RM/BED NO: WARD 6 BED 4 PT NAME:EBUNOLUWA OGUNSULIRE AGE:30 YRS

CODE:

ADMISSION 01

ATTENDING: NRS OLORUNDARE

SEX: FEMALE ADMISSION DATE:31/1/2024

ALLERGIES: MAIN DX: MALARIA IN PREGNANCY , PREECLAMPSIA

CURRENT DX: MALARIA IN PREGNANCY, PREECLAMPSIA

NURSING DX: FATIGUE RELATED TO

THE DISEASE CONDITION AS
EVIDENCED BY PATIENT
VERBALIZATION
IVF:IVF 0.9N/S ALT 5%D/W 500MLS PROCEDURES: CATHETERIZATION
6HRLY

ATTENDING:NRS OKAFOR
ACTIVITIES/THERAPIES: NOTES: PATIENT CAME INTO THE FACILITY ON ACCOUNT OF GENERALIZED BODY
WEAKNESS x 10HRS WITH ASSOCIATED NAUSEA AND VOMITING.PATIENT PRESENTED
WITH ELEVATED BLOOD PRESSURE OF 153/100MMHG. TAB ALDOMET 500MG TDS
AND NIFEDIPINE 20MG STAT WAS ADMINISTERED. PATIENT WAS GIVEN LOADING
DOSE OF MGSO4. PATIENT BLOOD PRESSURE GRADUALLY REDUCED WITHIN THE
NORMAL RANGE.
LINES/TUBES/DRAINS:IV LINE,
CATHETER

PRN MEDS:NIL

VITALS

T:36.3C

BLOOD SUGAR: P:92B/M

INPUT:2000MLS R:20C/M

OUTPUT:400MLS BP:107/67MMHG

MEDS ADM: SPO2:98%

-TAB NIFEDIPINE 20MG STAT HT:1.67CM

-IM CQ 200MG x 5 DOSES WT:95.8KG

-IV MGSO4 4MG STAT THEN 5MG FHR:150BPM

INTO EACH BUTTOCKS

-IM DEXAMETHASONE 12MG

12HRLY NOTE: VITAL SIGNS WAS STRICTLY MONITORED AND DOCUMENTED.

-TAB ALDOMET 500MG TDS

ATTENDING:NRS OLORUNDARE

RM/BED NO: WARD 6 BED 6 PT NAME: OLUWAKEMI OLA AGE:32 YRS

CODE:

ADMISSION 02

ATTENDING: NRS OLORUNDARE

SEX: FEMALE ADMISSION DATE:31/1/2024

ALLERGIES: MAIN DX: THREATENED ABORTION

CURRENT DX:THREATENED ABORTION

NURSING DX: PAIN RELATED TO THE

DISEASE CONDITION AS EVIDENCED
BY PATIENT VERBALIZATION

IVF:IVF 0.9 N/S ALT D/W 500MLS PROCEDURES:NIL

8HRLY

ATTENDING:
ACTIVITIES/THERAPIES: NOTES: PATIENT WAS ADMITTED ON ACCOUNT OF LOWER ABDOMINAL PAIN AND PV
BLEEDING. PATIENT WAS PLACED ON STRICT BED REST WITH ONLY BATHROOM
PRIVILEGE WHICH WAS ENSURED. DUE MEDICATIONS WAS SERVED AND
DOCUMENTED.

LINES/TUBES/DRAINS:IV LINE

PRN MEDS:NIL

VITALS

T:36.2C

BLOOD SUGAR: P:71B/M

INPUT:1000MLS R:20C/M

OUTPUT: BP:120/77MMHG

MEDS ADM:IM SPO2:983

METOCLOPRAMIDE 10MG STAT
HT:1.68CM

WT:101KG

FHR:

NOTE: 4HRLY VITALS WAS RECORDED AND DOCUMENTED

ATTENDING:NRS OLORUNDARE
 RM/BED NO: WARD 4 PT NAME:OJO ADEWUMI AGE:77 YRS

CODE:

