Lec1 Adult

Nursing 22 October 2020

Case Study Report

Name:- ‫ناو‬
Age:- ‫تەمەن‬
Sex:- ‫رەگەز‬
Occupation:- ‫کار‬
Marital status:-‫حالە زەوجی‬
Address:- ‫ناونیشان‬
Religion:- ‫ئایین‬
Chief complaint and Duration:- ‫السبب الرئيسي لدخول المستشفى والفترة‬
History of present illness:-)‫تاريخ المرض الحالي (وصف لحالة المريض‬
Past history:- ‫التاريخ السابق للمريض‬
1- History of all chronic diseases, such as Diabetes, Hypertension, Heart
diseases, Lung diseases, Kidney diseases and other chronic diseases:

2- History of drugs taking:

3- Family history:
4- Record any history of Allergy to (food, drugs, tape, chemicals and others):
5- Surgical history:
PHYSICAL EXAMINATION
A- Vital Signs:
Temp: Blood Pressure: Resp: Pulse:

B- Review of Systems: ‫مالحظة أجهزة الجسم األخرى‬

1- Respiratory system:
2- Digestive system:
3- Cardiovascular system:
4- Central nervous system:
5- Skelton system:

Medical Diagnosis: ‫التشخيص الطبي‬

Treatment: ‫العالج الطبي‬
Nursing Diagnosis: ‫التشخيص التمريضي‬
Nursing Care: ‫العناية التمريضية‬ Final Notes: ‫أي مالحظات‬
 ‫چاو بکاتەوە‬ ‫قسەکردنی‬ ‫جولەکردنه‬
Eye Opening (E) Verbal Response (V) Motor Response (M)

4=Spontaneous open 5=Normal conversation 6=Normal movement

3=Response to voice 4=Disoriented 5= Purposeful movement
E 2= Response to pain conversation but able to to painful stimulus

V 1=No response answer questions

3=Words, but not
4= Withdraws in response
to pain

M coherent
2=No words...only sounds
3= Flexion in response to
pain
1=None 2= Extension response in
response to pain
1=No response

Glasgow Coma Scale

Total = E+V+M= 15

90% less than or equal to 8 are in coma

Greater than or equal to 9 not in coma

8 is the critical score

Less than or equal to 8 at 6 hours - 50% die

9-11 = moderate severity

Greater than or equal to 12 = minor injury

The Glasgow Coma Scale provides a practical method for assessment of

impairment of conscious level in response to defined stimuli. ‫مقياس كالسكو وسيلة‬
‫عملية لتقييم مستوى الوعي ومدى االستجابة للمؤثرات الخارجية‬
 Physical examination or clinical examination

Is the process by which a medical professional investigates the body of a patient

for signs of disease. It generally follows the taking of the medical history — an
account of the symptoms as experienced by the patient. Together with the medical
history, the physical examination aids in determining the correct diagnosis and
devising the treatment plan.

Methods of physical examination:

1-Inspection:
Is a term when the examiner used eyes to observe body features, skin color,
respiration, movement, speaking.

2- Auscultation:
Is the technical term for listening to the internal sounds of the body, usually using
a stethoscope. Auscultation is normally performed for the purposes of examining
the
Cardiovascular system and respiratory systems (heart and lung sounds).
Gastrointestinal system (bowel sounds)
3- Percussion:
Percussion is a method used by a doctor to find out about the changes in
the thorax or abdomen. It is done by tapping on a surface to determine the
underlying structure. It is done with the middle finger of right hand tapping on the
middle finger of the left hand.

4. Palpation:
Palpation is a method of examination in which the examiner feels the size or shape
or firmness or location of something (of body parts when the examiner is a health
professional). Palpation is used by doctors for particularly for
Thoracic and abdominal examinations.
For examination of edema( swelling of any organ or tissue due to accumulation of
excess fluid) And palpation of pulses.

‫سوائل‬
‫غازات‬
‫گەورە بونی ئەندام‬

‫ هەناسەدان = خرخرە‬+ ‫التهاب‬

‫حەساسی و رەبۆ = خیسە خیس دەکا‬