NOOTAN COLLEGE OF NURSING, VISNAGAR

THIRD YEAR B.SC NURSING

EVALUATION FORM FOR CASE PRESENTATION

NAME OF STUDENT:
SUBJECT:

AREA OF HOSPITAL EXPERIENCE:

PERIOD OF EXPERIENCE:

Sr. No. Content Total Obtained

marks marks
1 History taking & physical
examination 04
2 Medication 04
3 Diagnostic test 04
4 Disease condition 14
5 Nursing care plan 10
6 Growth And Development 06
7 Health education & progress 06
notes
8 Reference 02
50

TOTAL MARKS OBTAINED:

REMARKS:

SIGNATURE OF GUIDE SIGNATURE OF STUDENT

 CASE PRESENTATION ON (HIGH RISK NEW BORN)

HISTORY TAKING
IDENTIFICATION DATA:
NAME :

AGE :

SEX :

ADDRESS :

DATE OF ADMISSION :

TIME OF ADMISSION :

NAME OF CONSULTANT :

O.P.D. NO. :

INDOOR NO. :

WARD NO. :

BED NO. :

M.L.C. : YES/NO

DIAGNOSIS :

PROCEDURE / SURGERY :
DONE

DATE OF SURGERY :

NAME OF THE SURGERY

101
PRESENT MEDICAL HISTORY:

PAST MEDICAL HISTORY:

PAST SURGICAL HISTORY

FAMILY HISTORY:

FAMILY TREE:

102
 FAMILY HISTORY:

HEALTH
NO. NAME AGE RELATION EDUCATION OCCUPATION
STATUS

SOCIO ECONOMIC DATA:-

IMMUNIZATION HISTORY
103
 FUNCTIONAL HEALTH PATTERN

Hygiene

Activity/Exercises:-

Rest/Sleep

Elimination Pattern:-

Cognitive / Perceptual:-

Self perception / self concept pattern:-

Coping stress tolerance:-

Personal habits:-

104
 GROWTH &DEVELOPMENT:

VITAL SIGN:

TEMPERATURE:
PULSE:
RESPIRATION:
B.P.:
ANTHROPOIMETRIC MEASUREMENT

Sr.No. Measurement Patient’s value Normal Value Remarks

1 Height

2 Weight

3 Head Circumference

4 Chest Circumference

5 Mid Arms Circumference

GROSS MOTOR

FINE MOTOR

SENSORY
105
PSYCHOLOGICAL

INTELECTUAL

SPEECH & LANGUAGE

PLAY

NUTRITION

106
 PHYSICAL EXAMINATION

GENERAL INFORMATION:

NOURISHMENT:

BODY BUILT:

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:

107
MOUTH & PHARYNX:

LIPS:
Cleft lips/palate;
TEETH:
MUCUS MEMBRANE& GUMS:
TONGUE:
THROAT &
PHARYNX: NECK:
CHEST:

THORAX:
BREATH SOUNDS:
HEART:
BREAST:
ABDOMEN:

INSPECTION:

AUSCULTATION:

PALPATION:

PERCUSSION:

EXTREMITIES:

MOVEMENT OF JOINTS:
TREMORS:
CLUMBING OF FINGERS:
OEDEMA:
BACK & SPINE:

CURVES:
MOVEMENT:

108
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:

109
 SYSTEMIC EXAMINATION:

CENTRAL NERVOUS SYSTEM:

CARDIO-VASCULAR SYSTEM:

RESPIRATORY SYSTEM

MUSCULO-SKELETAL SYSTEM:

110
 DIGESTIVE SYSTEM:

GENITO-URINARY SYSTEM:

INVESTIGATION

NAMEOF NORMAL
DATE PATIENT VALUE REMARK
INVESTIGATIONS VALUE
111
OTHERS
112
 MEDICATION

Pharmacological
Dose/ Mechanism of
Name/ Trade Indication Contra- Indications Side-Effects Nurses responsibility
Route Action
Name
113
 MEDICATION

Pharmacological
Dose/ Mechanism of
Name/ Trade Indication Contra- Indications Side-Effects Nurses responsibility
Route Action
Name
114
Anatomy and physiology:-

115
 DISEASE CONDITION

Introduction:-

Definition;-

Etiology

116
Pathophysiology

117
Clinical Manifestations:-

Book Picture Patient picture

118
Diagnostic Tests:-

Book Picture Patient picture

119
 MANAGEMENT:-

Medical Management:-

Book Picture Patient picture

120
12
1
Surgical Management:-

Book Picture Patient picture

122
 Dietary Management:-

Book Picture Patient Picture

Other Management:-

123
Complication:-

NURSING PROCESS:-

List of Nursing Diagnosis:

124
 NURSING CARE PLAN

Nursing Nursing Expected

Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come
125
 Nursing Nursing Expected
Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come
126
 Nursing Nursing Expected
Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come
127
 Nursing Nursing Expected
Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come
128
 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
129
 Nursing
Date Diet Medication Time Nursing Care Remarks Sign
Observation
130
 Nursing
Date Diet Medication Time Nursing Care Remarks Sign
Observation
131
HEALTH TEACHING:

PROGRESS OF PATIENT:-

132
SUMMARY:-

CONCLUSION:-

133
BIBLIOGRAPHY:-

SIGNATURE OF EVALUATOR SIGNATURE OF

STUDENT
134