Is there form on how to give shift report in ICU ?

  1. I am new grad, currently in orientating on an Intensive Care Unit. Coronary Care Unit (CCU), Medicine Intensive Care Unit (MICU), & Surgical Intensive Care Unit (SICU), all three units have just combined as one. !st, my worst difficulties are organization skills, 2nd, I have hard time connecting the dots, meaning when I hear a diagnosis or an acute problem It does not automatically click in my brain what labs to look for or what other potential problems to look for. 3rd, Giving shift report is uncomfortable especially when the receiving Nurse is tapping her feet, twiddling her thumbs, looking at the ceiling, as if I am incompetent. Critical Care Nurses, please give me some advice especially on how to give shift report, I was hoping to find some type of form to guide me.
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  2. 9 Comments

  3. by   Tweety
    Welcome to Allnurses.

    Since you are asking a specific question, I'll move your question to the Critical Care nurses forums.
  4. by   CardioTrans
    Someone just posted a form the other day for another new nurse in this forum.

    I don't have a form...but this is how I give report:

    Pt name........Dx.........MD.....allergies...

    Brief Hx

    Then start with head to toe:

    Neuro: Non responsive, pupils 3/3...etc

    Cardio: Sinus tach, BP range for shift.... In the cardio part I always include what IV access, drips etc...if they have gotten any blood....pertinent labs...

    Resp: ETT 7.0, and placement of tube... 22 at teeth....you would be surprised at how important this is and many nurses dont pay attention to it..... Vent settings...ABG's....lung sounds.....how much suctioning required....

    GI:.... bowel sounds, peg tubes...ng tubes... ostomies...etc

    GU: foley, urinary output for shift.... if on CVVHD etc

    Integumentary: any skin tears or wounds.... etc

    After we do head to toe....we talk about if there is anything that still needs to be done, or sometimes we talk about it in the head to toe.....also talk about the family... whether they are in the hospital, call, or if there are any issues that may come up......if there are any tests scheduled.... when they are scheduled.....or even if we traveled that day to CT, MRI, etc... and the results of that if they are known...

    Some of the things that I have listed in the "after" section, we may talk about while we go through the systems.... just depends.

    Hope this helps some! Good luck in your new job!
  5. by   RNperdiem
    I like to follow the format of the flowsheet. I am a visual learner type.
    The top of the flowsheet lists the name, diagnosis, past medical history, procedures done etc. I move down to vital signs, vent settings and follow the flowsheet through drips, diet, I&O's, procedures, assessments.
    There is a fine art of using the flowsheet as a report tool without totally reading what is written there. Nurses do tend to get restless when you do that.
    I finish up mentioning family, contact information or miscelleanous stuff that needs mentioning.
    A nurse who gave you the patient and is taking the same patient back gets more of an update than a full formal report.
    A floater or new grad gets a more in depth report with reminders about issues that are unit specific. For example, I would mention drawing tacrolimus level labs at 0800 to a floater not familiar with transplant patients.
  6. by   Chisca
    Well, if you are on night shift you only have to answer one question for the day nurses. Did you give a bath?
  7. by   nurseabc123
    Quote from Chisca
    Well, if you are on night shift you only have to answer one question for the day nurses. Did you give a bath?
    And two more important questions... Are they stooling?

    And are you back tonight/tomorrow?
  8. by   mrsituation
    Quote from Chisca
    Well, if you are on night shift you only have to answer one question for the day nurses. Did you give a bath?
    Amen brother!!!!
  9. by   Chisca
    And if you really want to raise some eyebrows ask them how much of an increase in oxygen consumption giving a bath causes.


    Answer- 40%.
  10. by   4fill
    I like to use he same technique that CardioTrans uses except that all tubes and drains are mentioned at the end with the I&O.

    Don't even think about not doing at least one bed bath, but do it before the end of the shift so that you can organize your assessment of the systems for report

    The world of ICU is the most enjoyable place in the hospital to work. Both responsibility and rewards are very high

    Since you are new to the field, you might look at some of the posts about "nurses eating their young".
    :angryfire
  11. by   squirlkeeperCCRN
    :spin:you are so right!!!! then the real report begins after you have answered whether or not you will be back in the morning.
    Quote from Chisca
    Well, if you are on night shift you only have to answer one question for the day nurses. Did you give a bath?
    I like the head to toe method as well (due to the fact that we no longer have flowsheets or anything written for that matter).

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