

HABITS.IEANY
NURSING HISTORY
1)HISTORY OF PRESENT ILLNESS

2)PAST HISTORY OF ILLNESS


PATIENTS PROFILE
NAME

2. FATHER's/ HUSBAND'SNAME

3. AGE & SEX

4 EDUCATION

5. OccUPATION

6. OccuPATION OF FATHER'S/HUSBAND 'S

7. MARITAL STATUS

8. RELIGION

9. ADDRESS

10. NAME 0F HOSPITAL

11. OPD NO.

12. IPD NO.

13. WARD NAME

14. BED NO.

15. DATE OF ADMISSION

16. DATE OF SURGERY

17. DR. CONCERNED

18. MEDICAL DIAGNOSIS

CHIEFCOMPLAINIS OR PROBLEMS
OBIECTIVES
1) GENERAL OBIECTIVE:

2) SPECIEICOBIECTIVES:
RAJASTHAN COLLEGE OF NURSAING, DAk USA
SOMNATH NAGAR, GANESHPURA ROAD, DAUSA

CASE STUDY
On

SUBMITTED
TO

SUBMITTED BY

DATE OF SUBMISSION

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