What is an example of a nursing report?

Patient: John Smith

Age: 65

Sex: Male

Diagnosis: Acute myocardial infarction

History of Present Illness:

Mr. Smith was admitted to the hospital yesterday with chest pain. He had been experiencing chest pain for approximately 30 minutes prior to arrival. The pain was described as squeezing and pressure-like. It was located in the substernal region and radiated to the left arm and jaw. Mr. Smith also reported shortness of breath, nausea, and vomiting.

Past Medical History:

Mr. Smith has a history of hypertension, hypercholesterolemia, and diabetes. He is also a former smoker.

Social History:

Mr. Smith is married with two children. He is a retired postal worker. He enjoys spending time with his family, fishing, and playing golf.

Medications:

Mr. Smith is taking metoprolol, lisinopril, and simvastatin.

Nursing Assessment:

On assessment, Mr. Smith is lying in bed in a semi-Fowler's position. He is alert and oriented x3. His vital signs are as follows:

* Blood pressure: 140/90 mmHg

* Heart rate: 80 bpm

* Respirations: 18 bpm

* Temperature: 98.6°F

* Oxygen saturation: 94% on room air

Mr. Smith's skin is warm, dry, and pale. His mucous membranes are moist. His heart sounds are regular and there are no murmurs, gallops, or rubs. His lungs are clear to auscultation bilaterally. His abdomen is soft, non-distended, and there is no tenderness or rebound. His extremities are warm and there is no edema.

Nursing Diagnosis:

* Risk for decreased cardiac output related to impaired contractility and decreased blood flow

* Activity intolerance related to decreased muscle strength and fatigue

* Ineffective airway clearance related to retained secretions and dyspnea

* Deficient knowledge related to medical treatment and disease process

Nursing Interventions:

* Monitor vital signs frequently.

* Administer oxygen as prescribed.

* Encourage coughing and deep breathing exercises.

* Perform suctioning as needed.

* Assist with activities of daily living as needed.

* Provide patient education about medications, diet, and activity restrictions.

Expected Outcomes:

* Mr. Smith will maintain adequate cardiac output as evidenced by stable vital signs and absence of edema.

* Mr. Smith will tolerate activity without dyspnea or fatigue.

* Mr. Smith will maintain clear airways as evidenced by absence of retained secretions and respiratory distress.

* Mr. Smith will demonstrate an understanding of his medical treatment and disease process.