JOSCO COLLEGE OF NURSING, NELAMANGALA, BENGALORE.

CARE STUDY FORMAT

MEDICAL AND SURGICAL NURSING

1. Patient identification data

2. History collection
3. Physical examination
4. Disease aspect
a. Definition
b. Incidence
C. Etiology & risk factors
Book picture Patient picture

d. Related anatomy and physiology

e. Pathophysiology/ Pathology
f. Clinical manifestation
Book picture
Patient picture

g Diagnosticmeasures
Book picture
Patient picture

h. Complications
Book picture
Patient picture

i. Management
Pharmacological management
a. Book picture
b. Pharmacological management in my patient drug file
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Dietary Management
a. Book picture
b. 24 hrs dietary recall and inference
 Surgical management
a. Book picture
b. Surgical management done in my patient
1. Name of the surgery
2. Date of the surgery
3. Name of the anesthesia
4. Pre-operative assessments/ orders
Operation notes
6. Post-operative orders
Nursing management
a. Book picture
b. Nursing care rendered to my patient
c. List of nursing problems
d. List of nursing diagnosis: pre-operative, post-operative.
e. Nursing care plan
Assessment | Nursing Objective | Plan ofRationale Implementation Evaluation
Diagnosis action
Subjective
data
Objective
data
5. Health education
6. Daily progress note
7. Nurses record
8. Conclusion
9. Bibliography