07:28 ADMITTED FROM A/D OFFICE A CASE OF 34 Y/O FEMALE AMBULATORY ACCOMPANIED BY

HUSBAND DUE TO ABOVE DIAGNOSIS FOR ELECTIVE CS TODAY UNDER DR FATMA ELNEMR
CONSENTED VITALLY STABLE T- P- R- BP- SPO2-
WITH ADMITTING ORDERS TO BE CARRIED OUT,NPO MAINTAINED AND ADVISED TO PT. NIL
ALLERGIES NOTED,
KEPT COMFORTABLY ON BED SAFETY PRECAUTION ADVISED.ALL CONCERNED STAFF AWARE OF
THE ADMISSION.
-DR MOHAMD GAMAL AND DR GALAL WERE INFORMED.

07:57 ADMITTED FROM A/D OFFICE A CASE OF 6 Y/O MALE AMBULATORY ACCOMPANIED BY
PARENTS DUE TO ABOVE DIAGNOSIS FOR ADENOTONSILLECTOMY TODAY UNDER DR HESHAM
ABDULWAHEED CONSENTED VITALLY STABLE T-36.7 P-100 R-25 SPO2-98% WITH ADMITTING
ORDERS TO BE CARRIED OUT,NPO MAINTAINED AND ADVISED TO PT. NIL ALLERGIES NOTED,
KEPT COMFORTABLY ON BED SAFETY PRECAUTION ADVISED.ALL CONCERNED STAFF AWARE OF
THE ADMISSION.
-DR A'HAMID AND DR GALAL WERE INFORMED.
08:11 DR SAMIR CAME AND SEEN THE PT CLERKING DONE
09:14 DR A'HAMID CAME AND SEEN THE PT CLERKING DONE
09:29 PT SENT TO OT2ND PER STRETCHER ACCOMPANIED BY UNDERSIGNED AND PORTER NOUR
ENDORSED TO SSN MARIE

15:58 PT CAME BACK WITH HN LORNA AND PORTER KHALIL POST ELECTIVE LOWER SEGMENT
C/S DONE BY DR.FATMA ASSISTED BY DR .JAMAL UNDER SPINAL ANESTHEISA BY DR.HATEM/
DR.SAMIR
BREATHING SPONTANEOUSLY AT ROOM AIR NIL DISTRESS NOTED WITH BEARABLE POST OP
PAIN NOTED
WITH ONGOING RL 500 ML + 10 UNITS SYNTOCINON X 125 ML / HR INFUSING WELL.
WITH DRESSING USED STERI-STRIPS,MEPILEX ,RELAX PAD ,HYPAFIX KEPT DRESSING DRY AND
INTACT.
WITH FOLEY CATHERTER FR.14 CONNECTED URINE BAG DRIANING CLEAR URINE FIX WITH
FLEXTRAK.WITH POST OP ORDERS MADE TO BE CARRIED OUT
PANTRY STAFF SIS ANALOU INFORMED OF THE DIET WITH CELEBRATION CAKE REQUEST GIVEN
V/S TAKEN T-36.4 PR-92 RR-19 BP-119/73 SPO2-97% ROOM AIR.
KEPT COMFORTABLE ON BED SAFETY PRECAUTION ADVISED.
PT COMPLAINED OF PAIN
FACIAL GRIMACE AND GUARDING BEHAVIOR NOTED
LIMITED BODY MOVEMENT

ALTERATION IN COMFORT; PAIN RELATED TO TISSUE TRAUMA

PT WILL VERBALIZED RELIEF OF PAIN AFTER SERIES OF NURSING INTERVENTION WITHIN THE
SHIFT

ASSESSED GENERAL STATUS

V/S MONITORED
DUE MEDS GIVEN AS ORDERED
ENCOURAGED DEEP BREATHING EXERCISES
PROMOTED REST AND COMFORT
REFER ACCORDINGLY

NSVD
08:55 TRANS-IN PT FROM L&D POST NSVD DONE BY DR ENAS JAMAL ALDEEN
ACCOMPANIED BY SN ANAMARIE PER STRETCHER CONSCIOUS/COHERENT BREATHING
SPONTANEOUSLY AT ROOM AIR.
NOT IN ANY FORM OF DISTRESS NOTED WITH FIRM WELL CONTRACTED UTERUS WITH RELAX
PAD PER VAGINA NIL BLEEDING NOTED BY HN LORNA.BABY TRANSFERRED TO NURSERY
KEPT COMFORTABLE ON BED SAFETY MEASURES ADVISED.
ALL CONCERNED STAFF AWARE OF THE ADMISSION.
WITH POST PARTUM ORDERS MADE TO BE CARRIED OUT.
PANTRY STAFF SIS KHULOD INFORMED OF THE DIET WITH CELEBRATION CAKE REQUEST GIVEN
V/S TAKEN T-36.5 PR-65 RR-19 BP-103/59 SPO2-98%

09:50 RECEIVED DISCHARGE APPROVAL THM AND OPC APPOIDNTMENT GIVEN WITH
INSTRUCTION BY SN MELANIE
REMOVED IVC

WENT HOME IN GOOD CONDITION ACCOMPANIED BY RELATIVE ALL CONCERNED AREAS AWARE
10:29 ADMITTED A 1MONTH OLD BABY BOY CARRIED BY MOTHER FROM ADMISSION AND
DISCHARGE OFFICE ACCOMPANIED BY P.R.O UNDER THE SERVICE OF DR. ABDULHAMEED.
BOOKED FOR CIRCUMCISION TODAY, CONSENTED VITAL SIGNS TAKEN AND RECORDED, RR:
32, HR: 139, T: 36.5, STABLE. ADMISSION ROUTINE CARE DONE, ALL AREAS MADE AWARE OF
THE ADMISSION. KEPT WARM AND COMFORTABLE.
CLERKING DONE BY DR. ABDULHAMEED.

11:00 SENT PATIENT TO OT2ND PER COT ACCOMPANIED BY UNDERSIGN ENDORSED TO SSN
MARIE.

11:40 BACK TO WARD PER COT POST CIRCUMCISION NOT IN ANY FORM OF DISTRESS WITH
POST OP DRESSING OF KALTOSTAT, ROLLED GAUZE WITH PLASTER DRY AND INTACT, NIL ACTIVE
BLEEDING NOTED. VITALLY STABLE. WITH POST OP ORDERS, CARRIED OUT. KEPT WARM AND
COMFORTABLE.

13:37- SEEN AND EXAMINED BY DR. ABDULHAMEED, NIL BLEEDING NOTED, HOME
MEDICATIONS INSTRUCTED.

13:55-DISCHARGED PATIENT IN GOOD CONDITION WITH HOME MEDICATIONS AND FOLLOW

UP CHECK UP INSTRUCTED TO MOTHER.