MEDICAL SURGICAL NURSING CARE STUDY FORMAT

INDEX
S.NO CONTENT PAGE NUMBER

1 INTRODUCTION

2 PATIENT PROFILE

3 AIMS OF CARE STUDY

4 HISTORY COLLECTION

5 PHYSICAL EXAMINATION

6 INVESTIGATIONS

7 MEDICATIONS

8 SURGICAL MANAGEMENT (only for surgical

care study )
9 ANATOMY AND PHYSIOLOGY OF _______

10 DISEASE CONDITION OF _________

11 COMPARATIVE STUDY

12 PROBLEMS & NEEDS

13 NURSING DIAGNOSIS

14 NURSING PROCESS

15 HEALTH EDUCATION

16 EVALUATION

17 CONCLUSION

18 BIBLIOGRAPHY
INTRODUCTION :-

I studentname II year GNM student of Apollo school of Nursing, As a part of our curriculum I have
posted at hospital name for clinical experience . I have taken patient name for mymedical/surgical care
study was admitted on date . He/ she came with the complaints of _________________. The patient
underwent investigations and he/she was diagnosed as diagnosis name.Now he/she is on treatment.

PATIENT PROFILE
Name :-
Age :-
Sex :-
Ward :-
Bed number :-
Occupation :-
Religion :-
Nationality :-
Language :-
Address :-
Date of admission :-
Diagnosis :-
Name of surgery (only for surgical) :-
Date of surgery (only for surgical) :-
Date of Care started :-
Date of Care ended :-

AIMS OF CARE STUDY

HISTORY COLLECTION:-
Socio economic history :-
My patient belongs to middle class family. He/She lives in own/Rent house. He/She is a bread
winner of the family. Her/His monthly income is _____/month.(Her/His Father /Mother is a
bread winner of the family). Her/His house has all the basic facilities like water and electricity
supply. They follow closed drainage system or Open field defecation. Hospital, Market, Library
and Transport is available within 2 km from his/her house
Personal history:-
She/he is vegetarian/Non vegetarian. He/She takes meals 3 times per day. Her/His sleeping
pattern is 8 hrs at night time,1-2 hrs at day time. His/Her bowel and bladder pattern is regular or
irregular. He/She voids 4-5 times per day. He/She has no habbits like tobacco or betal chewing,
smoking or alcohol. Her/His hobbies is watching TV/Listening music /reading book. She/He has
no allergy to certain drugs. She/He maintains good relationship with neighborhood.

Family history
 She/He lives in joint/nuclear family. There is no family history of hereditary disease such as
Diabetes mellitus, hypertension, epilepsy or cardiac diseases. There is no family history of
communicable diseases such as tuberculosis, bronchial asthma.
Or
Family history of diabetes mellitus for mother/father. She/He is on medical
treatment.
Family composition

S.NO NAME OF AGE SEX RELATIONSHIP MARRITAL EDUCATION OCCUPATION INCOME HEALTH
THE TO THE STATUS STATUS
FAMILY PATIENT
MEMBERS

Family tree:-
Note :-
Draw the family tree clearly by stating the key points by the side

MALE

FEMALE

DEAD

PATIENT

Past medical history :-

He/she has past history of DM, HTN, CAD, COPD, ASTHMA etc. my patient is on
regular /irregular treatment for past --------------- years. He/she is on drug name, dosage,
frequency &route. He/she was/wasn’t hospitalized earlier. ( if yes write in detail about the
hospitalization duration, treatment & complication)
or
There is no significant past medical history
Past surgical history
He/she has past history of any surgical treatment previously. ( if yes write in detail about the
name of the surgery , treatment & complication)
or
There is no significant past medical history

Present medical history

My patient name , age in years, got admitted in hospital name on date, with the complaints of ---
----------------- for ____ days. After a thorough investigations he/she was diagnosed as patient
diagnosis. Currently he/she is admitted in ward, floor for medical treatment . ( if necessary
patient plan for surgery)

Present surgical history

He/She underwent ____name of the surgery___ on ___date_____at __time_____. Patient
shifted from operation Theatre to recovery at ___time____. And shifted to ward at _time______.
There is no discharge like pus or blood from the surgical site.
PHYSICAL EXAMINATION
GENERAL EXAMINATION
Consciousness: conscious/ semi-conscious/ unconscious
Orientation: oriented to time/ place/ person
Nourishment: well nourished/ moderate nourished/ malnourished
Health : Healthy/ unhealthy
Body built: Thin/ moderate/ obese
Activity : Active/ dull
Look: Pleasant / happy/ alert/ sad/ depressed/ fearful/ anxious/ tired/ drowsy
Hygiene :Good/ bad
Speech: clear/ slurring/ stammering/ not clear/ maintains eye contact
Height: ______________ cms
Weight: ______________ Kgs

