NURSES NOTES Name of the patient: Mrs. Svitri Bai Chavan Age: 77years Sex: Female IPD No.

1178 DATE 01/03/2013 MEDICATION Tab Atorva 80 mg Tab. Clopitab 75 mg Tab. Aspirin 80 mg Inj. Clexane 40 mg. Inj. Pan 40 DIET NBM till 11 am. 1 glass of orange juice at 11 am. Khichadi with milk in the lunch at 12.30 pm. TIME 08.00 am NURSING OBSERVATION, INTERVENTION & REMARK Patient is lying on the bed. Greeted him. She responded back verbally. Patient is 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. SIGN Bed no. 01 Ward: Intensive coronary care Unit Date of admission: 20/07/2010 Diagnosis: Anterior wall MI with DM Surgery performed: Not performed Date of surgery: ---

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. 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. 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

02/03/2013

Tab Atorva 80 mg Tab. Clopitab 75 mg Tab. Aspirin 80 mg Inj. Clexane 40 mg. Inj. Pan 40

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

08.00 am to 1 pm

 DATE 03/003/2013 MEDICATION Tab Atorva 80 mg Tab. Clopitab 75 mg Tab. Aspirin 80 mg Inj. Clexane 40 mg. Inj. Pan 40 DIET 1 glass of milk and biscuits in the breakfast at 7 am. NBM after 7 AM till angioplasty. Plain khichdi with milk in the lunch at 12.15 pm. TIME 08.00 am To 01.00 pm

patient about angioplasty. Health education was given to the family of the client on after care of angioplasty. Explain about dietary management to the patient. Knowledge given about precaution after angioplasty. Uses of medication explained to the patient and family members. NURSING OBSERVATION, INTERVENTION & REMARK SIGN

Vital signs were monitored for the patient. Axillary body temperature 98.8F. Pulse 75/min. Respiratory rate 26/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.