Nursing Report

Nursing Report

Patient Name:

Jane Martinez

Patient ID:

2050-10048

Date of Report

August 18, 2050

Report Time:

8:00 am

Nurse:

[YOUR NAME]

Hospital:

[YOUR COMPANY NAME]

Patient Overview

Diagnosis

Type 2 Diabetes Mellitus, Hypertension

Admission Date

August 15, 2050

Current Room

305B

Primary Physician

Dr. Emily Carter

Vital Signs

Temperature

98.6°F

Pulse

78 bpm

Respirations

16 per minute

Blood Pressure

130/85 mmHg

Blood Glucose Level

142 mg/dL

Current Medications

Metformin

500 mg twice daily

Lisinopril

10 mg once daily

Aspirin

81 mg once daily

Recent Observations

Physical Condition:

  • Overall Status: The patient is stable with no new complaints of pain or discomfort. The patient reports feeling generally well and denies any acute issues.

  • Edema: No signs of peripheral or localized edema are observed. Extremities are noted to be well-perfused with no swelling.

  • Distress: No signs of respiratory distress, discomfort, or unusual fatigue noted. The patient appears comfortable and alert.

Diet:

  • Diet Compliance: The patient is adhering to a prescribed diabetic diet plan. Meals are consumed regularly with no issues.

  • Appetite: Appetite is reported as good, with consistent intake of meals and snacks as recommended.

  • Adverse Reactions: No gastrointestinal complaints such as nausea, vomiting, or diarrhea observed. No allergic reactions or food intolerances reported.

Activity:

  • Mobility: The patient is able to ambulate independently without assistance. Gait is steady and unassisted.

  • Physical Therapy: Actively participating in scheduled physical therapy sessions. Exercises are performed as directed, and the patient is making progress as expected.

  • Exercise Tolerance: No signs of fatigue or shortness of breath noted during or after physical activity.

Care Plan

Short-Term Goals:

  • Blood Glucose Monitoring: Regular monitoring of blood glucose levels will be performed to ensure they stay within the target range of 70-130 mg/dL before meals and less than 180 mg/dL two hours after meals. Blood glucose logs will be reviewed for any deviations.

  • Medication Regimen: Continuation of Metformin and Lisinopril as prescribed. Monitor for effectiveness by evaluating blood glucose trends and blood pressure readings. Assess for any adverse effects or medication interactions.

  • Dietary Adherence: Reinforce the diabetic diet plan with the patient. Provide assistance as needed to ensure dietary guidelines are followed. Collaborate with a dietitian if any challenges arise.

Long-Term Goals:

  • Blood Glucose Control: Aim to achieve and maintain optimal blood glucose control, with A1c levels ideally below 7%. This involves regular monitoring and adjustments to the care plan based on lab results.

  • Complication Prevention: Implement strategies to prevent complications related to diabetes, such as neuropathy, retinopathy, and nephropathy. Manage hypertension to reduce the risk of cardiovascular complications.

  • Health Promotion: Encourage lifestyle modifications including regular physical activity, smoking cessation, and stress management to enhance overall well-being and support diabetes management.

Medication Administration:

  • Metformin and Lisinopril: Administer medications as per the prescribed schedule. Monitor for side effects such as gastrointestinal issues from Metformin or dizziness from Lisinopril.

  • Documentation: Record administration times, doses, and any reactions observed. Report any issues to the oncoming shift.

Vital Signs Monitoring:

Frequency: Vital signs should be checked every 4 hours. This includes monitoring temperature, pulse, respiration rate, and blood pressure.

Assessment: Evaluate trends in vital signs to detect any changes that might require medical attention. Notify the physician if any abnormal values are noted.

Patient Education:

  • Diet and Medication Adherence: Educate the patient on the importance of sticking to the prescribed diet and medication regimen. Discuss strategies to manage blood glucose levels effectively.

  • Diabetes Management: Provide written and verbal instructions on managing diabetes at home, including signs of hypo- and hyperglycemia, and when to seek medical help.

Documentation:

  • Changes: Document any changes in the patient’s condition, such as new symptoms or changes in vital signs. Update the care plan and communicate these changes during handover to ensure continuity of care.

Notes and Recommendations

Follow-Up:

  • Blood Glucose Levels: Review blood glucose levels at the end of the shift and adjust medications if necessary based on trends and physician recommendations.

  • Dietitian Consultation: Schedule a follow-up with the dietitian to address any dietary concerns or adjustments required. Ensure that dietary plans are reviewed and updated as needed.

Special Instructions:

  • Monitoring: Watch for signs of hypotension (e.g., dizziness, lightheadedness) and hypoglycemia (e.g., sweating, tremors). Implement measures to manage these conditions if they occur.

  • Physician Notification: Notify the physician immediately if there are significant changes in the patient’s condition, such as uncontrolled blood glucose levels, persistent high blood pressure, or any new symptoms.

Signature:

[Your Name]

RN
Date: August 28, 2054

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