SBAR HAND OFF FORM.(NURSING STUDENTS)

LONDON SCHOOL OF PROFESSIONAL HEALTH SCIENCES, LOS ANGELES,CALIFORNIA 900000.

Student Nurse name:Lovesoda,Icecre.

SITUATION: Room 3124.

Date 03/13/21.

Age/Sex 46.

Chief complaint: SOB,Chest pain.

Primary Diagnosis: Atria Fibrillation. Surgery/ Procedures:Echocardiogram. BACKGROUND:

Secondary diagnosis:ESRD/HTN.

CODE STATUS: FULL CODE.

Intervention: 02@2liter NC.

Blood pressure medication given as ordered by the doctor. Assessment of pain,medicate as ordered with morphinesulfate 4mg IVQ3hours prn pain.Reasssessment in 30minutes.

Monitor blood pressure and notify the doctor for any critical value.

ASSESSMENT:

Neuro: Headache, dizziness.

Respiratory: dyspnea.

Cardiac: Chest pain.

GI/GU: Dialysis, Nocturia.

Musculoskeletal : Weakness LLE,Swelling.

Skin: Intact. No skin breakdown.

Psychological: Anxiety, depression.

Vital sign/pain: BP:,140/88,Hr:108,Temperature: 98.0,Resp:20.

Weight: 144lbs.

Height:5ft 4inches. Ambulates to the bathroom. No bowel movement today.

Blood sugar: N/A.

Laboratory:WBC 6.8.

H/H9.8/29.7%.

Creatinine:5.5.

Bun:28.

Xray: Chest Xray results: Pending.

IV lines/Fluids: Saline lock right ac 20guage,patent/clean/dry. RECCOMENDATION:

Vital signs within normal range.

Consultation: Cardiology consult.

Discharge Instruction:

Educate patient on medication and the side effects.

Risk of CHF.

Diet and Exercise.Balanced diet three times a day.Stop smoking.

Medication reconciliation done.

Pneumonia vaccine/flu vaccine given.

Is patient at risk for falls :No.

Suicidal risk: No.

Do patient have copy of advance Directive:No.

Copy of advance Directive on the chart.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

Leave a comment

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: