Free Case Note for Nursing Template
Case Note for Nursing
Prepared By: [Your Name]
Company: [Your Company Name]
Patient Details
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Full Name: Tracey Gleason
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Date of Birth: February 14, 2045
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Age: 76
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Gender: Female
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Medical Record Number: 3081759
Admission Details
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Date of Admission: May 4, 2060
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Admitting Diagnosis: Acute Myocardial Infarction (Heart Attack)
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Admitting Physician: Dr. Leonard Whitley
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Ward/Unit: Cardiac Intensive Care Unit (CICU)
Medical History
Ms. Gleason has a pertinent medical history that includes:
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Hypertension
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Type 2 Diabetes Mellitus
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Hyperlipidemia
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Coronary Artery Disease (diagnosed in 2050)
Current Medications
The patient is currently prescribed the following medications:
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Aspirin 81mg daily
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Lisinopril 10mg daily
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Metformin 500mg twice daily
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Atorvastatin 40mg daily
Allergies
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Penicillin - Rash
Nursing Assessment
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Initial Assessment (May 4, 2060): Upon admission, the patient presented with chest pain radiating to the left arm, dyspnea, and diaphoresis. Vital signs indicated tachycardia and hypertension. ECG confirmed acute myocardial infarction.
Ongoing Care and Monitoring
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Continuous cardiac monitoring
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Regular vital signs assessment every 2 hours
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Oxygen therapy at 2 L/min via nasal cannula
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Monitoring blood glucose levels four times daily
Plan of Care
Objectives include:
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Stabilize cardiac function
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Relieve chest pain
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Maintain normotensive blood pressure
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Control blood glucose levels
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Prevent complications (e.g., heart failure, arrhythmias)
Interventions
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Administer prescribed medications, including nitroglycerin as needed for chest pain.
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Ensure dietary modifications to a heart-healthy diet.
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Initiate cardiac rehabilitation program upon stabilization.
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Educate patient and family about lifestyle changes and medication adherence.
Progress Notes
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May 6, 2060: Patient shows significant improvement. Chest pain resolved after administration of nitroglycerin. Blood pressure stabilized within normal range. Patient engaged in light physical therapy with no complications.
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May 8, 2060: Discharge planning initiated. Collaborating with multidisciplinary team for home health support. Scheduled follow-up appointment with cardiologist on May 15, 2060.
Discharge Summary
Ms. Gleason is expected to be discharged on May 10, 2060. Prior to discharge, patient will undergo further cardiac evaluation and be equipped with comprehensive education on managing her condition at home. Care transition plans include home visits by a cardiac nurse and coordination with primary care for ongoing management.
These case notes are intended to facilitate a holistic approach to Ms. Gleason’s recovery, focusing on both immediate medical needs and long-term well-being.