ADMISSION 03

ATTENDING: NRS OLORUNDARE

SEX: MALE ADMISSION DATE:31/1/2024

ALLERGIES: MAIN DX: ACUTE ABDOMINAL PAIN ? CAUSE KIV GASTRITIS WITH
MALARIA FEVER

CURRENT DX:ACUTE ABDOMINAL PAIN ? CAUSE KIV GASTRITIS WITH

NURSING DX: HYPERTHERMIA MALARIA FEVER
RELATED TO THE DISEASE
CONDITION AS EVIDENCED BY
THERMOMETRIC READING OF 38.9C
IVF:IVF 5% D/SALINE 1LITRE 8HRLY FOR PROCEDURES: NIL
48 HRS

ATTENDING:NRS OLORUNDARE
ACTIVITIES/THERAPIES: NOTES: PATIENT WAS ADMITTED ON ACCOUNT OF RECURRENT VOMITING,
ABDOMINAL PAIN x 4HRS AND FEVER. PATIENT WAS PLACED ON NIL PER ORAL. DUE
MEDICATIONS WAS SERVED AND NIL EPISODE OF VOMITING SINCE
ADMISSION.THERE WAS AN INCREASE IN TEMPERATURE TO 38.6C, IM PCM 600MG
STAT WAS PRESCRIPTION AND ADMINISTERED.
LINES/TUBES/DRAINS:

PRN MEDS:

VITALS

T:37.4C

BLOOD SUGAR: P:86

INPUT: R:20

OUTPUT: BP:160/100MMHG

MEDS ADM:-IV OMEPRAZOLE 4 SPO2:98%

MG DAILY
HT:1.61CM
-IV CEFTRIAZONE 1G 12HRLY FOR
48 HRS WT:69.6KG

-IV FLAGYL 500MG 8HRLY FOR FHR:

48HRS

-IV HYOSCINE 120MG AT OHR,

NOTE:4HRLY VITALS WAS RECORDED AND DOCUMENTED.RBS=6.0MMOL/L
12HRS, 24HRS

ATTENDING:NRS OLORUNDARE

RM/BED NO: WARD 6 BED 5 PT NAME: ELIZABETH FEMI-OYEKAN AGE:53 YRS

CODE:

ADMISSION 04

ATTENDING: NRS OLORUNDARE

SEX: FEMALE ADMISSION DATE:31/1/2024

ALLERGIES: MAIN DX:ENTERIC FEVER

CURRENT DX:ENTERIC FEVER

NURSING DX: DEFICIENT FLUID

VOLUME RELATED TO STOOLING AS
EVIDENCED BY DEHYDRATION
IVF:IV 0.9 N/S 500MLS FAST PROCEDURES: CATHETERIZATION

ATTENDING:NRS OKAFOR
ACTIVITIES/THERAPIES: NOTES: PATIENT CAME INTO THE FACILITY ON ACCOUNT OF PASSAGE OF LOOSE
STOOL x 15 EPISODES. PATIENT WAS ADMITTED AND SHE WAS CATETERIZED. IVF
RINGERS LACTATE AND TAB LOPERAMIDE 2MG STAT. PATIENT HAD ONE EPISODE OF
STOOLING SINCE ADMISSION.

LINES/TUBES/DRAINS:IV LINE,
CATHETER

PRN MEDS:NIL

VITALS

T:36.3C

BLOOD SUGAR: P:100

INPUT:1000 MLS R:22

OUTPUT:400MLS BP:149/100

MEDS ADM:IV METRONIDAZOLE SPO2:99

500MG
HT:1.62
TAB LOPERAMIDE 2MG STAT
WT:96.8

FHR:

NOTE:

ATTENDING:NRS OLORUNDARE

RM/BED NO:AMENITY 1 PT NAME:BANKOLE SAMUEL AGE:72YRS

CODE:
INPATIENT 01

ATTENDING: NRS ADEWARA/NRS OLATUNJI

SEX:MALE ADMISSION DATE:06/01/2024

ALLERGIES:NIL MAIN DX:pyelonephritis 2nd to pyonephrosis 2 impactive

@ureteric calculus

CURRENT DX: Resolving hiccups and rti

NURSING DX:RISK FOR INFECTION

IVF:IV CIPROFLOXACIN 200MG 12HRLY INVESTIGATION:NIL

(NOT AVAILABLE AND NOT GIVEN) PROCEDURES:NIL

ATTENDING:NRS OLORUNDARE
ACTIVITIES/THERAPIES:AMBULATION

LINES/TUBES/DRAINS: IV LINE

PRN MEDS:NIL

VITALS

T:,36.0C

BLOOD SUGAR:nil P:70B/M

INPUT:NIL R:20C/M

OUTPUT:NIL BP:120/70MMHG

SPO2:97%

HT:1.60cm

WT:55.8kg

NOTE:

