Nurse’s Hospital Note
Nurse’s Hospital Note
Patient Name: Trace Durgan
MRN: 123456
Date: October 8, 2050
Time: 14:00
Nurse: Nurse [Your Name], RN
Unit: Medical-Surgical Unit
S: Subjective
The patient reports increased pain in the right knee, rating it as 7/10 on the pain scale. She states, “It hurts more when I walk or try to bend it.” The patient also mentions feeling a bit lightheaded when standing up quickly.
O: Objective
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Vital signs:
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BP: 120/80 mmHg
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HR: 78 bpm
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RR: 18 breaths/min
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Temp: 98.6°F
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Right knee swollen with mild erythema.
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The range of motion in the right knee is limited due to pain.
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No signs of acute distress were noted.
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The patient is alert and oriented to person, place, and time.
A: Assessment
Right knee pain, likely secondary to osteoarthritis exacerbation. Possible postural hypotension contributing to lightheadedness.
P: Plan
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Administer prescribed analgesics (Ibuprofen 400 mg) for pain relief.
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Encourage the patient to use the call light for assistance when getting out of bed.
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Continue monitoring vital signs every 4 hours.
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Educate the patient on proper techniques for standing up slowly to prevent dizziness.
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Follow up with the physician regarding knee pain management and possible imaging if symptoms persist.
Signature:
Nurse [Your Name], RN
Credentials: RN, BSN
Contact: [Your Email]
