Nurse Assessment Report
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
-
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
-
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.
