Nurse Patient Report
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
-
Temperature: 99.1°F
-
Blood Pressure: 140/85 mmHg
-
Pulse Rate: 78 bpm
-
Respiratory Rate: 18 breaths/min
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
-
Lantus (Insulin Glargine) 20 units at bedtime
-
Novolog (Insulin Aspart) per sliding scale
-
Ceftriaxone 1g IV daily
-
Metformin 1000 mg BID
-
Lisinopril 10 mg daily
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]
