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7/29/2019 Nurses Notes.GESTROENTERITUISdocx
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NURSES NOTES
Name of the patient: Mr. Gabrubhai Parmar Bed no. 12 Diagnosis: Acute gastroentritis
Age: 30 years Ward: Male medicine ward Surgery performed: Not performed
Sex: Male Doctors unit: II Date of surgery: ---
IPD No. I1007200106 Date of admission: 20/07/2010
DATE MEDICATION DIET TIME NURSING OBSERVATION, INTERVENTION & REMARK SIGN
21/07/2010 Inj. Cipro 100
ml BD IV
Inj. Metro 100
ml TDS IV
Inj. Buscopan
20 mg TDS IVInj. Emset 4 mg
TDS IV
Inj. Rantac 50
mg BD IV
1 glass of
orange
juice in the
breakfast
at 9 am.
Khichadi
with milk in
the lunch
at 12.30
pm.
08.00
am
09.00
am
10.00
am
11.00
am
12.00
MD
01.00
pm
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.
-
7/29/2019 Nurses Notes.GESTROENTERITUISdocx
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NURSES NOTES
Name of the patient: Mr. Gabrubhai Parmar Bed no. 12 Diagnosis: Acute gastroentritis
Age: 30 years Ward: Male medicine ward Surgery performed: Not performed
Sex: Male Doctors unit: II Date of surgery: ---
IPD No. I1007200106 Date of admission: 20/07/2010
DATE MEDICATION DIET TIME NURSING OBSERVATION, INTERVENTION & REMARK SIGN
22/07/2010 Inj. Cipro 100
ml BD IV
Inj. Metro 100
ml TDS IV
Inj. Buscopan
20 mg TDS IVInj. Emset 4
mg TDS IV
Inj. Rantac 50
mg BD IV
1 glass of
milk in the
breakfast
at 9 am.
Plain ricewith milk in
the lunch
at 12.15
pm.
08.00
am
09.00
am
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.
-
7/29/2019 Nurses Notes.GESTROENTERITUISdocx
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NURSES NOTES
Name of the patient: Mr. Gabrubhai Parmar Bed no. 12 Diagnosis: Acute gastroentritis
Age: 30 years Ward: Male medicine ward Surgery performed: Not performed
Sex: Male Doctors unit: II Date of surgery: ---
IPD No. I1007200106 Date of admission: 20/07/2010
DATE MEDICATION DIET TIME NURSING OBSERVATION, INTERVENTION & REMARK SIGN
23/07/2010 Inj. Cipro 100
ml BD IV
Inj. Metro 100
ml TDS IV
Inj. Buscopan
20 mg TDS IVInj. 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
09.00
am
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 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.
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7/29/2019 Nurses Notes.GESTROENTERITUISdocx
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