Nurse Assessment Report

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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

• Date: January 1, 2050

• Blood Pressure: 120/80 mmHg

• Heart Rate: 72 bpm

• Respiratory Rate: 16 breaths/min

• Temperature: 98.6°F

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

1. Acute pain related to headaches as evidenced by patient report of pain level 8/10.

2. Risk for falls related to dizziness.

V. Plan of Care

Interventions

1. Administer prescribed pain medication as needed.

2. Monitor vital signs every 4 hours.

3. 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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