Date: 06-02-2012 Timing: 8:30 am to 1:00 pm

As part of our ANP (ICU) posting, am posted in emergency ward no. 1. By 8:30 I reached the ward
and meet the nursing in-charge of the ward. She gave us the required basic orientation of the ward
including physical orientation e.g. articles, trolleys, medication and other thing available in the ward
for patient care, orientation regarding the routine and various nursing protocols followed by them.
She assigned us the patients. The brief biodata of the patient is as follow:

Identification data

Patient name S. Jagdeep Singh

Father name Late S. Aulak Singh

Cr. no. 20121210656

Age 20 year

Gender Male

Date of admission 27-01-2012

Bed no. 06

Education Matric

Occupation Driver

Monthly income Rs 6000 approximately

Address Fatehgarh sahib, Punjab.

Department General Surgery

Diagnosis Road side accident, mild head injury,

blunt trauma abdomen,

fracture of shaft of femur & tibia(open fracture)

Liver injury(Grade III)

Consultant Dr. V.Gupta

Chief complaint of the patient:

At the time of admission ,patient had h/o multiple episode of vomiting

h/o pain in abdomen and right leg

h/o immobility in right leg

laceration present at prochanter area

open wound with tibia(5x3 cm)exposed

no h/o loss of consciousness

no h/o hematemesis oe hematuria

no h/o pain in neck

Past history of patient

Past medical history: no h/o any systemic disease condition e.g. diabetes mellitus, pulmonary
tuberculosis,hypertension,etc

past surgical history: patient had not undergone any surgical procedure before this.

personal History:

patient is vegetarian

no h/o drug or alcohol abuse

Examination:

Patient is conscious

General condition of the patient was unstable

Vital Sign:

Temperature: 103.6F

Pulse: 122/min

Respiration: 28/min
Blood Pressure: 150/90 mm of Hg

sPO2: 93%

Gastro-intestinal system:

Liver: Palpable ,non tender

Spleen: Non-palpable

Abdominal girth increased

Tenderness of abdomen is present

A drain is also present on the lower left hypochondrial region.

CVS: S1S2 sound normal, no murmur or no additional sound heard.

Respiratory system: no abnormal respiratory sounds

Neurological examination: E4 V5 M6 , Pupil reactive

Treatment:

Sr.no Drug Dose Route Frequency Action Remark

.
1 Tab. PCM 500mg Orally 8 Hourly Anti-pyretic
2 Inj.
3
As part of our ANP posting , am posted in Respiratory Intensive Care Unit(RICU) on 13-02-2012 for
a week.

On 8.30 am, I reached the ward. Staff Nurse gave us the orientation of ICU, basic protocol they
follow, recording and reporting. One patient is assigned to me and the biodata & assessment is as
follow:
Identification data

Patient name Mrs. Alka

Spouse name Mr. Rajinder

Cr. no. 201201270144

Age 46 year

Gender Female

Date of admission 02-02-2012

Bed no. 01

Education Matric

Occupation Beautician

Address 559,Shrinagar,U.P.

Monthly income Rs 8500 approximately

Department Pulmonary Medicine

Diagnosis Right Lung Lesion

Consultant Dr. S.K.Jindal

Surgical procedure Lower Lobe Lobactomy

Date of Surgery 08-02-2012

Chief complaint of the patient: