CHN CASE STUDY AND CAREPLAN BY DR.ANJALATCHI MUTHUKUMARAN.docx

How to maintain the care plan and care study format for community health nursing subjects

1. ERA COLLEGE OF NURSING
SARFARAZGANJ LUCKNOW 226003

CARE PLAN FORMAT
COMMUNITY HEALTH NURSING

INTRODUCTION:
 General information
 Name of the client :
 House number :
 Name of the head of the family :
 Type of family :
 Size of family :
 Religion :
 Nationality :
 Address :

 History of client
Name
Chief complaints


MEDICAL HISTORY
PRESENT HISTORY

PAST HISTORY (general health status, acute infectious diseases, immunization, systemic,
disease, medications, hospitalizations, injuries, blood transfusion)


SURGICAL HISTORY
PRESENT HISTORY

PAST HISTORY (surgery-indications, name of hospital, type of anaesthesia, any complications)

2. BIRTH HISTORY
ANTENATAL HISTORY (regular-antenatal check up, maternal-health status, immunization,
illness, medications)

INTRANATAL HISTORY (mode of delivery with gestation apgar score, resuscitation if any,
complication if any)

POSTNATAL HISTORY (postnatal complications)

DEVELOPMENTAL HISTORY
S. N. Age Milestone Child pictures Remarks
1 6-8 weeks Looks at mother and smile
2 3 Months Holds head erect
3 4-5 Months Recognize mother
4 6-8 Months Sites without support
5 9-10 Months Crawling
6 10-11 months Stand without support

GROWTH AND DEVELOPMENT
Book picture Child's picture
Psychosocial development
Psycho sexual development
Emotional development


ASSESSMENT OF REFLEXES
Book picture Child's picture
Eyes
a) Blinking reflex
b) Capillary reflex
c) Doll's eye reflex

3. Nose
a) Sneezing reflex
b) Glabellar reflex

Mouth and throat
a) Sucking reflex
b) Rooting reflex
c) Extrusion reflex
d) Gag reflex
e) Yawn reflex

Extremities
a) Palmar grasp reflex
b) Plantar grasp reflex
c) Babinski reflex
d) Ankle reflex
e) Placing reflex
f) Stepping reflex

Mass reflexes
a) Dancing reflex
b) startle reflex
c) Tonic neck reflex
d) Trunk incurvation reflex
e) Crawling reflex



IMMUNIZATION STATUS
S. N. AGE Name of vaccine Doses Route Status Remarks





MENSTRUAL HISTORY
Age of attain menarche, duration and intervals of menstrual cycle- menstrual hygiene practices

4. OBSTETRICAL HISTORY (IF FEMALE)
ANTENATAL HISTORY

POSTNATAL HISTORY

FAMILY HISTORY
Type of marriage of parents (consanguineous non consanguineous) hereditary diseases, systemic
illness, psychiatric illness, communicable diseases.

PERSONAL HISTORY
Sleep pattern appetite diet pattern habits hobbies hygiene elimination pattern dressing personality e
allergy type of reactions activity and exercises and relationship with others.

SOCIO ECONOMIC HISTORY
Monthly family income breadwinner of family sources of income financial status type of house on rent
facilities ventilation electricity e drainage lighting water waste disposal and latrine facility availability
of hospital clinics health centre markets temple school and transportation.

 Demographic characteristics
S.
N.
Name of
the
family
members
Relationship Age/sex Educational
status
Occupation Income Marital
status
Health
status
1
2


Family tree
Pedigree keys:
Mail
Female
Relationship

5. or Died
or Patient
 Environmental conditions

1. ROAD MAP

2. COMMUNITY ENVIRONMENT

 Method of disposal
 Disposal of waste
 Drainage facility
 Solid waste
 Excreta disposal
 Disposal of died

 Communication facilities
 Transport station facility
 Religious resources
 Church/Temple/Mosque
 Schools/ Colleges
 Market /Shops
 Post office
 Banks
 Medical facilities
 Private clinics /nursing homes
 Recreation facilities
 Socio cultural believes

