Nurse Shift Report
Nurse Shift Report
[Your Company Name]
[Your Name]
Date: February 12, 2051
I. Patient Information
A. General Information
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Patient Name: John Doe
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Age: 72
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Room Number: 204
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Admission Date: January 5, 2051
B. Medical History
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Diabetes
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Hypertension
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Past surgeries: Appendectomy (2040)
II. Shift Summary
A. Observations
Patient exhibited stable vital signs throughout the shift. Reports of occasional dizziness were noted.
B. Medications Administered
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Insulin - 10 units at 8:00 AM
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Lisinopril - 20 mg at 9:00 AM
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Metformin - 500 mg at 12:00 PM
III. Nursing Care
A. Interventions
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Assisted with morning hygiene and dressing
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Monitored blood glucose levels pre and post meals
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Provided dietary recommendations per physician's orders
B. Patient Education
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Discussed symptoms of low and high blood sugar
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Emphasized the importance of medication adherence
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Reviewed proper use of a glucometer
IV. Upcoming Care Needs
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Monitor blood pressure every 4 hours
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Administer evening medications at 6:00 PM
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Prepare patient for a scheduled MRI at 11:00 AM, February 13, 2051
V. Communication
Reported observations and upcoming care needs to the oncoming nurse, Sarah Smith, at shift handover.
This Nurse Shift Report was officially written/prepared/created by: [Your Name]
