Nursing Handover Note Design
Prepared By: [YOUR NAME]
Date: June 16, 2050
I. Patient Identification
Name: | Mia Armstrong |
ID Number: | 123456 |
Age: | 65 |
Other Identifying Information: | Male, DOB: 1958-01-15 |
II. Current Health Status
Ms. Armstrong is currently stable. Recent changes include a slight increase in blood pressure overnight. Current vital signs are as follows:
Blood Pressure: | 140/90 mmHg |
Heart Rate: | 80 bpm |
Temperature: | 98.6°F |
Respiratory Rate: | 18 breaths per minute |
III. Medication Administration
The following medications have been administered to Ms. Armstrong:
Medication | Time | Notes |
|---|
Aspirin | 08:00 AM | Continue as ordered |
Metoprolol | 10:00 AM | The new dosage increased to 50 mg BID |
Paracetamol | 12:00 PM | Administered for minor headache |
IV. Care Plan Updates
Ongoing treatments for Mr. Doe include physical therapy sessions twice daily targeting mobility improvement. Dietary restrictions involve a low-sodium diet. Monitoring his response to the new Metoprolol dosage is crucial.
V. Special Instructions
Ongoing treatments for Ms. Armstrong include physical therapy sessions twice daily targeting mobility improvement. Dietary restrictions involve a low-sodium diet. Monitoring her response to the new Metoprolol dosage is crucial.
VI. Pending Lab Results
The following tests have been ordered and are expected to return by tomorrow morning:
Test | Expected Timeline |
|---|
Complete Blood Count (CBC) | Tomorrow Morning |
Basic Metabolic Panel (BMP) | Tomorrow Morning |
Lipid Profile | Tomorrow Afternoon |
VII. Hand-Off Notes
During the shift, Ms. Armstrong exhibited minor dizziness post-metoprolol administration, which subsided within an hour. Reinforce fall precautions. Keep an eye on her blood pressure levels and ensure clarity of communication regarding medication changes. No other significant issues reported. The next shift should focus on determining the cause of the overnight blood pressure increase.
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