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    Format of Clinical Presentation

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    upadhyayshivang787
    The document outlines the format for clinical presentations at the College of Nursing, GMC in Azamgarh, India. It includes 19 sections that provide guidelines for collecting and presenting a patient's identification data, history of present illness, past medical/surgical history, review of systems, physical examination, diagnostic tests, medications, disease condition, nursing diagnoses, care plan, health education, nursing notes, patient progress, summary and conclusion.

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    Format of Clinical Presentation

    Uploaded by

    upadhyayshivang787
    1K views9 pages
    The document outlines the format for clinical presentations at the College of Nursing, GMC in Azamgarh, India. It includes 19 sections that provide guidelines for collecting and presenting a patient's identification data, history of present illness, past medical/surgical history, review of systems, physical examination, diagnostic tests, medications, disease condition, nursing diagnoses, care plan, health education, nursing notes, patient progress, summary and conclusion.

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    The document outlines the format for clinical presentations at the College of Nursing, GMC in Azamgarh, India. It includes 19 sections that provide guidelines for collecting and presenting a patient's identification data, history of present illness, past medical/surgical history, review of systems, physical examination, diagnostic tests, medications, disease condition, nursing diagnoses, care plan, health education, nursing notes, patient progress, summary and conclusion.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views9 pages

    Format of Clinical Presentation

    Uploaded by

    upadhyayshivang787
    The document outlines the format for clinical presentations at the College of Nursing, GMC in Azamgarh, India. It includes 19 sections that provide guidelines for collecting and presenting a patient's identification data, history of present illness, past medical/surgical history, review of systems, physical examination, diagnostic tests, medications, disease condition, nursing diagnoses, care plan, health education, nursing notes, patient progress, summary and conclusion.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 9

    College of Nursing, GMC, Azamgarh

    Format of Clinical Presentation


    1. Identification Data/Biographic Data
     Name
     Age:
     Gender
     Race:
     Mother Tongue:
     Education:
     Occupation:
     Marital Status:
     Religion:
     Diagnosis:
     Consultant:
     Ward:
     Bed No.:
     Date of Admission:
     IPD No.:
     Name of Surgery:
     Date of Surgery:
     Hospital Name:
     Residential Address:
    2. INFORMANT
    3. CHIEF COMPLAINTS:
    4. HISTORY OF ILLNESS:
    Present Medical History
    Present Surgical History
    Past Medical History
    Past Surgical History
    Obstetrical and Menstrual History (Female)
    5. FAMILY HISTORY:
     Family Components-

    Name Age Gender Education Occupation Marital Relationship Health


    Status With Status
    Patient
     Family Tree/Pedigree Chart
     Family History of Any Illness
    6. SOCIO-ECONOMIC HISTORY:
     Earning Members
     Monthly Income
     Type of House
     Bio-hazards
     Water Facility
     Lighting Facility
    7. OCCUPATIONAL HISTORY:
     Occupation
     Nature of Job
     Environment of job
     Exposure of any substance
     Duration of Exposure
    8. PERSONAL HISTORY
     Hygiene
     Dietary Pattern
     Fluid
     Sleep and Rest
     Elimination Pattern
    -Bowel habits
    -Bladder habits
     Activity of daily living
     Allergic Reaction
     Hobbies/ interest
     Bad habit
    9. PHYSICAL EXAMINATION
    A. General appearance
     Nourishment
     Body build
     Hygiene and grooming
     Activity
     Health
     Posture
     Movement
    B. Mental Status
     Consciousness
    C. Behavior
     Look
     Attitude
     Affect/ mood
     Speech
     Orientation
    D. Vital Signs
     Temperature ---------- oF/oC
     Pulse--------------beats/Min.
     Respiration-----------breaths/Min.
     Blood pressure------------mmhg
     SpO2 ---------------%
    E. Anthropometric Measurement
     Height------------cms
     Weight-----------Kgs
     BMI---------------Kg/m2
    F. Head
     Shape and Size
     Scalp
    G. Hair
     Texture
     Colour
     Grooming
     Pediculesis
     Dandruff
     Distribution
    H. Face
    I. Eyes
     Eyebrows
     Eyelashes
     Eye lids
     Eye balls
     Pupils
    - Colour
    - Size
    - Reaction to Light

