Scribd Logo
Hochladen

Willkommen bei Scribd!

  • New Shift Report Sheet 2008

    Hochgeladen von

    cutevives
    1K Ansichten1 Seite
    This document contains a nursing intershift report sheet for a patient at Montefiore Medical Center. It includes sections for documenting the patient's history, current status of major body systems, and care plans. Key details provided include the patient's age, sex, admission date and length of stay, diagnoses, procedures, medical history, code status, allergies, neurologic and psychiatric assessment, vital signs, lab results, intravenous access, respiratory support, gastrointestinal and genitourinary status, skin condition, discharge plans, teaching provided, and any outstanding consults, tests, or procedures. The plan is to fully document the patient's condition and care overnight in this standardized report.

    Originalbeschreibung:

    New Shift Report Sheet

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Verfügbare Formate

    DOC, PDF, TXT oder online auf Scribd lesen

    Stufen Sie dieses Dokument als nützlich ein?

    Sind diese Inhalte unangemessen?

    Dieses Dokument melden
    This document contains a nursing intershift report sheet for a patient at Montefiore Medical Center. It includes sections for documenting the patient's history, current status of major body systems, and care plans. Key details provided include the patient's age, sex, admission date and length of stay, diagnoses, procedures, medical history, code status, allergies, neurologic and psychiatric assessment, vital signs, lab results, intravenous access, respiratory support, gastrointestinal and genitourinary status, skin condition, discharge plans, teaching provided, and any outstanding consults, tests, or procedures. The plan is to fully document the patient's condition and care overnight in this standardized report.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Als DOC, PDF, TXT herunterladen oder online auf Scribd lesen
    Markieren Sie unangemessene Inhalte
    1K Ansichten1 Seite

    New Shift Report Sheet 2008

    Hochgeladen von

    cutevives
    This document contains a nursing intershift report sheet for a patient at Montefiore Medical Center. It includes sections for documenting the patient's history, current status of major body systems, and care plans. Key details provided include the patient's age, sex, admission date and length of stay, diagnoses, procedures, medical history, code status, allergies, neurologic and psychiatric assessment, vital signs, lab results, intravenous access, respiratory support, gastrointestinal and genitourinary status, skin condition, discharge plans, teaching provided, and any outstanding consults, tests, or procedures. The plan is to fully document the patient's condition and care overnight in this standardized report.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Als DOC, PDF, TXT herunterladen oder online auf Scribd lesen
    Markieren Sie unangemessene Inhalte
    von 1

    MONTEFIORE MEDICAL CENTER- The University Hospital for the Albert Einstein College of Medicine

    NURSING SERVICES-CRITICAL CARE MANAGEMENT INTERSHIFT REPORT SHEET Room:____________ DATE:____________ Patient______________________Age___Sex____ Admitted: _____HD:________LOS:_______ Diagnosis:__________________________Procedure___________________________________ Comorbid Conditions\Hx:_____________ Code Status:______Allergies____________________ ______________________________________________________________________________
    SIGNIFICAT HOSPITAL HISTORY

    Neuro: Orientation:
    Psych/Soc

    BODY SYSTEMS Neuro:

    PLAN:

    VARIANCE

    Extremity Strength Activity Fall Precaution: CV:

    Pupils: Temp: Weight: Restraints

    Rhythm: HR: BP: A Line Swan Ganz: PA PAWP CVP: CO Pacer Wires: K+: CPK: CBC: Hct: PT Mg+: MBs: Trop: HGB PTT Ca: Edema (small= +1 moderate=+2 Pitting= +3) Pulses (R) (L) (absent=0 weak=1 strong=2) PICC/Central line/ IJ: Hep Lock:

    Cardiovascular:

    PLAN:

    VARIANCE

    DRIPS:

    cc/hr

    PUL:
    BS: Coughing Chest Tubes: ABG:

    Extub:

    RR:

    O2
    Mask: Triflow Cuff Pressure

    Respiratory

    PLAN:

    VARIANCE

    GI BS NG Diet: Feeding Chemstrip: GU Foley: Urine Output:

    Sputum Bipap: Mode: FiO2 TV rate Abd Contour Flatus: pH: BM Appetite: Cath Care: PD Hemo SG

    GI:

    PLAN:

    VARIANCE

    GU: I&Os

    PLAN:

    VARIANCE

    Skin/dressing/incisions: Braden Scale: Other: Discharge Plan: Variance to Discharge Plan: Barrier Resolution: Consults:

    Specimens: Test, Labs Procedures, hx, preps Other: Teaching/Learning: Consults: Special Needs:

    Ca Mg

    PTT PT

    CPK CKMB

    CKMB% TROP

    Das könnte Ihnen auch gefallen