ATTENDING:NRS OLORUNDARE

MEDS ADM:-Tab 400mg tds

-tab vit c 1000mg bd

-daravite caps 1 dly

-Tab omeprazole 40mg dly

-Cough syr 10mls tds(not

available)

-Tab Amlodipine 10mg daily

 RM/BED NO: WARD 6 AGE:37YRS

BED 3 PT NAME:ADELAKUN BUKOLA

CODE:

INPATIENT 2

ATTENDING: NRS ADEWARA/NRS OLATUNJI

SEX:FEMALE ADMISSION DATE:30/01/2024

ALLERGIES: NIL MAIN DX:MALARIA RX FAILURE KIV CHEST FOCUSED SEPSIS

CURRENT DX:MALARIA RX FAILURE KIV CHEST FOCUSED SEPSIS

NURSING DX:RISK FOR INFECTION

RELATED TO WEAKENED IMMUNE
SYSTEM
IVF:IVF 5% DEXTROSE WATER 1LITRE INVESTIGATION:FBC
12HOURLY

PROCEDURES:NIL

ATTENDING:NRS OLORUNDARE

ACTIVITIES/THERAPIES:NIL NOTES: PATIENT WAS MET IN AN IMPROVED STATE OF HEALTH ON ASSUMPTION OF

DUTY, DUE MEDICATIONS WAS SERVED AND DOCUMENTED. PATIENT VOMITED
TWO TIMES AND IV PROMETHAZINE 25 MG STAT. THERE WAS NO EPISODE OF
VOMITING AFTER THE MEDICATION WAS ADMINISTERED.

LINES/TUBES/DRAINS: IV LINE
INSITU

PRN MEDS:NIL

VITALS

BLOOD SUGAR:NIL T:36.1C

INPUT:1000MLS P:80BPM

OUTPUT:NIIL R:20CPM

MEDS ADM: BP:124/74MMHG

IV CEFTRAZONE 1G 12HRLY SPO2:98%

IM CHLOROQUINE 200MG HT:1.62cm

12HRLY*5DOSES
WT:71.6kg
IV GENTICIN 80MG 12HRLY

COUGH SYRUP
10MLSbTDS(NOT AVAILABLE)
NOTE:4HOURLY VITAL SIGNS WAS DONE AND WELL DOCUMENTED

ATTENDING:NRS OLORUNDARE
 RM/BED NO:WARD 5 PT NAME:ISEOLUWA OWOSOLA AGE:23YRS

CODE:

INPATIENT 3

ATTENDING: NRS OLORUNDARE

SEX:MALE ADMISSION DATE:30/01/2024

ALLERGIES: NIL MAIN DX:Avulsion injury to the R fingers

CURRENT DX: Avulsion injury to the R fingers

NURSING DX:ACUTE PAIN RELATED
TO AVULSION INJURY AS EVIDENCED
BY PATIENT VERBALIZATION
IVF:NIL INVESTIGATION: NIL

PROCEDURES: WOUND DRESSING

ATTENDING:NRS ALIU

ACTIVITIES/THERAPIES: NOTES:PATIENT WAS MET CALM ON BED ON ASSUMPTION OF DUTY. DUE

MEDICATIONS WAS DONE AND DOCUMENTED. WOUND DRESSING WAS DONE AND
NIL THERE WAS NO COMPLAINTS FROM THE PATIENT.

