Nursing Notes Examples

 

The following are four nursing notes examples varying between times of a patient’s admittance:
Acute Pancreatitis Nursing Note (Example)
Patient Name and Age: Kane Schneider, 33

Date: May 14th, 2022

Chief Complaint: The patient’s chief complaint is acute pancreatitis, which they developed after eating a large amount of greasy food. The patient also reports that they have been experiencing nausea and vomiting since they arrived at the hospital.

Diagnosis: Acute Pancreatitis

History: The patient reports that they have had similar symptoms in the past and have had several episodes of acute pancreatitis over the past few years. The patient has had all of their gallbladders removed in attempts to treat this condition.

The patient has not been taking any medication for nausea, but has been receiving IV fluids for hydration due to their vomiting.

Physical exam: Vital signs are stable — pulse = 72 beats per minute, respirations = 16 breaths per minute, temperature = 98.2 degrees Fahrenheit (F). Physical examination reveals a pale and diaphoretic person in moderate distress with abdominal tenderness on palpation in the epigastric area.

No jaundice or bruising is present on examination of the skin or mucous membranes. Abdominal distention is present with peripheral edema noted around the umbilicus area as well.
Urinary Tract Infection Nursing Note (Example)
Patient Name and Age: Elaina Hassan, 77

Date: January 29th, 2022

Chief Complaint: She has been experiencing fever, chills, and dysuria for two days.

History of Present Illness: Patient has previously experienced mild hypertension and heart failure.

Physical exam: Vitals – The patient’s temperature is 99 degrees Fahrenheit. The pulse is 100 beats per minute and regular. The blood pressure is 140/90 mm Hg.

Diagnosis: Urinary tract infection.

Assessment: She appears to be in moderate distress and is slightly tachycardic at 104 beats per minute. Patient demonstrates evidence of right lower quadrant tenderness on palpation as well as suprapubic tenderness on deep palpation. The patient’s urine dipstick test reveals 1+ blood and no white blood cells or nitrites present in her urine sample.

Evaluation: She has been treated with antibiotics and fluids, and can now urinate without discomfort.
Alcohol Withdrawal Nursing Note (Example)
Patient Name and Age: Willie Brandt, 41

Date: March 21st, 2022

Diagnosis: Alcohol withdrawal

Assessment: Patient was brought in by his family for alcohol withdrawal. When they brought him in, he was experiencing tremors, hallucinations, and confusion.

History: Patient has been drinking alcohol for 24 years, and his family noticed that he started to drink more heavily over the past few years.

Plan of care: Monitor vital signs every 15 minutes; check urine output every hour; administer IV fluids as ordered; administer medication as ordered (e.g., benzodiazepines); monitor electrolytes every 6 hours or as ordered; provide emotional support to patient and family; educate patient on how to avoid future episodes.
Upper Respiratory Infection Nursing Note (Example)
Patient name and Age: Jazmin Adkins, 25

Diagnosis: Upper respiratory infection, including rhinitis and pharyngitis.

Assessment: Patient presented with symptoms of a cold, including runny nose, sore throat, cough, and congestion. Symptoms have persisted for 2 weeks.

History: Patient works as a bartender at a local restaurant. Two evenings per week she works late into the night and does not get enough sleep; she also drinks alcohol on these nights (about 4 drinks).

She washes her hands frequently at work but does not use hand sanitizer before touching his face or putting his hands in his mouth. Patient often smokes cigarettes outside work hours and is always around cigarette smoke when out with friends or family members who smoke regular