o fdentificatio

NCMe Suman

A9e - S0 yrs
|Gendor- feuale
Oard
warl- fenate Madial
Bed N0. - 10 By-Avesh sharma

educational Status - gh pass

locupation -- Home wox Ker
Religion - Hindu
Marital Status- narried
Address - Ratangarh , Churu
2023
|Dae OF acdission - || Tuly
|PrDuisiona Diaqnosis - Diarthoea
Doctor Lnchorge -
o HistDIY
"Present Medical Histony -
Mrs. SUman qot aditted DBH Hospi tal on ilo723
with pre sent itness t oakeny stol ,vonuting and louo grade
fever . Abdomina pain etc.

"Present Surgicau History -

There s no Surgicad Hisony eg te patient tite aprende ctomy.
| Past Nodical istoay -
the pauient te DM, HTN
here isIs no past Modical isy e%O
past
ete.
" Past
Gurgicod Mistry
Thore fs Do past surglcoad tistony o tke paient
o Percong Hygiene
Hygie ne - "ygicned
sleep - seeig purcin is distuhd from
Stool fassage - x¢ess wnery stool is ased,3Ti ne|day
utne assage - Normal urine assage
cic Relatonship - HOving goocd relatfonship coith
the soiety

Nucto a
member - s
Total no. O7 faki iy
ype 6t House- Cemented

fanily compositfon -
RelaHon oith educ ationasocupation Heal th
Name Gender Age Patfent Starus Staus

SobaolalMale
Yrs
Hushand
Pass
labou
Heaithy
2
Suma fenale50
Yrs
aient selt Pass House wite unhecutny
Aashu 20 BA Shudent
3 Yrs

simraneuale daugnter Shudent

Heathy
|Yrs

fomiy Tree -
Sos
(ramer) Patient
(nothor)
SS yo

(sod O(daugwerJ

key wordo
 ECOnOíc Staus i
MIs- SUMan belongs iddto class MIS SUNaO
othas- annuad Income e
houseoHe hey maintaio good elaHon sip with
fanoly abot L,50,00o /

a) Geeral appearance
NOUrÍShment well nourishod
Body Bilt Thin bocy
Healt unhaaltny
- dul! (rired)
b Mental Stahus
conciousness - ConSciUS tn time place or person
Look - AnxoUS LOoried

C Posure
Body cunes - NNomal
MOuement Tripaired range o7 Motion
dj stin CondiHon
Colour Paller

Texure dryness dohydrction

remperature - Warm (AaHent Is wam to touch)
Lesions Absent

e Head, face,hur
clean
Scalp
faco Pale cul, no enlargement B Parotid and
Colaur k hair - Black

| Neuroiogical est
Coordin aHon test - NomcU t coordinaHon test
test - Alormal equilibum est
Equitibnum

eyebows fuenty distibuted

Eye lashes Novma

Gye ids NOSMOl

Cye ballS Nomo
red
conjucri a
ScIercI No ma

Cornea and îris -

Pupils tquals and reacted to ignr
lens Transperent
fye muscle - Normat

vísíon Norma

h) fars
Ear - No discharqe
Tympaníc MenNbrane - NOrma!
Heaning NoMa

Externcl nates- NO discharqe

Nostis NOsmal
JJ MOuth and pharynx
Lips Dehydrale (Dry)
odour O* mØuth - food Smell Prosent

Toeth - SQual ond ohite- vellooish in colour

fongue - Dy due o denydration
Throat and pharynx - entargec Dnsiis.
kj NecK
Lymph nodes - No enlargement
Thyoid 'and s - Norma! in Size
Range MOtÍON Iupaired range ok moion
chest
Thorax Aiormal
eroath SOunds - NOMol Sound

Heart No abnorma heart Sound is heard.

Observation Abdomeo Paín
Auscultatíon Bouel Sound is present
alpation Palpable abdomen
Percussion - No tuid collection
N xtre oities movements k Joints

BacK Norma

P Genitals and rectum

nodes Aoma
|Tnquina! yniph
Presence Of Sexually tsansmitted disease - absent
Frtag Vagina! dischorqe - absent (No dichorge is found)

DNitad sign

Date farcners Paient's value NOma value Remarks

Tenperahure 98.6°f Thcre sed
Dy
Pul se 78 beats| nin 60-ID0 beets i n NOTMa

Respíratfon 22 breath|in l6-24 breath ñn NOrMo

Blood Pressure I4o /10O MM încreased

Temperahure 99-3°f 98-6°F Dn cheased
Day
2
Pulse 76 beats in Go -l00 beats in NOEmal
Respiration 20 breath in 16-24 brecth n Nosma

