Nurses Narrative Report
Nurses Narrative Report
I. Introduction
This narrative report provides a comprehensive overview of the patient care provided by [Your Company Name]'s nursing team for the period ending June 30, 2050. The report aims to detail key observations, interventions, and outcomes during this period.
II. Patient Overview
A. Admission Details
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Patient Name: [Patient's Name]
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Admission Date: June 1, 2050
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Medical Record Number: MRN2050001
B. Medical History
The patient presented with a history of hypertension and diabetes. Relevant past treatments include regular insulin injections and blood pressure management.
III. Nursing Assessments
A. Initial Assessment
Upon admission, the nursing team conducted a thorough assessment of [Patient Name]'s vital signs, including:
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Temperature: 98.6°F
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Blood Pressure: 120/80 mmHg
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Heart Rate: 75 bpm
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Respiratory Rate: 18 breaths per minute
B. Ongoing Assessments
Subsequent assessments focused on monitoring [Patient Name]'s glucose levels and cardiovascular status and evaluating responses to treatment protocols outlined by the medical team.
IV. Care Plan and Interventions
A. Nursing Diagnosis
Based on assessments, the primary nursing diagnosis was ineffective glucose management related to insulin resistance, which guided the development of the care plan.
B. Interventions Implemented
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Administered insulin injections as prescribed by Dr. Alex Smith.
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Monitored blood glucose levels every 4 hours and adjusted insulin dosages accordingly.
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Provided patient education on dietary modifications for diabetes management.
V. Collaboration with the Healthcare Team
A. Interdisciplinary Meetings
Regular meetings were held with endocrinologists, dietitians, and physical therapists to discuss [Patient Name]'s progress and adjust treatment plans as necessary.
VI. Patient Progress and Outcomes
A. Progress Notes
Throughout the reporting period, [Patient Name] demonstrated stable blood glucose levels within the target range, indicating a positive response to insulin therapy.
B. Discharge Summary
Upon discharge on June 15, 2050, [Patient Name]'s blood pressure was stable, and his diabetes management plan was adjusted for outpatient follow-up with the endocrinology clinic.
VII. Conclusion
In conclusion, the nursing team at [Your Company Name] provided diligent and compassionate care to [Patient Name], achieving favorable outcomes as evidenced by stable glucose levels and improved patient understanding of diabetes management. Continuous collaboration with the healthcare team ensured comprehensive care delivery.