LINES/TUBES/DRAINS:NIL

PRN MEDS:NIL

VITALS

T:36.4c

BLOOD SUGAR:NIL P:74bpm

INPUT:NIL R:20cpm

OUTPUT:NIL BP:123/67mmhg

MEDS ADM: SPO2:98%

Tab diclofenac 50mg b.d HT:1.70cm

WT:80,0kg
Tabs ciprofloxacine
500mg b.d
Tabs flagyl 400mg tds

NOTE:NIL
 RM/BED NO: PT NAME:PRECIOUS SAAMSON AGE:26YRS

CODE:

INPATIENT 4

ATTENDING: NRS OLORUNDARE

SEX:FEMALE ADMISSION DATE:30/01/24

ALLERGIES: MAIN DX:malaria with prostration

CURRENT DX:malaria with prostration

NURSING DX:

ACTIVITIES/THERAPIES:NIL
IVF: 5% DEXTROSE WATER 500MLS NOTES:PATIENT WAS MET IN AN IMPROVED STATE OF HEALTH ON ASSUMPTION OF
INVESTIGATION:MP,FBC
6HOURLY DUTY. DUE MEDICATIONS WAS SERVED AND DOCUMENTED. NIL EPISODE OF
VOMITING AND PATIENT WAS CALM THROUGHOUT THE SHIFT

PROCEDURES:NIL

LINES/TUBES/DRAINS:IV LINE

PRN MEDS:NIL

VITALS ATTENDING:NRS OLORUNDARE

T:36.2C

BLOOD SUGAR:NIL P:77BPM

INPUT:1000MLS R:20CPM

OUTPUT:NIL BP:109/76MMHG

MEDS ADM: SPO2:99%

IM CHLOROQUINE HT:1.70C/M
200MG*5DOSES
WT:66.0kg
TAB CIPROFLOXACIN 500MG BD
1/52

NOTE:NIL

ATTENDING:NRS OLORUNDARE
 RM/BED NO: WARD 3 PT NAME:AKINBOYEWA OLUGBENGA AGE:68YRS

CODE:

INPATIENT 5

ATTENDING:NRS ADEWARA/NRS OLATUNJI

SEX:MALE

ALLERGIES: NIL

NURSING DX: IMPAIRED PHYSICAL MOBILITY

ADMISSION DATE:28/01/24

MAIN DX:acute on CKD with background dementia

CURRENT DX:Resting tremors ?cause KIV adverse rxn to setraline in a know CKD Px

IVF:0.9%NORMAL SALINE 1L 24HRS INVESTIGATION: URINE MCS, ABDOMINAL SCAN, ECHOCARDIOGRARHY

PROCEDURES:NIL

ATTENDING:NRS OLORUNDARE
ACTIVITIES/THERAPIES:NIL NOTES:PATIENT HAD NIL COMPLAIN THROUGHOUT THE SHIFT, HE REACTED TO
SETRALINE WHICH WAS WITHOLD,TAB PROPRANOLOL 40MG WAS CHANGED TO TAB
BISOPROLOL 2.5MG DLY, PATIENT PERSONAL HYGEINE WAS ENSURED. PATIENT IS
STILL HAVING TREMORS OF THE TWO LIMBS.

BED BATH WAS DONE,ORAL HYGEINE WASENSURED

LINES/TUBES/DRAINS:IV LINE

PRN MEDS:NIL

VITALS

T:36.3C

BLOOD SUGAR:NIL P:68BPM

INPUT:500MLS R:20CPM

OUTPUT:900MLS BP:122/64MMHG

SPO2:98%

HT:1.66cm

WT:115.9kg

NOTE: 4HRLY VITALS WAS RECORDED AND DOCUMENTED

ATTENDING: NRS OLORUNDARE

MEDS ADM:

-Iv furosemide 40mg daily

-Tab rosuvastatin 20mg
DLY
-Tab vit c 1g bd
-Tab vit e 1000iu dly
-Tab encephabol I bd
-Tab diazepam 4mg
nocte
-Tab Vasoprin 75mg dly 2/52
 RM/BED NO: WARD 6 BED 5 PT NAME:YEMI PIRISOLA AGE:55YRS

CODE:

DISCHARGED 1

ATTENDING: NRS OLORUNDARE

SEX:FEMALE ADMISSION DATE:29/01/24

ALLERGIES: NIL MAIN DX: malaria rx failure kiv urosepsis

CURRENT DX:improved
NURSING DX:NIL
IVF:Iv Quinine 600mg in 500mls 5% D/W PROCEDURES:NIL
alt with 500mls 5% D/S over 4hrs each *6
doses

ATTENDING:NRS OLORUNDARE

ACTIVITIES/THERAPIES:NIL NOTES:PATIENT WAS MET IN AN IMPROVED STATE OF HEALTH ON ASSUMPTION OF

DUTY, SHE WAS DISCHARGED AFTER LAST DOSE OF QUININE.

