Multiple Patients Nurse Report
I. Introduction
Prepared By: [Your Name]
Contact Information: [Your Email]
Date of Report: June 18, 2050
Time of Report: 07:45 AM
This report provides an overview of the patients currently under my care, aiming to ensure effective communication during shift change and continuity of care. Each patient's status and care needs are summarized briefly.
II. Patient Details
Patient | Medical Diagnosis | Treatment Plan | Medications |
|---|
[Patient's Name] | Acute myocardial infarction (AMI) | Bed rest, cardiac monitoring, antiplatelet therapy | Aspirin 81 mg PO daily, Clopidogrel 75 mg PO daily |
[Patient's Name] | Pneumonia | Antibiotics (Levofloxacin), incentive spirometry, respiratory therapy | Levofloxacin 500 mg IV q24h, Acetaminophen 650 mg PO q6h PRN |
[Patient's Name] | Sepsis secondary to urinary tract infection | Fluid resuscitation, broad-spectrum antibiotics, renal function monitoring | Ceftriaxone 1 g IV q24h, Vancomycin 1 g IV q12h |
[Patient's Name] | Traumatic brain injury (TBI) | Neurological assessments, ICP monitoring, sedation management | Propofol infusion per sedation protocol, Mannitol 20% IV PRN |
III. Nurse's Assessment
Overall, the patients are stable with varying responses to treatment interventions. [Patient's Name], recovering post-PCI for acute myocardial infarction, shows stable cardiac enzymes and vital signs within normal limits. [Patient's Name], being treated for pneumonia, has shown resolution of fever and improved oxygen saturation on nasal cannula therapy.
[Patient's Name], managed for sepsis secondary to urinary tract infection, remains hypotensive despite fluid resuscitation and initiation of vasopressors. [Patient's Name], with a traumatic brain injury, maintains stable intracranial pressure with appropriate management of sedation and neurological assessments showing no signs of deterioration.
IV. Action Steps
Immediate Actions: Administer scheduled medications and monitor responses.
Continued Care: Coordinate with specialty teams for ongoing assessments and adjustments in treatment plans; facilitate family meetings to discuss care plans and patient progress.
Patient Education: Provide education to patients and families regarding diagnoses, treatments, and discharge planning.
Updates Needed: Communicate any changes in patient conditions promptly to the healthcare team; update families on patient progress and involve them in care planning where appropriate; document all care interventions and patient responses in the electronic health record (EHR).
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