History should be Focus on physical examination which include

• Present illness,
• Patient past medical history
• Previous or present medications and allergies
• Family background social history
• Finally occupational history
• If any pathological investigation done if yes notify in short

Presentation of patient Case

• Describe the case in a narrative form.
• Demographics of patient (age, sex, height, weight, race, occupation).
• Avoid patient date of birth, initials and father name.
• Describe a short patient's complaint.
• Present illness as well as medical history must be listed
  1. Include the important details of your current problem.
  2. Share your past medical history
  3. Include your social history.
  4. Write out your questions and expectations.

Three Types of Patients

1. The patient depends on your decision.
2. The patient's want problem must resolve without thinking of another alternative
3. Patient want to avoid surgery

Short Nursing Care Feedback

This page help how to asses database

Provides an overview of the more commonly the signs and symptoms and corresponding diagnostic findings.

Nursing

Establishes a general ranking of needs and concerns on which the Nursing Diagnoses are ordered in constructing the plan of care which can be altered according to the individual client situation.

Goal to Discharge

Identifies short-term and intermediate goals to be achieved by the client before being “discharged” from nursing care. They may also provide guidance for creating long-term goals for the client to work on after discharge.

Nursing Diagnosis

The general need or problem (diagnosis) is stated without the distinct cause and signs and symptoms, which would be added to create a client diagnostic statement when specific client information is available. For example, when a client displays increased tension, apprehension, quivering voice, and focus on self, the nursing diagnosis of Anxiety might be stated: severe Anxiety related to unconscious conflict, threat to self-concept as evidenced by statements of increased tension, apprehension; observations of quivering voice, focus on self.

In addition, diagnoses identified within these guides for planning care as actual or risk can be changed or deleted and new diagnoses added, depending entirely on the specific client information.

Possible evidence

These lists provide the usual or common reasons (etiology) why a particular need or problem may occur with probable signs and symptoms, which would be used to create the “related to” and “evidenced by” portions of the client diagnostic statement when the specific situation is known.

When a risk diagnosis has been identified, signs and symptoms have not yet developed and therefore are not included in the nursing diagnosis statement. However, interventions are provided to prevent progression to an actual problem. The excep- tion to this occurs in the nursing diagnosis risk for Violence, which has possible indicators that reflect the client’s risk status.

Nursing Interventions

Nursing Interventions Classification (NIC) labels are drawn from a standardized nursing language and serve as a general header for the nursing actions that follow.

Division of Nursing actions are independent—those actions that the nurse performs autonomously; and collaborative— those actions that the nurse performs in conjunction with others, such as implementing physician orders. The interventions in this book are generally ranked from most to least common. When creating the individual plan of care, interventions would nor- mally be ranked to reflect the client’s specific needs and situation. In addition, the division of independent and collaborative is arbitrary and is actually dependent on the individual nurse’s capabilities and hospital and community standards.

This abbreviated plan of care or care map is event- or task-oriented and provides outcome-based guidelines for goal achieve- ment within a designated length of stay. Several samples have been included to demonstrate alternative planning formats.

Importance of Exercise Plan

• Improve physical activity
• Maintain range of motion,muscle strength and muscle mobility
• Reduces physical risk
• Reduces medical complication
• Prevent psychological complications

Physical therapists and related professions often use muscle testing.

Muscle testing is used to determine

• Gait Analysis
• Strength Training Exercises
• Muscle tolerance
• Measure muscle strength and function
• Help to plan exercise Therapy
• It help to evaluate exercise tolerance

Mental symptoms of anxiety can include:

• Nervousness, restlessness, or being tense
• Feelings of danger, panic, or dread
• Heart rate increases
• Uncomfortable breathing
• Increased or heavy sweating
• Associated with mild or moderate trembling
• Weakness and lethargy
• Difficulty in decision making
• Unable to sleep
• Stomach discomforts
• Mild or moderate Hallucination
• Fear complex
• Disturb behaviors
• Difficult to concentrate

Function of Naturopathy

• Nutrition and dietary consultation which help to prevent some medical problems and complications.
• To advise Herbs
• Hot and cold water Therapy.
• Sauna and steam bath advice
• Mud bath
• Light Massage for relaxation
• Acupressure
• Basic Counselling techniques