NURSE’S NOTES
Name of the patient: Mr. Rajeshbhai Chopaniya Bed no. 29 Diagnosis: Acute appendicitis
Age: 24 years Ward: Male surgery ward Surgery performed: Appendectomy
Sex: Male Doctor’s unit: III Date of surgery: 14/07/2010
IPD No. I1007130106 Date of admission: 13/07/2010
DATE MEDICATION DIET TIME NURSING OBSERVATION, INTERVENTION & REMARK SIGN
14/07/2010 Inj. Patient 08.00 Patient is lying on the bed. Greeted him. He responded back verbally.
Ceftriaxone 1 was kept am Patient is well oriented to time, place and person. He reported disturbed
gm BD IV NBM as he sleep last night because of severe pain in lower abdomen. He has
has to altered bowel elimination pattern due to oconstipation. Client has
Inj. Pantocid40 undergo reported two episodes of vomiting and low grade fever. Pain scale – 6.
mg OD IV surgery. The appetite of the patient is poor.
Tab. Dan-P 500 09.00 The bed was unclean and untidy. Bed making procedure was performed
mg BD am and bed looks neat and tidy now.
Liq. Creamaffin 10.00 Pre-operative medications are administered to the patient according to
3 tsp HS am the orders.
11.00 Vital signs were monitored for the patient. Axillary body temperature -
am 99°F. Pulse – 78/min. Respiratory rate – 22/min. Blood pressure –
130/90 mmHg.
12.00 Patient was transferred to the operation theater in a wheel chair for
MD surgical intervention of appendectomy.
NURSE’S NOTES
Name of the patient: Mr. Rajeshbhai Chopaniya Bed no. 29 Diagnosis: Acute appendicitis
Age: 24 years Ward: Male surgery ward Surgery performed: Appendectomy
Sex: Male Doctor’s unit: III Date of surgery: 14/07/2010
IPD No. I1007130106 Date of admission: 13/07/2010
DATE MEDICATION DIET TIME NURSING OBSERVATION, INTERVENTION & REMARK SIGN
15/07/2010 Inj. A glass of 08.00 Patient is lying on the bed. Greeted him. He responded back verbally.
Ceftriaxone 1 milk with 3 am Patient is well oriented to time, place and person. He reported disturbed
gm BD IV biscuits in sleep last night because of severe pain in lower abdomen. He has
the normal bowel and bladder elimination pattern. Client has not reported
Inj. Pantocid40 brekfast at any episodes of vomiting and low grade fever. Pain scale – 5. The
mg OD IV 8 am. appetite of the patient is poor.
Tab. Dan-P 500 Khichadi 09.00 The bed was unclean and untidy. Bed making procedure was performed
mg BD with milk am and bed looks neat and tidy now.
in the
Liq. Creamaffin lunch at 10.00 Post-operative medications are administered to the patient according to
3 tsp HS 12.30 pm am the orders.
11.00 Vital signs were monitored for the patient. Axillary body temperature -
am 101°F. Pulse – 78/min. Respiratory rate – 22/min. Blood pressure –
130/90 mmHg.
12.00 Heat application with hot water bag was done to relieve pain.
MD
01.00 Blood sample collection was done post-operatively for total blood count
pm and electrolytes.
NURSE’S NOTES
Name of the patient: Mr. Rajeshbhai Chopaniya Bed no. 29 Diagnosis: Acute appendicitis
Age: 24 years Ward: Male surgery ward Surgery performed: Appendectomy
Sex: Male Doctor’s unit: III Date of surgery: 14/07/2010
IPD No. I1007130106 Date of admission: 13/07/2010
DATE MEDICATION DIET TIME NURSING OBSERVATION, INTERVENTION & REMARK SIGN
16/07/2010 Inj. A cup of 08.00 Patient is lying on the bed. Greeted him. He responded back verbally.
Ceftriaxone 1 tea with 3 am Patient is well oriented to time, place and person. He reported disturbed
gm BD IV biscuits in sleep last night because of pain in lower abdomen. But intensity of th
the pain was reduced. Pain scale – 2. He has normal bowel and bladder
Inj. Pantocid40 brekfast at elimination pattern. Client has not reported any episodes of vomiting
mg OD IV 9 am. and low grade fever. The appetite of the patient is fair.
Tab. Dan-P 500 Sabji and 3 09.00 The bed was unclean and untidy. Bed making procedure was performed
mg BD rotis in the am and bed looks neat and tidy now.
lunch at
Liq. Creamaffin 12.30 pm 10.00 Medications are administered to the patient according to the orders.
3 tsp HS am
11.00 Vital signs were monitored for the patient. Axillary body temperature -
am 99°F. Pulse – 78/min. Respiratory rate – 20/min. Blood pressure –
120/90 mmHg.
12.00 Heat application with hot water bag was done to relieve pain.
MD
01.00 Health education on home care and care of the wound, follow-up etc
pm was given to the parents and client as well.