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NURSES NOTES

Name of the patient: Mrs. Svitri Bai Chavan Bed no. 01 Diagnosis: Anterior wall MI with DM

Age: 77years Ward: Intensive coronary care Unit Surgery performed:Not performed

Sex: Female Date of admission: 20/07/2010 Date of surgery: ---

IPD No. 1178

DATE MEDICATION DIET TIME NURSING OBSERVATION, INTERVENTION & REMARK SIGN

01/03/2013 Tab Atorva 80

mg

Tab. Clopitab 75

mg

Tab. Aspirin 80

mg

Inj. Clexane 40mg.

Inj. Pan 40

NBM till 11

am.

1 glass of

orange juice

at 11 am.

Khichadi

with milk inthe lunch at12.30 pm.

08.00 am Patient is lying on the bed. Greeted him. She responded back verbally. Patientis well oriented to time, place and person. She reported disturbed sleep last

night because of chest pain.

Prepare patient for CAG. Shift the patient to cath lab for CAG. Received patient from cath lab after angiography. Medications are administered to the patient according to the orders. 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.

02/03/2013 Tab Atorva 80

mg

Tab. Clopitab 75

mg

Tab. Aspirin 80

mgInj. Clexane 40

mg.

Inj. Pan 40

1 glass of

milk in the

breakfast at 9

am.

Plain rice

with milk inthe lunch at

12.15 pm.

08.00 am

to 1 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.Pulse78/min. Respiratory rate28/min.

Medications were administered as per doctors order. The rights of medicationadministration were followed.

Blood sugar checked. Insulin given to the patient subcutaneously. Prepare the patient for 2D ECHO. Angioplasty advised to the patient by doctors, so knowledge given to the

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patient about angioplasty.

Health education was given to the family of the client on after care ofangioplasty.

Explain about dietary management to the patient. Knowledge given about precaution after angioplasty. Uses of medication explained to the patient and family members.

DATE MEDICATION DIET TIME NURSING OBSERVATION, INTERVENTION & REMARK SIGN03/003/2013 Tab Atorva 80

mg

Tab. Clopitab 75

mg

Tab. Aspirin 80mg

Inj. Clexane 40

mg.

Inj. Pan 40

1 glass of

milk and

biscuits in

the breakfast

at 7 am.

NBM after 7AM till

angioplasty.

Plain khichdi

with milk in

the lunch at

12.15 pm.

08.00 am

To

01.00 pm

Vital signs were monitored for the patient. Axillary body temperature 98.8F. Pulse

75/min. Respiratory rate26/min.

Prepare the patient for angioplasty.

Send the patient to cath lab for angioplasty.

Received patient after angioplasty.Instruct the patient about precaution after PTCA.

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.

Patient was provided with the lunch and she had it nicely.