 Housing conditions
 Floor map of house
 Type of house : Pakka/Kaccha/Semi pakka
 Ownership: own/ rent
 Number of rooms :
o Ventilation :
Natural : Windows /doors
Artificial : Fans/Air condition/Nill
o Source of light
Natural : Adequate /inadequate
Artificial : electricity/ gas pump/kerosene
o Water supply
Source : well/ tap/ hand pump
Adequate /inadequate:
o Kitchen : separate /common

6. Size : adequate/ small
Fuel used : kerosene/ gas/ wood
o Disposal of waste :
o Drainage : closed/ open
o Disposal : dumping/ incineration
o Latrine facility
o Presence of domestic animals : yes/ no (if yes specify)
o Presence of insects :
o Presence of rodents :
o Presence of stay dog/ cats :
o Presence of accidental hazards:

 Economic condition

 Transportation and communication

 Nutritional status
 Food habits
 Number of males
 Staple food
 Common vegetables
 Use of RAW vegetables
 Adequacy of nutrition consumption
 Cooking practices
 Method of preservation of food

7. PHYSICAL ASSESSMENT AND SYSTEMIC ASSESSMENT

GENERAL APPEARANCE
 Consciousness : conscious/ semi conscious/ coma
 Orientation : oriented to time place and person
 Sign of distress : pain/ Dysnea/ Fatigue
 Body built : farm/ muscular /excessively thin
 Posture and gait : normal/ coordinated /uncoordinated
 Body movement : normal /tremors/ immobility

VITAL SIGNS
 Temperature :
 Pulse :
 Respiration :
 Blood pressure :
Impression

ANTHROPOMETRIC MEASUREMENTS
 Length /height : Cms
 Weight : Kgs
 BMI :
 Head circumference :
 Mid arm circumference :

Impression

HEAD TO FOOT EXAMINATION
SKIN AND NAILS
 Colour : Pink/ Brown/ Flushed/Pallor/ Cyanosed/Icterus/ Acrocyanosis/ Pigmentation
Lanugo (Newborn)
 Moisture : Moist /Dry /Sweating
 Temperature : Cold And Clammy/Worm
 Texture : Smooth/ Rough /Thick/ Coarse /Scally
 Turgor : Normal clasticity/ Poor elasticity/Wrinkled
 Edema : Absent/Present/Dependent/Pitting/pedal/Orbital/Generalized
 Integrity : Intact/Lesions/Birth marks/Moles/Scars/Rashes

8.  Lesions/Rashes: Present/Absent
 Purpuric spots: Present/Absent
 Common skin variations: Present/Absent/Milia/Erythema Toxicum/Mangolian
spot/Miliaria/Harlequin color changes/Telangietatc Navi
 NAILS : Clean/Smooth/Dry/Brittle/Splinting/Cracling/Clubbibg/Splinter/haemorrh
age/paryncyla
 Colour : Pink/Pale/blue
 Capillary Refill: Normal/Poor

HEAD AND SCALP
 Skull size, Shape, Contour : Normal/Macrocephali/Microcephaly
Symmetrical/Asymmetrical/ Hydrocephalus/Acromegaly/nodules/Masses/Lumps
 Scalp : Lesions, Dandruff/Pediculosis
 Hair :ColourFine/Thick/Stright/Curly/Shiny/Dry/Brittle/Distribution/Alopecia/Hir
sutism/Hirsutism
 Fontanels(If Infant)
 Anterior fontanel
o Size Shape:Length/Width/Diameter/Hot/Pulsating/Bulged/Depressed
o Posterior fontanel Width in Cms Triangular/Flat/Hot/Pulsating/Bulged/Depressed
o Sutures: Normal/Widened
o Scalp vein: Visible/Not visi
o Crack pot sign: Present/Absent
 Birth injuries: Absent/Caput Succedancum/Cephalic hematoma

