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H2T ASSESSMENT
NEURO: LOC: (Alert / Drowsy / Lethargic) Orientated x _____ (person / place / time)
ADMITTING DIAGNOSIS:
Behaviour (appropriate / cooperative / non-compliant / combative / aggressive)
HPI:
Dizziness ______ Headache _____ Syncope ______ Weakness ______
Numbness / Tingling ______ Facial Droop _______ Strength ________
CVS: Chest Pain: Y | N Location: ______________ Severity: _______ Radiating: ____________
Pulses: Radial ___ | Pedal ___ (absent – 0, weak – 1+, N – 2+, bounding 3+)
DIAGNOSTICS: Edema:
Weights *Telemetry? Y | N (rhythm: ________)
IV SITES: Heparin IV rate: @ ______u/hr
*ACS Protocol / DVT Protocol aPTT Due @ _____
IVF:
ENDOCRINE: (QID / TID / BID / OD) Accuchecks
PERTINENT LAB VALUES: BLOOD WORK TODAY? Y | N *Diab. Meds:
Analgesic:
J.SUBCHAK, 2023
NURSING PRIORITIES TIMELINE MORNING HANDOVER REPORT
1
MEDICATION TIMES o
o
o
SCHEDULED MED LIST PRN MED LIST o
o
o
o
o
CHARTING CHECKLIST
CEF CHECKED o
J.SUBCHAK, 2023