Free 24 Hours Nursing Patients Report

I. Patient Overview

Patient Name: [Patient's Name]
Date of Admission: June 18, 2050
Attending Physician: Dr. Troy D. Williams
Room Number: 302
Primary Diagnosis: Pneumonia

A. Condition Summary

Medical History: The patient has a history of asthma and seasonal allergies.

Current Condition: Stable with occasional coughing.

Vital Signs:

• Temperature: 98.6°F

• Heart Rate: 82 bpm

• Blood Pressure: 120/80 mmHg

B. Nursing Assessment

• Neurological: Alert and oriented x3.

• Cardiovascular: Regular heart rhythm, no murmurs.

• Respiratory: Breath sounds clear; cough is productive.

• Gastrointestinal: Bowel sounds normal in all quadrants.

C. Nursing Interventions

Medications Administered:

• Antibiotics: Azithromycin 500 mg IV q24h

• Bronchodilator: Albuterol, 2 puffs q4h PRN

Treatment Plan:

• Respiratory therapy every 6 hours.

Nutritional Support:

• Regular diet, encourage fluids.

II. Nursing Care Plan

A. Nursing Diagnosis

Priority: Impaired Gas Exchange related to pneumonia.

Goals:

• Improve oxygenation levels.

• Decrease cough frequency.

B. Interventions

1. Physical Care:

   • Encourage deep breathing exercises.

   • Monitor oxygen saturation levels.

2. Emotional Support:

   • Provide reassurance and explain procedures.

3. Patient Education:

   • Educate on the importance of respiratory hygiene.

III. Progress Notes

A. Shift Change Report

Evening Shift (June 18, 2050):

• The patient was admitted with a productive cough and started on antibiotics.

Night Shift (June 18–19, 2050):

• Their vital signs were stable, and they responded well to bronchodilator therapy.

B. 24-Hour Summary

General Observations:

• The patient remains stable, and coughing is less frequent.

Nursing Response:

• Increased respiratory assessments due to productive cough.

IV. Discharge Planning

A. Discharge Goals

Expected Discharge Date: June 20, 2050

Recommendations:

• Continue taking antibiotics at home for the prescribed duration.

• Follow-up with primary care physician in one week.

B. Follow-Up Care

Post-Discharge Care Plan:

• Provide discharge instructions and medication schedule.

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