FACE: Symmetry/Sensadon asymmetry/Puffy/old man face

EYES:
 Vision
 Size: Normal/Small/Lar
 Space: Normal/Widened
 Eyebrows: Symmetrical/Asymmetrical Curved/Straight/Thick/Thin/Sparse
 Eye lids: Swollen/Infected/Ptosiss/Ectropion/Chalacian/Sunset sign/Masses
 Eye lashes: Long/short/Curved/N
 Sclera: White/Red/Pink/Discharges/Blue/red
 Color: Gray/Blue/Red/Brown/Brush field spots
 Conjunctiva: Pale/Pink/Red/Jaundiced/Sub conjunctival Hemorrhage
 Lacrimal Punctum: Normal/Redness/ Excessive tearing
 Cornea: Opaque/congenital cataract/Intact
 Pupils: PERRLA ( Pupils equally round reacting to light accommodation)
 Eye movement: Normal/Week/Nystagmus/Strabismus/estropia/exotropia
 Lacrimal gland:Tender/Non Tender/Swollen/Tearing

9.  Pupillary reflex:Present/Absent
 Corneal Reflex to Touch: Blinking / No response
 Corneal reflex to light: Blinking No response
 Squint: Yes/No
 Vision field: Intact/normal
 Vision: Normal 6/6 or 20/20/ Myopia/Presbyopia

EARS
 Pinnae Size and shape: Large/ small/ Symmetry/Asymmetry/Flexible Completely
formed/Incompletely formed/Swollen/Pithole
 Posistion: Equal to outer canthus of eyes/Low set /High set
 Ear canal: Clean/Discharges/Cerumen/Nodules/Foreign objects Disc
 Tympanic membrane: Whitish and intact/redness/ulging Perforated
 Hearing: Normal(Whisper test, Weber and Rhinne' s test)
 Startle Reflex: Present/Absent in response to loud noise

NOSE
 Size and Shape : Long /Short Swollen/Flaring of Nostrils
 Patency: Patent/Obstructed with mucus/ Discharges/Polyps/Blood/Bony obstruction
 Septum: Midline/Deviated/Perforated
 Nasal mucosa: Pink/Red/Bluish
 Discharges: Watery/Mucoid/Purulent/Blood
 Sinuses: Tender/ Non tender
 Minor disorders: Absent / Milia
 Congenital disorders: Absent /Cleft palate

MOUTH AND PHARYNX:
 LIPS
 Colour: Pale/Pink/Cyanosed/Red
 Shape: Symmetrical/Asymmetrical
 Moisture: Smooth/Moist/Dry
 Lesions: Absent/Crackles/Figures
 Congenital Anomalies: Absent/Cleft lip

 TEETH
 Natural Teeth: Present/Absent/color

 GUMS
 Colour: Pink/Pale/Red
 Lesions: Absent/Swollen/Bleeding/Gingivitis/Ulcerated/Spongy

10.  BUCCAL MUCOSA:
 Colour: Pink/Dark Red
 Moisture: Dry/Moist
 Lesions: Instact/Ulcers/Chancre/Cleft lip and cleft palate

 TONGUE
 Colour:Pink/White
coated/Thrush(Candidiasis)Giry/Fissure/crackled/Bluish/Microglossia/Macro
glossia/Glossitis/Halitosis
 Moisture: Dry
 Size: Macroglossia/Microglossia Frenulum of upper lip & Tongue: Midline/Extended upto
lips
 Movement: Normal/Tongue Tie
 Uvula: Midline/Deviated
 Palate: Normal/Cleft palate/Epstein pearls
 Gag reflex: Present/Absent
 Salivation: Absent/Minimal/Profuse or drooling
 Cry: Vigourous Cry/ Weak/ Hoarse/Hight piched/Absent Cry

