Nursing Note

Prepared by: [YOUR NAME]

Date and Time: 2024-01-17, 08:00 AM

Patient: John Doe

Age: 65

Medical Record Number: 123456

Complaint: Pneumonia

Patient's Report:

• Cough, fever, and difficulty breathing for three days.

Vital Signs:

• Temperature: 101.2°F

• Blood Pressure: 120/80 mmHg

• Heart Rate: 95 bpm

• Respiratory Rate: 22 breaths/min

Assessment:

• Signs of pneumonia, the risk for breathing difficulties.

Interventions:

• Gave antibiotics and a fever reducer.

• Provided oxygen through the nasal cannula.

• Encouraged deep breathing exercises.

• Educated patient and family on infection control.

Response:

• Fever reduced to 99.5°F.

• Oxygen levels improved to 96%.

• The patient feels more comfortable.

Plan:

• Continue antibiotics, and monitor progress.

• Check vital signs regularly.

• Promote mobility.

• Collaborate with respiratory therapy.

Physician notified. Ongoing monitoring and care are planned.

Note Templates @ Template.net