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:

  • Cough, fever, and difficulty breathing for three days.

Vital Signs:

  • Temperature: 101.2°F

  • Blood Pressure: 120/80 mmHg

  • Heart Rate: 95 bpm

  • Respiratory Rate: 22 breaths/min

Assessment:

  • Signs of pneumonia, the risk for breathing difficulties.

Interventions:

  • Gave antibiotics and a fever reducer.

  • Provided oxygen through the nasal cannula.

  • Encouraged deep breathing exercises.

  • Educated patient and family on infection control.

Response:

  • Fever reduced to 99.5°F.

  • Oxygen levels improved to 96%.

  • The patient feels more comfortable.

Plan:

  • Continue antibiotics, and monitor progress.

  • Check vital signs regularly.

  • Promote mobility.

  • Collaborate with respiratory therapy.

Physician notified. Ongoing monitoring and care are planned.

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