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Medical Surgical Nursing Case Presentation

This document contains a template for presenting a patient case in medical-surgical nursing. It includes sections for collecting the patient's personal data and medical history, documenting vital signs and physical assessments, lab results, medications, the disease condition, nursing care plan, and health education provided. The template aims to systematically document all relevant clinical information about a patient to fully present their case.

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Endla Srini
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2K views6 pages

Medical Surgical Nursing Case Presentation

This document contains a template for presenting a patient case in medical-surgical nursing. It includes sections for collecting the patient's personal data and medical history, documenting vital signs and physical assessments, lab results, medications, the disease condition, nursing care plan, and health education provided. The template aims to systematically document all relevant clinical information about a patient to fully present their case.

Uploaded by

Endla Srini
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Patient's Data
  • Patient History
  • Physical Examination
  • Systemic Examination
  • Diagnostic Tests and Medication
  • Disease Condition
  • Supplementary Information
  • Nursing Assessment and Care Plan

DOON INSTITUTE OF MEDICAL SCIENCES, FACULTY OF NURSING

SAHSAPUR, SHANKARPUR

SUBJECT:- MEDICAL SURGICAL NURSING-1 (PRACTICAL)

PERFORMA FOR CASE PRESENTATION

PATIENT’S DATA

NAME OF THE PATIENT

AGE

SEX

RELIGION

LANGUAGES

ADMISSION/ IN-PATIENT NO

NAME OF THE WARD

DATE OF ADMISSION

MARITAL STATUS

EDUCATIONAL STATUS

OCCUPATION

DATE OF SURGERY (IF ANY)

DATE OF CARE STARTED

DATE OF CARE ENDED

INFORMANT

CONSULTANT DOCTOR

DIAGNOSIS

CHIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS-

HISTORY OF PAST ILLNESS-

 MEDICAL :
 SURGICAL :

PERSONAL HISTORY

 Habits
 Nutrition
 Appetite
 Personal hygiene
 Sleep pattern
 Elimination pattern

FAMILY HISTORY

Name of the Relationship Age/ Sex Marital Occupation Health Educational


family with patient status status background
member

FAMILY TREE

PSYCHOSOCIAL HISTORY

VITAL SIGNS
PARAMETERS PATIENT VALUE NORMAL VALUE REMARKS
Temperature
Pulse rate
Respiratory rate
Blood pressure
Spo2
PHYSICAL EXAMINATION
General appearance & Behaviour:

Height :
Weight :
Conscious :
Look :
Activity :
Body built :
Posture :
Temperature:
Pulse rate:
Respiration rate:
Blood pressure:

HEAD TO TOE ASSESSMENT


1. Head
 Hair-
 Scalp-
 Forehead –
2. Eyes
 Eyebrows
 Eyelashes
 Eyelids
 Sclera
 Pupil
3. Ear
 External ear
 Tympanic membrane
4. Nose
 External nares
 Nostrils
5. Mouth
 Lips
 Gums
 Tongue
 Teeth
6. Neck
 Lymph node
 Range of motion

SYSTEMIC EXAMINATION
1. Nervous system
2. Cardio vascular system
 Inspection
 Palpation
 Auscultation
 Percussion
3. Respiratory system
 Inspection
 Auscultation
 Palpation
 Percussion
4. Gastro intestinal system
 Inspection
 Auscultation
 Palpation
 Percussion
5. Genitourinary system
6. Musculoskeletal system
 Inspection
 Palpation
7. Integuementary system
8. Endocrine system

INVESTIGATIONS

Date Investigation carried out Patient value Normal values Remarks


DIAGNOSTIC TESTS-

MEDICATION-

SR Name of the Dose / Action Side effect Nursing responsibility


No. drugs route /
time

DISEASE CONDITION

1. Introduction
2. Definition
3. Etiology

In book In patient

4. Pathophysiology

In book In patient

5. Clinical manifestation

In book In patient

6. Diagnostic evaluation

In book In patient

7. Medical management

In book In patient
8. Surgical management (if any )

In book In patient

NURSING ASSESSMENT –

NURSING DIAGNOSIS (ACCORDING TO PRIORITY)-

NURSING CARE PLAN –

Assessment Nursing Goal Planning Rationale Implementation Evaluation


diagnosis
1. Subjective
data
2. Objective
data

HEALTH EDUCATION:-

CONCLUSION

SUMMARY

BIBLIOGRAPHY

DOON INSTITUTE OF MEDICAL SCIENCES, FACULTY OF NURSING SAHSAPUR, SHANKARPUR SUBJECT:- MEDICAL SURGICAL NURSING-1 (PRACTICAL)
HISTORY OF PRESENT ILLNESS- HISTORY OF PAST ILLNESS-  MEDICAL :  SURGICAL
PHYSICAL EXAMINATION General appearance & Behaviour: Height : Weight : Conscious : Look : Activity : Body built : Posture :
 Teeth 6. Neck  Lymph node  Range of motion SYSTEMIC EXAMINATION 1. Nervous system 2. Cardio vascular system  Inspect
DIAGNOSTIC TESTS- MEDICATION- SR No. Name of the drugs Dose / route / time Action Side effect Nursing responsibility DISEA
8. Surgical management (if any ) In book In patient NURSING ASSESSMENT – NURSING DIAGNOSIS (ACCORDING TO PRIORITY)- NURSING

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