Nursing Progress Report
NURSING PROGRESS REPORT
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Prepared by: |
[Your Name], RN |
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Company: |
[Your Company Name] |
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Date: |
May 15, 2050 |
I. Introduction
This report offers a detailed overview of the nursing progress for the patient mentioned below, encompassing assessments, treatment plans, progress notes, and discharge planning strategies, aiming to ensure comprehensive care and effective transition.
II. Executive Summary
A. Patient Background
The patient, Ms. Emily Johnson, a 45-year-old female, was admitted to our facility on May 25, 2024, presenting with acute respiratory distress syndrome (ARDS) as the primary diagnosis. Her medical history includes hypertension and mild asthma, which might contribute to her current condition.
B. Current Condition Summary
Ms. Johnson's physical condition has exhibited noticeable improvement since admission. While she initially presented with severe dyspnea and hypoxemia, her respiratory status stabilized, with a significant reduction in respiratory rate and improved oxygen saturation levels. However, she continues to experience moderate anxiety, which warrants ongoing attention and support from the nursing team.
C. Treatment Progress Overview
The treatment plan has focused on addressing Ms. Johnson's respiratory distress through a combination of pharmacological interventions and respiratory physiotherapy. Notably, she has responded positively to oxygen therapy, corticosteroids, and bronchodilators, with evident improvements in lung function and oxygenation levels.
III. Patient Information
|
Name |
Age |
Gender |
Admission Date |
Diagnosis |
|---|---|---|---|---|
|
Emily Johnson |
45 |
Female |
May 25, 2024 |
Acute Respiratory Distress Syndrome |
IV. Current Condition
A. Physical Condition
Ms. Johnson's current physical assessment reveals a notable improvement in vital signs compared to admission. Her respiratory rate has decreased from 24 to 18 breaths per minute, and oxygen saturation levels have risen from 92% to 96%. Despite these improvements, she continues to require supplemental oxygen at 2 liters per minute via nasal cannula to maintain adequate oxygenation.
B. Mental State
In terms of mental state, Ms. Johnson continues to exhibit signs of anxiety, including restlessness and increased heart rate. While she responds well to reassurance and relaxation techniques, her anxiety levels remain a concern and necessitate ongoing monitoring and support.
C. Medication Status
Ms. Johnson's current medication regimen includes oxygen therapy to maintain oxygen saturation levels above 95%, methylprednisolone 40mg IV every 6 hours to reduce inflammation and improve respiratory function, and albuterol inhalation as needed for bronchodilation.
V. Assessment
|
Parameter |
Initial Assessment |
Current Assessment |
Progress |
|---|---|---|---|
|
Vital Signs |
HR: 110 bpm |
HR: 90 bpm |
Stable |
|
RR: 24 breaths/min |
RR: 18 breaths/min |
Improved |
|
|
SpO2: 92% |
SpO2: 96% |
Improved |
|
|
Laboratory Results |
PaO2: 60 mmHg |
PaO2: 80 mmHg |
Improved |
|
Pain Assessment |
5/10 |
2/10 |
Decreased |
VI. Treatment Plan
|
Intervention |
Frequency |
Duration |
Response |
|---|---|---|---|
|
Oxygen Therapy |
Continuous |
- |
Improved Saturation |
|
Methylprednisolone |
Every 6 hours |
5 days |
Reduced Inflammation |
|
Respiratory Physiotherapy |
Daily |
30 minutes |
Improved Lung Function |
VII. Progress Notes
Ms. Johnson has demonstrated a positive response to treatment, with noticeable improvements in respiratory function and overall well-being. Nursing staff continue to monitor her closely for any signs of respiratory distress or complications and provide appropriate interventions as necessary. Moreover, Ms. Johnson actively engages in respiratory physiotherapy sessions and expresses a willingness to participate in her care.
VIII. Discharge Planning
The discharge planning process involves coordinating home oxygen therapy and scheduling follow-up appointments with the pulmonologist and primary care provider to ensure continuity of care post-discharge. Additionally, Ms. Johnson will receive comprehensive education on self-management techniques, medication adherence, and lifestyle modifications to optimize her recovery and prevent future exacerbations.
IX. Conclusion
In conclusion, this report encapsulates Ms. Emily Johnson's nursing progress throughout her hospitalization for acute respiratory distress syndrome. By addressing her physical and psychological needs holistically, we aim to facilitate a smooth transition to home care and support her continued recovery journey.
