NURSING CASE STUDY GUIDELINE

 NURSING CASE STUDY GUIDELINE

1.   Introduction:-

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

 4.   Socio economical history

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-

Medical management-

Nursing management-Surgical management-

Journal study:-

LAB INVESTIGATION

·       X-ray:-

·       USG:-

·       ECG:-

·       OTHER SPECIFIC INVESTIGATION:-

MEDICATION CHART

INTAKE OUT PUT CHART

NAME OF PATIENT- IP NO.-

AGE& SEX-                                 WARD-

DATE-                                                    DIAGNOSIS-

FLUID BALANCE = TOTAL INTAKE – TOTAL OUTPUT

1^STday care

Date-                                                          time-

Vital sign-

Temperature-

Pulse-

Respiration-

Blood pressure-

List of problem :-

1.        .

2.        ..

3.        …

Nursing diagnosis:-

1.        .

2.        ..

3.        …

2^ND DAY CARE:-

3^RD DAY CARE:-

4^th DAY CARE:-

5^TH DAY CARE:-

HEALTH EDUCATION:-

SUMMARY:-

CONCLUSION:-

BIBLIOGRAPHY:-(ATLEAST 4 BOOK AND 2 JOURNAL)