NOOTAN COLLEGE OF NURSING
VISNAGAR
THIRD YEAR B.SC NURSING
EVALUATION FORM FOR CASE STUDY
NAME OF STUDENT:
SUBJECT:
AREA OF HOSPITAL EXPERIENCE:
PERIOD OF EXPERIENCE:
Sr. No Content Maximum Obtained
marks marks
1 History taking & physical
examination 08
2 Medication 08
3 Diagnostic test 08
4 Disease Condition 28
5 Growth And Development 32
6 Nursing care plan 10
7 Health education & progress notes 04
8 Reference 02
TOTAL 100
SIGNATURE OF SUPERVISOR: SIGNATURE OF STUDENT:
64
CASE STUDY
HISTORY TAKING
IDENTIFICATION DATA:
Name of the Patient :
Age :
Sex
:
Father’s occupation
Education
Date of admission
Source of information
Diagnosis
Present complaints
PRESENT MEDICAL HISTORY:
65
PAST MEDICAL HISTORY:
PAST SURGICAL HISTORY
FAMILY HISTORY:
FAMILY TREE:
66
FAMILY HISTORY:
NO. NAME AGE RELATION EDUCATION OCCUPATION HEALTH
STATUS
SOCIO ECONOMIC DATA:-
IMMUNIZATION HISTORY
67
FUNCTIONAL HEALTH PATTERN
Hygiene
Activity/Exercises:-
Rest/Sleep
Elimination Pattern:-
Cognitive / Perceptual:-
Self perception / self concept pattern:-
Coping stress tolerance:-
Personal habits:-
68
PHYSICAL EXAMINATION
GENERAL INFORMATION:
NOURISHMENT:
BODY BUILT:
VITAL SIGN:
TEMPERATURE:
PULSE:
RESPIRATION:
B.P.:
ANTHROPOIMETRIC MEASUREMENT
S.no. Measurement Patient’s value Normal Value Remarks
1 Height
2 Weight
3 Head Circumference
4 Chest Circumference
5 Mid Arms Circumference
DEVELOPMENT:
1 GROSS MOTOR
69
2 FINE MOTOR
3 SENSORY
4 PSYCHOLOGICAL
5 INTELECTUAL
6 SPEECH & LANGUAGE
70
7 PLAY
8 NUTRITION
9 IMMUNIZATION
Age Immunization Taken Not taken Remarks
At 6 Wks BCG & OPV
BCG ( If not taken )
At 10 Wks DPT-1,OPV-1, &
Hepatitis B-1
DPT-2,OPV-2 &
Hepatitis B- 2
At 10 Wks
At 14 Wks DPT-3, OPV- 3 &
Hepatitis B -3
At 9 months Measles
At 16-24 DPT & OPV (
months BOOSTER)
At 5- 6 Years DT
At 10 & 16 TT
yrs
71
SKIN CONDITION:
COLOUR:
TEXTURE:
LESIONS:
HEAD & FACE:
LESIONS
SCAR
HAIR DISTRIBUTION
HAIR COLOUR:
EYE:
EYE BROWS:
EYELASHES:
EYE LIDS:
EYE BALLS:
CONJUNCTIVA:
SCLERA:
CORNEA & IRIS:
PUPIL:
LENS:
EARS:
EXTERNAL NARES:
NOSTRILS:
MOUTH & PHARYNX:
LIPS:
Cleft lips/palate;
TEETH:
72
MUCUS MEMBRANE& GUMS:
TONGUE:
THROAT & PHARYNX:
NECK:
LYMPH NODES:
CHEST:
THORAX:
BREATH SOUNDS:
HEART:
BREAST:
ABDOMEN:
INSPECTION:
AUSCULTATION:
PALPATION:
PERCUSSION:
EXTREMITIES:
MOVEMENT OF JOINTS:
CLUBBING OF FINGERS:
OEDEMA:
BACK & SPINE:
CURVES:
MOVEMENT:
73
GENITALS & RECTUM:
INGUINAL LYMPH GLANDS:
PATENCY OF URINARY MEATUS & RECTUM (IN INFANT):
DESCENT OF TESTES (IN INFANT):
VAGINAL DISCHARGE:
PRESENCE OF STDs:
NEUROLOGICAL TESTS:
REFLEXES:
74
SYSTEMIC EXAMINATION:
CENTRAL NERVOUS SYSTEM:
CARDIO-VASCULAR SYSTEM:
RESPIRATORY SYSTEM:R
MUSCULO-SKELETON SYSTEM:
DIGESTIVE SYSTEM:
75
GENITO-URINARY SYSTEM:
INVESTIGATION
1). BLOOD/URINE/ANY OTHER BODY FLUID
NAMEOF NORMAL
DATE PATIENT VALUE REMARK
INVESTIGATIONS VALUE
76
MEDICATION
Pharmacological
Dose/ Mechanism of
Name/ Trade Indication Contra- Indications Side-Effects Nurses responsibility
Route Action
Name
77
78
MEDICATION
Pharmacological
Dose/ Mechanism of
Name/ Trade Indication Contra- Indications Side-Effects Nurses responsibility
Route Action
Name
79
MEDICATION
Pharmacological
Dose/ Mechanism of
Name/ Trade Indication Contra- Indications Side-Effects Nurses responsibility
Route Action
Name
80
Anatomy and physiology:-
81
DISEASE CONDITION
Introduction:-
Definition;-
Etiology
82
Pathophysiology
83
Clinical Manifestations:-
Book Picture Patient picture
84
Diagnostic Tests:-
Book Picture Patient picture
85
MANAGEMANT:-
Medical Management:-
Book Picture Patient picture
86
Book Picture Patient picture
87
Other Management:-
Complication:-
88
NURSING PROCESS:-
List of Nursing Diagnosis:
89
NURSING CARE PLAN
Nursing Nursing Expected
Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come
90
Nursing Nursing Expected
Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come
91
Nursing Nursing Expected
Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come
92
Nursing Nursing Expected
Planning Intervention Rational Evaluation
Assessment Diagnosis Out Come
93
NURSES NOTES
Name of the patients:- Diagnosis;-
Age/Sex: - Name of Surgery:-
Date of Admission; - Date of Surgery:-
Ward/Bed no.:- Dr. In charge:-
Nursing
Date Diet Medication Time Nursing Care Remarks Sign
Observation
94
Nursing
Date Diet Medication Time Nursing Care Remarks Sign
Observation
95
Nursing
Date Diet Medication Time Nursing Care Remarks Sign
Observation
96
HEALTH TEACHING:
PROGRESS OF PATIENT:-
97
SUMMARY:-
CONCLUSION:-
98
BIBLIOGRAPHY:-
SIGNATURE OF EVALUATOR SIGNATURE OF
STUDENT
