Help!!! I am supposed to make a report for a doctor...

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Specializes in PCU.

Help me, please! I am supposed to write a report for a doctor on a patient in ICU. Pt has AMI, DKA, metabolic acidosis. She is on several critical drips, her VS are not the greatest, you get the picture? Well, my problem is that I have no idea what all the doctor would be looking for. I prepared the report for the nurse coming on duty, but what does the information for the doctor look like??? I have not yet had to do one of these and do not want to forget any vital information that a doctor would need. Below is the report I prepared for the nurse taking over care of the client. Would you critique it and tell me what your doctors expect of you? Thanks a million in advance.

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Prepare report for nurse receiving client or assuming care. Prioritize appropriately.

Mrs. X is a 70 year-old female admitted with acute myocardial infarction, diabetic ketoacidosis, right upper lobe pneumonia, metabolic acidosis, and dehydration. She is allergic to Sulfa drugs. She’s sedated, paralyzed, her pupil reaction is sluggish, and she responds to painful stimulus. She is intubated. The tube measures 21 at the lip. Her ventilator settings are: TV – 500; rate – 16; FiO2 – 50%; PEEP – 3. She has coorifice crackles bilaterally. Her respirations are even and unlabored.

Her mean arterial pressure is 67. She’s been running a sinus-tach rhythm. Her BP has been in the 90’s/50’s, pulses are 1+ pedal and radial bilaterally. She has a Foley. Her urine output has been 8 ml/h for the last three hours. She has a central line on the right internal jugular. She has an arterial line in the right brachial artery and 2 IV lines on her left forearm above the wrist. She is receiving dopamine, 3 mcg/min; propofol, 45 mcg/min; Levophed, 16 mcg/min; amiodarone; 16.6 ml/h; and regular insulin, 4 units/h.

A Swan – Ganz catheter insertion was attempted unsuccessfully. Internal jugular vein was hard to visualize and International Normalized Ratio was 1.9. Three units of fresh frozen plasma were ordered and administered via open line at 1800 hours. A vitamin K injection (1 ml) was administered on the left lower abdominal quadrant. Vasopressin (50 ml) is to be administered 30 minutes before the doctor attempts the catheter insertion again at 2100 hours. It is in the refrigerator.

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Information needed to report to physician

???

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Specializes in Newborn ICU, Trauma ICU, Burn ICU, Peds.

Uhhhhhhh, got me...

In 15 years I have NEVER had to prepare a report for the physician. That is something that another physician, NP, or PA should do. Their realm of practice is much different than ours.

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Potassium is never, ever administered as an injection in the abdomen.

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Specializes in Education, FP, LNC, Forensics, ED, OB.

Are you a student preparing an assignment, hmwright13? Or, are you needing to know what information to give to a physician when you call to give a report when you need an order?

A potassium injection (1 ml) was administered on the left lower abdominal quadrant.

Potassium .....abdominal quadrant??? No. This is not right and would never be done.

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Specializes in 5 yrs OR, ASU Pre-Op 2 yr. ER.
A potassium injection (1 ml) was administered on the left lower abdominal quadrant.

Who wrote for THAT order?????

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Physician report would be heart rate, average blood pressure, urine output average per hour for the past three hours and drips and rate of each pt is currently on.

That would be your report.

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I am sure be vitamin K....not potassium.

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Specializes in PCU.

Yikes. thank you for catching that. It was a typo. The K+ was actually administered via IV. The SC injection was a vitamin K shot we gave while trying to lower the INR. I will correct that ASAP! Trying to throw this together and cutting and pasting has got my eyes going screwy.

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Specializes in PCU.
Are you a student preparing an assignment, hmwright13? Or, are you needing to know what information to give to a physician when you call to give a report when you need an order?

Potassium .....abdominal quadrant??? No. This is not right and would never be done.

Yes. I am a student preparing an assignment and have absolutely no clue exactly what the physician would want to know. I have not had enough interaction with one and my term in ICU was all too brief to find out what the reqs were; surely not the same as MedSurg; after all, the goals of care in each of those units is different.

BTW, what info do you recommend having on hand when calling to give a report when I need an order?

And yes, the K+ is a typo. This was given via IV. The vit. K was the abd SC injection. Sorry. That must have been scary to read:eek:

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Specializes in PCU.
Physician report would be heart rate, average blood pressure, urine output average per hour for the past three hours and drips and rate of each pt is currently on.

That would be your report.

Oh, good! Thank you. I was worried about giving too much or too little information. Thank you.

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Specializes in Newborn ICU, Trauma ICU, Burn ICU, Peds.

She's sedated, paralyzed, her pupil reaction is sluggish, and she responds to painful stimulus.

She is receiving dopamine, 3 mcg/min; propofol, 45 mcg/min; Levophed, 16 mcg/min; amiodarone; 16.6 ml/h; and regular insulin, 4 units/h.

A vitamin K injection (1 ml) was administered on the left lower abdominal quadrant. Vasopressin (50 ml) is to be administered 30 minutes before the doctor attempts the catheter insertion again at 2100 hours. It is in the refrigerator.

I was going to bring up the potassium, but I decided it had to be a typo.

Now I know that we are proofreading, I'll give you a couple more ideas:

You say she's paralyzed? With what agent and how often? If she *is* paralyzed, she should NOT be responding to painful stimlui.

dopamine is mcg/kg/min

amiodarone is mcg/kg/min (or mg/kg/day if being given as a precursor to a switch to oral threapy for conversion).

propofol is mcg/kg/min

vasopressin 50 ml?

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Specializes in Education, FP, LNC, Forensics, ED, OB.
Yes. I am a student preparing an assignment and have absolutely no clue exactly what the physician would want to know. I have not had enough interaction with one and my term in ICU was all too brief to find out what the reqs were; surely not the same as MedSurg; after all, the goals of care in each of those units is different.

BTW, what info do you recommend having on hand when calling to give a report when I need an order?

And yes, the K+ is a typo. This was given via IV. The vit. K was the abd SC injection. Sorry. That must have been scary to read:eek:

I know how you made the typo, too. You saw 'K' and wrote out potassium, right?

Anyway, glad you edited your post with the correct info.

Now, when you call a physician/NP/PA/CNS, he/she will want to know who the patient is, why you are calling and a brief description of the diagnosis and problem at hand (chief complaint).

Then he/she will want to know vital signs and any other pertinent information relative to the call, ie: recent lab reuslt/s, diagnostic study/s result/s, etc.

If you are calling about something for pain, where the pain is located, new, rating, and recent previous attempts at alleviation. If for fever, for example, what the temp is now and if you have attempted to give antipyretics and reduce fever, etc.

Many ways to do this. Just the facts and keep it brief but inclusive.:)

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