Patient Preparation
sophia4
PatientPreparationbrainandSBAR2.docx|
Patient Preparation/Case Study 5 pts |
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Room: |
Name: |
Age/Sex: |
Surgical Day: |
Admit Date: |
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Code:
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Allergies: |
Isolation: |
Diagnosis: |
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Activity: |
PMH:
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Vitals: |
O2 |
Pain |
BS |
Medications Time:
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Diet: % Eaten: |
Diagnostics: |
Fall Risk: |
Last BM: |
Report/Notes: |
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IV: |
Labs: |
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Start Date:
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Fluid and Rate:
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Change Date:
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Intake: Total for Shift________ IV: PO: |
Therapies: PT OT RT |
Treatments: |
Immunizations Status |
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Output: Total for shift ________ Urine: Drains: Emesis: |
Education Needs: |
Health Promotion |
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Pre-Clinical Nursing Assessment: (from the client chart) 5 pts
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Neuro:
Pain Assessment:
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Cardio/Tele
Edema
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Resp:
Lungs/O2: |
GI:
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GU/Repro:
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Behavioral Health: |
DVT Prophylaxis:
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Skin:
Braden Score: |
Notes: |
Current Nursing Assessment: (during this shift) 5 pts
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Neuro:
Pain Assessment:
Pain interventions:
Pain Reassessment:
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Cardio/Tele Assessment:
Edema
Vitals:
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Resp: Assessment:
O2:
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GI: Assessment:
Last BM:
Intake:
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GU/Repro: Assessment:
Output: |
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Behavioral Health: |
DVT Prophylaxis:
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Skin: Assessment:
Wound/dressing:
Dressing Change:
Braden Score:
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Misc: |
Pre-Clinical Prep-Pharmacology: 10 pts
List each medication you will administer this shift and PRNs in last 24 hours (10 pts)
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Medications: Generic/Trade , Route, dosage, Time |
Pharm. Class: |
Mechanism of Action In OWN WORDS: |
MOST Common Side Effects: |
Nursing Responsibilities: Include assessments needed and special administration instructions |
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Client Name: __________________ Age: __________y/o M/F Admitted: ________Room # _______Doctor _________ FULL CODE/DNR 5 pts
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S Situation |
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B Background |
PMH: Dm / CHF / HTN / CAD / PCI / Liver dz / PVD / GERD / COPD / Asthma / CKD / ERSD / Smoker Drug Abuse / Psych / CVA / Dementia / Hypothyroid / CA /_________ |
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Tests: MRI / X-ray / CT/ Echo EF: ____ / Endo / US / Cath Results of tests: |
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A Assessment
Contact: MRSA C – Diff ESBL Flu COVID Droplet Neutropenic
Need: Urine Cx Resp Cx Flu Swab COVID Swab MRSA Swab
Extras: Daily Weight Strict I &O Fall Risk Observation 1:1 Sitter NPO @ Midnight |
IV # _______ R / L SL Date: __________ Site AC / FA / Hand/ Wrist / UA Central: IJ / PICC / Port / Dialysis |
IVF NS / ½ NS / D5 ½ / D2 NS / LR / Abx IV Rate: _______ ml/hr Drips: heparin / blood / TPN / diabetic / Cardiac |
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Neuro: AXO x _____ / Confused Activity: Up ad lib / 1 / 2 / Bed-rest Walker / Cane Neuro Checks / Restraints / Bed Alarm |
Pain: Level Location: Medication: Frequency: |
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Respiratory O2 @ _____ L NC / RA / NRB / CPAP / BIPAP Trach Breath Sounds: Clear / Diminished / Wheezing / Crackles / Course Cough Productive / non-productive Treatment: Nebs / IS / CPT |
Vital Sign Trends HR Temp BP RR O2
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Cardiovascular SB / NSR / ST / A fib / A flutter / A paced / V paced/ PVC / PACs/ AICD / Murmur / Block Edema none / Gen / Trace / 1+ / 2+ / 3+ Pitting / non-pitting R / L/ Bilateral Arms/Leg Pulses DP Radial Dopplers / +1 / +2 |
VTE Prophylaxis SCDs / Foot Pumps Heparin / Lovenox Coumadin / Xarelto Eliquis / None Needed Needs Other |
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Gastrointestinal Diet Reg / Clear / Full / AHA / ADA / Dysphagia I II III / Soft / Renal / NPO Hypo / Active / Hyper / Nausea / Vomiting / Diarrhea G-tube (LWS / Gravity) / Ostomy Last BM ______ |
Genitourinary Voiding / Foley / Incontinence / Anuria Clear / Cloudy Yellow / Amber / bloody BR / Urinal / Bedside comm / Bedpan Dialysis: M Tu W Th F Sa Sun |
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Musculoskeletal Weakness: RUE / LUE / RLE / LLE Numbness: RUE / LUE / RLE / LLE |
Skin: (Wounds & Dressings) |
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BG Monitoring AC&HS ? Q6h / Q ___h |
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Labs: |
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Drains: Chest Tube / JP / Hemovac / Wound Vac R / L Level: _______ Serosanguinous/Sanguineous |
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R Recommendation |
Scheduled Procedures: Cath / US / Stress / Echo / Dopplers / MRI / CT Consults: PT / OT / GI / Cards / Neuro / Nephro / Wound / Ortho / Psych / Pulm / Surg Discharge to: Home / Home Health / Assisted Living/ Nursing Home/ Rehab Discharge Day: ___________ |
Put it All Together to Think Like a Nurse (complete this during your shift)
1. What data did you collect from the medical record and the patient that is RELEVANT to the nurse? 1 pt
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RELVEVANT Data: |
Clinical Significance: |
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2. Identify data gaps. What did you not find out about your patient that would be useful for their ongoing care?1 pt
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Data Gaps: |
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3. What problems might you see in your patient/identify the most likely problems. Why might you see those problems? Rank them in order of priority. What additional data would be needed relevant to the problem?1 pt
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Patient Problems: |
Why: |
Rank: |
Additional Data Needed: |
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4. Using your identified problems this shift, what is the physical nursing priority and priority interventions to advance the plan of care? 3 pt
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Nursing Priority: |
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Outcome (SMART Goal) |
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Interventions: |
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5. Using your identified problems this shift, what is the psychosocial nursing priority and priority interventions to advance the plan of care? 3 pt
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Nursing Priority: |
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Outcome (SMART Goal) |
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Interventions: |
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6. Education Priorities/Discharge Planning: What educational/discharge priorities were taught to your patient during your clinical day? 1 pt
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Education PRIORITY: |
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Priority Topics to Teach: |
Rationale: |
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