Patient Information:
- Patient Name: John Smith
- Family/whanau present at the meeting: Wife, Mary Smith
- Location: Hospital room
Assessment:
Pain:
- Provocation: Worse with movement, better with rest. Quality: Sharp, stabbing. Region: Right flank. Severity: 7/10. Timing: Constant, with exacerbations.
Medications:
- Morphine, 10mg IV q4h. Side effects: Constipation.
Elimination:
- Bowels open size: Small.
- Bowel type: Hard.
- Bladder output: 200ml, toilet.
- Nausea or vomiting: None.
Sleep:
- Quality of sleep: Poor, restless sleep, 4 hours.
- Sleep location: Bed.
- Medications or sedatives: Zopiclone 7.5mg at night.
Social:
- Family staying to support: Wife, Mary Smith, providing emotional support and assistance with personal care.
- Family education of medications: Syringe driver education provided to wife.
- Reason for visit/admission, including patient’s verbalized concerns or symptoms: Admitted for pain management related to metastatic cancer. Patient expresses concerns about pain control and end-of-life care.
- Any expressed concerns about treatment, care, or the healthcare environment: Patient expresses concerns about pain control and end-of-life care.
- Patient’s and family’s understanding of the diagnosis, treatment plan, and care needs: Patient and wife understand the diagnosis and treatment plan, including palliative care goals.
Objective:
- Vitals: BP 130/80, HR 88, RR 18, Temp 37.0, Oxygen Saturation 96% on room air.
- Physical assessment findings: Patient appears weak and fatigued. Skin integrity intact. No edema. Lung sounds clear. Abdomen soft, with tenderness in the right flank. Mobility status: Ambulatory with assistance.
- Prioritization of patient care needs: Pain management, symptom control, and emotional support.
Future planning:
- Ceiling of care: Full resuscitation, antibiotics as needed.
- Burial or cremation: Discussed with patient and wife. Dr. Emily Carter to complete paperwork.
Interventions + Evaluations:
- Specific nursing interventions performed or initiated during the shift, including administration of medications, treatments, patient education provided, coordination of care, etc.: Administered Morphine as prescribed. Provided pain assessment and reassessment. Educated patient and wife on pain management strategies and side effect management. Coordinated with the palliative care team.
- Response to interventions: Patient reports some relief from pain after Morphine administration.
- Evaluation of patient’s response to interventions and progress towards care goals: Pain levels decreased from 9/10 to 7/10. Patient appears more comfortable.
- Any changes in patient status or findings: Patient's pain level improved slightly.
Additional Notes:
- Any patient or family education provided, including discharge planning or instructions for home care: Educated patient and wife on pain management, medication side effects, and advance care planning. Provided information on community resources.
- Communication with patient and family about care decisions, concerns, and preferences: Discussed patient's wishes regarding end-of-life care and advance directives with the patient and wife.
- Any safety concerns or incidents reported: None.
Plan for Continuing Care:
- Next steps in patient’s care plan, including any planned adjustments to interventions, additional tests or procedures, follow-up needs, etc.: Continue pain management. Monitor for side effects. Schedule follow-up with palliative care team.
- Care plan adjustments or interventions planned for the shift, including medication administration, wound care, mobility assistance, patient education, etc.: Administer Morphine as prescribed. Continue to assess pain levels. Provide emotional support.
- Scheduled procedures or tests for the day: None.
- Collaboration with other healthcare team members (mention planned discussions or interventions involving physicians, physical therapists, social workers, etc.): Discussed patient's case with the palliative care physician and social worker.
