New grad nervous about giving change of shift report

I was freaked out about giving report back when I was the agency nurse who didn't know how the place did anything. I would listen very carefully to what was said in the one I was given at the beginning of my shift to get a sense of what they cared about and how much detail they needed. Each place will have their own little quirks that deviate from the sort of standard report info. But you can hardly go wrong by giving a sytem review, noting anything out of the ordinary. In my current job, we use the system review exclusively, and we give report in multidisciplinary rounds twice a day. Great practice!

A lot of the new GN's that started with me were nervous about giving report. Where I work we record ( voice care) And we would just pretty much read the focus note we wrote on the chart. It covered all the systems and then at the end we'd add in anything that we thought necessary. That way we weren't saying 'um' and pausing all the time trying to figure what to say next. We sounded smooth and got lots of compliments! haha.

novanurse77 - Just give a quick oral head-to-toe assessment concentrating on the primary nursing diagnosis & medical diagnosis. Imagine what you would want to hear in report at the beginning of your shift.

I agree with the earlier posts. I was also terrified as a student nurse of giving handover! I found it helpful to first write a brief summary of the patient info (Mrs X is a 43yo female admitted on ___ for ___. She underwent ___ on ___)

Then write down the systems such as:

CNS/Neuro: Pain issues, fever etc
CVS: ECG changes etc
Resp: Any O2 therapy, any abnormal assessment data
GIT: Any abdo issues etc
GUT/Renal: Urine output, fluid status
Social: Any issues

It really does get easier with practice to the point that you realize you KNOW the patient, and you learn how to get the info across.

Another thing. Imagine you are the patient and you want your nurse to know what's up.
Then like CG said start at the top and work down-head to toe.
I like to include the last vital signs too, and IV count and whether it is to continue.

I am a new nurse too, & I have a sheet I fill out. I make a copy for the next nurse to have, & just go over it verbally w/them. It has name, age, dx, admit date,code status, doctor & consults. Brief hx, iv size, site, fluids running & rate. Allergies, diet, resp tx, o2 if using, activity, sx site & condition, drains, jp, ng, penrose,foley, dsg..w/d ect. Any procedures scheduled, or labs...labs out of whack. If it does not apply to their situation..I don't go there. Hope this helps!

depending on the patient load and your duties, it's damn near impossible at times. for example, i'm in long term care, where i finish a shift in one hall with 30 patients, then go to the rehab hall where i've got 27 people i've never seen for one 8 hour shift (working total of 16 hours). not to mention that i've got to do chart reconciliations, lab sheets, etc.. all sorts of duties made up for the night nurse. then i'm peppered with questions when the oncoming nurses (who work this floor regularly) come in at 7 am. as though i know intimate details of a patient i only saw in bed during the night and maybe gave a few pills to. some nurses do power trip.

it's a joke. if you break your neck, you can give meds and treatments and do your night work, and stop anything major from happening, such as a patient losing their airway ....but as far as compiling and giving a detailed report... unless something is important and needs attention, they can look it up themselves as far as i'm concerned. it's all there in the logs, if they need to know. i can't carry who's got a foley and what their output was in my head, and i'll be darned if i'm going to play the ubernurse game. not to mention that there's 2 nurses in the day and they've got a full support staff.

all i want to know when i come on is who is doing fine, and who needs attention. otherwise, it goes in one ear and out the other. if i need to know, i look at the patient chart. that's why we have charts.

traumahawk99 - You bring up some excellent points. My take on your post is the shift report depth is applicable to the particular environment, i.e. LTC, ICU, Med/Surg, OR, etc., and the bottom line is always hit the major highlights.

Hi novanurse77,

I don't know if you're still an active member now, but I was wondering if you have tips of your own now that it's been about 2 years. I myself am a new grad and having the same problem you had back then. I've read all the other replies and they had good info. Just curious to see how you got thru it. Thanks!