VITAL SIGNS
Temperature:_______________ Celsius/Fahrenheit
Pulse: ______________________ beats/min
Respiration: _________________ breaths/min
Blood pressure: ______________ mm of Hg

SKIN
Color: Fair/ brown/ dark in complexion
Texture: Normal/ dry
Skin turgor: Normal/ decreased
Hydration: good/ moderate/ dehydrated
Discoloration: Absent/ yellowish/ cyanosis/ vitiligo/ pallor/ increased pigmentation
Lesion/Masses: Absent/ macule/papule/ nodule/ vesicle/ pustule
Subjective symptoms: No complaints/ pain/ feeling cold/ warmth tingling/ numbness
NAILS
On observation: Intact/ onycholysis/ peeling or cracking / paronychia
Nail beds: Pink/ cyanosed/ pale
Nail plate: Absent/ flat/ clubbing/whitening
Schamroth’s window test: Normal/ abnormal

HAIR
Color: Black/ brown/ red/ grey/ dyed
Texture: Normal/ dry
Grooming: Not groomed/ well groomed
Distribution: Normal/ scanty/ bald/ alopecia

HEAD
Shape: Normocephalic/ micro/ macro/ hydrocephalic
Scalp: clean/ pediculosis/ presence of dandruff/ any scar
Face: Puffiness/ moon face/ Bell’s palsy/ no complaints
Subjective symptoms: No complaints/ if any _____________

EYES
Eyes brows: Symmetrical/ equally distributed/ asymmetrical/ scanty
Eye lashes: Absent/ equally distributed/ presence of dandruff
Eye lids : Normal/ oedematous/ ptosis
Pupilliary reflex: Reacting to light/unequal reaction (specify which eye)
Pupil shape: Round/oval/irregular/pin pointed.
Pupil size: Pin pointed/2mm/3mm/dilated.
Sclera: White/reddish/yellowish
Conjunctiva: Normal/pale/yellowish/conjunctivitis
Vision: Normal/Abnormal (specify including use of spectacles)
Subjective symptoms: No complaints/pain/itching/increased/decreased tear production

EARS
Pinna: Normally placed/anotia/microtia/macrotia/melotia
Cerumen: Absent/packed with
Ottorhoea: Absent/purulent/serous/bloddy/sanginunous
Hearing: normal/decreased (specify) _________
Subjective symptoms: No complaints/otalgia/tinnitus/vertigo/autophony
NOSE
Nasal septum: Midline/deviated
Nasal pathway: patent/obstructed/nasal polyp
Smell: Normal/absent
Rhinorrhoea: Absent/watery/purulent/mucoid/epistaxis
Frontal & maxillary sinuses: Painful/tender/sinusitis/no complaints
Subjective symptoms - any other (specify) ______________
MOUTH & PHARYNX
Lips: Dry/cracks; symmetrical/asymmetrical
Color: Pink/pale/dark
Gums: color-pink/pale dark; bleeding/pus
Tongue: Moist/dry/coating/lesions/anlyloglossia
Position: Midline/deviated
Mobility: Voluntary/not possible
Color: Pink/pale/reddish/dark
Taste: Normal/absent
Teeth: Dental caries/decay/dentures; Color-white/yellowish/stains
Mucus membrane: Color ______; moist/dry/lesions
Breath odour: Halitosis –present/absent; fetid – present/absent
Pharynx: Sore throat/infection/pain/irritation
Gag reflex: Present/absent
Tonsils: Color ________;enlarged/not enlarged/painful
Voice: Clear/harsh/aphonia/dysphonia
Subjective symptoms: No complaints/toothache/dysphagia/odynophagia/throat pain

NECK
Range of motion: Possible/painful/absent
Lymph nodes: Not enlarged/enlarged/painful
Trachea: Midline/deviated
Thyroid gland: Not enlarged/enlarged/removed
Jugular veins: Distended/not distended
Subjective symptoms: no complaints/ if any ___________