LINES/TUBES/DRAINS:IV LINE

PRN MEDS:NIL

VITALS

T:

BLOOD SUGAR:NIL P:

INPUT: R:

OUTPUT:NIL BP:

SPO2:

HT:

WT:

NOTE:NIL

ATTENDING:NRS OLORUNDARE
 RM/BED NO: WARD 6 BED 6 PT NAME:OGINI OLALEKAN AGE:5YRS

CODE:

DISCHARGED 02

ATTENDING: NRS OLORUNDARE

SEX:MALE ADMISSION DATE:29/01/24

ALLERGIES: NIL MAIN DX:malaria kiv gi focused sepsis

CURRENT DX:STABLE
NURSING DX:NIL
 INVESTIGATION:NIL

IVF:

PROCEDURES:NIL

ATTENDING:NRS OLORUNDARE

ACTIVITIES/THERAPIES:NIL NOTES:PATIENT WAS MET IN A STABLE STATE OF HEALTH ON ASSUMPTION OF DUTY,

HE WAS REVIEWED AND DEEMED FIT FOR DISCHARGE ON:

TAB ACTII BD 3/7

PO AMOXIL 5MLS TDS *1/52

LINES/TUBES/DRAINS:IV LINE

PRN MEDS:NIL

VITALS

T:

BLOOD SUGAR:NIL P:

INPUT:NIL R:

OUTPUT:NIL SPO2:

HT:

WT:

NOTE:NIL

ATTENDING:NRS OLORUNDARE

MEDS ADM: NIL

 RM/BED NO: 7 PT NAME:DAVID DANIEL AGE:39YRS

CODE:

DISCHARGED 03

ATTENDING: NRS OLORUNDARE

SEX:MALE ADMISSION DATE:29/01/2024

ALLERGIES: NIL MAIN DX:malaria rx failure kiv chest focused sepsis

CURRENT DX:improved
NURSING DX:NIL
IVF:Iv Quinine 600mg in 500mls 5% D/W PROCEDURES:NIL
alt with 500mls 5% D/S over 4hrs each *6
doses

ATTENDING:NRS OLORUNDARE

ACTIVITIES/THERAPIES:NIL NOTES:PATIENT WAS MET IN AN IMPROVED STATE OF HEALTH ON ASSUMPTION OF

DUTY AND WAS DISCHARGED HOME AFTER LAST DOSE OF QUININE

LINES/TUBES/DRAINS:IV LINE

PRN MEDS:NIL

VITALS

T:

BLOOD SUGAR:NIL P:

INPUT:NIL R:

OUTPUT:NIL BP:

MEDS ADM: SPO2:

HT:

WT:

NOTE:NIL

ATTENDING:NRS OLORUNDARE
 RM/BED NO: BED 2 WARD 7 PT NAME:AROWOLO DICKSON AGE:43YRS

CODE:

DISCHARGED 04

ATTENDING: NRS OLORUNDARE

IVF:Iv Quinine 600mg in 500mls 5% D/W PROCEDURES:NIL

alt with 500mls 5% D/S over 4hrs each *6
doses

ATTENDING:

ACTIVITIES/THERAPIES:NIL NOTES:PATIENT WAS TAKEN OVER IN AN IMPROVED STATE OF HEALTH, HE WAS

REVIEWED BY THE DOCTOR AND WAS DEEMED FIT FOR DISCHARGE ON:

TAB ACT IV BD *3/7

TAB PCM II TDS * 3/7

LINES/TUBES/DRAINS:NIL
CAP AMOXIL 500MG TDS 1/52

TAB AMLODIPINE 10MG DLY 1/12

COUGH SYRUP 10MLS TDS 5/7

PRN MEDS:NIL

VITALS

T:

BLOOD SUGAR:NIL P:

INPUT:NIL R:

OUTPUT:NIL BP:

SPO2:
 RM/BED NO:WARD 7 BED 7 PT NAME:ADELEKE ADEBISI AGE:27YRS

CODE:

DISCHARGED 05

ATTENDING: NRS OLORUNDARE

SEX:MALE ADMISSION DATE:

