Report For Transferring To a Higher Level of Care

Reason for transfer of care and assessment related to that
General
1. Gender
2. Code Status/Allergies
3. Presenting complaint
  1. History r/t complaint
4. Other history
Neuro
1. GCS
2. Pupils
3. Strengths
4. A&O level
Cardio
1. HR
2. BP–> reference range, meds needed to control HTN
3. Heart sounds
Resp
1. Lung sounds
2. Airways
  1. Where
  2. When placed
  3. Current measurements (ie.24 at the teeth)
  4. When the dressing was changed
3. Vent settings
4. Saturation history
GI/GU
1. Diet/NPO status
2. Last BM
3. Lines/drains
4. Catheter present–>urinary output
5. Dialysis and frequency
Musculoskeletal
1. Ambulation
2. Strengths
3. Motor
4. Any traction/trauma
Skin
1. Any skin breakdown, lesions
2. Dressings
3. Prevention ie. sacral prevention pad
Other
1. Lines/access
2. temperature/fever
3. Edema
4. Pulses

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Transcript

Okay guys, anytime there’s a transfer from a lower level of care to a higher level of care. So let’s say from the floor of the ICU, it’s really important to give just the most important information. Giving a full head to toe assessment is not the best way to handle these types of reports. What you need to know also is that certain types of nurses and certain floors require certain information. The most important thing that you can do is to give the highest level of information. If they have any questions, they’ll come back to you. All right, Marine. Yeah, this patient is coming to the ICU and the reason she’s coming, she’s um, she’s having a hypertensive crisis. The last pressures are like 200/102. So, the other thing is her neuro is totally intact, but she has been complaining of a little bit of blurred vision.

Okay. So this is Mrs Wickham. She’s a 58-year-old female. She is full code, no allergies. She was admitted two days ago for chest pain and hypertension. Then, uh, we checked cardiac enzymes, did an EKG. It was all within normal limits. So we’ve been trying to get her pressures down. Perfect. The biggest thing is that she’s been getting low beta LOL PRN and it’s not working, so she’s probably going to need to go on a nicardipine drip. Everything else is, uh, in terms of neuro is fine. Strengths motor intact, her pulses are threes to ones. She does have a 22 gauge to the left PIV. Um, she has a low sodium diet, but I anticipate that that’ll change also with bathroom privilege. I anticipate that will also change. Other than that skin’s intact. So her biggest concern is that we got to get her pressures down. Do you have any other questions? I will let you know if I have questions. All right. Thanks. Now go out and be your best selves today. And as always, happy nursing.

Report For Transferring To a Higher Level of Care

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