CHEST
Inspection: Thorax: Symmetrical/asymmetrical/flat/barrel chest
Thorax expansion: Normal & equal/delayed/shallow/unequal
Cough: Absent/if present (dry/whooping/productive) aggravating factors if any
Palpation: Presence of nodules/enlarged lymph nodes
Percussion: Presence of air or fluid
Auscultation: Heart sounds: S1, S2/murmur/gallop sounds
Breath sounds: Normal/wheeze/friction rub/rhonchi/crackles/stridor
Apical pulse: ______ beats/min
Sputum: Absent/ if present specify following: Odour: absent/bad odour, Consistency:
frothy/mucoid/rusty/sticky/purulent, Color: green/yellow/blood stained
Subjective symptoms: No complaints/diaphoresis/Dyspnea/giddiness/palpitations/chest
pain/shoulder pain/chest tightness/exercise intolerance/any other _________

BREAST & AXILLA

Symmetry: Symmetrical/asymmetrical
Areola& nipple – color: _______; retracted/inverted/dimpling
Discharge: Absent/milky/ yellowish/purulent/lesions/masses:
Absent/ulceration/nodes/swelling/moving/painful/tender
Axillary nodes: Not palpable/palpable/moving/painful/tender
Hair distribution: Well distributed/scanty/absent
Subjective symptoms: if (any) ________________

ABDOMEN
Inspection: Flat/abdominal pulsation
see/lineanigra/distention/pigmentation/scar/hernia/peristaltic movement
seen/striae/keloid
Umbilicus: Clean/infected/everted
Auscultation: Bowel sounds: Present/absent
Percussion: Fluid/masses/air
Palpatation: Liver margins/palpable spleen/tenderness/inguinal hernias
Appetite: Normal/increased/anorexia
Subjective symptoms: No complaints/nausea/vomiting/heart burn/polyphagia/abdominal
cramps/belching/flatulence/abdominal pain
Any other sign/symptom: ________________

MUSCULOSKELETAL
Postural curves: Normal/kyphosis/lordosis/scoliosis
Muscle tone: Normal/hypertonia/hypotonia/flaccid/spastic/rigid
Muscle strength: Normal/weaker than normal/hyperactive

UPPER EXTREMITIES
Symmetry: Symmetrical/asymmetrical
Range of motion: Possible/if impossible (specify) _______
Reflexes: Biceps-normal/abnormal
Triceps-normal/abnormal
Edema/swelling: absent/if present (specify area) _________
Joints: No complaints/swollen/ stiff/tender/crepitus __________
Deformity: Absent/if present (specify) ____________

LOWER EXTREMITIES
Symmetry: Symmetrical/asymmetrical
Range of motion: Possible/if impossible (specify) _______
Reflexes: Patellar -normal/abnormal
Achilles tendon-normal/abnormal
Plantar-normal/abnormal
Edema/swelling: absent/if present (specify area) _________
Joints: No complaints/swollen/ stiff/tender/crepitus __________
Deformity: Absent/if present (specify) ____________
Gait: Normal/limp/steppage/scissoring/dystonic/ataxia
Varicose veins: Absent/if present (specify area) _________
Dependency level: Independent/partial dependent/fully dependent
GENITO URINARY
Lesions/scar: Absent/if present (specify area) _________
Discharge/infection: Absent/if present (specify area)_________
Voiding: Continent/incontinent/catheterized
Color of urine: _________
Subjective symptoms: No complaints/dysuria/pruritis/nocturia/oligurua/ any other ____

RECTUM & ANUS

Parianal skin integrity: Intact/excoriation/rashes/lesions/haemorrhoids/bleeding
Bowel elimination pattern: Normal/constipation/loose stools/ diarrhea
Subjective symptoms: Pain before or while passing stools/blood or mucus in stools/rectal mass/
any other ___

NEUROLOGICAL TEST
Coordination test - Reflexes
Equilibrium test – Test for sensation

INVESTIGATIONS
➢ GENERAL INVESTIGATIONS
S.NO DATE NAME OF THE PATIENT VALUE NORMAL VALUE REMARKS
INVESTIGATION

➢ SPECIFIC INVESTIGATIONS
x-ray ,ECG.ECHO,ULTRASOUND,CT-SCAN,MRI,PET SCAN,BIOPSY (write only
report/impression/summary of this investigations)
MEDICATIONS
Medications list
S.NO DRUG NAME DOSAGE ROUTE FREQUENCY
Medication description
S. Name Dosage Route Frequency Action Indication Contra Side Nursing
No Of The Indication Effects Responsibility
Drug
1 Drug Write List List Down List Down List List Down
Name With Down Down
Group Units
Name

SURGICAL MANAGEMENT( only for surgical care study)

