Nurse Assessment Report
I. Nurse Information
Prepared By: [Your Name]
Email: [Your Email]
Affiliated Company: [Your Company Name]
II. Patient Information
Patient Name: John Doe
Patient ID: 123456
Date of Birth: January 1, 2025
Gender: Male
III. Assessment Details
Chief Complaint
Patient complains of severe headaches and dizziness.
Vital Signs
Physical Examination
The patient appears alert and oriented. No distress noted.
System | Findings |
|---|
Cardiovascular | Normal heart sounds, no murmurs detected. |
Respiratory | Clear breath sounds, no wheezing or crackles. |
Gastrointestinal | Abdomen soft, no tenderness. |
IV. Nursing Diagnosis
Acute pain related to headaches as evidenced by patient report of pain level 8/10.
Risk for falls related to dizziness.
V. Plan of Care
Interventions
Administer prescribed pain medication as needed.
Monitor vital signs every 4 hours.
Educate the patient on fall precautions.
VI. Follow-Up
Next Appointment: January 15, 2050
Additional Recommendations: Follow up with neurology for further evaluation.
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