ALLERGIES:NIL MAIN DX:malaria kiv sepsis (chest focused) in a known

substance user

NURSING DX: CURRENT DX:improved

IVF: PROCEDURES:NIL

ATTENDING:

ACTIVITIES/THERAPIES:NIL

LINES/TUBES/DRAINS:IV LINE

PRN MEDS:NIL

VITALS

T:

BLOOD SUGAR:NIL P:

INPUT: R:

OUTPUT:NIL BP:

MEDS ADM: SPO2:

HT:

WT:

NOTE:

ATTENDING:NRS OLORUNDARE
 RM/BED NO: WARD 6 BED 4 PT NAME:OMOSEBI MARIAM AGE:34YRS

CODE:

DISCHARGED 06

ATTENDING: NRS OLORUNDARE

SEX:FEMALE ADMISSION DATE:29/01/24

ALLERGIES: NIL MAIN DX:hyperemesis gravidarum

CURRENT DX:improved
NURSING DX:NIL
IVF: PROCEDURES:NIL

ATTENDING:NRS OLORUNDARE

ACTIVITIES/THERAPIES: NOTES:PATIENT WAS MET IN AN IMPROVED STATE OF HEALTH ON ASSUMPTION OF

DUTY AND WAS DISCHARGED HOME ON:

TAB HEMATINICS 1/12

LINES/TUBES/DRAINS:IV LINE

PRN MEDS:

VITALS

T:

BLOOD SUGAR: P:

INPUT: R:

OUTPUT:NIL BP:

MEDS ADM:NIL SPO2:

HT:

WT:

NOTE:NIL

ATTENDING:NRS OLORUNDARE
 RM/BED NO: WR 6 BED 1 PT NAME:OLUWATOYIN ALADEYOKUN AGE:

8YRS

CODE:

DISCHARGED 07

ATTENDING: NRS OLORUNDARE

SEX:FEMALE ADMISSION DATE:29/1/24

ALLERGIES: NIL MAIN DX:?sepsis gi and chest focused kiv malaria

CURRENT DX:IMPROVING
NURSING DX:NIL
IVF:Iv
Quinine 440mg in 220mls PROCEDURES:NIL
5% D/W alt with 220mls 4.3%
D/S over 4hrs each then
Iv Quinine 220mg in 220mls 5%
D/W alt with 220mls 4.3% D/S
over 4hrs each x 5 doses

ATTENDING:NRS OLORUNDARE

ACTIVITIES/THERAPIES:NIL

LINES/TUBES/DRAINS:IV LINE

PRN MEDS:NIL

VITALS

T:3l

BLOOD SUGAR:NIL P:

INPUT:NIL R:

OUTPUT:NIL SPO2:

MEDS ADM: HT:

WT:

NOTE:NIL

ATTENDING:NRS OLORUNDARE
 RM/BED NO: BED 2 WD 6 PT NAME:OGUNDARE DUNMININU AGE:6YRS

CODE:

DISCHARGED 08

ATTENDING: NRS OLORUNDARE

SEX:FEMALE ADMISSION DATE:29/1/24

ALLERGIES: NIL MAIN DX:acute gastritis kiv sepsis + malaria

CURRENT DX:improved
NURSING DX:NIL
IVF:Iv
Quinine 360mg in 180mls PROCEDURES:NIL
5% D/W alt with 180mls 4.3%
D/S over 4hrs each then
Iv Quinine 220mg in 180mls 5%
D/W alt with 180mls 4.3% D/S
over 4hrs each x 5 doses

ATTENDING:NRS OLORUNDARE

ACTIVITIES/THERAPIES: NOTES:PATIENT WAS TAKEN O VER IN AN IMPROVED STATE OF HEALTH AND WAS
DISCHARGED HOME AFTER LAST DOSE OF QUININE ON:

PO ACT II BD 3/7

PO AMOXIL 5MLS TDS 1/52

LINES/TUBES/DRAINS:IV LINE

PRN MEDS:NIL

VITALS

T:

BLOOD SUGAR:NIL P:

INPUT:NIL R:

OUTPUT:NIL SPO2:

MEDS ADM:iv ceftriaxone 1g HT:

dly WT:
Iv quinine 180mg*5doses

NOTE:NIL

ATTENDING:NRS OLORUNDARE