 TONSILS: Enlarged/redness/dysphagia/uvula-mobile/midline/gng refles

NECK
 Appearance: Long /Short & thick/Symmetrical/Assymetrical/ Torticollis (Wry Neck) Jugular
vein distension/Carotid bruits
 Thyroid: Palpable/Nodules/Tenderness
 Trachea: Midline/Deviated
 Lymph node: Palpable/Not palpable/Mobile/Hard/Firm
 Movements: ROM Possible/Not possible
 Neck vein: Distended/ Not distended

CHEST
 INSPECTION
 Thoracic configuration
o Size: Anterior posterior & lateral diameters are equal/Un equal
o Shape: Normal/ Funnel shaped/ Pigeon shaped
o Chest movement: symmetrical/ Asymptomstic
o Breast: Normal/Red/Tenderness/Enlarged/Supernumerary Nipple/Witch's milk

 Respiration
o Rate:
o Rhythm: Regular/Irregular/Periodic breathing
o Depth of respiration: Deep/Shallow
o Quality: Difficult/Labore

11. o Character of breath sounds: Inspiratory stridor/Expiratory Ghunt/Apneic
spells/seesaw respiration
o Retraction: No retraction/Sterna/Intersostals/Supra coastal Visible pulsation

 PALPATION
 Tendrness: Present/Absent
 Abnormality: Absent/Cryst/Crepitus/Trill

 AUSCULTATION
 Lung sounds: Bilaterally equal/Diminished/Absent/Cracles/Ronchi/Wheeze/Peural
friction/Equal air entry
 Adventitious Sounds: Cracies/Wheezes

HEART
 Position: Left fifth midclavicular line/Right Sternal boarder
 Heart sounds: S1, S2 sounds/Murmurs/Heart rate
 Apical Pulse: Normal/Arrhythmias/Dextro cardio

 PERCUSSION: Normal resonance/Hyper resonance /Dullness

ABDOMEN
 INSPECTION: Symmetrical/Asymmetrical rounded/Flat/Scapoid/Sunken
 Abdominal Skin: Taut without wrinkles or creases/Shiny
 Peristalic movement: Visible Non visible
 Umbilicus: Normal/Infected/Hernias/Flat/Protruding/Green colour /Bleeding
 Umbilical cord: 2 arteries & 1 vein/1 artery & I Vein
 Visible vein: Present/Absent
 Ascites: Present/ Absent
 Congenital anomalies: Ompahalocele/Gastroachiaisis/Bladder extrophy
 Liver: Palpable/Not palpable
 Spleen: Palpable/Non palpable
 Palpable mass: Present/ Absent
 Bladder: Palpable/Not palpable

 AUSCULTAT
 Bowel sounds: Metallic clicks & gurgles/ Hyper active/Hypo active
 Frequency of bowel sound: 5 sounds per Minute/More/Less

 PERCUSSION: Normal/Dullness/Hyper active

BACK

12.  Spine: Intact/Mass/Perforated
 Shape: Normal/Kyphosis/Lordosis/Scoliasis
 Vertebra: Intact/Tenderness/Masses
 Neural Tube defects: Present/Absent
 Posture: Normal/Abnormal

GENITALIA
 Anal Opening: Patent/Occluded
 Excoriation: Present/Absent
 Fistula: Present/Absent

FEMALE GENITALIA:
 Labia and Clitoris: Normal/Edematous/Fused Labia
 Urethral opening: Normal/Absent
 Vaginal Discharge: Present/Absent/Bloody/Mucoid
 Congenital anomalies: Absent/Fistula/Ambigous genitalia

MALE GENITALIA
 Urethral opening: Tip of glans penis Prephomisis/Hydrocele/Hernia/Epithelial pearls
 Testes: Palpable/Not palpable /Descended/Undescended/Hypoplastic/Hydrocele/Mass
 Penis: Normal/Micropenis
 Scrotum: Large, Edematous, Pediculous and covered with Rugac/Cryptorchidism

