Report & Record محمد ابوهاشم PDF

# Report & Record ## Faculty of Nursing Administration Department Fourth Year **Head Nurse Name:** Mohamed_ABo Hashem **Hospital Name:** Chest & Heart **Department Name:** Cardiothoracic surgery **Date:** 21.3.2023 **Group:** (3) **Under Supervision:** Dr. Doha # Statistical Record **Hospital nam...

# Report & Record ## Faculty of Nursing Administration Department Fourth Year **Head Nurse Name:** Mohamed_ABo Hashem **Hospital Name:** Chest & Heart **Department Name:** Cardiothoracic surgery **Date:** 21.3.2023 **Group:** (3) **Under Supervision:** Dr. Doha # Statistical Record **Hospital name:** chest & Heart. **Department name:** Cardiothoracic surgery. **Time:** 12:00 PM **Head nurse name:** mohamed Abo Hashem. | Date | Patient census | Admissions | Discharges | Transfers | Deaths | Critical Patients | Total Number | |---|---|---|---|---|---|---|---| | 21/3/2023 | 12 Pt | 1 | 1 | 1 | | 7 | 11 | **Signature:** H.N: Mohamed Abo hashem # Medication Record **Hospital name:** Chest & Heart. **Patient census:** 11 **Group:** (3) **Department:** Cardiothoracic surgery. **H.N name:** Mohamed ABo Hashem. **Date:** 21.3.2023 | Patient name | TYPE | medication Prescribed | Dose | Route | frequency | Remarks | |---|---|---|---|---|---|---| | Ibrahim Rajab Ali | | glucose 500CC | I.V | | 12 hrs | | | | | Perfergan 50 CC. | I.V | | 12hrs | | | | | Cefotax 19m. | Iv | | 924 hrs | | | | | Saline 9% 500CC | I.V | | 912 hrs | | | | | Voltaren 1ampoul | I.m | | S.o.S | | | | | Flagyl tablet | oral | | & 8 hrs | | | Ahmed El-Sayed hussein | | Cefotax 19m | I. v | | 12 hrs | | | | | glucose 5% 500 CC | I.V | | 912 hrs | | | | | Panadol 1 tablet | oral | | S.o.S | | | | | Saline 9% 500 CC | I.V | | 9, 12 hrs | | | | | FarColin 5 drops | inhalation | | 9,6 hrs | | | | | +Saline 2,5 cm | | | | | | | | +Atrovent 0,5 ml | | | | | | Ahmed mohamed Ibrahim | | diclo Phin lampoul | I.M | | S.o.S | | | | | Cefotax 19m | I. V | | q 12 hrs | | | | | glu Cose 5%. 500CC | I.V | | 924 hrs | | | | | PulmaCort 0,5 ml | inhalation | | 26 hrs. | | | | | +Saline 2,5 cm | | | | | **Signature of H.N:** Mohamed Abo hashem mohamed. # Shift Report **Hospital name:** Chest & Heart **H. N name:** Mohamed Aba Hashem. **-No. of Beds:** 12 **-Date:** 21-3-2023 **-Time:** 12:00 PM **-Department name:** Cardio the ta **Icu.** **-Group:** (3) **-Patient Census:** 11 | Room No | Bed No | Patient name. | dia Ino sis | Summary of Patient Condition | |---|---|---|---|---| | | | | chronic obstructive Pulmonary disease (COPD) | Plé stable. General Condition., Conscious, Pte normal V.S, measured at 10:00 Amp, Cannula in right arm, Patent and dry, insereted in 20.13/2023 at 10:00 Am, Ptc headache at 10:00 Am, Provide and maintain environment quiet, give analgesic, headache relievedat 10:30 Am, PL attached e1.v line in right arm, Patent & Flow (To Tal I. v infusion 9, 24 hrs 2000 cc.), At_10:00 Am Start with 500CC Saline and finishe, To Tal amount intake 500 cc, Pte wound in chest, clean & Dry | | | (1) | Ibrahim Rajab Ali | | | | (2) | (2) | Ahmed El-Sayed hussein | Pruemonia | Pt'e unstable general condition, Conscious, Pte abnormalV.S (T:38.4°C, P: 78 blmin, R: 20 c/min, BP: 90/60mmhg) measure at 10:00 Am, Pte Cannula in left hand, Patent & Flow, inserted on 19/3/2023, at 10:00 Am, Pt elever at 10:00 Am, give antipyratic, Cold Compress, but fever not relieved at 12:00 PM, PE attached é I. v line in left hand, Patent & flow (Total I.v infussion 724 hrs 2000cc.), At 10:00 Am start with 50cc pline and finished, To Tal amount intake 500cc., Pt. Pre Pared foroferation. عبر طحالة but operation Postponded To 24-3-2023 due To un stable Condition. | | (3) | (1) | Ahmed mohamed Ibrahim | respiratory failure | Ptenstable Seneral Condition, comatused, Pté abnormal v.S (T:36.4℃, P:58b/min,, R:Pton ventilator, BP: 110/60 mmhg), measure at 10:00 Am, Pté Cannula in Right Arm, Patent & flow, inserted in 13/3/2023, at 10 Am, Ptattached with I.V line in figh Arm (To Tat flow I. v infusion 9, 24 hrs 5) At 10:00 Am start with 500cc Saline and finished, To Tal-amount intake 500cc, Pton ventilator attaché ET Tat lo Am, suction done At 11:00 AM, Cholacterstic with large amourit | **-No of admission:** (1) **-No of death :** (0) **-No of critical:** (7) **-No of discharge (1)** **-No of transfer: (1)** **Signature of Head nurse:** Mohamed ABO Hashem # Incident Report Form **spital name:** Chest & Heart **1. N name:** Mohamed ABo hashem **Date:** 21/3/2023 **Patient name:** Ahmed El-Sayed hussein.. **Date of admission:** 18-3-20 23 **Date of incident:** 21-3-2023. **Responsible Person name:** Mr Sobhi **Name of the First name:** mr Ahmed time of the incident: his brother (mohamed El-Sayed hussein) **TYPe of the incident:** - Error in medication -Diagnostic Procedure -other ✓ **-Patient movement (fall).** **- Treatment** **Description of the incident:** -During my morning shift, mr Ahmed sobhi, who was les posible for Care Mr Ahmed El-Sayed hussein. adminstered overdose of Insulin at 10:00 Am, 21-3-2023, Pt suffered from hypoglicemia, he was Confused, disordered, sweated, anxiety, had headache, tired, Dr Ali Tharwat was notified at 10:30 Am. **+ measure To be Taken:** Phisican intervention: Phisician examine Pt, and describe medication for him. Nursing intervention: adminster medication To Patient accroding To doctor order, reasure Patient.. **Date:** 213-2023 **Time:** 10:30 AM **signature:** Dr. Ali Tharwat mr. Ahmed sobhi **followup:** _oral waring giving to the nurse and he Promise won't do that again, if he repeated it written waring will be done. Patient become well. **Signature of H.N:** Mohamed ABo hashem.