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Case Study Format

This document outlines a standardized format for collecting a patient's medical history and performing a physical assessment. It includes sections for biographical data, medical history, family history, assessment of each body system, vital signs, case studies, and nursing care plans. The format is comprehensive and allows for documenting all relevant healthcare information about a patient in an organized manner.

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Akansha gandharv
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205 views

Case Study Format

This document outlines a standardized format for collecting a patient's medical history and performing a physical assessment. It includes sections for biographical data, medical history, family history, assessment of each body system, vital signs, case studies, and nursing care plans. The format is comprehensive and allows for documenting all relevant healthcare information about a patient in an organized manner.

Uploaded by

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

BIOGRAPHICAL DATA
 Name
 Age
 Sex
 Marital status
 Hosp. ID No.
 Ward/Bed No.
 Address
 Telephone No.
 Religion
 Education
 Occupation
 Monthly Family Income
 Admission Date
 Discharge Data
 Diagnosis
 Surgery
 Date Of Surgery
 Name Of Dr.

HISTORY OF PATIENT
 Chief complaints
 Hist. Of Present Illness
 Hist. Of Past Illness
 Family History
Name Of Age Sex Education Occupation Relationship Health
Family Status
Member

 Family Tree/ Genogram

 Vocational/ Educational/ Financial History


 Type Of Work
 Type Of Education
 Financial Well Being
 Impact of illness

 Social/ Leisure/ Spiritual/ Cultural History


 Description Of Social Life
 Leisure Interests
 Religious beliefs/ practices
 Impact of illness

 ADL[Activity Of Daily Living]


 Description of daily activity pattern
 Impact of illness

 Health Habits
 Tobacco, Alcohol, Other Drug Use
 Diet/ Description Of Daily Intake
 Mobility And Exercise Pattern
 Sleep Pattern
 Elimination
 Hygienic Practices

 Psychological history
 Stressor/ Self Concept

 Menstrual History
 LMP

 Sexual And Marital History


 General Health
 Occupation
 Relationship
 Staying together
 No. Of Children
 General Health

HEAD TO TOE ASSESSMENT


General assessment
 Dependency Level
 Completely/partially dependent or independent
 Tubings/ catheters attached

 Physical appearance
 Body Build
 Sensorium And Mental Status
 Bromhidrosis/ Halitosis
 Speech
 Posture
 Gait
 Movement
 Energy Level
 Wt.
 Ht.
 BMI

Vital Signs
 Temp.
 Pulse
 Resp.
 BP
 Pain

Integument
SKIN
 Color
 Vascularity
 Lesions
 Temp.
 Moisture
 Turgor
NAILS
 Shape
 Texture
 Angle
 Color
HAIR AND SCALP
 Skull
 scalp

Head And Neck


 Face
 Lymph Nodes
 Thyroid Gland
 ROM

Eyes
 Eye brows
 Eye lashes
 Eye lids
 Eye balls
 Conjunctiva
 Sclera
 Iris
 Corneas
 Pupil
 PERRLA
 Lens And Fundus
 Muscles
 Vision
Ears
 Ext. ear
 Tympanic membrane
 Hearing

Nose
 Ext. nares
 Nostrils

Mouth And Pharynx


 Lips
 Teeth
 Mucous membranes
 Gums
 Tongue
 Throat And Pharynx

Breast And Axilla


 Shape
 Symmetry
 Skin
 Areola
 Nipple
 Axillary, subclavicular, supraclavicular lymph nodes

Thorax And Lungs


 Ant. Thorax

Cardiovascular And Peripheral Vascular


System
INSPECTION
 Precordium
 Configuration
 Pulsation
 Jugular Veins
 Peripheral Veins
PALPATION
 Carotid Artery
 Pulsations
AUSCULTATION
 Carotid Artery
 Precordium

Abdomen And Gut


 Inspection
 Auscultation
 Percussion
 Palpation

Anus And Rectum


Genito-urinary System
 Inspection
 Palpation

Musculoskeletal System
 Inspection
 Palpation

Neurological System
 Gross Motor And Balance Tests
 Touch Sensation
 Pain Sensation
 Position/ Kinesthetic Sensation
 Mental Status
 Cranial Nerves
 Sensory System
 Reflexes

CASE STUDY
 Introduction
 Definition
 Etiology
In Book In Patient

 Risk Factors
In Book In Patient

 Anatomy/Physiology
 Pathophysiology
 C/F
In Book In Patient

 Diagnostic Evaluation
In Book In Patient
 Radiological
 Laboratory

Investigation Patient’s Value Normal Value Remarks


 Radiological
 Laboratory

 Management
1) Medical
2) Surgical
3) Nursing

Medical management
In Book In Patient
 Pharmacological
 Non – pharmacological

Drug Dose Route Frequency Action Side Nurse’s


Effects Role

Surgical Management
In Book In Patient

Nursing Mangement
 List of nursing diagnoses based on priority needs
 Nursing process
Assessment Nursing Goal Nursing Rationale Implementation Evaluation
Diagnosis Intervention

 Complications
In Book In Patient

 Health Education
 Summary And Discharge Planning
 Bibliography/References

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