Island Home Health Care ‫ايالند هوم للرعاية الصحية المنزلية‬

PATIENT NAME: MOUZA HAMOOD AL QUBAISI MRN: 000124 DATE: 09.10.19

TIME DETAILS
09.10.19 Received patient on semi fowler’s position, connected to pulse oximeter for continuous
2130H monitoring with oxygen saturation of 97%, on continuous oxygen at 0.5 LPM per nasal cannula
per oxygen concentrator; PEG tube FR.18 Mic-key button in situ, PEG stoma (-) granulation, (-)
leak, (-) redness, (-) signs of infection, with dressing dry and intact; on PEG tube feeding via
continuous feeding pump Glucerna 1.0 Kcal/ml at 450 ml/hr; GCS – 10/15: eye opening – 4,
verbal response – 2, motor response – 4; involuntary jerking movements of both hand;
bipedal pitting edema +1 kept elevated on pillow; bedbound on diaper with urine and stool
incontinence; not in cardiopulmonary distress, side rails up at all times, on fall prevention and
safety precaution maintained.-----------------------------------------------------------JEG

2200H Checked RBS: 112mg/dl. Flushed PEG tube with 40ml of water.------------------------------------JEG
2300H Feeding on hold. Voided freely to a 100ml of urine, BM of ~50g, perineal care done, kept dry,
diaper changed; gloves replaced. Positioned on left side lying position with knees bend
supported with pillows, with HOB elevated at 45 degrees. Hand washing done after removal
and proper disposal of gloves.------------------------------------------------------JEG
10.10.19 Vital signs checked and recorded, within normal range. Administered due medication as
0000H ordered with pre and post flushing of 100ml of water. Due nebulization rendered as ordered;
chest and back tapping done. Resumed PEG feeding. Hand washing done after proper removal
and disposal of gloves.------------------------------------------JEG
0200H Put feeding on hold. Voided freely to a 100ml of urine, BM of ~50g, perineal care done, kept
dry, diaper changed; gloves replaced. Placed on right side lying position, knees supported with
pillows, with HOB elevated at 45 degrees. Resumed feeding.----------------------------------------JEG
0400H Vital signs checked and recorded, within normal range. Administered Simethicone with pre
and post flushing of 100ml of water.------------------------------------------------------------------------JEG
0430H Put feeding on hold. Deep suctioning done using guedel airway with minimal amount of loose,
whitish secretions. Hand washing done proper after removal and disposal of gloves.--------------
--JEG
0500H Put feeding on hold. Voided freely to a 100ml of urine, BM of ~50g, perineal care done, kept
dry, diaper changed; gloves replaced. Placed on semi fowler’s position, knees supported with
pillows, with HOB elevated at 45 degrees. Resumed feeding.---------------------------------------JEG
0600H Flushed PEG tube with 40ml water, on bowel rest for 4 hours. Due nebulization rendered as
ordered; chest and back tapping done.---------------------------------------------------------------------JEG
0800H Monitored vital signs. Abdominal girth: 127cm. Morning care done. Oral care and eye care
rendered. Voided freely of 800ml straw colored urine, BM of ~50g, perineal and anal care
done with soap and water, diaper changed; gloves replaced. PEG care done aseptically using
Dermacyn spray. Placed on left side lying position. Flushing of 100ml of water done, SAP
observed. Hand washing and aftercare done.------------------------------------------------------------JEG
0930H Not in distress, clinically stable. PEG tube dry and intact. GCS of 10/15. Endorsed to morning
shift nurse for continuity of care.----------------------------------JEG

NURSE ON DUTY: JESSICAMILLE EVANGELISTA GO, GN41379

IHHC/NRSG/FORM/0006-16