Nurse Brain Sheet Telemetry Unit SBAR PDF

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Summary

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Description

NURSE BRAIN SHEET – TELEMETRY UNIT SBAR

S

Patient name

Age

Room

allergies

Physician

Admit

number 1

Attending Code status

date 2 Dx

Consultant

Advanced directive on chart?

Dx

s Pgr/#

C/O

B

History

Isolation

Anesthesia

A

Restraints CHF MI PNA

Surgeon

Surgery:

Core Measures

Fall risk Va ccine‐ PNA Flu

EBL

Anesthesiologist

Cardiac: BP/HR/Peripheral pulses/Edema/Heart sounds

Pain/sedation

Current rhythm

Pain scale

Daily wt?

Location Meds type and last dose

DVT prophylaxis Pulmonary: Breath sounds/Secretions/ SpO2/UPAs/PIP/ Spontaneous VT & VE

Vent/bipap etc

Accu checks

A1C

settings Frequency

GI

Last Results Skin Wounds/Drainage

NG/OGT

BS

Last BM

Diet

GI Prophylaxis

GU Foley/void

Staple s Drain s Location

Output Ducub photo on admission IV

Date inserted

Fluids

Gtts

Psych Social

Meds

Pending orders

Na

Cl

Bun

gluc

mg

BNP

K

Co

Cr

Ca

Phos

DDimer

Coags INR

Hct W

UA

CXR

Pl Cultures

PTT Cardiac enz

R

1

2

3

CT

Next lab

DC Plan. Is pt informed of plan_ 24 hour orders reviewed__

MRI Echo

Hgb Shift goals...