DANI PHILIP

RAMA COLLEGE OF NURSING, MANDHANA, KANPUR

MEDICAL AND SURGICAL NURSING
FORMAT FOR CASE STUDY

Student's Name :........................................................................

Course and Year of study :........................................................................

HISTORY COLLECTION:

I. Baseline data/ Bio-graphical data/ Biodata:

Name:
Age:
Gender:
Marital Status:
Religion:
Occupation:
Income:
Address:
Bed number:
Ward number:
Date of Admission:
Admission Number:
Diagnosis/ Provisional Diagnosis:
Date of Surgery, if any:
Name of the consultant:

II. Chief Complaints/ Presenting Complaints:

Description of the chief complaints with which the client has come to hospital.
Duration of illness.

III. History of Illness:

A. History of present illness: Onset, Symptoms, Duration, Precipitating illness/alleviating
factors.
B. History of past illness: Illness, Surgeries, Allergies, Immunisation, Medications.

IV. Family History:

Type, Composition of family.
History of illness among family members.
Congenital and Psychological problems.
Family tree.

IV. Socio-economic Status:

Monthly income and its sources.
Monthly expenditure on health and other aspects.
Educational status and occupation of family members
Assets (Own house, four wheelers, Two wheelers, TV, Refrigerator etc)
Involvement with society and social activities.

V. Environmental Status:
Type of house: Kaccha/ Pucca/ Others
Lighting and ventilation of house
Water source and it's sanitation
Drainage system: Open/ Closed/ Absent
Presence of vectors such as flies, mosquitoes etc.
Waste disposal system including toilet facility
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VI. Personal History:
Ethnic background
Personal appearance and physique
Nutritional status
Hygiene
Mental status
Sleep, rest, exercise and work
Elimination pattern
Habits and hobbies

VII. Menstrual and Obstetric history (Women):

Age of Menarche:
Regular/irregular cycle
Scanty/heavy cycle
Last menstrual period (LMP)
Menstrual hygiene
Number of pregnancies, deliveries, abortions, obstetrical surgeries
Gynaecological history

PHYSICAL ASSESSMENT:

I. General Conditions:
Appearance
Sensorium
Co-operativeness
Gait and posture
Height and weight
Mood and affect

II. Vital Signs:

Temperature
Pulse
Respiration
Blood Pressure

III. Head to toe assessment:

HEAD: Examine the hair, scalp, skull, and face.
Cranium: Scalp and hair.
Face: Forehead: Inspect skin for any scars, injuries, blemishes etc.
Eyes:
Check visual acuity and screen the visual fields.
Note position and alignment of the eyes.
Observe the eyelids.
Check any abnormal secretions, infections etc.
Inspect the sclera and conjunctiva of each eye.
With oblique lighting, inspect each cornea, iris, and lens.
Compare the pupils, and test their reactions to light.
Assess extraocular movements.
With an ophthalmoscope, inspect the ocular fundi.

Ears:
Inspect the auricles, canals, and drums for discharge, cerumen impaction, infection.
Check auditory acuity. If acuity is diminished, check lateralization (Weber test) and
compare air and bone conduction (Rinne test).
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Nose and Sinuses:
Examine the external nose; using a light and nasal speculum, inspect nasal
mucosa, septum, and turbinates.
Palpate for tenderness of the frontal and maxillary sinuses.
Observe for any discharges, growth, infection etc.
Assess the olfactory sense on both nostrils.

Mouth and Pharynx:

Inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils, and pharynx.
Sense of Gustation (taste)

Chin and Cheek: Inspect for any scars, injuries etc

NECK:
Move behind the sitting patient to feel the thyroid gland and to examine the back,
posterior thorax, and lungs.
Inspect and palpate the cervical lymph nodes.
Note any masses or unusual pulsations in the neck.
Feel for any deviation of the trachea.
Observe sound and effort of the patient's breathing.
Inspect and palpate the thyroid gland.
Assess the Range of motion of the neck

TRUNK: CHEST, ABDOMEN AND BACK

Back:
Inspect and palpate the spine and muscles of the upper back.
Inspect, palpate, and percuss.
Identify the level of diaphragmatic dullness on each side.
Listen to the breath sounds; identify any adventitious (or added) sounds

Breasts, Axillae:
Female: Inspect the breasts with patient's arms relaxed, then elevated, and then
with her hands pressed on her hips.
Male and Female: Inspect the axillae and feel for the axillary nodes.

Chest/Anterior Thorax and Lungs.

