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Community Health Nursing

This document contains templates for collecting family and patient health information as part of community health nursing assessments. It includes sections for collecting identification information, housing conditions, family composition, transportation/communication, nutrition, illness history, pregnancy status, family planning, and treatment preferences. Nursing care plans, vital sign graphs, and notes pages are also provided as templates to document nursing assessments and interventions. The overall purpose is to systematically gather relevant health and social data on families and individuals in the community.

Uploaded by

Maggie Ganotra
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
1K views8 pages

Community Health Nursing

This document contains templates for collecting family and patient health information as part of community health nursing assessments. It includes sections for collecting identification information, housing conditions, family composition, transportation/communication, nutrition, illness history, pregnancy status, family planning, and treatment preferences. Nursing care plans, vital sign graphs, and notes pages are also provided as templates to document nursing assessments and interventions. The overall purpose is to systematically gather relevant health and social data on families and individuals in the community.

Uploaded by

Maggie Ganotra
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Cover Page
  • Family Profile Data
  • Nursing Care Plan
  • Vital Sign Graphic Sheet
  • Nurse’s Notes

www.drjayeshpatidar.blogspot.

com
1

COMMUNITY HEALTH NURSING

(NO. _____)

NAME OF STUDENTS :- _________________________________

CLASS :-__________________________________

DATE FROM :-________________ TO ______________


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FAMILY PROFILE DATA

Primary Health Centre: ________________________________


Sub Centre : _______________________________
Name of the Village: _________________________________

1. IDENTIFICATION INFORMATION

Head of family – Name:__________________________________________

Occupation : ___________________________________________________

Address_________________________________________________________________

________________________________________________________________________

Type of family: Nuclear Joint

Religion: Hindu Muslim Christian Any other

2. HOUSING CONDITION

1.Type of House: Completed Independent Tileld Sheeted


Hut Owned Rented

2. Rooms : Number - Adequate Inadequate

3. Kitchen : Separate Attached to room.

4. Fuel Used : Gas Kerosene Fire Wood Electricity

5. Ventilation : Adequate Inadequate

6. Bath Room : Separate Common

7. Lighting : Electricity Oil Lamp

8. Drainage : Open Close

9. Water Supply : Tap/Hand Pump Well Chlorined. - Yes/No Open Tank Chlorinated

10 Toilet : Own Public Open field

11 Disposal of Waste:Composing Burning Buying

12 Cattle Shed : Separate Within the House


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3. FAMILY COMPOSITION

S Name Relationship Age Sex Education Occupation Health Immun


N With Head Status ization
of the Family Status
1

4. TRASPORT AND COMMUNICATION FACILITIES B. Communication Media

A. Transport Yes No
Own Yes/No Telephone

Tractor Tempo Wheeler Television

Bus City Bus RSRTC Private Radio

Autos Taxies Train Newspaper/Magazines


Post & Telegraph

5. LANGUAGES KNOWN

Marwadi Mewadi Gujrati


English Hindi Any Other

6. A)NUTRITIONAL PATTERN

Vegetarian Non Vegetarian


Staple Food : Rice Wheat Ragi Mixed
Vegetables : Grown Purchased Quantity used per day: ……kg
Milk : Quantity used per day ………litres
Non Vegetarian Dish: Specify…………………. How often ……………
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B) NUTRITIONAL STATUS OF FAMILY MEMBERS

Name of the Member Nourished/Under Nourished Malnutrition

7. RECORD OF ILLNESS

Name of the Member Age Illness Duration Main Investigation Treatment


Characteristics done

7. PREGNANT WOMAN

Name Age Gravida No. of Children Whether Registered in Receiving Iron


& Para Living Hospital/Nursing Home and Folio Acid

9. ELIGIBLE COUPLES

Name Age Family Planning Method Not interested willing to use


Adopted in Family Planning Family Planning method

10. IN CASE OF SICKNESS, WHERE DO YOU GO FOR TREATMENT?

Name/Primary Health Centre Private Nursing Home

Sub Centre Indigenous Doctor/Dai


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NURSING CARE PLAN

Assessment Nursing Diagnosis Objective/ Goals Nursing Interventions Evaluation Outcome


www.drjayeshpatidar.blogspot.com

Assessment Nursing Diagnosis Objective/ Goals Nursing Interventions Evaluation Outcome


www.drjayeshpatidar.blogspot.com

Vital Sign GRAPHIC SHEET


* Mouth
* Rectal
Month……………………….

Name, Age, Sex, Status Religion Hospital No.


Occupation, Income Ward, unit, Bed No.
Date:
No. of Days
Days Post-op
Time
Temp
C F
Pulse
210 41.1 106
200 40.6 105
190 40.8 104
180 39.4 103
170 38.9 102
160 38.3 101
150 37.8 100
140 37.2 99
130 36.7 98
120 36.1 97
110 35.6 96
100 35 95
90 Resp-060
80 50
70 40
60 30
50 20
40 10
B.P.
7a.m. to 7p.m.
(Total in m.l.)
Intake
7p.m. to 7a.m.
(Total in m.l.)

7a.m. to 7p.m.
(Total in m.l.)
Urine
7p.m. to 7a.m.
(Total in m.l.)
Stools No. of Times
Aspiration/Drainage
(24 Hrs. Total in m.l.)
Sputum
Weight
Bath
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NURSE’S NOTES

Date Time Nursing Intervention Signature

1 www.drjayeshpatidar.blogspot.com COMMUNITY HEALTH NURSING (NO. _____)
www.drjayeshpatidar.blogspot.com FAMILY PROFILE DATA Primary Health Centre: ________________________________ Sub Cen
www.drjayeshpatidar.blogspot.com 3. FAMILY COMPOSITION S N Name Relationship With Head of the Family Age Sex Educ
www.drjayeshpatidar.blogspot.com B) NUTRITIONAL STATUS OF FAMILY MEMBERS Name of the Member Nourished/Under Nourish
www.drjayeshpatidar.blogspot.com NURSING CARE PLAN Assessment Nursing Diagnosis Objective/ Goals
www.drjayeshpatidar.blogspot.com Assessment Nursing Diagnosis Objective/ Goals Nursing Interventi
www.drjayeshpatidar.blogspot.com Vital Sign GRAPHIC SHEET * Mouth * Rectal Month……………………….
www.drjayeshpatidar.blogspot.com NURSE’S NOTES Date Time Nursing Intervention Signature

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