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!!!

[GQRN]

I see a lot of nurses provided you a way to take report. It will take some time, eventually you will develop your own method of taking report and giving report.

When I starteda as a new grad, I had no clue what to report off the 1st day. So I started adding little things day by day and deleting some, and finally developed a nice report integrating the SBAR system. It worked well, and now I don't even need to read anything when I give report.

It took me a good year to start reporting off without reading, so don't stress about it. Try different methods and some posted on here. Go from there...

You really don't need to tell them, lungs are clear, bowl sounds present, pulses palpable... UNLESS THEY ARE ABNORMAL. The nurse will assess all those anyways.

[GQRN]

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!

WOWWWWWWWWWW... I'M GOING TO PRINT THIS

I bet you the nurse I'll get report from, I'll barely get 50% of this information.

[LSRNgrad2008]

You really don't need to tell them, lungs are clear, bowl sounds present, pulses palpable... UNLESS THEY ARE ABNORMAL. The nurse will assess all those anyways.

I tend to still pass along that stuff, because if lung sounds are clear on my shift and then all of sudden they are not, or if bowel sounds were present and then not it's still good to give the next shift the pts baseline, it's nice to know kind of stuff but if you don't pass it along I suppose they can always look at prior shift assessments

[GQRN]

I tend to still pass along that stuff, because if lung sounds are clear on my shift and then all of sudden they are not, or if bowel sounds were present and then not it's still good to give the next shift the pts baseline, it's nice to know kind of stuff but if you don't pass it along I suppose they can always look at prior shift assessments

You are a new grad, so I expect you to do that, keep it up. But in a few years, you will understand why I said what I said.