Nursing Assessment Sheet
Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]
Date: November 12, 2050
I. Patient Information
Field | Details |
|---|
Patient Name | Duane Wiza |
Patient ID | 12345 |
Date of Birth | March 15, 1980 |
Gender | Male |
Phone Number | 222 555 7777 |
Address | Buffalo, NY 14201 |
II. Admission Information
Field | Details |
|---|
Admission Date | November 12, 2050 |
Admission Reason | Chest pain, shortness of breath |
Primary Diagnosis | Acute Myocardial Infarction (MI) |
Secondary Diagnosis | Hypertension |
Allergies | Penicillin, Aspirin |
Insurance Provider | BlueCross Insurance |
III. Vital Signs
Vital Sign | Normal Range | Current Reading | Time Recorded |
|---|
Blood Pressure | 120/80 mmHg | 140/90 mmHg | November 12, 2050 09:00 AM |
Heart Rate | 60-100 bpm | 110 bpm | November 12, 2050 09:00 AM |
Respiratory Rate | 12-20 breaths/min | 22 breaths/min | November 12, 2050 09:00 AM |
Temperature | 98.6°F (37°C) | 99.2°F (37.3°C) | November 12, 2050 09:00 AM |
IV. Medical History
Field | Details |
|---|
Chronic Conditions | Hypertension, Type 2 Diabetes |
Past Surgeries | Appendectomy (2015), Knee Surgery (2018) |
Current Medications | Metoprolol, Lisinopril, Insulin |
Family History | Father: Myocardial Infarction at age 55 |
Immunizations | Flu vaccine (2024), Pneumococcal vaccine (2023) |
V. Pain Assessment
Field | Details |
|---|
Pain Location | Chest, Left Arm |
Pain Severity | 8/10 (on pain scale 0-10) |
Pain Description | Sharp, radiating pain |
Pain Onset | November 12, 2050, 8:30 AM |
Pain Relief Measures | Administered Nitroglycerin |
VI. Mental and Emotional Status
Field | Details |
|---|
Cognitive Status | Alert, oriented to time, place, and person |
Mood | Anxious, worried about diagnosis |
Behavior | Cooperative, verbal communication intact |
Sleep Patterns | Difficulty sleeping due to pain |
VII. Nursing Care Plan and Interventions
Intervention | Goal | Expected Outcome |
|---|
Administer prescribed medication | Reduce chest pain and control hypertension | Pain level reduced to 3/10 or lower |
Oxygen therapy | Improve oxygenation | Oxygen saturation maintained at 95% or higher |
Monitor vital signs every hour | Ensure patient stability | Stable vitals within normal limits |
VIII. Acknowledgement
Field | Details |
|---|
Nurse Name | [YOUR NAME] |
Date | November 12, 2050 |
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