Blood PressUre
ng Notmol'
Tenperature 98-6°F 98.6 "NOTMa
Pulse 10 beots in 60-100 be atsun NoGMal

Respiraion l6-24 bcathn NOTMa

Blood 120180 MM OHa NOrMal

Pressure
 Chiek

Inuestigaions
NOtmal value Remarks
Ihuestigaton Paent Report
f4.2 9m1dL L-16 8mldi NorMa
Hb
u35- 5. bS millionL NOrma
Rgc 4 39 miion JL
Hemaocoil 33 35-45 . decrease
Nat 132 meq ld 135-145 meqld decrease

Kt 2-8 meq|dl 3-8-5-0 meqld decreaSe

94 meq dl 96-106 megldu decreasSe

BUN 8mgldu 10-20 ma làl decrease

D Medications -

NOMe e the drg Dose Route frequeny ACtÍon

Inj Antiemetic
ondansetron

nj. Renitiding 0.30me Antacíc

RL l00m fuid

înj AnixXocin Antibiotl cs

înj- cestriaxone 250 Ma Anibiotics

oral l-0-0
Tab. inc

oral 6-& tine

ORS
 Chiek Complaínts

" lou qiacde fever x

Waten 8bols
aday
3days
Abdominal paio

Ausing biagnosis
J Diarhoeg relctec to the indiqestion and increased
fluic Secre tion in the Gastroin testinal lumen
ingectfon
decreased fuid absorption
secondo
Oatery Stools.

2) fmbalancod Ntítorn less than bocy requirement

and Nuthens
related ot electolyes
cliagg hoea and freque nt
secomdory
O watny stools.
31 reloted losS S tuids and eiectalytes
to
fom l0ose stools seconday and
EXercise oleran ce
ngeceion Causing decreased
iethargd
the disease
beycent knoulcdge regardóng home
Complicaon and
Condition its
Care NGnge ment
 Chortlo" |wateny
Stools fenesmus |
abdomenUSG Pale
" and vi"
Negatve
Balance |"
objetfue
Data
tal uegt frequent voaitigtredness AndiSubjectiue
ge Data
weaKness Abclomina
Assessment
and decrecwedShowS
BP
ston
and
loss
dry assing
Feeble
Pulses
tachycardia
monitoríng
Shoas discomBprtain &
sin
reveal
e
explosive

Passing ftid tunonGasto

decreased
food absoxptfon the luid
- Diatshoea
and
o retatedcient to
atey
sDols. secondary intestfna
resuhng ingection
increased
the DiagnosisNursing
poisoning sCreton indigestion

n Care
increosed
Consiseny
the ttdocrocwed
stbol dionrheea
frequenyand ObjecHue /
experien

oth cQ Plan

|and
2 Assess )
and eiectye
hygene Lo9Auni foods.|hand Unctean outside
8
areas I daink |WStools.
boiled ateny |DRS |d5J rink Of lilce unclean
Preducs
InDlerances
4
eating
3 rite fac trequeny diarheoa
MaintcunAduicQ ASsesS Calect
Adaúni'ster Trtruct
prescrlbed. AcuicQ Aduice eachAduicQ Aduice ang deinking
tors
odour fntervenfon
aeply 00m that
inthe ster hygine the foods thewell. plenty GI
dgs , histony Consis tency the
the food the tBme the diseases. the the
ec B and
emollients. prescribed.as Tu entespecialyClient water cused
At
peri-cent hygiene
fluid wile Client client ay
cuent and CLient' s unsake
regoring
the Cause
ater 1
as - tuds. edanyfoocule foors etc. sto cenby
ciamhea anal to likehandting s to to that pre diarheoa olour
auod topasing to to sence Food water s
Os
& from drink the
area üntan 0s the
To and To and diqheoa To dionheoa that TO and To
To
burning electroly
anus. fothe
eplaco To Quoid
foodTo in To
Didentitye lausiaing
auoo
and interuention.
treat prevent
Maintin
Poåsoring ng
Prevent nahtan replaco replaco ingetion identty denhty
avoid Mantain intlerance cCuse RaHonale
pmuide
them.
Sensatfon balanQ the the the the
diarhea frritetion
electolytes. lost food GT
waler tds thereby Appropriate the
uid hydrahon Hds treat
and to factrrs
poisoninection. Cause
in and and
hyglene Bost trening the
the loss
to
MOUntenancePassingdecheased
by aswasCAient'
diarhoea
et euidencod
tated s
ealuaton
doection
Pattern. Stool
and
evaluatfon increase
by and
euidence
as oith
damprove and
NutítHon tolerated vomi
tBng diarhoea
Client's
8tcus
weignt absene
toods NOUseO
and

