Handover Report Template for Nursing Students

[Surname, first name, student number; scheduled lab time/day, tutor full name]
 Use this template for your task 2 written assignment
 Ensure you update the header with your own unique details
 Ensure you use Australian spell check
 Ensure you update your reference list, and this is always on a separate page
at the end of the document
 Use your verbal handover tool as a trigger to structure your handover, noting
some information may/may not be relevant; e.g. under identification stating
the patients full name and age is sufficient if the URN is unknown.
 Short succinct sentences would be appropriate in Part 1.
 Review the course FAQ’s that relate to Task 2 on Blackboard (under ‘Getting
Started’ tab)
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[Surname, first name, student number; scheduled lab time/day, tutor full name]
Part 1
Identification
My name is (). I am the nurse currently caring for the patient by the name John
Williams. John William has already identified his next of kin, and he/she is aware of the
current situation regarding John Williams medical status. The relatives of John Williams have
not yet presented themselves to the medical facility. This handover report was written to help
the next nurse who will be assigned to the patient.
Situation
John Williams was admitted to the hospital with complains of difficulty in breathing.
Additionally, John Williams also complained of respiratory failure. John Williams is very
sick, and I suspect that he might be suffering from pleural effusion. Moreover, I also suspect
that John might be suffering from complications from an intercoastal drainage tube that was
inserted in his left side.
Background
John Williams is a retired police officer. John Williams was also hospitalized six
weeks ago after complaining of breathing problems. John started experiencing the difficulties
in breathing after a surgical procedure known as gastrectomy was performed on him to treat
stomach cancer. He is an alcoholic drinker but only drinks in moderate quantities. In addition
to drinking, John is also a smoker. Besides, John also experiences bowel bladder habits on
regular occasions. The bowel bladder habits may be the reason John is experiencing pain. The
bowel bladder habits may be caused from the surgical procedure that was conducted on his
stomach. Additionally, John Williams also suffers from Chronic obstructive pulmonary
disease.
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[Surname, first name, student number; scheduled lab time/day, tutor full name]
His medication chart includes prn Panadol to relieve the pain, multivitamin to
supplement his body with vitamins and minerals, and Salbutamol 5 mg NEB prn to assist
mitigating the difficulty in breathing. Additionally, John William has a prescription of prn 5
mg Morphine SC to reduce his pain that was caused due to the breathing problems. His pain
level was 7/10. Furthermore, John was also prescribed with 1 gram of amoxicillin to be taken
every six hours to help cure or prevent any bacterial infections. The bacterial infections may
occur either due to the respiratory failure or the operation that was performed in his stomach.
In addition, John was also administered with IVC flushes q4h accompanied by 5ml N\Saline
0.9% through nebulization. There are no current alerts or allergy issues.
Assessment
John Williams is extremely distressed and uncomfortable. His current condition is
worse compared to the previous health status. His body temperature was recorded at 37.6°C,
his heart rate was recorded at 78 beats per minute, and blood pressure monitor at 162/90.
Moreover, his oxygen saturation level was recorded at 96%. Additionally, John’s respiratory
rate was recorded at 24 breaths per minute, the level of pain during respiration was 2-3 out of
10. He was admitted to the Integrated Comprehensive Care for 30 minutes. According to the
recorded information that was obtained after John was observed for 1000 hours, his body
temperature indicated that he might be having a fever. Additionally, his heart rate was
between 60 to 100 beats per minute, indicating that it was normal. His blood pressure
indicated that he was in stage 2 hypertension. His oxygen saturation level was at 96%, which
is good and therefore, no concern. Furthermore, the level of pain during respiration was 2-
3/10, indicating that he had no severe pains. The pains are caused due to the fact that john
Williams is experiencing difficulties in breathing.
Recommendations
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