Section –I
Particulars Related to Candidate
Name:
Father/Husband Name:
Attach
Roll Number: University Registration Number:
Photograph
Semester: Session:
1. Objective of Log Book:
This log book is a prerequisite of appearing in the BS Nursing Examination.
It will keep record of various academic achievements.
It will identify any deficiency in specific area.
It will help the Department in assessing the trainee.
2. Instruction to students:
The candidate will maintain the log book during the whole period of his/her training.
Portfolio Contents
1. Case Studies
2. History of patients
3. Disease (Definition, sign & symptoms, Causes, investigation, pathophysiology, medical management,
Nursing Management)
4. NCPs
5. Drug Card
6. Reflective Log
7. Article related to each case study
He/she will fill the column of the log book on the same day of activity.
The teacher/supervisor must sign all the entries.
The candidate shall bring the Log Book in the final examination.
Log Book not signed by the relevant authorities will make the student ineligible for the examination.
SECTION-II
DAILY OBJECTIVE
S. # 0BJECTIVES DATE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
History Taking Form 01
Patient
MR #: Foundation Receipt #:
Name: Date / Time:
Department: _ Address:
Section (A) presenting complaints (P/C)
Vitals P/C Hour/Days/month/year
Blood Pressure (BP)
Heart Rate (HR)
Temperature
Respiratory Rate(R/R)
Section B (previous medical and surgical history)
Medical History (Medications) Surgical History
Section C (General physical examination)
Extra Examination
J (Jaundice)
A (Anemia)
C (Cynosis)
K (Kolinichiya)
L (Lymph nodes)
E (Edema)
T (tremors)
Section D (Investigations)
Extra Examination
Section E (Medical Diagnosis)
Section F: (Treatment)
IV/IM Oral
Follow-up/referral
Physical Assessment/Assessment Tool 01
Gordon’s Functional Health Pattern
Patient Name: MR No. Ward/ Unit: Date of Admission:
Age: Sex: Occupation: Language:
Education: _ Marital Status: Children: Male:
Female: socio-economic status: Chief Complaints:
Medical Diagnose:
Past Medical/Surgical History: Hospitalization
Surgery
Home Medication:
Immunization Status:
Vital Sign: BP Pulse Respiration Temperature
Health perception Health Management pattern:
Patient views about his/her health and how he/she manage his/her health.
Patient’s views about his/her illness and how he/she manage
his/her illness. Patient knowledge about his/her disease:
Patient knowledge about disease prevention:
List of current medication:
Over the counter drugs:
Allergies: Food:
Drugs:
Others:
Nursing Diagnosis:
Nutrition Pattern:
Number of meal per day: Breakfast Lunch Dinner Snacks
Food Preferences: (a) Likes (b) Dislikes
Amount of fluid per day Route (IV) Oral other:
Tube Feeding (Explain) Any Dietary Restriction Any Fluid Restriction
Skin: Turgor Color Texture Edema
Hair: Texture Distribution Oral Mucous Membrane Gums
No. of Teeth Alignment Denture Height Weight
Labs: Hb Hct WBC ESR RBC Platelets PT
APTT INR Albumin Na K Ca
Nursing Diagnosis:
Elimination Pattern:
Urine: Frequency/24hrs: voiding self/Catheterized Color Amount/24hrs any
pain/Discomfort during urination Any problem with bladder control:
Retention/incontinence
Stool: Frequency/24hrs any laxatives used Constipation/Incontinence
Nursing Diagnosis
Activity Exercise Pattern:
Life style: Active Sedentary Breathlessness during activity or at rest Cough (Dry/Productive)
If Productive Color Odor Characteristic Amount SOB
O2/min Via Inhalation Therapy Sputum Tests
Nursing Diagnosis:
Circulation:
Pulse rate/min Rhythm Amplitude Peripheral pulses Capillary
refill Extremities Color Temperature
Nursing Diagnosis:
Cognitive Perceptual Pattern:
Level of Consciousness: Oriented to Time Place Person if unconscious GCS
Any Speech difficulty
Memory: Recent Remote Vision Glasses Hearing aid
Pain: Characteristic Onset Location Duration Exacerbation
Radiation Relieving Factors Associated Factors
Nursing Diagnosis:
Rest and Sleep Pattern:
No. of hour’s sleep/24 hours: Home Hospital Naps any problem to fall/stay asleep
Use of tranquilizers any home remedy to induce sleep Evidence of lack of sleep
Quality of sleep
Nursing Diagnosis
Self-Perception / Self-concept pattern:
Patient perception of his or herself grooming Voice tone
Eye Contact Gesture/Congruent with words
Nursing Diagnosis
Role relationship pattern:
Family (Nuclear/Extended) Responsibilities in family Role shared by
Role in decision making Leisure entertainment activities Socialization
Satisfaction with family/Work
Nursing Diagnosis
Coping/Stress Pattern
Affect/Mood: Calm Angry Irritable Anxious Withdrawal
Apathetic Common stressors Coping behavior during stress Sharing of stress with
Use of Alcohol /Pan/Tobacco/Cigarette/Drugs
Nursing Diagnosis
Sexuality/Reproductive Pattern:
History of birth control: Age of Puberty Onset of Menses (F) Menstruation cycle Amount
Pain/Problem Frequency Menopause No. of children Alive
Dead Marital Relation with spouse Self breast examination (F)
Self testicular examination (M)
Nursing Diagnosis
Value believe pattern:
Things important in life Spirituality Religious Beliefs
Any spiritual conflict Satisfaction with life
Nursing Diagnosis
Disease 01
DEFINITION:
CAUSES:
SIGN & SYMPTOMS:
INVESTIGATIONS:
PATHOPHYSIOLOGY:
COMPLICATIONS:
MEDICAL MANAGEMENT:
NURSING MANAGEMENT:
DRUG CARD 01
NURSING CARE PLAN 01
Patient Name: Age: Sex: Bed # Date of Admission:
Medical Diagnosis:
Problem (Nursing Diagnose):
Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
SUBJECT DATA: SHORT TERM GOALS
OBJECTIVE DATE: LONG TERM GOALS
Reflective log 01
