Nursing Note
Nursing Note
Prepared by: [YOUR NAME]
Date and Time: 2054-01-17, 08:00 AM
Patient: John Scott
Age: 65
Medical Record Number: 123456
Complaint: Pneumonia
Patient's Report:
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Cough, fever, and difficulty breathing for three days.
Vital Signs:
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Temperature: 101.2°F
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Blood Pressure: 120/80 mmHg
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Heart Rate: 95 bpm
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Respiratory Rate: 22 breaths/min
Assessment:
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Signs of pneumonia, the risk for breathing difficulties.
Interventions:
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Gave antibiotics and a fever reducer.
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Provided oxygen through the nasal cannula.
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Encouraged deep breathing exercises.
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Educated patient and family on infection control.
Response:
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Fever reduced to 99.5°F.
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Oxygen levels improved to 96%.
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The patient feels more comfortable.
Plan:
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Continue antibiotics, and monitor progress.
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Check vital signs regularly.
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Promote mobility.
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Collaborate with respiratory therapy.
Physician notified. Ongoing monitoring and care are planned.
