New Nurse having trouble with report

caliheartRN · Jun 26, 2012

One way to organize your report is to go through your information by systems (neuro, resp, cardiac, etc) making sure to include lines/drains/tubes where important. Then you can add any important events that happened that shift (Xrays/extra labs/procedures/changes in condition)

You can have an outline that you follow when giving report that reminds you what system/category to talk about next, until you become more comfortable giving an organized report!

Goodluck!

Double-Helix, BSN, RN · Jun 26, 2012

I make a brain sheet for each of my patients while receiving report in the morning. I organize it by system, like this:

Diagnosis/PMH:Cardiovascular:

Respiratory:

GI/GU:

Neuro:

IV Access:

Labs:

When I receive report, I write down pertinent information in each section, and throughout the day I make additional notes or changes as needed. Then, when I give report, I basically read off my brain sheet so I don't forget anything. This way, I have the information in front of me so I don't forget anything, and I always give report in the same order so I develop a routine.

Here's an example of what I might write on a typical sheet:

Diagnosis/PMH: Viral pneumonia in Left Lower lobe. PMH Asthma- diagnosed at age 5. Cardiovascular: HR 110-130, BP wnl. Warm, pink, +2 cap refill, +2 pulses. (-) murmur

Respiratory: O2 via nasal cannula at 3 lpm. Sats 94-98%. Albuterol nebs q 4 hours. Tachypnea in 30's. No retractions,nasal flaring. Lung sounds clear on right, crackles/diminished in Left.

GI/GU: Clear liquids only. Voiding to commode with supervision to transfer. Last BM overnight.

Neuro: PERRLA, A&O x 3. Steady transfers.

IV Access: Right AC PIV. Maintanence fluids D5 1/2NS with 40 mEq KCl/L at 70 mL/hr

Labs: This AM: CBC and BMP done. Pertinent results- WBC 15,000. K+ 3.1 (replaced po per protocol). Labs due: Repeat CBC and BMP tomorrow AM.

While you don't have to do exactly as I do, I highly suggest that you develop your own organization system where you have notes available while giving report. Also, try to develop a format and routine when giving report, so you cover the same information in the same order each time. That will make it easier for you to remember what information you need to include and not leave out something important.

Reigen · Jun 26, 2012

Name, diagnosis,code status, doctor, activity, diet, important info for today (such as surgery, blood work, etc.), abnormal vs's, iv's and other tubes, etc. Mentation, and depending on the diagnosis what you did for the patient surgical patient? Dressing condition sutures/ staples? Circulation movement sensation?

Doing a head to toe might help you as well...

Mentation

vitals signs

lung sounds

heart tones tele strip rhythm

abdomin and bowel status

urinary status void/foley suprapubic catheters

edema

MochafreakRN · Jun 26, 2012

Thank you, both of you! I think you're right, and I need to use a system (and I think both of your systems system is the right way to go) and that it's a matter of getting in the habit of doing it the same way every time. Thank you again!

Nurse Kyles, BSN, RN · Jun 28, 2012

On my unit everyone uses the same sheet. Does your unit have a SBAR report sheet? This is the layout of ours ( it is in 2 columns):

Pt name/age/drs

Advanced Directive?

Code Status?

Admit Date HX of DX

PMH

Respiratory

O2

Cardiac

Vitals

Telemetry

GI:

Diet

Blood Sugars

Last BM

GU

Pain

PRNS

Scheduled Labs/procedures

Isolation? What kind?

Neuro

Fall Risk

Skin

Wounds

SCD/Teds?

Activity

New orders

Notable Labs

IV

Fluids

Drips

D/C plans

It is so much easier when everyone uses the same sheet, because it is so scripted that you don't really forget anything. I take report in a color like orange or purple. When I do my assessment, I circle everything that is the same in black, and make notes throughout the shift in black. Then when I give report, I can easily differentiate what info change throughout my shift. I hope you can find a system that works for you! Good Luck!