Nursing Assessment Sheet Template

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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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