     Corneal Reflex
     Conjunctiva
     Sclera
     Lens
     Vision
     Eye Movement
     Discharge
    J. Ear
     Symmetry
     Position
     Ceruman
     Discharge
     Hearing acquity
    K. Nose
     External nose
     Nasal septum
     Smell
     Mucus Membrane
     Rhinorrhoea
    L. Mouth And Pharynx
     Outer lips
     Inner lips
     Mucous membrane
     Teeth
     Gums
     Tongue
     Tongue Movement
     Taste
     Palate
     Odour
     Pharynx
     Voice
     Tonsils
    M. Neck
     Range of motion
     Thyroid Gland
     Lymph Nodes
     Trachea
     Carotid Artery
     Jugular Vein
    N. Chest
     Shape and Size
     Thorax
     Skin
     Breath Sound
     Breast
     Nipple
     Heart Beat
     Heart Sound
    O. Axilla
     Hair
     Lymph Node
    P. Abdomen
     Inspection
     Auscultation
     Palpation
     Percussion
     Abdominal Girth_________cms
     Inguinal Lymph Nodes
     Appetite
    Q. Back
    R. Skin
     Colour
     Texture
     Temperature
     Lesions
     Turgor
     Discoloration
     Sensation
    S. Upper Extremity
     Symmetry
     Range of Motion
     Peripheral Pulse
     Reflexes
     Edema
     Cyanosis
     Joints
     Deformity
    T. Lower Extremity
     Symmetry
     Toe nails
     Range of Motion
     Peripheral Pulse
     Reflexes
     Edema
     Cyanosis
     Joints
     Deformity
    U. Nails
     Shape
     Texture
     Nail bed colour
     Tissue surrounding nails
     Capillary refill
    V. Genitals and rectum (Male and Female)
     Urethral Orifice
     Hemorrhoids
     Vaginal discharge
     Enlargement of prostate gland
     Testis
     Labia majora and lebia minora
     Fistula
    W. Neurological test
     Orientation to time/place/person
     Coordination test
     Response to test
    X. Psychological Assessment
     Clients perception
     Emotional health
     Social health
     Physical health
     Spiritual health
     Intellectual health
    Y. Review of related system
     Inspection
     Auscultation
     Percussion
     Palpation
    10. LABORATORY INVESTIGATION

    Sr. No Name of Investigation Normal Value Patient Value

    Other
    Investigation
    (USG, X-ray,
    MRI, CT-
    Scan etc.)
    11. Present medication history
    Sr. No. Current Action Dose/Frequency/ Adverse Nursing
    Medication route reaction Responsibility

    In case of
    surgical
    clients/patients
    a) Pre-
    operative
    order
    (Medicine)
    b) Post-
    operative
    order
    (Medicine)

    Disease Condition
     Introduction
     Definition
     Diagram with (Anatomy & Physiology of Disease)
    Comparative Studies:-
     Risk factor
    Book Picture Patient Picture

     Etiology
    Book Picture Patient Picture

     Pathophysiology
     Clinical Manifestation
    Book Picture Patient Picture
     Diagnostic findings
    Book Picture Patient Picture

     Complication
     Medical Management
    Book Picture Patient Picture

     Surgical Management
    Book Picture Patient Picture

     Nursing management
    12.List of NANDA Nursing Diagnosis
    13.Nursing Care plan
    Sr. Assessment Nursing Goal Planning Rational Implementation Evaluation
    No Diagnosis

    Subjective
    Data:

    Objective
    Data:
    14. HEALTH EDUCATION
     Medication
     Hygiene
     Diet
     Exercise
     Follow – up
    15. NURSES RECORD

    Date Time Recording Diet Signature

    16. Patient Progress


     Day 1
     Day 2
     Day 3
     Day 4
     Day 5
    17.Summary
    18.Conclusion
    19.Bibliography

    Name & Signature


    of Student Signature of Evaluator
    Date: Date:

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