ANUS/RECTUM: Hemorrhoids/inflammation/Lesions/Fissures/Skin
tags/Rectocele/Patency/Imperforated anus
 Meconium: Passes/Not passed (IF NEW BORN)
 Anal Fissure/Fistula: Present/Absent (IF NEW BORN)

EXTREMETIES
 Shape & Size: Normal/Asymmetrical/swollen/edema/defourmities/rashes/prosthesis/Vericose
veins
 Range of Motion: Possible/Not possible/Stiff
 Upper extremities: Normal/Diminished
 Lower extremities: Normal/Diminish
 Digits: Normal Polyactyly/syndactyly
 Creases: Present/Absent
 Muscle Tone&strength: Normal/ Weak/Firm/Muscular/Flaccid/Spastic/atropy/tremors

13.  Congenital anamelies: Hip Dislocation/Club foot
 Ankle edema: Present/Absent
 Allis sign: Present/Absent
 Ortolani test: Positive/Negative
 Barlow: Positive/Negative


SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM:
 INSPECTION: Respiration rate Tachypnea/Bradypnea/Apnoca/Labored/Shallow Gasping
 Shape & Symmetry: Symmetrical/Barrel, Pigeon, Funnel shaped Rhythm -
Regular/Irregular
 Movement Of Chest Wall: Intercostals And Accessory Muscle Relaxation
 A.P& Transverse Diameter: 1.2
 Lesions: Cyanosis, Sears

 PALPATION: Tenderness, Lumps, Crepitus, Thoracic Excursion, Tactile Fremitus, Mass
 PERCUSSION: Resonance/ Dullness Flatness
 AUSCULTATION: Normal Lung Sounds/ Adventitious Breath Sounds -Crackles, Wheezing
Rhonchi Pleural Friction/rub/stidor

CARDIO VASCULAR SYSTEM:
 INSPECTION: Visible Pulsation/Jugular Venous Distension/Edema (0-4)
 PALPATION: Pulse & Heart Rate /Thrills/Allen's T
 AUSCULTATION: S1/S2/S3/S4 / Murmurs. Split Heart Sounds/ Blood Pressure

GASTRO INTESTINAL SYSTEM :
 INSPECTION: Contour , Enlargement Ascitis, Umbilicus, Movements, Visible Peristalsis,
Lesions, Scar, Striae, Hair Distribution
 AUSCULTATION: Bowel Sounds - Present /Absent
 PERCUSSION: Fluid Collection - Thrill /Dullness
 PALPATION : SoftFirm/Hard/Tenderness/Organomegaly/Hernia

RENAL SYSTEM:
 INSPECTION: Redness In Flank Region/Ederna
 PALPATION: Tenderness /Palpable
 URINE OUT PUT: Amount /Frequency/ Color/ Turbidity

14. MUSCULOSKELETAL SYSTEM
 INSPECTION: Size, Symmetry, Shape, edema, Deformity, Prosthesis gait, ROM of Each
joint, Skin colour and characteristics
 PALPATION: Muscle tone, Strength (0-5), Bony articulation
 REFLEXES:

INTUGUMENTARY SYSTEM
 INSPECTION: Skin color/ Integrity/ Redness/Papule/ Blisters/ Shape/ Moisture/ Dry/ Edema
 INSPECTION: Type of edema/Tenderness/ Pain

REPRODUCTIVE SYSTEM
FEMALE: Discharges/Lumps/Masses/Menstrual abnormalities/Prolapsed/ Cystocele Rectocele
MALE: Phimosis/Priapisim/ Epispadiasis/ Hypospadiasis /Hydrocele/Hernia
SCORE

CENTRAL NERVOUS SYSTEM :
 GLASCO COMA SCALE (GCS) (1 -15)
RESPONSE SCORE

EYE OPENING
Spontaneously 4
To command 3
To pain 2
No response 1

MOTOR RESPONSE
Obeys commands 6
Localize pain 5
Flexion withdrawal 4
Flexion 3
Extension 2
No response 1

