NURSES NOTES Name of the patient: Mr. Prashant Khatri Age: 50 years Sex: Male IPD No.

47954 DATE 06/12/2012 MEDICATION Isoniazid (INH) (300 mg daily) Rifampin (Rifadin (600 mg daily) Pyrazinamide (1 g daily) Ethambutol (Myambutol) 1 gm daily Tab. Voveran 5mg BD Tab. Rantac 150 mg BD DIET 1 glass of milk with 2 slices of bread 1 glass of orange juice at 11 am. Khichadi with milk in the lunch at 12.30 pm. TIME 08.00 am to 4 pm 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 breathing difficulty. Breakfast given to the patient. Medications are administered to the patient according to the orders. Nebulisation given to the patient. A soft diet containing khichadi was given to the client. Client had it nicely. SIGN Bed no. 08 Ward: Male Pulmonology Ward Date of admission: 03/12/2012 Diagnosis: Pulmonary Tuberculosis Surgery performed: Not performed Date of surgery: ---

Health education on the food hygiene and handling of the food in the house is given to the patient and his wife.

06/12/2012

Isoniazid (INH) (300 mg daily) Rifampin (Rifadin (600 mg daily) Pyrazinamide (1 g daily) Ethambutol (Myambutol) 1 gm daily Tab. Voveran 5mg BD Tab. Rantac 150 mg BD

1 glass of milk in the breakfast at 9 am. Plain rice with milk in the lunch at 12.15 pm. 1 glass of orange juice at 2 pm.

08.00 am to 4 pm

The bed was unclean and untidy. Bed making procedure was performed and bed looks neat and tidy now. Vital signs were monitored for the patient. Axillary body temperature - 99F. Pulse 78/min. Respiratory rate 28/min.

Medications were administered as per doctors order. The rights of medication administration were followed. Explain about dietary management to the patient. Knowledge given about disease condition. Steam inhalation given to the patient. Breathing exercises taught to the patient with demonstration.. Uses of medication explained to the patient and family members. Explain the dietary management and disease condition to the patient and family members.

DATE 07/12/2012

MEDICATION Isoniazid (INH) (300 mg daily) Rifampin (Rifadin (600 mg daily) Pyrazinamide (1 g daily) Ethambutol (Myambutol) 1 gm daily Tab. Voveran 5mg BD Tab. Rantac 150 mg BD

DIET 1 glass of milk and biscuits in the breakfast at 7 am. Plain khichdi with milk in the lunch at 12.15 pm.

TIME 08.00 am To 4 pm

NURSING OBSERVATION, INTERVENTION & REMARK Vital signs were monitored for the patient. Axillary body temperature 98.8F. Pulse 75/min. Respiratory rate 26/min. Medications were administered as per doctors order. The rights of medication administration were followed. Oral hygiene given to the patient. Lubrication applied to the lips and extremities skin. Patient look anxious about the disease and treatment so the explanation given about the disease and treatment. Steam inhalation given to the patient. Some deep breathing exercises and energy conservation techniques were taught to the client. Patient was provided with the lunch and He had it nicely. Health education given to the patient and family members. Nebulisation (asthaline) given to the patient.

SIGN

DATE 08/12/2012

MEDICATION Isoniazid (INH) (300 mg daily) Rifampin (Rifadin (600 mg daily) Pyrazinamide (1 g daily) Ethambutol (Myambutol) 1 gm daily Tab. Voveran 5mg BD Tab. Rantac 150 mg BD

DIET 1 glass of milk and biscuits in the breakfast at 7 am. Diet given to the patient containing, Rice,chapatti and green leafy vegetable.

TIME 08.00 am To 4 pm

NURSING OBSERVATION, INTERVENTION & REMARK Vital signs were monitored for the patient. Axillary body temperature 98.8F. Pulse 75/min. Respiratory rate 26/min. Medications were administered as per doctors order. The rights of medication administration were followed. Oral hygiene given to the patient. Lubrication applied to the lips and extremities skin. Patient look anxious about the disease and treatment so the explanation given about the disease and treatment. Some deep breathing exercises and energy conservation techniques were taught to the client. Patient was provided with the lunch and He had it nicely. Health education given to the patient and family members. Nebulisation (asthaline) given to the patient.

SIGN