Critical Care New Shift Report Sheet 2008
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Transcript of Critical Care New Shift Report Sheet 2008
MONTEFIORE MEDICAL CENTER- The University Hospital for the Albert Einstein College of Medicine
MONTEFIORE MEDICAL CENTER- The University Hospital for the Albert Einstein College of MedicineNURSING SERVICES-CRITICAL CARE MANAGEMENT INTERSHIFT REPORT SHEETRoom:____________
DATE:____________Patient_____1____________Age___Sex____ Admitted: _____HD:________LOS:_______
Diagnosis:__________________________Procedure___________________________________
Comorbid Conditions\Hx:_____________ Code Status:______Allergies__________________________________________________________________________________________________SIGNIFICAT HOSPITAL HISTORYBODY SYSTEMS
Neuro:
Orientation: Psych/Soc Pupils:Extremity Strength Temp:Activity Weight:Fall Precaution: Restraints Neuro: PLAN: VARIANCE
CV:
Rhythm: HR:
BP:
A Line
Swan Ganz: PA PAWP
CVP: CO
Pacer Wires:
K+: CPK: CBC: Hct: PT
Mg+: MBs: Trop: HGB PTTCa:
Edema (small= +1 moderate=+2 Pitting= +3)Pulses (R) (L) (absent=0 weak=1 strong=2) PICC/Central line/ IJ:
Hep Lock:DRIPS: cc/hr
Cardiovascular: PLAN: VARIANCE
PUL: Extub: RR: O2 BS: Mask:Coughing Sputum Triflow
Chest Tubes: Bipap:ABG: Mode: Cuff Pressure
FiO2 TV rateRespiratory PLAN: VARIANCE
GI Abd ContourBS Flatus:
NG pH:
Diet: BM
Feeding Appetite:
Chemstrip:GI: PLAN: VARIANCE
GU Foley: Cath Care: SG PD
Urine Output: Hemo
GU: PLAN: VARIANCEI&Os
Skin/dressing/incisions:
Braden Scale: Specimens:Test, Labs
Procedures, hx, preps
Other:Other:
Discharge Plan:Variance to Discharge Plan: Barrier
Resolution:
Consults:Teaching/Learning:Consults:
Special Needs:
Ca PTT CPK CKMB% Mg PT CKMB TROP