Surgery Proposed
Pre Operative Check List

SNO CRITERIA YES NO N/A

1 Vital Signs
a. BP
b. Temp
c. Pulse
d. Respiratory rate
e. Blood sugar __________ Time ________
2 Antimicrobial Bath
3 Voided
4 On Continuous Bladder Drainage
5 Bowel Preparation
6 Pre op Medication Administered
7 Surgical Site Marked
8 Skin Preparation
9 NBM
10 Loose Tooth / Dentures
11 Contact lenses / Glass Removed
12 Prosthesis Present
13 Nail Polish Removed
14 Jewellery Removed
15 Blood Group and RH Typing _____ Cross Match ________
16 Consent taken
17 HIV/HbsAg/MRSA/ HCV/Positive
18 Scrub done if Indicated
Surgery Done
Operation Notes
Post Anaesthesia Care/Immediate Post Op Care

Time
Vital Signs BP in MM Hg
Pulse / mt
Resp / mt
Temp o F
SPO2
Pain Score
C.V.P
Level of Alert / Oriented
Consciousness Drowsy
Asleep / Sedated
Disoriented
Unresponsive
Intake IV fluids
Oral
Blood & blood products
Epidural / Nerve Block
infusion
Output Urine
Drain-Rt
Drain- Lt
NG – Aspiration
I/O : Total Intake Balance:

: Total Out put Remarks :

Irrigation Total amount infused
Total amount drained
Remarks
Post operative nursing care plan

Interventions Nursing care implemented

Positions

Patient safety

Pain management

Nebulization

Blood sugar / ABG CBG: ABG : Yes / No

Blood Specimen sample

X- ray

Post Op ECG and Review

ICE pack

Knee brace / POP

Exercises

DVT prophylaxis surgical site

Surgical site

Patency of tubes

Patient and Family Education :(Prosthesis/Stent/Stones/Post Op Care)

Check List before transfer from PACU

Parameters Observations Remarks

Surgical site Intact / Oozing
Patient Safety Side Rails/Safety Belts/Locks
Reflexes Gags/Cough
Tubes & Drains Intact : Yes/ No
Movement of Present / Absent
Limb/Peripheries
General condition of Stable / Critical
the patient

Post Operative Medications

ANATOMY & PHYSIOLOGY OF -----------

First page draw the diagram of the organ
Mark the parts of the organ on the right side
Colour the diagram

DISEASE CONDITION OF -------------------

First page draw the diagram of the diseased organ
Definition
Causes
Pathophysiology
Clinical manifestation
Investigation
Management
➢ Medical management
➢ Surgical management
➢ Dietary management
➢ Nursing management

COMPARITIVE STUDY OF ------------------

Book picture Patient picture
causes
Clinical features
Investigation
Medical management
 Surgical management
Nursing management
Prognosis

PROBLEMS & NEEDS

S.NO PROBLEMS NEEDS

NOTE:-
1. List out minimum 5 problems and needs
2. For surgical patients list out pre operative problems and needs separately & post
operative problems and needs separately
NURSING DIAGNOSIS
NOTE:-
MEDICAL CAREPLAN
1. Minimum 5 nursing diagnosis

SURGICAL CAREPLAN
1. Minimum 5 Pre operative nursing diagnosis
2. Minimum 5 Post operative nursing diagnosis
NURSING PROCESS
Subjective data :-
Objective data:-
Nursing diagnosis
Goal
s.no planning Rationale Implementation Evaluation
1

Note:-
Write nursing process for all nursing diagnosis list
HEALTH EDUCATION(According to disease condition)
1.PERSONAL HYGIENE
2.DIET
3.MEDICATION
4.EXERCISE
5. FOLLOW UP
EVALUATION :-
Patient Evaluation
My patient name was suffering from diagnosis was under treatment. When i took him /her
for my medical/surgical care study ,he/she was very anxious and nervous. By giving care he/she
was cooperative and was satisfied by my quality care.

Student Evaluation
I student name Ist year GNM student of Apollo school of Nursing have taken patient name for
my medical /surgical care study . By taking this care plan I have learnt how to give quality care
by meeting the basic needs and gained the patient’s satisfaction by rendering tender loving care.

CONCLUSION
By taking this care study I have learnt how to assess the patient , and find out the problems and
needs by following the appropriate implementation of nursing care.

BIBLIOGRAPHY
Name of the author, BOOK NAME, edition, publication, publication year, page number
Note
1. Minimum 5 relevant bibliography ( Medical surgical book -2, nursing process book -1,
anatomy &physiology book -1,nursing foundation book -1,drug book -1, journal if any )

2. Write author’s name & book name in capital letters

3. Under line the book name with inverted colons. Eg . ( “ FUNDAMENTALS OF
NURSING “)