REPORT: Today’s date:______________
Date of admission:_________________ Admitting dx:__________________________ |
VS & Pain Assessment___________I&O______
O2 Sat:
Tele (attach strip):
I.V.’s
I&O (as ordered; note values):
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ASSESSMENT FINDINGS
(focused assessment)
Document full head-to-toe separately |
MEDICAL HISTORY
SURGICAL HISTORY |
LABS (significant or abnormal, relate to client disorder; date, time performed; when is next blood draw ordered?)
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MEDS (routine)
MEDS (prn): date, time, last given & reassessment data
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DIAGNOSTIC TESTING (results or pending) | Client Problems (actual or potential)
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MEDICAL ORDERS
Diet: ___________________________
Activity:_________________________
Labs:
Procedures & Dx Testing:
Other: |
What are you on alert for today?
THINGS TO DO (include timeframe)
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CLIENT OUTCOMES (evaluation)
END OF SHIFT REPORT (write on back or use SBAR handoff)
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Head-to-Toe Assessment
Neurological |
Cardiovascular |
Gastrointestinal |
Oriented: | Apical Pulse: Regular Irregular
Rate: _____/min. |
Abd: Soft Non Tender
Tender |
Awake Alert Oriented
Person Place Time |
Basic Rhythm (attach strip): | Bowel Sounds X4 Hyper Hypo Absent |
Unresponsive Lethargic | Peripheral Pulses: Present
Upper Lower |
Stool/Appearance:_______ Ostomy:______ |
Speech: Clear Garbled Slurred | Amplitude (+1 to +4):
Doppler Absent |
NGT cont intermittent clamped |
Appropriate Aphasic
Inappropriate |
Edema Location: | Incontinence |
ROM: Full Limited: Complete Below |
Respiratory |
Feeding tube (type)
Rate: ___, Type of feeding:________ |
Facial Droop: Right Left None |
Even Unlabored Uneven |
Genitourinary |
Left Upper Extremity: Against Resistance Against Gravity | Labored SOB SOB with exertion | Urine: Clear Cloudy
Incontinence |
Rigid Flaccid
Numbness or tingling |
Lungs: Clear Bilateral | |
Right Upper Extremity: Against Resistance Against Gravity | Abnormal Lung Sounds |
Musculoskeletal |
Involuntary Flaccid | Cough: Productive
Nonproductive |
Gait: Steady Stand by assist
Minimum assist Moderate assist |
Left Lower Extremity: Against Resistance Against Gravity | Sputum: Color ________ Amount:_____________ | Device: Crutches Walker
Cane |
Involuntary Flaccid | Consistency:__________ Suction:______________ | Traction Type:______
Check: every ___hours |
Right Lower Extremity: Against Resistance Against Gravity | O2: ____Liters
Delivery device: N/C Mask Vent Trach |
CMS checks every_____ hrs
within normal |
Involuntary Flaccid | O2 saturation: _____% | |
Grasp R: Normal Weak Absent |
Psychological |
Integumentary |
Grasp L: Normal Weak Absent | Calm Cooperative Restless | Warm Cool Diaphoretic Color______ |
Pupils R: ___mm Sluggish Brisk Fixed | Anxious Combative Depressed | Preventative Measures |
Pupils L: ___mm Sluggish Brisk Fixed
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SensoryVisual impairment: Yes NoAuditory impairment: Yes No Assistive devices: |
Breakdown
Special Skin Care:________________ |
Surgical Site |
Location: Dressing Clean & Dry Changed |
Incision: Approximated with no s/s infection |
Redness Drainage (quality & amount) |
Nurses Notes:_____________________________________________________________________________________________________
Generic/Trade Name | Dosage | Route | Frequency
(times to be administered) |
Therapeutic
Drug Action & Classification |
Why is this client taking medication? | Nursing Process
Significant Assessment & Interventions |
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MEDICATIONS
(List all PRN Medications currently ordered for the client)
Generic/Trade Name |
Dosage |
Route |
Frequency(times to be administered) |
TherapeuticDrug Action & Classification |
Why is this client taking medication? |
Nursing ProcessSignificantAssessment & Interventions |
Problem: Problem: Problem:
Problem: Problem:
NURSING INTERVENTIONS/OUTCOMES
Priority #1
Problem: _______________________________________________
Intervention(s) |
Expected Outcome (Client Response) |
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Priority #2
Problem: _______________________________________________
Intervention(s) |
Expected Outcome (Client Response) |
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Priority #3
Problem: _______________________________________________
Intervention(s) |
Expected Outcome (Client Response) |
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Nova Southeastern University
Nursing Department
SBAR Hand-Off Form
SITUATION: Patient Initials: ________ Age :_________ Dx: ________________________________ Admit Date: ________
Room #:_________
BACKGROUND:
Medical Hx Allergies Code Status Interventions / Responses
____________________________________________________________________________________________________
ASSESSMENT:
Neuro Vital Signs (include pain)
Respiratory Accu Checks
Cardiac Lines / Fluids
GI / GU Abnormal labs
Musculoskeletal X-ray Results
Skin Nursing Diagnoses
Psychosocial Intake/Output
RECOMMENDATIONS:
Goals
Consults Test / Treatments Discharge Needs