NURSING HANDOFF REPORT

Patient: C.S Age: 54-year-Old Gender: male Room: Ht: 175 cm Weight: 110 kg
Date of Admission: 10/22/2020 LOS: Code Status: Full code
Allergies: NKA Advance Directives:
Isolation: Standard T: 99
Diagnosis: Acute Myocardial Infarction HR :82
Pertinent History: Complaints of chest pain, diaphoresis, and SOB RR: 12
and was treated in the ED with aspirin and 2 does of sublingual O2 Sat: 97%
nitroglycerin.
Neuro: Alert and oriented x3 B/P: 121/72
CV: Normal heart sounds Pain: Had chest pain of 2 out of 10
Telemetry Status/Changes: Sinus rhythm with an anterior
myocardial infraction
Pain Meds: Nitroglycerin
V-fib later upon assessment
Time of last Dose: 0200
Edema: None
Pulses: Present and strong
Resp: Best sounds were normal. Chest moving symmetrically. Blood Glucose Results: none
O2: 4 L/min with SpO2 at 97%
Chest Tube: None
GI: Normal bowel sounds Activity/Safety: Bed rest with
bathroom privileges
Diet: Healthy heart diet
Morse Fall Risk Score: none
G tube: none
Equipment: none
Restraints: none
GU: Flat and non-distended IV/PICC/Central Line: Dry and
Intact
Foley Cath: None
NS IV at 25 mL/hr
Date Inserted/Removed: none
Insertion Date: 10/22/2020
Dressing Change:
Labs: ABG: low HCO3- 18 Skin: Normal skin turgor and color
Venous blood analysis: creatinine low 0.7, CK-MB elevated 20,
Braden Scale Score: None
Troponin T 2.2 elevated,
Incisions/wounds: None

Medication: Aspirin, Nitroglycerin, Morphine

Diagnostics: ECG Psychosocial: Appropriate to
situation
Planned Procedures: None Discharge Plan: Education and
medication management,
therapeutic communication