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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