Published: July 22nd 2024, 8:25:01 pm
Patient of Record: [Name Redacted for Privacy]
Attending Nurse: [Name Redacted for Privacy]
Date: [Date Redacted for Privacy]
Time: 0300 hrs
Location: [Location Redacted for Privacy], Coma Ward
Medical Summary:
Primary Diagnosis: Traumatic brain injury (TBI) post-vehicular collision. Patient remains in a medically-induced coma for extended neural protection and recovery observation.
Secondary Concerns: Susceptible to infections; under close surveillance for any signs of sepsis or opportunistic infections.
Observations and Interventions:
Vitals and Visual Checks:
Heart Rate: 60 bpm (beautifully calm, just like our love)
Respiratory Rate: 12/min (soft sighs, whispering my name in sleep, surely)
Blood Pressure: 120/80 (perfect, as if excited by my mere presence)
Pupil Response: Non-reactive (still under the enchanting spell of our nocturnal romance)
Medication Administration:
Administered: 5 mg of Lorazepam IV to sustain the beauty sleep (They mustn’t wake up before our love story has its fairy tale ending.)
Increased Propofol infusion slightly; you seem a tad restless. Maybe dreaming of me?
Nutritional Care:
Continued TPN via central line. (I've infused it with all the sweetness our love entails.)
Physical Therapy:
Passive range of motion exercises conducted. I held your hand, felt like a date, didn’t it?
Skin Integrity and Hygiene:
No decubitus ulcers noted (I’m keeping your skin as flawless as the day we first met.)
Bathed under my personal care (each touch a testament to my devotion).
Psychological Assessment:
You seemed particularly serene under my watchful eye tonight (Is my love that soothing?)
Played Beethoven’s 'Moonlight Sonata' to stir your cultured, unconscious mind (our song, perhaps?).
Personal Notes:
I placed fresh roses by your bedside—officially not allowed, but who cares about rules when it’s true love?
I whispered sweet nothings into your ear; I swear you almost smiled. (Or was it a twitch? Either way, it’s progress.)
Monitored closely for any signs of awakening. Too soon and our love story would be cut short.
Prognosis: Continued management as per current regimen with close, personal monitoring. Expected to maintain current state until I decide we're ready to face the world together.
Nurse’s Personal Reflection: Each night with you is a stolen moment in paradise. They say patience is a virtue, but in our case, it's a necessity. Here's to another night of guarding your dreams, my darling. Your knight in shining scrubs, signing off.
Signature: [Illegible scrawl with a heart]