2. Identification data:-
· Name of patient
· Age/sex
· Marital status
· Religion
· Languages
· Educational status
· Occupation
· Nationality
· Address
· Date of admission
· Hospital ID no.
· Ward & bed no.
· Provisional diagnosis
· Consultant
· Date of discharge
3. Data collection:- INFORMER -
· Present medical history
· Past medical history
· Present surgical history
· Past surgical history
· Family medical history – genetic & communicable
· Family history, family tree
5. Personal history
ü Diet
ü Sleep & rest
ü Use substance such as alcohol, drugs, tobacco etc.
PHYSICAL EXAMINATION:-
DATE –TIME –
ØVital sign –
ü Temperature
ü -Respiration
ü -Pulse
ü -Blood pressure
ØAnthropometric measurement
ü Height (cm)
ü Weight (kg)
ØGeneral appearance
ü Body build
ü Nourishment
ü Posture
ü Activity
Ø Mental status
ü Consciousness –conscious, semiconscious & unconscious
ü Orientation
ü Mood & effect
ü Memory
ü Behavior
Ø Skin –
ü Color- bluish, pallor, yellow & pink
ü Moisture- wetness, oily
ü Texture- smooth or rough, thick or thin
ü Turgor – poor or good
ü Edema- pitting, generalized
ü Lesions-wound, papules, vesicles etc.
Ø Head –
ü Hair- color, distribution & alopecia
ü Scalp –dandruff, lesions, infection
Ø Eyes-
ü Symmetry-
ü Eye brows –normal or absent
ü Eye lashes –infected or not
ü Eye lids- edema, lesions, eversion, entropion, inversion
ü Eye balls – sunken or protruded
ü Conjunctiva- color or infected
ü Pupils- reaction
ü Sclera- color
ü Cornea-
ü Ophthalmoscope( Retina)-
ü Visual acuity
Ø Mouth –
ü Lips- dry or wet ( infected)
ü Tongue- dryness, color, patches
ü Teeth- carries, equality & dental plaque
ü Odors-
ü Gums-
Ø Ear-
ü External ear-
ü Internal ear(otoscope)-
ü Hearing capacity.
Ø Nose-
ü Nasal septal-
ü Discharge-
ü Mucosa- redness, dryness, nasal polyps
Ø Neck-
ü Range of motion-
ü Tonsils-
ü Thyroid gland-
ü Lymph nodes-
Ø Chest –
ü Breast examination( in female)
ü Inspection-symmetry, Shape
ü Palpation-tenderness, hardness or mass
ü Percussion-fluid collection
ü Auscultation-heart sound, breath sound
Ø Back-
ü Spinal cord-
ü Posture- lordosis, kyphosis or scoliosis?
Ø Abdomen-
ü Inspection-distention, color, rashes or dilated vein
ü Palpation-tenderness, enlargement of organs
ü Percussion-fluid or gas collection
ü Auscultation-bowel sound
Ø Extremities-
ü Nails-shape, hemorrhage, clearance
ü Fingers- clubbing of fingers, ankle edema & varicose vein.
ü Movement- joint, types of abnormality
NEROLOGICAL EXAMINATION:-
ü Reflexes- deep tendon or superficial
ü Test of sensation-
Genitalia-
Male -
ü Inguinal lymph node- enlarged or palpable.
ü prostate gland- enlarged
Female-
ü Vaginal discharge-
ü Vulvar examination-
Anatomy & physiology:-
Disease condition:-
Introduction
Definition
Etiology
Pathophysiology
Clinical manifestation-
Management:-
Diagnostic evaluation-
Nursing management-Surgical management-
Journal study:-
LAB INVESTIGATION
· X-ray:-
· USG:-
· ECG:-
· OTHER SPECIFIC INVESTIGATION:-
INTAKE OUT PUT CHART
NAME OF PATIENT- IP NO.-
AGE& SEX- WARD-
FLUID BALANCE = TOTAL INTAKE – TOTAL OUTPUT
1STday care
Date- time-
Vital sign-
Temperature-
Pulse-
Respiration-
Blood pressure-
List of problem :-
1. .
2. ..
3. …
Nursing diagnosis:-
1. .
2. ..
3. …
2ND DAY CARE:-
3RD DAY CARE:-
4th DAY CARE:-
5TH DAY CARE:-
HEALTH EDUCATION:-
SUMMARY:-
CONCLUSION:-
BIBLIOGRAPHY:-(ATLEAST 4 BOOK AND 2 JOURNAL)
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