Professional Documents
Culture Documents
I. INTRODUCTION
a) Patient Information: Name, age, gender, educational status, address,
religion, diagnosis, date of admission, doctor in charge.
b) Student Information: Name, class, date of care started, date of care
ended ward/unit.
c) Brief introduction in a paragraph.
II. INTRODUCTION OF THE CHILD (Briefly in a paragraph)
III. HISTORY:
A) SOCIOECONOMIC BACKGROUND
i) Property, Income in addition to salary
ii) Family’s and social relationships
iii) Description of house and surroundings
iv) Family’s health attitude, belief and practice with regard to disease.
B) FAMILY HISTORY
i) Brief in 4-6 sentences.
ii) Family genogram
iii) Family’s details in a table.
Health status
S.No.
Age
Occupation
Gender
member
statusEducational
Name of
childRelation with
1.
2.
C) BIRTH HISTORY
a) Antenatal History
b) Intranatal History
c) Postnatal History
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D) PERSONAL HISTORY
a) Diet History
b) Personal Hygiene
c) Sleep Pattern
d) Bowel and bladder pattern
e) Immunization status
f) Vital Signs
E) MEDICAL HISTORY
a) Past Medical History
b) Present Illness/Present Medical History
F) SURGICAL HISTORY
a) Past Surgical History
b) Present Surgical History
G) INVESTIGATIONS
H) MEDICATIONS
a) Category
b) Action
c) Available forms
d) Indications
e) Contraindications
f) Dosage and routes
g) Side effects
h) Special precautions
i) Drug interactions, if any
j) Nursing considerations.
I) PHYSICAL EXAMINATION
a) General Appearance
b) Anthrometric Measurements
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c) Summary
Psychosexual development
Spiritual development
Summary
K) Disease Condition:
L) THEORY APPLICATION
M) NURSING PROCESS APPLICATION:
Lecturer,CON,DMCH.