SBAR Report Sheet, Nursing Handoff, Brain Sheet PDF

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SBAR Report Sheet, Nursing Handoff, Brain Sheet...

Description

Room: Full/DNR/Chem PMHx:

Pt:

MDs:

Admit Date:

Dx:

NOK:

PCP:

Last PRNs:

IVF:

Strict I&Os Daily Wt:

PIV CVC PICC Cardiac: Tele_________ Pulses – 4/6 Edema:

Resp: O2__________ CPAP/IPPD/CPT NPC/PC

GI: Last BM Abd: Diet:

inserted: GU: Foley Void Irrigate Diaper

PT/OT/SLP OOB/Assist Bedrest/Turn BRP/BSC/BP Cane/RW

Lungs: Supp/TF

S1/S2/S3/S4 BPs JVD CR Angioseal? R/L Shoulder? R/L

RT Q3/4/6/8 P Neuro: A&Ox__ Defecits?

PEG/G/J/NGT

Skin: Braden Rash Wound Care:

Mattress: Atmos Rental Drains:

ANC: PT INR PTT U/A U C/S Sputum C/S

PRNs:

08:

07 08

12: 09 16:

10 11

Falls/Aspirate Restraints:

Q4/6/8 WBC RBC Hgb Hct MCH MCV MHCH RDW PLT Neutro Bands

Isolation:

Glu Na K Cl CO2 AGAP BUN Cr GFR Ca Mg Phos Bili Alk Phos Amy Lip

Tchol LDL HDL Tgl Risk

Blood C/S

Cdiff/Guiac

Todays ToDo:

Accuchecks: AC/HS/Q6/Q4 0730 1130 1200 1630 1800

BNP D-D T&X MRSA Screen

Protocols: K < 3.8 < 3.9 Mg < 1.8 Phos < 2.5 Heparin New Orders:

PPD: D/C plan Home/HH/SNU/Rehab LTAC/NH/AL Eval/Accept

12 13 14 15 16 17 18...