VERBAL RESPONSE
Oriented 5
Confused 4
In appropriate words 3
In comprehensible sounds 2
No response 1
Total 15

 COGNITIVE PERCEPTUAL PATTERN
 Mental status: Orientation: Person/place/time

15.  Level of Consciousness: Alert/Drowsy/Lethargic/Difficult/Unable to arouse/Other
 Memory: Intact/Recent Memory deficit/Remote memory deficit
 Thought process: Answers questions appropriately/Answers un reliably

 ASSESSMENT OF REFLEXES
Book Picture Clients picture
Superficial and deep
 Abdominal
 Achilles
 Comeal
 Biceps
 Triceps
 Plantar
 Babinski



 MOTOR FUNCTION: MUSCLE STRENTH AND CO ORDINATION
 MUSCLE POWER GRADING
GRADE DESCRIPTION
5/5 Full range of motion against gravity with extreme resistance
4/5 Full range of motion against gravity with some resistance
3/5 Full range of motion against gravity with no resistance
2/5 Full range of motion with gravity eliminated
1/5 Slight contraction visible
0/5 No movements


 ASSESSMENT OF CEREBELLAR
 Finger to finger test
 Finger to nose test
 Putting test
 Romberg test
 Tandom walking test

SENSORY EXAMINATION
 Response to touch
 Response to pain and temperature
 Propioception

CRANIAL NERVE ASSESSMENT

16. Nerve Name of the
cranial nerve
Function Assessment Findings
1 Olfactory Sense of smell Close the eye, occlude
nostril and identify the smell

2 Optic Control visual activity
and visual field
Cover one eye position a
news paper 12-18 inches and
read the letters

3,4,5 Occulomotor,
Trochlear,
Abducens
Control Pupillary
reaction
An object moved
systematically in various
directions

6 Trigemina Control facial sensation
and jaw movement
The patient to close his eyes
then the various parts of the
face is gently touched using
a wisp of cotton

7 Facial Control facial muscles Assessed by having the
patient wrinkle her fore head
smile, showing her teeth

8 Auditory/Vestibule
Choclear
Controls hearing and
sense of balance
Webers test and Rinnes to
evaluate air and bone
conduction

9,10 Hyppoglossall,
Vagus
Controls swallowing,
the gag reflex,
articulation
Instruct the patient to pen his
mouth and say ah. Use the
tip of tongue depressor to
stimulate the back of the
pharynx. Swallowing is
tested by asking the patient
to drink a clear fluid

11 Spinal accessory Controls the trapezius
and sternocleido
mastoid muscle
Instruct the patient to rise
both shoulders and to hold
tightly and apply resistance
to shoulders using both
hands

12 Glosso pharyngeal Controls tongue
movement and strength
Is assessed by having the
patient protrude her tongue

17. SHORT TERM GOALS/LONG TERM GOALS

DISEASE CONDITION
Compare with Books Picture and client picture
Book Picture Patient Picture


DIET PLAN
NUTRITIONAL ASSESSMENT (24 hour Recall) Date
Time Food item Quantity CHO(grams) Protein(grams) Fat(grams) KCAL






Total
Kcal








MENU PLAN Recommended 24 hours dietary plan
Time Food item Quantity CHO(grams) Protein(grams) Fat(grams) KCAL






Total
Kcal

18. COMMUNITY NURSING DIAGNOSIS
1. .
2. .

COMMUNITY NURSING PROCESS
ASSESSM
ENT
NURSIN
G
DIAGN
OSIS
GO
AL
PLANNING/INTER
VETION
RATION
ALE
IMPLIMENT
ATION
EVALUA
TION
Subjective
data




Objective
data
(should be
a
measurabl
e or
observable
data)




BAG TECHNIQUE PRO CEDURE

HEALTH EDUCATION

THEORY APPLICATION

RECORDING AND REPORTING

SUMMARY

CONCLUSION

19. BIBLIOGRAPHY

Reference