Free 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:

  • Temperature: 98.6°F

  • Blood Pressure: 130/80 mmHg

  • Pulse Rate: 72 bpm

  • Respiratory Rate: 16 breaths/min

• Pain Level: 4/10 (controlled with analgesics)

• Fluid Balance:

  • Input: 1200 mL

  • Output: 1100 mL (urine output)

• 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

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.

Report Templates @ Template.net