Example Of Nursing Report

Nursing reports are essential for ensuring seamless communication and effective care between healthcare providers. As a nurse, you must be able to write clear, concise, and accurate reports to keep your colleagues informed about your patients' condition, progress, and treatment. To help guide you, we have provided an example of a nursing report that reflects best practices and standards of care.

Example of Nursing Report

Below is an example of a nursing report for a patient admitted to the hospital. This report includes vital information such as the patient's medical history, physical assessment findings, nursing diagnoses, and ongoing care plan:

Medical History: The patient is a 56-year-old female with a history of hypertension, type 2 diabetes, and coronary artery disease. She was admitted to the hospital with complaints of chest pain and shortness of breath.

Physical Assessment: The patient is alert and oriented with clear speech and good eye contact. She presents with moderate distress and reports a pain scale of 7/10. Her vital signs are as follows: blood pressure 150/90 mmHg, heart rate 100 bpm, respiratory rate 22 breaths/min, and oxygen saturation 96% on room air. Lung sounds reveal decreased breath sounds in the left lower lobe. ECG shows ST elevation in leads II, III, and aVF.

Nursing Diagnoses: Based on the patient's medical history and physical assessment, the following nursing diagnoses have been identified:

• Acute pain related to myocardial ischemia as evidenced by chest pain and ST segment elevation.
• Anxiety related to hospitalization and fear of cardiac event as evidenced by moderate distress and tachycardia.

Nursing Care Plan: To address the nursing diagnoses above, the following interventions have been initiated:

• Administer nitroglycerin sublingually every 5 minutes for chest pain relief and re-evaluate after each dose
• Provide emotional support and education on relaxation techniques to reduce anxiety and promote comfort.
• Encourage deep breathing exercises and use of incentive spirometer to improve oxygenation and lung function.

Download the Example Nursing Report:

If you want to see the full example of a nursing report, BizzLibrary.com offers a variety of report templates to help you create accurate and effective nursing reports for your patients. Visit our website and download the nursing report in PDF format and modify to suit your specific needs and circumstances.