PATIENT’S IDENTIFICATION DATA

Patient’s Name :_______________________________________________________

Father/Husband Name:_________________________________________________

Age:______________________Sex : _______________________________________

Address :_____________________________________________________________

Education : ________________________Occupation:________________________

Income Per Month: __________________Religion :__________________________

Date of Admission : __________________Indoor Number :____________________

Ward :____________________________ Bed No.:___________________________

Marital Status:______________________Diagnosis :_________________________

Doctor’s Name:______________________ Name of Surgry:___________________

Date of Surgery:____________________Date of Data Collection:_______________

Name of Hospital:______________________________________________________

CHIEF COMPLAINTS

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HISTORY OF PRESENT ILLNESS

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PAST MEDICAL HISTORY

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PAST SURGICAL HISTORY

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SOCIO-ECONOMICAL STATUS

SocialStatus:__________________________________________________________
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EconomicaStatus:_____________________________________________________

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 HABITS

Smoking : __________________________________________________

Tobacco chewing : ___________________________________________

Alcohol Consumption : ________________________________________

Vegetarian : _________________________________________________

Non-vegetarian : _____________________________________________

FAMILY HISTORY

Sr. Name of Family Age Relation Marital Health

Sex Education Occupation
No Members (Yrs) with patient status status
MENSTRUAL HISTORY
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DIETETIC HISTORY
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ACTIVITY AND EXERCISE

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SLEEP / REST
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ELIMINATION
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COGNITIVE/PERCEPTUAL
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 PHYSICAL EXAMINATION
General Appearance

 Level of Consciousness:_________________________
 Orientation:-To Place/ Person/Time:_______________
 Activity:_____________________________________
 Body Built:___________________________________
Anthropometric Measurement

 Height:_____________________________________
 Weight:_____________________________________
 Mid upper arm circumference :________________
Vital Signs

 Temperature:_________________________________
 Pulse: ______________________________________
 Respiration: _________________________________
 Blood Pressure: __________________________
Head

 Hair:_______________________________________
 Colour of Hair:_______________________________
 Scalp:_______________________________________
 Pediculosis:__________________________________
Face

 Face:_______________________________________
 Facial Puffiness:______________________________
Eyes

 Eye Brows:__________________________________
 Eye Lid/Lashes:______________________________
 Eye Ball:__________________________________
 Conjunctiva:_______________________________
 Sclera:____________________________________
  Puncta:____________________________________
 Cornea:____________________________________
 Iris:_______________________________________
 Pupils:_____________________________________
Nose

 Nasal Septum:______________________________
 Nasal Polyp:________________________________
 Nasal Discharge:____________________________
Mouth

 Number of Teeth:____________________________
 Dentures :__________________________________
 Dental Carries:______________________________
 Odour of Mouth:____________________________
 Gums:_____________________________________
Lips

 Crack/Healthy:______________________________
 Cleft Lips:_________________________________
 Stomatitis:_________________________________
Ears

 Size:______________________________________
 Shape:_____________________________________
 Position And Alignment:______________________
 Redness:___________________________________
 Discharge:__________________________________
 Cerumen:___________________________________
 Lesions:____________________________________
 Foreign Body:_______________________________
 Hearing Acuquity:____________________________
 Use of Hearing Aids:__________________________
 Tuning Fork Test:_____________________________
  Weber test:__________________________________
 Rinne test:___________________________________

SYSTEMIC EXAMINATION

Respiratory System

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Cardio Vascular System

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Peripheral Lymphatic System

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Digestive System

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Genito Urinary

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Intigumentory System

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Musculo Skeletal System

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Neurological Assessment ( Glascow Coma Scale)

Eye Opening _________

None 1=

To pain 2=

To speech 3=

Spontaneous 4=

Motor Response _________

None 1=

Extension 2=

Flexion response 3=

Withdrawal 4=

Localizes pain 5=

Obeys commands 6=

Verbal Response _________

None 1=

Incomprehensible 2=

Inappropriate 3=

Confused 4=

Oriented 5=

Minimum Score:- 3

Maximum Score:- 15 Patient Score:__________

LABORATORY INVESTIGATIONS
Sr.
Date Investigation name Normal value Patients value Remark
No.

OTHER INVESTIGATION
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PRESENT MEDICATION HISTORY

Sr.
Current Medication Dose/Frequency Route Last Dose Taken
No.
MEDICATION

Name of
Dose/Route Mechanism of Action Indication Contra-Indication Side-Effects Nurses Responsibility
Medication
 Name of
Dose/Route Mechanism of Action Indication Contra-Indication Side-Effects Nurses Responsibility
Medication
 Name of
Dose/Route Mechanism of Action Indication Contra-Indication Side-Effects Nurses Responsibility
Medication
 DISEASE CONDITION

INTRODUCTION
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DEFINITION
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DIAGRAM
RISK FACTOR
Book’s Picture Patient Picture

ETIOLOGY /CUASES
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PATHOPHYSIOLOGY
CLINICAL MANIFESTATION
Book’s Picture Patient Picture

DIAGNOSTIC TEST
Book’s Picture Patient Picture
MEDICAL MANAGEMENT
Book’s Picture Patient Picture

SURGICAL MANAGEMENT
Book’s Picture Patient Picture
LIST OF NURSING DAIGNOSIS

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NURSING CARE PLAN
Assessment Diagnosis Expected Outcome Intervention Rational Evaluation
Assessment Diagnosis Expected Outcome Intervention Rational Evaluation
Assessment Diagnosis Expected Outcome Intervention Rational Evaluation
Assessment Diagnosis Expected Outcome Intervention Rational Evaluation
Assessment Diagnosis Expected Outcome Intervention Rational Evaluation
HEALTH EDUCATION
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PATIENT PROGRESS
DAY-1

DAY-2

DAY-3

DAY-4
NURSES NOTES

Date Diet Time Medication Nurses Role

SUMMARY

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BIBLIOGRAPHY

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Signature of the Student Signature of the Evaluator

Date : Date :