Published Feb 24, 2013
NursingBro
258 Posts
It was fun and I learned alot but I did get nervous with all of the documentetion the rn was doing.
I am sure I will be doing most of this as an LVN. Did everyone also feel like this with all of the documentation, abbreviates, nuirsing notes, and report?
To be honest I dont even know what I am supposed to say when you report. What I think is I have to go through each patient and say what i did to them that day and any important info they should know about like a scar, bleeding in open wound etc...
I guess my main question is did all of you also feel like this your first day of work? I felt like U knew very little compared to them because they know where everything is, the patients, all of the forms etc..'
I really want to be a great nurse!
Jsconce
5 Posts
It was fun and I learned alot but I did get nervous with all of the documentetion the rn was doing.I am sure I will be doing most of this as an LVN. Did everyone also feel like this with all of the documentation, abbreviates, nuirsing notes, and report?To be honest I dont even know what I am supposed to say when you report. What I think is I have to go through each patient and say what i did to them that day and any important info they should know about like a scar, bleeding in open wound etc...I guess my main question is did all of you also feel like this your first day of work? I felt like U knew very little compared to them because they know where everything is, the patients, all of the forms etc..'I really want to be a great nurse!
Google SBAR nursing report. That will give you a template as to what key points need to be reported to next shift. Hope this helps :)
CYoungLPN, LPN
266 Posts
Aw today was ur first day? What shift are u working? I just got a job in a LTC facility I'm nervous but super excited what did u bring with u for ur first day? I just bought a new stethoscope & scissors online
I'm sure if u have a good brain sheet u can report off of that there are tempers floating around Allnurses
I was very excited and I bought a new stethoscope and a folder with some documentation human resources gave me. Also a pen and a small notebook for notes.
The hardest part to me was all of the new documentation I have never seen. Its different then all of the documents I have seen at nursing homes, hospice etc...
I wil do my best and I will continue my education to try to learn as much as possible. I really want to be a great nure!
Thanks I made a small copy to paste on my small notebook =)
TheCommuter, BSN, RN
102 Articles; 27,612 Posts
At the rehab hospital where I work, we give report like this:
Doe, Jane
75 y/o female pt. of Dr. Smith admitted with left total knee arthroplasty
Left knee incision approximated with staples and covered with dressing
History of DJD, HTN, DM, Bipolar disorder, hypercholesterolemia
Pt. is on a 2000 ADA diet, on finger stick blood sugars AC and HS
AOx4, continent of bowel and bladder, moderate assist with transfers
Has appointment at orthopedic surgeon's office on Thurs. 2/28 at 2pm
I hope I get that advanced one day. If they made me do a report without knowing almost anything about a patient it would be like this:
James Smith. 56 male patient. Removed staples from wound located in the right thigh. Reported pain of 8, gave all ordered medications. Assisted patient to chair. Patient is on a regular diet. Blood Pressure 120/80, pulse 75, respiratory rate 18, 98% O2 sat. One Bowel Movement and assisted with transfer back to bed.
Is this pretty bad?
turnforthenurse, MSN, NP
3,364 Posts
I remember the first time I ever gave report. I was a student. We went through SBAR and all of that (and that's really how you should report nowadays) but I was so nervous, I just completely blanked. I was like, "okay this is Mr. X, here for dehydration....um, what else do you want to know?" As a nurse, I knew how to give report but I was very nervous in the beginning. I don't know why. It gets better with time, though, and now I have no problem giving report, even if it's to a nurse I do not know.
Having that SBAR template with you will help. When I give report, it usually goes something like this:
"Room 1 is Mrs. Y, a 52yo admitted for chest pain, patient of the hospitalist. History of HTN, DM and hyperlipidemia. Patient has blood sugars AC&HS, their last one was 150. Patient is on a cardiac diet and will have a stress test this AM. Consent form has already been signed. Patient is alert & oriented x4, walkie talkie. Lungs are clear. 20G to the left AC, saline locked. Patient is on room air. Patient is in sinus rhythm on the monitor. Patient has a nitro paste patch on the left thigh and has been pain-free all shift. For labs this AM, H&H was 13/39%, WBCs were 5.1, Mg was 2.1, K was 3.4, so I went ahead and replaced per protocol and they will be drawn at 0715. Troponins have been negative x3. BNP was 42. Creatinine was 0.8. Patient's chest x-ray showed no acute disease. Any questions?"
Usually information like that suffices. Sometimes I do forget to mention something so I always ask if the on-coming nurse has any questions for me. Report is always done with the chart in front of us.