MED/SURG SBAR REPORT Date____________

Situation: Diagnosis: ______________ Procedure:______________ _______________________ Report from:_____________ Report to: ______________ Isolation Type:

Pt. Name: ________________________ Room #: ________________________ Admission, Transfer, or Observation Date: _________________________________ ALLERGIES:______________________ Code Status:______ Tele: Y N

Admitting MD:_________ ______________________ Consulting MD:_________ ______________________ ______________________ Advance Directives:_____ Monitor#______________

Pt Alert/Oriented/Confused/AMS Fall Risk: High____Mod____Low____

Rate /Rhythm:_________________________ Core Measures / Critical Pathways: AMI: PNEUMONIA: VACCINE SCREEN CHF: SURGICAL:

Background: Pertinent past medical history: Results of current clinical/diagnostic test: Critical labs/Complications/Medications

Assessment: Most recent Vital Signs: T________P________R________B/P_______SPO2_______Weight________ Pain Site:_____________ Current Pain Scale_____________ Last pain med given:___________

Recent Meds given: __________________________________________________________________ Next Accu check Due: ________________ Last Accu check #:___________________ Central Line/PICC Site:________________________ Drips/Infusions:_______________________________

Pending Labs or exams________________________________________________________________

Recommendation: Treatments: Labs / Tests: Nursing Care Plan Priority:

Anticipated Questions, Needs, Problems Services:

Pt. initials: DX:

Physical Assessments: Full body and focused Patient number 1 Patient number 2 Time: Pt. initials: DX: Safety Assessment:

Time:

Safety Assessment:

General Survey:

General Survey:

Integumentary: Neurologic: HEENT: Thorax & Lungs: Cardiac: Gastrointestinal: (GI) Musculoskeletal: (upper & lower) Genitourinary: (GU) Pulses Brachial Radial Femoral Dorsalis pedis Post tibial Vital signs: Right Left

Integumentary: Neurologic: HEENT: Thorax & Lungs: Cardiac: Gastrointestinal: (GI) Musculoskeletal: (upper & lower) Genitourinary: (GU) Pulses Right Brachial Radial Femoral Dorsalispe dis Post tibial Vital signs: Left

DIAGNOSTIC LAB TESTS

LAB TESTS LAB TESTS SODIUM Creatine Phosphokinase POTASSIUM (CPK) MAGNESIUM CK-MB Brain CHLORIDE Natriuretic Peptide (BNP) CALCIUM RBC TOTAL PROTEIN Hemoglobin ( Hgb) Albumin Hematocrit (Hct) WBC A/G RATIO Neutrophils GLUCOSE Lymphocytes CO 2 PLATELETS BUN PT / INR CREATININE PTT Total BILIRUBIN Sed. Rate or ESR AST; ALT Urinalysis: CHOLESTEROL Color/ pH HDL; LDL Specific gravity TRIGLYCERIDES Leukocyte esterase TSH Bacteria T 3; T 4 Yeast Casts Glucose, Ketones Proein

Acceptabl e Acceptable Range Range

Patient Results Patient Results

Result Value Result High/Low Value High/Low

Rationales for Abnormal for Results Rationales Abnormal Results

MEDICATION ADMINISTRATION WORKSHEET Scheduled Medications: Route Nursing Generic/Trad Side Dose Implications/Contraindications e Effects Frequen Category/Act cy ion

Specific Reason for use with this patient

PRN Medications: Generic/Trad Route Dosage e Frequen Category/Act cy ion

Side Effects

Nursing Implications/ Contraindication s

Specific Reason for use with this patient

NARRATIVE NOTES Date/Time

Student: _______________________________

NUR 130 WEEKLY SELF-EVALUATION Date: ________________

As objectively as possible, evaluate your own performance in the following areas:

Communication

Nursing Skills

Time Management

The client reports of chest pain radiating to the left arm and neck and back.

1. Changes comfort pain (acute pain) associated with tissue ischemia secondary to arterial occlusion, tissue inflammation. 2. Changes in tissue perfusion (heart muscle) associated with decreased blood flow. 3. Activity intolerance related to imbalance between O2 supply and demand tissue metabolism.

- Verbalize relief/control of pain. - Verbalize causative factors associated with chest pain.

Observe vital signs bedrest with Fowler position / semi-Fowler Reduce environmental stimuli instruct patient in medication effects, side-effects, contraindications and symptoms to report.

1. pain is indication of MI. assisting the client in quantifying pain may differentiate pre-existing and current pain patterns as well as identify complications. 2. this provides information that may help to differentiate current pain from previous problems and complications. 3. Respirations may be increased as a result of pain and associate anxiety. 4. to reduce oxygen consumption and demand, to reduce competing stimuli and reduces anxiety. 5.pain control is a priority, as it indicates ischemia

The client verbalized and demonstrated understanding of information given regarding condition, medications, and treatment. The client had an improved feeling of control as evidenced by verbalizing a sense of control over present situation