Surgical Nurse Report
Prepared by: [Your Name], RN
Email: [Your Email]
Phone: [Your Company Number]
Date of Report: [Current Date]
I. Patient Information
Patient Name: [Patient's Name]
Age: 67
Medical Record Number: 123456
Admission Date: June 15, 2050
Diagnosis: Cholecystitis
Procedure: Laparoscopic Cholecystectomy
II. Current Condition
Vital Signs:
Pain Level: 4/10 (controlled with analgesics)
Fluid Balance:
Other Observations: The patient is alert and oriented. She is experiencing mild discomfort at the incision site but has no signs of infection. Mobility is gradually improving with assistance.
III. Surgical Plan
Preoperative Checklist | Status |
|---|
Consent form signed | Yes |
Allergies verified | Yes (Penicillin) |
NPO status | Yes (Since midnight) |
Surgical site marked | Yes |
Intraoperative Details | Information |
|---|
Anesthesia type | General anesthesia |
Incision site | Four small incisions in the abdomen |
Instruments and supplies used | Laparoscope, surgical clips, and standard surgical instruments |
IV. Postoperative Care
A. Immediate Post-op
Recovery room admission time: 10:30 AM
Initial assessment findings: Stable vital signs, responsive to stimuli, and no immediate complications observed
B. Recovery Phase
Monitoring plan: Vital signs every 15 minutes for the first hour, then hourly
Pain management strategy: IV morphine initially, transitioning to oral acetaminophen and ibuprofen
C. Other Considerations
Ensure early ambulation to prevent blood clots and encourage deep breathing exercises to reduce the risk of pneumonia.
V. Discharge Planning
Anticipated Discharge Date: June 18, 2050
Home Care Instructions:
Keep incisions clean and dry
Follow prescribed pain management regimen
Gradually resume normal activities, avoiding heavy lifting for at least two weeks
Follow-up Appointments: Scheduled for June 25, 2050, with Dr. [Doctor's Name] for postoperative evaluation and removal of surgical clips if necessary.
VI. Conclusion
This Surgical Nurse Report captures the essential details of [Patient's Name]'s surgical journey, from preoperative preparations to postoperative care and discharge planning. The patient's condition is stable, and is expected to recover well with proper care and adherence to discharge instruction.
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