Nursing Handover Note

Prepared By: [YOUR NAME]

Date: April 18, 2050

A Nursing Handover Note is an essential communication tool in healthcare, enabling the transfer of patient information between nursing staff during shift changes or care transitions. By documenting key details about patient status and treatments, these notes promote continuity of care and enhance safety. Effective handover notes equip incoming nurses with crucial insights for informed decision-making, ultimately improving patient outcomes and healthcare efficiency.

I. Patient Identification

Name	Jack Simmons
Age	45
Medical Record Number	123456789
Diagnosis	Acute Myocardial Infarction

II. Current Status

Vital Signs	Blood Pressure: 130/85 mmHg Heart Rate: 76 bpm Respiratory Rate: 16 breaths/min Temperature: 98.6°F
Recent Lab Results	Troponin: Normal Electrolytes: Within normal limits CBC: Slightly elevated WBC count
Changes in Condition	Patient reports reduction in chest pain. No symptoms of nausea or dyspnea observed in the past 24 hours.

Vital Signs

Blood Pressure: 130/85 mmHg
Heart Rate: 76 bpm
Respiratory Rate: 16 breaths/min
Temperature: 98.6°F

Recent Lab

Results

Troponin: Normal
Electrolytes: Within normal limits
CBC: Slightly elevated WBC count

Changes in

Condition

Patient reports reduction in chest pain. No symptoms of nausea or dyspnea observed in the past 24 hours.

III. Care Needs

Medication Administration	Aspirin 81 mg once daily Metoprolol 50 mg BID Atorvastatin 40 mg once daily
Treatments Required	Continuous cardiac monitoring Frequent vital signs every 4 hours Physical therapy evaluation for post-discharge activities
Special Considerations	Monitor for signs of bleeding due to anticoagulant therapy. Encourage patient to report any unusual bruising or bleeding.

Medication Administration

Aspirin 81 mg once daily
Metoprolol 50 mg BID
Atorvastatin 40 mg once daily

Treatments

Required

Continuous cardiac monitoring
Frequent vital signs every 4 hours
Physical therapy evaluation for post-discharge activities

Special

Considerations

Monitor for signs of bleeding due to anticoagulant therapy. Encourage patient to report any unusual bruising or bleeding.

IV. Safety Issues

Allergies	Penicillin Nuts
Fall Risks	High fall risk. Ensure bed rails are up and call bell is within reach.
Other Concerns	Patient has history of hypertension, requiring close monitoring.

V. Pending Tasks

Scheduled Tests	Echocardiogram scheduled for tomorrow at 10:00 AM.
Follow-Up Appointments	Cardiology follow-up appointment scheduled for one week post-discharge.
Additional Care Activities	Complete discharge planning notes and coordinate with social services for post-discharge support.

Scheduled Tests

Echocardiogram scheduled for tomorrow at 10:00 AM.

Follow-Up

Appointments

Cardiology follow-up appointment scheduled for one week post-discharge.

Additional Care

Activities

Complete discharge planning notes and coordinate with social services for post-discharge support.

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