The patient position is supine. Ask the patient to lie down. Stand at the right side of
the patient's bed. Inspect, palpate, and percuss the chest.
Shape of the chest: Normal, Barrel, Pigeon chest,
Listen to the breath sounds, any adventitious sounds, and, if indicated, transmitted
voice sounds.

Abdomen.
With the patient supine and the head of the bed flat, inspect, auscultate, palpate,
and percuss the abdomen. Palpate lightly, then deeply, to assess the liver, spleen,
kidney, and aorta. Ask about pain, dysphagia, nausea, vomiting, diarrhea, and
hematemesis
Assess the liver and spleen by percussion and then palpation. Try to feel the
kidneys; palpate the aorta and its pulsations.

Pelvic assessment:
Genitalias should be assessed for infections, tenderness, ulcers, discharges etc.
Perineum and sacrococcygeal area: Smooth, free of lesions, swelling, inflammation
and tenderness.
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Anal mucosa: Deeply pigmented, coarse, moist, and hairless; no lesions,
inflammation, rash, masses, or additional openings; anal opening closed; no
leakage of feces or mucus; no tissue profusion (normal).
Prostate: Gland small, smooth, mobile, and nontender, median sulcus palpable.

EXTREMITIES: UPPER AND LOWER EXTREMITIES

Skin and nails
Pulses: All pulses palpable 2 (femoral popliteal, posterior tibial, and dorsalis pedis).
Reflexes: Deep tender reflexes normal 2 (biceps, brachioradialis, triceps, patellar,
Achilles, Babinski, negative).
Strength: Equal bilaterally (except on right foot), no involuntary.
Joint mobility: Periarticular tissue around the joints are free from swelling, pain,
tenderness, warmth, or nodules.

IV. SYSTEMIC ASSESSMENT:

Integumentary System
Skin colour (Pallor, Erythema, Cyanosis and Jaundice) and pigmentation
Hydration
Scars / marks
Wounds /infestations
Nails: colour, curvature, strength
Hair: colour, texture

Neurological System
Level of Consciousness
Pupillary assessment
Mental status assessment
Cranial nerve assessment
Motor function assessment
Sensory Function assessment
Reflexes and tones
Cerebellar functions

Cardio-vascular system
Inspection: Chest symmetry, contour, diameter, scars
Palpation: Pulsations, Masses, tenderness, thorax expansion, tracheal position.
Percussion: Resonant sounds such as dullness, flatness over lung fields.
Auscultation: Heart beats, heart sounds and it's abnormalities.

Respiratory system
Inspection: Chest symmetry, contour, diameter, scars, rate and depth of respiration.
Palpation: Pulsations, Masses, tenderness
Percussion: Resonant sounds such as dullness, flatness over cardiac silhouette.
Auscultation: Breath sounds: Normal—bronchial, bronchovesicular, and vesicular
sounds heard (normal), no ronchi or crackles.

Gastrointestinal system
Inspection: Contour, shape, Symmetry, Pigmentation and colour, Scars, masses,
abdominal respiration
Palpation: Light palpation: Abdomen smooth with constant softness. Deep palpation:
organ enlargement, abnormal masses, bulges, or swelling.
Percussion: Flatness, dullness, tympany
Auscultation: Bowel sounds, vascular sounds
Check for bowel habits and frequency
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Urinary system
Discharges, masses, contour and shape of urethra
Urine frequency, colour, amount

V. Investigations

Sl No Date Investigations Actual Value Normal Value Inference

VI. Treatment:

Name of Nurse's
Sl No Dose Route Frequency Action Side effects
the Drug Responsibility

VII. Description of disease and Comparison with Client picture.

Definition
Related Anatomy and Physiology
Epidemiology
Epidemiology related to Client Epidemiology by Book Review Interpretations
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Management:

Related to Clent Book Review Interpretations

1. Medical

2. Surgical

3. Nursing

VIII. Nursing Process:

1. Nursing diagnoses based on priority.

2. Nursing Care Plan:

Sl. Assessment Nursing Goals/ Interventions Implementation Rationale Evaluation

N Diagnosis expected Mark ( ) or (X)
outcomes

( ) or (X)

( ) or (X)

( ) or (X)

( ) or (X)

3. Nursing Care Provided (Depends on number of days you are exposed with the client)
Day 1:
Day 2:
Day 3:
Day 4:
Day 5:

IX. Discharge Planning if any and Health Education:

Health education includes Diet, exercise, rest, medications, follow up care, lifestyle modification,
coping, rehabilitative techniques, preventive measures etc.

Conclusion

Bibliography