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RADHA GOVIND INSITUTE OF NURSING SCIENCES, MEERUT

Case Study
Demographic data:

Name:-
Age:-
Gender:-
Date of birth:-
Address:-
Education:-
Occupation:-
Marital status:-
Religion:-
I.P.D NO:-
Ward no:-
Date of admission:-
Provisional diagnosis:-
Final diagnosis:-
Name of surgery:-
Date of surgery:-
Type of anesthesia:-
Allergic To:-
Date of discharge:-
Chief complaints:-

A. Brief socioeconomic history

1. Personal history:-
Generalappearance:-
Habbits:- Hobbies:-
History of past illness:-
History of present illness:-
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2. Family history:-
Nuclear / joint family:-
Members:-
Hereditary / communicable disease:-

Family tree:-

- Male

- Female

- Patient

Family composition:-

S.NO NAME OF THE PERSON RELATION SHIP WITH AGE SEX EDUCATION OCCUPATION HEALTH
PATIENT STATUS

3. Socio economic history:-Bread

winner:- Monthly income:-

Relationship with others:-

4. Past medical history:-

5. Present medical history:-
6. Past surgical history:-
7. Present surgical history:-
8. Nutrition history:-
Vegetarian / non- vegetarian:-Body
built:-
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Well balance diet:-

Any restriction if yes why:-
9. Elimination history:-
Bowel pattern:-
Bladder pattern:-

10. Menstrual & obstetric history:-Menstrual

history:- Obstetrical history:-

B. PHYSICAL EXAMINATION
Head to toe examination:-
 General appearance:-
 Nourishment:- Well- nourished or under nourished
 Body build:- Thin or obese
 Health:- Healthy or unhealthy
 Activity:- Active or dull (Tired).
 Mental status:-
 Consciousness:- Conscious, unconscious, delirious,talking
incoherently
 Look:- Anxious or depressed etc.
 Posture:-
 Body curves:-
 Lordosis:-
 Kyphosis:-
 Scoliosis:-
 Movement:- Any limp.
 Anthropometric measurement:-
 Height:-
 Weight:-
 Vital signs:-
 Temperature:-
 Pulse:-
 Respiration:-
 B.P
 skin:-
 Color:- pallor, Jaundice, cyanosis, flushing, etc.
 Texture:- Dryness, flaking, wrinkling or excessivemoisture
 Temperature:- Warm, cold, and clammy
 Lesions:- Macules, papules, vesicles, wounds, etc,
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 Head and face:-

 Shape of the skull and fontanel:-
 Skull circumference:-
 Scalp:- Cleanliness, condition of the hair, drandruff,pediculi,
infections like ringworm
 Face:- Pale, flushed, puffiness, fatigue, pain, fear,anxiety,
enlargement of parotid glands, etc.
 Eyes:-
 Eye brows:- Normal or absent
 Eye lashes:- Infection, sty
 Eye lids:- Edema, lesions, ectropion, entropion
 Eye balls:- sunken or protruded
 Conjunctiva:- Pale, red, purulent
 Sclera:- jaundiced
 Cornea and iris:- Irregularities and abrasions
 Pupils:- Dilated, constricted reaction to light
 Lens:- Opaque or transparent
 Fundus:- Congestion, hemorrhagic spots
 Eye muscles:- Strabismus (squint)
 Vision:- Normal, myopia, hypermetropia

 Ears:-
 External ear:- Discharges, cerumen obstruction the earpassage
 Tympanic membrane:- Perforations, lesions, bulging
 Hearing:- Hearing acuity

 Nose:-  External nares:- Crusts or discharges

 Nostrils:- Inflammation of the mucus membrane, septaldevations.
 Mouth and pharynx:-
 Lips:- Redness, swelling, crusts, cyanosis, angularstomatitis
 Odor of the mouth:- Foul smelling
 Teeth:- Discoloration and dental caries
 Mucus membrane and gums:- Ulceration and bleeding,swelling, pus
formation
 Tongue:- Pale, dry, lesions, sordes, furrows, tongure tie,etc
 Throat and pharynx:- Enalarged tonsils, redness and pus
 Neck:-
 Lymph nodes:- Enlarged, palpable
 Thyroid gland:- Enlarged
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 Range of motion:-
Flexion, Extension and
rotation.

 Chest:-
 Thorax:- Shape, symmetry of expansion, posture
 Breathe sounds:- Sigh, swish, rustle, wheezing, rales,crepitations,
pleural rub, etc.
 Heart:- Size and location, cardiac murmurs
 Breasts:- Enlarged lymph nodes.
 Abdomen:-
 Observation:- Skin rashes, scars, hernia, ascitesdistension,
pregnancy, etc.
 Auscultation:- Bowel sounds, fetal heart sounds
 Palpation:- Liver margin, palpable spleen, tenderness atthe urea of
appendix, inguinal Hernias
 Percussion:- Presence of gas, fluid or masses.
 Extremities:-
 Movement of joints:-
 Tremors:-
 Clumbing of fingers:-
 ankle edema:-
 varicose veins:-
 reflexes:-
 Back:-
 Spina bifida curves:-
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 Genital and Rectum:-

 Inguinal lymph glands:- Enlarged, palpable
 Patency of urinary meatus and rectum (in infants):-
 Descent of the testes:-
 Vaginal discharges :-
 Presence of sexually transmitted diseases:-
 Hemorrhoids:-
 Enlargement of the prostate gland:-
 Pelvic masses:

 Musculoskeletal system:-

 Inspection

 Palpation

 Range of motion

 Muscle tone and strength

 Neurological system

 Level of Consciousness:-

 Behavior

 Cranial Nerve Function

Assessment:-
Subjective data-

Objective data-
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11. Case in detail

 Introduction
 Definition
 Etiology
 Pathophysiology
 Clinical manifestations
 Diagnostic findings
 Surgical management
 Nursing management

12. Nursing diagnosis

*minimum seven diagnosis

13. Nursing care plan

*explain any five diagnosis

14. Health education

*Personal hygiene :-
*Diet
*Medication
*Rest and sleep

*Follow up
15. Discharge plan

16. Conclusion

17. Bibliography