NURSES NOTES

Name of the patient: Mr. Gabrubhai Parmar Age: 30 years Sex: Male IPD No. I1007200106 Bed no. 12 Ward: Male medicine ward Doctors unit: II Date of admission: 20/07/2010 Diagnosis: Acute gastroentritis Surgery performed: Not performed Date of surgery: ---

DATE MEDICATION 21/07/2010 Inj. Cipro 100 ml BD IV Inj. Metro 100 ml TDS IV Inj. Buscopan 20 mg TDS IV Inj. Emset 4 mg TDS IV Inj. Rantac 50 mg BD IV

DIET 1 glass of orange juice in the breakfast at 9 am. Khichadi with milk in the lunch at 12.30 pm.

TIME 08.00 am

NURSING OBSERVATION, INTERVENTION & REMARK Patient is lying on the bed. Greeted him. He responded back verbally. Patient is well oriented to time, place and person. He reported disturbed sleep last night because of abdominal pain and passage of watery stools twice at night. He has altered bowel elimination pattern. Client has reported no episodes of vomiting. Pain scale 6. The bed was unclean and untidy. Bed making procedure was performed and bed looks neat and tidy now. Medications are administered to the patient according to the orders. Client was given a preparation of oral rehydration solution. One sachet in a 1 litre of water was given and advised to drink it frequently. A soft diet containing khichadi was given to the client. Client had it nicely. Health education on the food hygiene and handling of the food in the house is given to the patient and his wife.

SIGN

09.00 am 10.00 am 11.00 am 12.00 MD 01.00 pm

NURSES NOTES
Name of the patient: Mr. Gabrubhai Parmar Age: 30 years Sex: Male IPD No. I1007200106 DATE MEDICATION DIET TIME Bed no. 12 Ward: Male medicine ward Doctors unit: II Date of admission: 20/07/2010 NURSING OBSERVATION, INTERVENTION & REMARK SIGN Diagnosis: Acute gastroentritis Surgery performed: Not performed Date of surgery: ---

22/07/2010 Inj. Cipro 100 ml BD IV Inj. Metro 100 ml TDS IV Inj. Buscopan 20 mg TDS IV Inj. Emset 4 mg TDS IV Inj. Rantac 50 mg BD IV

1 glass of milk in the breakfast at 9 am.

08.00 am

Plain rice with milk in the lunch 09.00 at 12.15 am pm. 10.00 am 11.00 am 12.00 MD 01.00 pm

Patient is sitting on the bed. Greeted him. He responded back verbally. Patient is well oriented to time, place and person. He reported disturbed sleep last night because of abdominal pain and passage of watery stools once at night as well as change in environment. He has altered bowel elimination pattern. Normal urinary elimination pattern. Client has reported no episodes of vomiting. Pain scale 3. Vital signs were monitored for the patient. Axillary body temperature 99F. Pulse 78/min. Respiratory rate 22/min. Medications were administered as per doctors order. The rights of medication administration were followed. Client was given a preparation of oral rehydration solution. One sachet in a 1 litre of water was given and advised to drink it frequently. Health education was given to the family of the client on maintaining personal hygiene and avoiding outside food. Heat application was performed using hot water bag for relieving abdominal pain in the patient and patient got relief.

NURSES NOTES
Name of the patient: Mr. Gabrubhai Parmar Age: 30 years Sex: Male IPD No. I1007200106 DATE MEDICATION DIET TIME Bed no. 12 Ward: Male medicine ward Doctors unit: II Date of admission: 20/07/2010 NURSING OBSERVATION, INTERVENTION & REMARK SIGN Diagnosis: Acute gastroentritis Surgery performed: Not performed Date of surgery: ---

23/07/2010 Inj. Cipro 100 ml BD IV Inj. Metro 100 ml TDS IV Inj. Buscopan 20 mg TDS IV Inj. Emset 4 mg TDS IV Inj. Rantac 50 mg BD IV

1 glass of milk and biscuits in the breakfast at 9 am. Plain khichdi with milk in the lunch at 12.15 pm.

08.00 am

Patient is sitting on the bed. Greeted him. He responded back verbally. Patient is well oriented to time, place and person. He reported a good sleep last night. He has altered bowel elimination pattern but now the frequency of the diarrhoea has decreased. Normal urinary elimination pattern. Client has reported no episodes of vomiting. Pain scale 1. Client reported an improvement in appetite also. Vital signs were monitored for the patient. Axillary body temperature 98.8F. Pulse 75/min. Respiratory rate 20/min. Medications were administered as per doctors order. The rights of medication administration were followed. Some deep breathing exercises and energy conservation techniques were taught to the client. Heat application was performed using hot water bag for relieving abdominal pain in the patient and patient got relief. Patient was provided with the lunch and he had it nicely.

09.00 am 10.00 am 11.00 am 12.00 MD 01.00 pm