Change of shift report

[SAL51]

What things need to be said in report? what is important? I had a horriable experience in change of shifts because I am still new (graduated in May and passed my boards in July 08!!!) but still cannot get a hold of what needs to be said. Any help would be great to make it go smooth and to make sure I everything in that I need to. Thank You!!!

[icyounurse, BSN, RN]

It depends on what type of floor/unit you work in. Obviously ICU will be way more detailed than the floor. We have SBAR sheets that help me out when I am really tired and afraid I will forget something. It has spaces for different body systems and history/ect.

I have a routine with my report, I usually start with pt's name, age, gender, date she was admitted and diagnosis on admit. Then I briefly mention the event/series of events that brought the pt to the hospital, followed by medical/surgical history and list of MD's on the case. Then I go through the systems head to toe. Start with head: for example "she is alert and oriented x3, then respiratory, "she is on 2L o2 per nc and lungs are clear. IS at bedside" ect. Then I mention IV access and fluids/gtts going if any. And then we review orders and any upcoming procedures.

BUT this is ICU and my report takes forever because its only on 2-3 pt's. I have a hard time floating to the floor and you may have to give a more abbreviated report on a med surg floor due to high pt volume.

Hope this helps!!

I too had a hard time with report as a new nurse. And just getting a routine helped.

[SAL51]

Thanks it helps some. I work on the Oncology floor. usually have 4-5 patients

[RN1982]

When I give report, I report why the patient came in, the surgery they had, drains/tubes/ivs. Forgot to mention wounds. Also I make sure to report the drips and/or any boluses I had to give the patients. I do go through a very brief head to toe of systems.

[PICNICRN, BSN, RN]

I give a brief history including weight and allergies and then start "head to toe" giving an assessment, then v/s trends, lines, drips, anything that I did on my shift(boluses/road trips/ect) then finally family/social issues. Short sweet and to the point!!

[BGgirl]

I just hit the hightlights. Anything abnormal assessment wise, any dressings, wounds. If I spoke with the doc about anything significant I will mention it. Abnormal labs and what I did about them.

It's nice to pass on things like if you need to crush their meds in order for them to take them. I also mention if certain tests still need to be done or if they were already completed and any results if I know them.

Most basic info will be on the kardex for the pt so I usually don't repeat that stuff.

[KeniRN]

I work on a pediatric Rehab unit but have also worked on the onco unit several years ago. We use the same outline on both units.

Neuro/NeuroVascular (AAO, perrla, cap refill, ambulatory status)

Resp (CTA, pOx, 02)

CardioVascular (VS, on monitor, afebrile)

IV/Central Lines (PIV, broviac, port, PICC)

ID/Isolation Precautions (contact, droplet, reverse)

GI/GU (diet, NPO, tube feeds/Continent, Incont, catheters, LBM)

Skin/Incisions/Drains/Hardware (wound care, drainage)

Labs/Tests (scheduled, pending or results)

Psychosocial

Patient/Family Teaching (what was done, what needs to be done)

Anticipated discharge date (if applicable)

Daily Rounds (things discussed in MD rounds in the AM)

Hopefully I didn't forget anything. If I did, I'm so sorry.

Hope this helps!

Fine tune as pertains to your unit.

:) Keni RN

[nerdtonurse?, BSN, RN]

My "brain" is typed up sheet that goes as follows:

Pt's last name,room, doc, consults, allergies

DNR/Full code, significant hx, admitting diagnosis, orientation (A/O x3, x1?)

Fall precautions y/n, aspiration precautions y/n, seizure precautions y/n, isolation y/n (and for what?)

Fingersticks? BID / TID / QID with space to record FSBS/coverage

IV location, infusing what, date to be changed

PICC/TLC location, infusing what on what port, date to change ports/dressing

TELE: rhythm/rate at start of shift, and every 4 hr thereafter

cap refill y/n, pulses y/n, JVD y/n with space to write deficits

Pacemaker type/location and DVT prevention (lovenox/TEDS/SCDS/other)

Resp rate, sounds, sats, with type of O2 if ordered: LPM, NC, venturi, p/rebreather, full/rebreather, tubes/traches and schedule for trach care

Diet: type, fluid restriction? If PEG'd, schedule and product (Jevity, Osmolite, etc.) amount and flush, TPN

GI: Last BM, Incontinent/constipated/diarrhea/blockage/rectal tube

UT: urine color, incontinent/anuric/other foley y/n, removed y/n peed? y/n

Skin: temp/type, wounds, tenting, edema, wounds (type/location/dressing/change date) and locations of each TURNING SCHEDULE!

Mobility: moves x4, contractures, ROM probs, etc.

Sensory: blind/deaf/HOH L/R/bilateral

Labs: BUN, Creat, HGB, HCT, K, Mg, PT/INR, APTT, RBC, WBC

Blood: consent signed, WB/PRBC/FFP # units and when hung

Procedures: consents signed, checklists?

Then at the bottom, I write what they've got up for next shift -- MRA/MRI, xray, CT, and anything I need to give the next shift a heads up on.

Hope this helps!

[casperx875x]

I find it helpful to know what happened during the previous shift. New meds started, procedures, low BP or any change in pt's status, abnormal labs - were they addressed, etc. I also like to know who is following the pt - pulmonary, gi, renal, etc. I am a new nurse also and have already seen how different it can be receiving report from different people. I aspire to be a nurse who takes care of her patients well and is able to give a concise and appropriate shift reports.

[Kaylesh]

We use SBAR as well for our handovers. I find it makes life so much easier especially after a busy shift .. It helps keep things/thoughts/problems at hand..

For those not familiar with SBAR

S= Symptoms (what they came in with/for)

B=Backround ( Past History)

A=Assessment ( what has been going on and what is going on currently)

R=Recommendation(what the plan is for the patient) ex: cxr,bloods, hourly urine outputs,dicscharge next day, PT/Ot etc..

It makes our handovers much quicker and streamlined too ..

[Virgo_RN, BSN, RN]

We are supposed to use SBAR, but I just skim over my brain sheet. I cover:

Name, age, diagnosis, medical history, treatment plan, systems assessment, IV sites and drips, pertinent labs, and any significant events during my shift.

[LSRNgrad2008]

I'm a new grad and the change of shift report was tough, we did partial verbal and partial taped, and in ICU they do mostly tape report. Anyway we use SBAR and it's a printed form at the nurses station and they are trying to get the whole hospital to use it. Same as the other post below:

Its to get everyone in a routine, and it helps to pass along important info....I don't give every VS that I took for example...I simply report off their ranges and baselines, when I get report I usually flip the sheet over to the back and jot down the previous shifts quick assessment stuff, because my assessment might be the same but it might not and I don't want to fill up the front sheet with all of the prior shift assesment info. The sheet is pretty standard: You could even type one up if you wanted to be anal and make copies and keep them at work:

Name: CODE status

Allergies

Diagnosis:

PMH:

VS

Neuro

Cardiac

Resp

GU

GI

Integ:

Musculo

IV's

Pain

Labs

Pending tests

Etc Etc