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
Vital signs:
BP: 120/80 mmHg
HR: 78 bpm
RR: 18 breaths/min
Temp: 98.6°F
Right knee swollen with mild erythema.
The range of motion in the right knee is limited due to pain.
No signs of acute distress were noted.
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
Administer prescribed analgesics (Ibuprofen 400 mg) for pain relief.
Encourage the patient to use the call light for assistance when getting out of bed.
Continue monitoring vital signs every 4 hours.
Educate the patient on proper techniques for standing up slowly to prevent dizziness.
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]
Note Templates @ Template.net
