Nurse-To-Nurse End of Shift Nurse Report

NURSE-TO-NURSE END-OF-SHIFT NURSE REPORT

Prepared by: [Your Name]


I. Patient Information

Category

Details

Name:

John Doe

Age:

58 years old

Medical Record Number:

MRN123456

Room Number:

305

II. Summary of Condition

A. Patient's Current Status

As I finish my shift, John Doe is recovering well post-surgery following a total hip replacement performed two days ago. He is currently pain-free at rest and rates his pain at 2/10 during movement. John is compliant with physical therapy sessions and has been ambulating with a walker. His vital signs are stable and within normal limits.

B. Changes Since Last Report

Since my last report, John Doe's pain management regimen was adjusted from intravenous to oral acetaminophen (1000mg PO every 6 hours as needed) due to improved pain control and oral intake. He is now tolerating a regular diet and has had no nausea or vomiting. The wound dressing was changed earlier today, and the incision site remains clean and dry without signs of infection.

C. Plan of Care

The current plan of care includes continued monitoring of pain levels, assistance with mobility as needed, ensuring adequate hydration, and educating the patient on deep breathing exercises to prevent respiratory complications post-surgery. Anticipate discharge planning for tomorrow pending physician assessment.

III. Medical History

Condition/Issue

Details

Past Medical History:

Hypertension, Type 2 Diabetes, Osteoarthritis

IV. Current Medications

Medication Name

Dosage

Administration Time

Acetaminophen

1000mg PO

Every 6 hours as needed

Metformin

1000mg PO

Daily with breakfast

Losartan

50mg PO

Daily

V. Allergies

Allergen

Reaction

Penicillin

Rash

Aspirin

None

Sulfa Drugs

None

VI. Vital Signs

Vital Sign

Measurement

Blood Pressure:

130/80 mmHg

Heart Rate:

78 bpm

Respiratory Rate:

16 breaths/min

Temperature:

98.6°F

VII. Recent Assessments

Assessment Type

Findings

Neurological:

Oriented x3, no deficits

Cardiovascular:

Regular rhythm, no murmurs

Respiratory:

Clear breath sounds bilaterally

VIII. Ongoing Treatments

The Treatment/Procedure

Details

Physical Therapy

Exercises for mobility; patient ambulates with a walker as tolerated

Wound Care

Incision site clean and dry; dressing changed every 12 hours or as needed

Patient Education

Deep breathing exercises to prevent atelectasis; review of post-discharge instructions

IX. Special Instructions

Instruction

Details

Fall Risk Precautions

Keep the bed in a low position; assist with ambulation; educate the patient on the use of a walker

Dietary Restrictions

Regular diet; encourage hydration; avoid high-sodium foods to prevent fluid retention

Discharge Planning

Scheduled for discharge tomorrow pending physician assessment; review discharge instructions with patient and family

X. Concerns/Issues

A. Patient's Response to Treatment

John Doe has responded well to pain management and physical therapy interventions. Continued encouragement of mobility and deep breathing exercises are recommended to prevent complications.

B. Potential Complications

Monitor for signs of infection at the surgical site, including increased redness, swelling, or drainage. Report any changes promptly to the physician.

C. Recommendations

Coordinate with physical therapy for ongoing rehabilitation exercises. Ensure patient and family understand post-discharge care instructions, including medication management and follow-up appointments.


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