boseline
Prouides
ASsessnent lo5t intare
episodes.
dicerheal
reduce ineroted
ntion Ntitfonal by
and Maúnrain
the
Alutiional
needs
interve
îtigestHon
Preent
To and
diqestiontuids inteeHon
and
relieve
diarhoeaMaintin
tuid
electroytes
NutiHonal calse
and

ctient
the adequate the ient
Mainoin
utiHona
(vents
easy further imPrDve
HydraHonnt
Rationce episodes
iarhe clie anenia diarhoa
thedirhe
through
the the Can

t theideniy
tostoy
mecion.
help
in digestlon.
in epacean sfood&
G
preent
thethe stoo).
ettuucs.indigestton Prevent
On aid Naintalo ot To
trect
Patern,
fo
meet
buane.
|needs
vg9ies.oody
treo
atabascd These Staus
fo 6 To To To To To dianheTo
To
Stcs
clienteme and fbods
tfme& 6 auoid fnec dink
inolerancQ for Dom qs
MuHvitanìns
rescribed.
sotid
take to
Cient
to talee abour Sters
the and
NttYitiona
tare
rc~ly. carbohydrcte client meats. stools
home
prepa
ration pods.
to i| to
Suemental
Adninisler
m t Sot
intàke
8ugar
decrese freqenteach to cheeseCaient we flids
87 weight cient wntey client spicy bÐiled warmed ke
ctient
the
Aduico Cienrfom
nCds Anti(operanicde
Dnterveion ceient Aiquts,
blanthe heavy tids
foods
Gnd cauSes
ns,cream
ike
the fu pods
the tneient the encouroqe
e the
Aduice passing the Pashiesis theo tempercure. Adinister the ng
NutitHonc thelow auoid oRS also
Smati Instrut
Prescribed
Adinister Proscribed.
water
.foodeati
4Ssess K o teach that tthat richfros
etc
fat, Aduice
the AticC
Chec Atuico A Tech
nt eatand drink
|ager foots, water auoid
ok loo
y
Ple 6J U
iCe
ORS. foocd
0)
iron
8 2J 3) S 8 Jo g 2 13)
adequcte
food
ntote anl
Mutåon absence
ok
tessMaintons
objeckue diaxthoea
Nausea
client
with
an

than
body requiro
ments
Diagnosis
Cmbalanced 0 electro'gies
Secendoy
Ntientsiarhoea
frequent
Passing
loss
t
reloted Stools.
and chstendodand
and
tender

discomost Posiive
and decrooed
Hb
RBC,
voni
ting Dyspepsia
,ndigestion papation
AbdominaMoni
ong
shouwsblood
COUntShoos
ASsessment
Nursing and
- weignt
DecrOased
Data:
cve
Subje Objec
ve
Daa ntake
occult
burosPain counts
PlaeLets
WeC Abdomen
and
Nawsea -under
Anorexia Abdonúncd
diarhoea for Cncreased
Abdomeo.
decreased
Presence
aNI Shouos Stoo USG

"
 |Objecfue
Data. Subjecive
DataNUrsing
Dec
Decreised
SbolPresence Weak droosy
Sunken
eyes. lookS
haustedex Stools
frequent Lethara
Diziness xDsí
nessWtery
Stools
loose
Stool s reased
-organ'sms ic
cIs and'
and ASsessment
BloodOf
in
Tred
and
Passing &xercíse
presencQ
Shows
feeble
Pulses lay
teeling
oTolerance.
lo0se

toose fom |and lrelated

Tolerance
decreased
exercise,
Clnd
|cauirgsecordagy 0ss|fatgue
bhgnosis
electDly
walery e
ethargy stools
to
tes uds
absencet5and Perormincreased
ietha«gd acHuly Chjectíue |
fatiguowerbalises
retie etient
with fo
|actiies s 4 |3)
Sensitvity
thenaduice
acHuHes a uJSupplements
the AnHbiotícs
12) 10) Nuitlona
adqute|anneeded, 7) dianrhoeal
81 Ca! side ctient OF anchelectrolyies
the 6 exertion frtAcequcte restBed 2ftigue
debecatton Moniorand
jue AduiceThtervention
modercUe Puttern
as Aduie
Prescribed. Poide PDuíde Aduinister
Adninister
Once Administer
Adintster Advice
muttivitanin oF
ASSess
For actúty juices
pleny
dioghoea the
as
Assistance
the when caulAssistancecessalonuntthei the the the
orik.
heavyand Client Ctient heeds cient tV i
reportS. Per the An- episodes. perprm oRS ot PaterO.
cifent bell mildto
prescibed rient Cause
progressfo is flids tuids
and
to sensitiue
milddo the prescribet.
diasrhoel 8 a to
Stopeed to Aduice to to
cin K. to
cultue bedthe
themeet
avoid rake the of
Naintun wtn
asTo
|balance balanco the fomfutgue. To Toidenty|he |o
de|relieve relieveTo |& Toindependently. retieethereby ciaboea
exertfon
from sicebedneeds
Shrenaus fatgue.
Pertging
AcHuities. thereby
|relieve
To o Tmprue
fatiguo 4 Peromírg
Independently
To fo fatiguc
erkprming To TmproUethe To retieve
reisetreat trect thereba retleve tuic replace
prevent PrRuent meet Conserve Ratonale
the Of pprDpriae
energy relieve ín inand
diarhoecs fatique. G1
Diarrhoea reueve actoiY.
relieve
fatigue theaciies aculHes the the the
faHique intecon cËaarhoea client electolyte ener Cn
fatie. body nd
taids
o electolyte body.
fom
episodes Perorm faigue. fom
from
uointainlost and Cause.
and at &

