A good report sheet?

i worked in surgical icu as my first job, then cardiology and then onco and now research in tbi and all i can tell you is that what they told us in school really is true: head to toe by systems...then line, (ivs) . for instance: aao x3 (neuro), 2 l nc (resp), telebox #23 sinus rhythm in the 70s, (cardiac), soft diet at 70% (they are on a soft diet eatting about 70% of it)=gi, voiding and bm this morning. patient has bath room priv. ( gi and gu). pulses present x 4. pt has embolic stocking on. pt is oob (out of bed) to chair and has pt 3xs a week. patient has a patent peripheral iv from yesterday in the right ac (anticubital). then you could say if they are getting iv antibiotics or blood or something special. for instance, q8 hour rocephin is hanging and then pt has ns (normal saline) to kvo (keep vein open) which is usually 20-30 ml/hr depending on the institution. i know it seems like alot but that way, the person you are giving report to will get a complete picture of the patient. most important, tell the next nurse what is still pending, if you are pending lab results or a consult or whatever. remember, you are only one person and you have only 8 or 12 hours, and you are not expected to do everything. highlight for them what is on hold or coming. understand that you will rarely get as thorough of a report as you give but...people willl know that they cannot mess with you. draw a picture of your patient in your head and tell the next nurse, in an organized way, what you see. best to do walking rounds, coming and going, so you know what you are giving them and you can ask questions about what they are giving you. in icu it is more complicated in a sense but simpler in another. you give readings for each system. neuro is the same but respiratory may be ventilator readings and you may have a feeding running and propofol (for pain and anethesia), and an antibiotic and/or fluids running all at the same time. you may have an arterial line measuring one set of readings, you may have a telemetry box wit another, an eeg with a third. you may have a shunt draining, chest tubes draining, a foley draining, a wound vac draining, all with reading and tubings. so it is the basics multiplied by three but you have just to be flexible and know your patient and know what is important. that is why they drilled nursing diagnosis into us-so that we know what to focus on and what is important.

i am sorry that there is so much but there is no short answer. after some time, you will develop your own style and based on your unit, some of the categories will not be as important as others. for instance, in a dialysis unit, urinary output is important. in a cardiac unit, you want to know intake, output, meds and rhythm, in icu, it depends on what put them in your icu. neuro icu you focus on loc and changes in mentation, surgical icu, you focus on risk for infection and all those other things. that should get you started. just do not look for easy answers.

Wow thank you so much for the replies. :loveya:I found a lot of good ideas on the website and I'll be sure to check the other links as well. Thank you. Thanks especially for the advice Valkyria. With my limited experience I'm learning pretty quickly that there really are no easy answers, especially in the ICU.