Free Critical Care Nurse Report

Critical Care Nurse Report

I. General Information

Patient Name: [Patient's Name]
Medical Record Number: 123456
Date of Birth: [Birthdate]
Gender: [Gender]
Date of Report: [Date]
Time of Report: [Time]

Summary:
This report provides an update on the critical care status of the patient, [Patient's Name], currently admitted to the intensive care unit (ICU). The purpose is to communicate essential information regarding the patient's condition, recent interventions, and ongoing care plan.

II. Vital Signs

Vital Sign	Result
Temperature	37.5°C
Blood Pressure	120/80 mmHg
Heart Rate	95 bpm
Respiratory Rate	20 breaths per minute
Oxygen Saturation	98%

III. Current Medications

Medication 1: Levofloxacin - 750 mg IV q24h
Medication 2: Furosemide - 40 mg IV q12h
Medication 3: Propofol - 50 mcg/kg/min IV

IV. Recent Procedures

Central line placement: Successful, no complications.
Arterial blood gas (ABG) analysis: pH 7.35, PaO2 90 mmHg, PaCO2 40 mmHg.

V. Assessment

[Patient's Name] remains stable following admission to the ICU with improved respiratory function noted post-intubation. Vital signs indicate maintained hemodynamic stability, with blood pressure within normal limits and heart rate steady. Laboratory results reveal a reduction in inflammatory markers, suggesting a positive response to initial antibiotic therapy.

However, ongoing support with vasopressors is necessary to maintain adequate perfusion. Neurological assessments show responsiveness to stimuli, indicating preserved neurological function at this time. The patient's condition warrants continued close monitoring, particularly for any signs of sepsis recurrence or respiratory compromise.

VI. Plan

Immediate Plan	Short-term Plan	Long-term Plan
Adjust Propofol infusion per sedation assessment protocol	Continue ABG monitoring every 4 hours Consider weaning from ventilator if stable	Consult with infectious disease specialist for antibiotic optimization

VII. Nurse's Notes

Response to Treatment: [Patient's Name] has shown improved oxygenation and stable ventilator settings post-intubation.
Family Communication: Regular updates provided to the family, who remain supportive and engaged in care discussions.
Comfort Measures: Nursing interventions focused on maintaining patient comfort throughout the shift.
Sedation Management: Ensured adequate sedation levels to optimize patient comfort and respiratory support.
Infection Control: Strict adherence to infection control protocols to minimize risk of secondary infections.

Prepared by:

[Your Name], RN
Nurse On Duty

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