Re: Shift report form
I work in an open heart unit and report was one of the things that I stressed over for the first couple months. I basically use a modified fancas in which I put everything that pertains to cardiac and fluids at the top.
I start off with the history and then I do the following:
IV's - what is running where and at what rate.
Cardiac - heart tones, ectopy/arrhythmias, rate/BP, chest tubes, urine/foley, vascular/pulses, edema, pacer wires, incisions.
I usually talk about the labs and meds at this point.
Respiratory - lung sounds, SATS, vent/O2, rate, suctioning/cough, spirometer
GI - bowel sounds, diet, BM's, nausea, emesis
Neuro - A&O?, pupils, strength, movement
I complete it by talking about the family and visitation.
I think this is a good way to give report on an open heart unit because it addresses the most important stuff first and moves down the line.
Nursing News