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March 20, 2024

Shift Summary (SBAR) S: patient was admitted on 3/7/2024 with cellulitis of the lower leg, and wound infection

Shift Summary (SBAR) S: patient was admitted on 3/7/2024 with cellulitis of the lower leg, and wound infection with purulent drainage, gangrene and swelling. B: Patient is diabetic, has a history of diabetic peripheral neuropathy, a non-healing foot ulcer that led to an amputation of the left great toe. Patient also has atrial fibrillation, hypertension, CKD, nicotine dependence without complication and obesity. A: Patient’s wound was debrided and dressed with clean wet to dry dressing. Patient is receiving NS IV fluids and antibiotics 9piperacillin-tazobactam(Zosyn) 3.375g infusing in NS 100mL mini bag IVPB to treat infection. Pt vitals, bedside blood glucose and I&O hourly monitoring. Medication administration. R: Continuous monitoring of patient’s glucose levels

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