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:
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:
Treatment Plan:
Nutritional Support:
II. Nursing Care Plan
A. Nursing Diagnosis
Priority: Impaired Gas Exchange related to pneumonia.
Goals:
B. Interventions
Physical Care:
Emotional Support:
Patient Education:
III. Progress Notes
A. Shift Change Report
Evening Shift (June 18, 2050):
Night Shift (June 18–19, 2050):
B. 24-Hour Summary
General Observations:
Nursing Response:
IV. Discharge Planning
A. Discharge Goals
Expected Discharge Date: June 20, 2050
Recommendations:
B. Follow-Up Care
Post-Discharge Care Plan:
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