Nursing Assessment Sheet
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 |