ease
Pergpimdiaxthoea
ComBort acHiHes and
CessaHon retieved ctient'
evidenced s
fatigueEvauaion
and
oith Ok asaas
 crient
gained
fual
uaHon knoaletge
herapeutfcNarageverbalisig
ment tne hygienc.
pinipLes
are
egimen
home
and

în a teanuent
Compete
ORS
1 Dnection e5 treatmnt
for
complete
Ctientnd Maintan4 onHon poisontny
iarrno
episodeo
further
teat volUMeSton
Stahus. gidelineo
Ratonae
langquge
Oon
ther dnnk Pre
venr 9cin
khowledy2
ondi
atolerance y. disease
diarhca
fuethe
the levet dige CoMpicatons
recee food
Dim1hoa
understonding ond c Preuent T
edUCate vent
predËaghoea.
l isease prevent
To and
recove
own
their Pore in Prevent nt treauent
home aud Preve follbw
pre aonaelid f
To To
thÍl To at To thethe To
diseaseo or and To To To
.
or teachingdiarhoea Modalitiesandexplatn each the
CHoo
language dentku
to
menbers day Smat & ul te0ch the king
baitted &foods
essenta
Coe
visits
srae
the
an peravofd dehydratton
ike
cOmpicaton
hydrated. warMed betpre regaraing
eot
ony Signs tate 7 preUent
uq. din that handting nanagement
Care to
ins
ORSpare and
treatment
on the aboutavojd
anofood
about client
up
fn
ient'sfangly the preoRSo Consume
teds causes,
CLient
the
on
Gndfrequent cËent to eect each is Uso
Ctient
DntervenHon client
the
Acujce ctient Shocle
pingnt preschbed Cthent & oater washng booklet follou
contGNnaled
follo others
aFood
ntolerance demonot
PreraraHon
to clie o bojled
cient 4 or
to
untilretieved,
ctient
l the& |6
Educae
the
Kee
hypovoleic side e
MCASUres to eating
the toitetng the
theasiny
and include mecls ts and for the tnc
ektects and reular
s00-20o0
signifcant &TeOch AdujCe sEdycate
diet the Instuct Tnsruct
hand ProuideDlanhoea
AduicQ
ASSess kendition,
Sympoms needAdu•ce as feochMCubers rdinking
bland home
the
heavy about
Cugs Side- water agerteo hONO
sicr
and asK Fethe and A
9 10 12) for
2 3
on its and Monagenent
Knowledge Care
objece Home
Pngnosis
Condition
disense
Cient

the its Nanaqe

Compicaton
Condition,
Deflent
knowledge
biagnosis regarcing
sease
home

ment
andcare
cisease
regarctingManagement
awareness topractice
hygenic
diarhoea.
Compicaions
clie
tË
pinciplesQnd modiicalion
mecícaHon pngnosis complicaions
s
Management
strange
core
the
regarding
Quories Iliterae its
disease
Qbout
the the
ment
sess
As andciagnosis
bout
the onqoingdietay
Data
SubjecueOk Care Quanes
reted about follo
lack Data
objectfue woried
home r for
Condition
balises Conctifon
unoare 10
ursing sueries reatment
Need "Need
Qbout toots "Need
Ver
6
 Hoadth ducatfon
’ Personal bygiene
adtricod palient to take gath daly
’ Diet
atviccd parient baloncod diet
time.
adyited t tate vegetables and faits and tiquid foo.

General advico 9
adriced the Patient water and thon cold
and USe
Qduiced MOsqito net
- aduicod t abot Personal hyglene.
Medfcaton and ollo

adviced patient tare medicafon at proper

time
xplaincd reqardig regudar Medicod Checkup.

htcter Consumption is more Tmportant to prevent clehydratfor,