IDSTORY COLLECTION
PATIENT PROFILE
I. History Collection:
Name
Age
Sex
Education
Occupation
Religion
Marital Status
Husband's Name
Wife's Name
Address
Date of Admission
Diagnosis
Ward Name
I.P. No
Bed No.
III. Chief complaints
IV. History of Health status:
(a) Present Medical History
(b) Past Medical History
(c) Present Surgical History
(d) Past Surgical History
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V. Family History
(a) Family Tree
Name of family Health
Age Relationship Occupation Remarks
Member status
VI. Personal History
(a) Habits
(b) Sleep
(c) Nutrition
(d) Elimination Pattern
VII. Socio Economic Status
(a) Housing
(b) Ventilation
(c) Electricity
(d) Water supply
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PHYSICAL ASSESSMENT/EXAMINATION
Vital signs:
Temperature
Pulse
Resp. Rate B.P.
General Appearance
Nourishment
Body build
Health
Activity
Consciousness
Look
Body curves
Movement
Height
Weight
Skin
Colour
Texture
Temperature
Lesions
Rashes
Lumps
Itching
Dryness
Moles
Head
Sm:
Shape
Hair & Scalp/ Skull/ face
Colour
Distnbution
Hair loss
Dandruff
Lice
Healthy
Eyes
Vision/Visual Acuity
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Eyeballs
Conjunctiva
Sclera
Cornea and Iris
Pupils
Fundus
Eye muscles
Eye brows
Eye lashes
Lens
Glasses
Discharge
Pain
Itching
Ears
Hearing
Ear Canals
Ear Drum
External Ear
Tymphanic Membrane
Pain
Itching
Ringing
Vertigo
Nose & Sinuses
Deviated nasal septum
External Nares
Nostrils
Discharge
Allergies
Frequent colds
Obstruction
Pain
Epistaxis
Mouth & throat
Tongue
Lesions
Lips
Bleeding
Tooth decay
Dental care
Odour
Throat & Pharynx
Mucus Membrane
Gums
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Neck
Stiffuess
Limited motion
Lymph nodes
Swelling
Pain
Thyroid Gland
Swallowing Reflex
Cervical Spine
Muscles of Back(Neck)
I. Respiratory System
H/O Smoking
Sputum (Colour)
Asthma
Wheezing
Haemoptysis
Cough
Shortness of Breath
Inspection
Palpation
Percussion
Auscultation
II. Cardio Vascular System
H/O Hypertension
Varicose veins
Dyspnea
Orthopnea
Chest pain
Palpitation
Claudication
Heart sound
Pulse
Heart beat
Inspection
Palpation
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Percussion
Auscultation
III. Gastro Intestinal System
Shape & Symmetry
Abdominal girth
Pain
Abdominal distension
Artificial Openings
Anorexia
Diarrhea
Nausea
Constipation
Vomiting
Hemetemes is
Food intolerance
Bowel sounds
Abdomen
Soft & Tender
Inspection
Palpation
Percussion
Auscultation
IV. Genito urinary system
Nocturia
Dysuria
Incontinence
Infection
Frequency
H/0 Illness (or) surgery
Inspection
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Palpation
Percussion
Auscultation
V. Genito Reproductive system:
Female
Menses
Menarche
Cycle
Duration
No. of Pregnancies
Menopause
Vagina I Discharge
H/O STD
Male
Pain
Soreness
Discharge
H/O STD's
Swelling
VI. Musculo-skeletal system
Posture
Muscular pain/cramps
Pain
Swelling
Upper extremities
Range of motion
Colour of extremities
Any deformities
Lower extremities
Range of motion
Colour of extremities
Any deformities
Inspection
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Palpation
Percussion
Auscultation
VII. lntegumentary system
Color
Texture
Moisture
Dryness
Bleeding
Discharge
Infection
VIII. Hematological System
Rb%
Bleeding tendencies
Any blood transfusions
IX. Neurological system
Level of consciousness
Activity
Dizziness
Posture & gait
Tremors (or) seizures
Sensation of pain
Mental status
Motor function
Sensory function
Cranial nerves
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GCS
Reflexes
INVESTIGATIONS:
[Link] Name of Investigations Patient Value Normal Value Remarks
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MEDICATION CHART
S. Name of the drug Dose Route Frequency Action Side Nurse's
No Effects responsibility
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INTAKE AND OUTPUT RECORD
Name: Hospital No. Age: Sex:
Date Time Oral Naso Intra Other Total Urine Vomitus Aspirations Other Total
Fluids Gastric Venous Routs
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Kardex form
Date Medications Dose Time Date Nursing care plan Time
Date Treatment Dose Time
Age Sex Bath T.P.R B.P Diet
Religion
Name of the patient Bed Diagnosis Doctor name IPNO
no
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NURSES NOTES
Name: [Link]:
Age: Ward:
Sex: Diagnosis:
Bed No: Doctor Name:
TIME DIET MEDICATIONS NURSING CARE PLAN
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Theory application: ( For Msc level)
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NUTRITIONAL ASSESSMENT:
[Link] Time Food item [Link]
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Anatomy and physiology: ( with diagram)
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Disease condition:
Book picture Patient picture
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NURSING DIAGNOSIS: {Sdays)
Day-1:
Day-2:
Day-3:
Day-4:
Day-5:
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Nursing Care Plan:( Sdays)
Assessment Diagnosis Goal Planning Rationale Implementation Evaluation
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Health Education:(Sdays)
Day-1:
Day-2:
Day-3:
Day-4:
Day-5:
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Recording and Reporting:
(Sdays) Day-1:
Day-2:
Day-3:
Day-4:
Day-5:
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Summary:
Mr/Ms/Mrs. x was admitted in ........ Hospital on .........(date) with chief
complaints of ... .................................... and he/she was diagnosed as
. . . . .. . .. . . ... . .. . . . . and he/she was given the
treatment like
. . . . .. . .. . . ... . .. . . . .. . .. . . . ... . . .. .. . he/she was now better than during the
time of admission.
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Discharge plan:
Mr/Ms/Mrs. x was admitted with chief complaints of ...............................
And diagnosed as . .. . . . . . .. . . . .. . ... .... he/she was given the quality care for
his improvement of health status and he was better now and doing all his activities
of daily living and health education also given to the patient and their family
members . He/she was planned to discharge within 3days as per the condition of
the patient and orders of the physician.
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Conclusion:
If I got a chance of taking care of the patient with chief complaints
of.......................... & diagnosed as .......................... & I will able to take
care of the patient independently with quality of care & for better outcome &
improvement ofthe patient's health status.
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Bibliography:
Book references:
Journal references:
Web references:
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