Nurse Patient Report
I. Patient Details
Name: [Patient's Name]
Medical Record Number: 12345
Date of Admission: June 10, 2050
Current Ward/Unit: Medical-Surgical Unit, Room 304
II. Current Assessment
[Patient's Name] is a 56-year-old female admitted for complications related to type 2 diabetes. She is currently stable but requires close monitoring for blood glucose levels and signs of infection.
A. Vital Signs
B. Other Observations
Skin: Warm and dry with no lesions.
Extremities: No edema, good capillary refill.
Mobility: Ambulates with assistance due to recent episodes of dizziness.
III. Treatment and Care Plan
A. Diagnosis
Uncontrolled type 2 diabetes with peripheral neuropathy and a recent diabetic foot ulcer.
B. Medical Orders
Insulin therapy: Lantus 20 units at bedtime, Novolog sliding scale for meals.
Antibiotics: Ceftriaxone 1g IV every 24 hours for foot ulcer.
Wound care: Daily dressing changes with sterile technique.
Diet: Diabetic diet with calorie count monitoring.
Labs: Daily blood glucose levels, HbA1c, CBC, and BMP.
C. Nursing Interventions
Monitor blood glucose levels before meals and at bedtime.
Administer medications as per the schedule.
Perform wound care and monitor for signs of infection.
Assist with activities of daily living as needed.
IV. Medications
V. Patient Education
[Patient's Name] demonstrates good understanding of her care plan, asking relevant questions and expressing willingness to adhere to recommendations.
Key Teaching Points:
Importance of blood glucose monitoring and insulin administration.
Proper foot care techniques to prevent ulcers and infections.
Dietary recommendations for managing diabetes.
Recognition of hypoglycemia and hyperglycemia symptoms.
VI. Collaboration and Communication
A. Interdisciplinary Team
Primary Care Physician: Dr. [Name]
Endocrinologist: Dr. [Name]
Wound Care Specialist: [Name]
Dietitian: [Name]
B. Handover Notes
Ensure continuous monitoring of blood glucose levels and adjust insulin doses as needed.
Continue current antibiotic regimen and monitor for signs of infection.
Provide patient education on discharge planning and follow-up care.
VII. Summary and Recommendations
[Patient's Name] has shown gradual improvement since admission. Her blood glucose levels are stabilizing, and the foot ulcer is responding to treatment. The priority for the next shift includes maintaining strict glucose monitoring, continuing with the wound care regimen, and reinforcing patient education on diabetes management. Encourage ambulation with assistance to enhance mobility and prevent complications.
Prepared by:
[Your Name], RN
[Date]
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