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.

7/29/2019 Nurses Notes.GESTROENTERITUISdocx

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