NOOTAN COLLEGE OF NURSING

VISNAGAR
THIRD YEAR B.SC NURSING
EVALUATION FORM FOR CASE STUDY

NAME OF STUDENT:
SUBJECT:

AREA OF HOSPITAL EXPERIENCE:

PERIOD OF EXPERIENCE:
Sr. No Content Maximum Obtained
marks marks
1 History taking & physical
examination 08
2 Medication 08
3 Diagnostic test 08
4 Disease Condition 28

5 Growth And Development 32

6 Nursing care plan 10

7 Health education & progress notes 04

8 Reference 02

TOTAL 100

SIGNATURE OF SUPERVISOR: SIGNATURE OF STUDENT:

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 CASE STUDY

HISTORY TAKING

IDENTIFICATION DATA:
Name of the Patient :

Age :

Sex
:
Father’s occupation

Education

Date of admission

Source of information

Diagnosis

Present complaints

PRESENT MEDICAL HISTORY:

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PAST MEDICAL HISTORY:

PAST SURGICAL HISTORY

FAMILY HISTORY:

FAMILY TREE:

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 FAMILY HISTORY:

NO. NAME AGE RELATION EDUCATION OCCUPATION HEALTH

STATUS

SOCIO ECONOMIC DATA:-

IMMUNIZATION HISTORY

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 FUNCTIONAL HEALTH PATTERN

Hygiene

Activity/Exercises:-

Rest/Sleep

Elimination Pattern:-

Cognitive / Perceptual:-

Self perception / self concept pattern:-

Coping stress tolerance:-

Personal habits:-

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 PHYSICAL EXAMINATION
GENERAL INFORMATION:

NOURISHMENT:

BODY BUILT:

VITAL SIGN:

TEMPERATURE:
PULSE:
RESPIRATION:
B.P.:

ANTHROPOIMETRIC MEASUREMENT

S.no. Measurement Patient’s value Normal Value Remarks

1 Height

2 Weight

3 Head Circumference

4 Chest Circumference

5 Mid Arms Circumference

DEVELOPMENT:

1 GROSS MOTOR

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2 FINE MOTOR

3 SENSORY

4 PSYCHOLOGICAL

5 INTELECTUAL

6 SPEECH & LANGUAGE

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 7 PLAY

8 NUTRITION

9 IMMUNIZATION

Age Immunization Taken Not taken Remarks

At 6 Wks BCG & OPV

BCG ( If not taken )

At 10 Wks DPT-1,OPV-1, &

Hepatitis B-1

DPT-2,OPV-2 &
Hepatitis B- 2
At 10 Wks

At 14 Wks DPT-3, OPV- 3 &

Hepatitis B -3

At 9 months Measles

At 16-24 DPT & OPV (

months BOOSTER)

At 5- 6 Years DT

At 10 & 16 TT
yrs

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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:

MOUTH & PHARYNX:

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

CHEST:

THORAX:
BREATH SOUNDS:
HEART:
BREAST:

ABDOMEN:

INSPECTION:

AUSCULTATION:

PALPATION:

PERCUSSION:

EXTREMITIES:

MOVEMENT OF JOINTS:

CLUBBING OF FINGERS:
OEDEMA:

BACK & SPINE:

CURVES:
MOVEMENT:

73
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:

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 SYSTEMIC EXAMINATION:
CENTRAL NERVOUS SYSTEM:

CARDIO-VASCULAR SYSTEM:

RESPIRATORY SYSTEM:R

MUSCULO-SKELETON SYSTEM:

DIGESTIVE SYSTEM:

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 GENITO-URINARY SYSTEM:

INVESTIGATION

1). BLOOD/URINE/ANY OTHER BODY FLUID

NAMEOF NORMAL
DATE PATIENT VALUE REMARK
INVESTIGATIONS VALUE

76
 MEDICATION

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

77
78
 MEDICATION

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

79
 MEDICATION

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

80
Anatomy and physiology:-

81
 DISEASE CONDITION

Introduction:-

Definition;-

Etiology

82
Pathophysiology

83
Clinical Manifestations:-

Book Picture Patient picture

84
Diagnostic Tests:-

Book Picture Patient picture

85
MANAGEMANT:-

Medical Management:-

Book Picture Patient picture

86
Book Picture Patient picture

87
Other Management:-

Complication:-

88
NURSING PROCESS:-

List of Nursing Diagnosis:

89
 NURSING CARE PLAN

Nursing Nursing Expected

Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come

90
 Nursing Nursing Expected
Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come

91
 Nursing Nursing Expected
Planning Implementation Rational Evaluation
Assessment Diagnosis Out Come

92
 Nursing Nursing Expected
Planning Intervention Rational Evaluation
Assessment Diagnosis Out Come

93
 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

94
 Nursing
Date Diet Medication Time Nursing Care Remarks Sign
Observation

95
 Nursing
Date Diet Medication Time Nursing Care Remarks Sign
Observation

96
HEALTH TEACHING:

PROGRESS OF PATIENT:-

97
SUMMARY:-

CONCLUSION:-

98
BIBLIOGRAPHY:-

SIGNATURE OF EVALUATOR SIGNATURE OF

STUDENT