Giving/Getting Report

bahamagirl · Jun 8, 2006

Giving report can be a little tricky when you first start out. It needs to be clear and concise as well as organized. I always start by stating the name and age, diagnosis, past medical history and what brought the patient to the unit. Then report in systems, neuro, hemodynamics, pulmonary, gi,gu, relevant bloodwork, lines and drips running and then social issues. Eventually you will find what works for you but I find you end up covering everything if you go in systems. I don't write anything down in report but if you need to do that then go right ahead. Good luck.

TennRN2004 · Jun 8, 2006

It helps as a new nurse to jot down some notes when you're getting report. For example, any tests or procedures the pt may have in the am and need to be NPO after midnight for? You may get crazy busy running around and forget to turn the tube feeding off at midnight if you don't write yourself a reminder. Also, things like are they a diabetic or on steroids or TPN having their bloodsugars monitored? I used to write that kind of stuff down too. It also helps to make yourself a to do list. As you think of things you need to do, keep a list handy to keep yourself on track. I also keep a list of the patients hx, doctors, surgeries, etc. close. If you need to call a doc in the middle of the night, you want to have all your ducks in a row.

As far as giving report, it just takes time. I used to beat myself up driving home thinking I forgot to tell the day shift nurse this or that. Most of the time, the experience dayshifters can wing most of it they are in such a good routine. As long as you get the most important info-code status-if they're a DNR, family issues, pertinent lab work-were elytes treated by you, did you give blood for a low h/h, etc., then they can pretty easily pick up where you left off. One thing that helps me is I go straight down my flowsheet. I start with pt diagnosis/surgery, MDs on the case, allergies, pt history, then go into VS-hr, bp, rr, o2, uop, neuro, and go on down the list. It's a pretty succint way of giving all the major info. Go over the mar with oncoming to let them know when you last gave your prns-ativan, pain med, etc. Also, if I things that need to be addressed, but don't necessarily warrant giving the MD a call at 10 pm on my shift, I'll pass that onto dayshift. For instance, the patient has had their central line in for coming on 2 weeks, does the MD want a PICC if pt is gonna be long termer, or family has a question about something and wants to be updated when MD rounds.

Most older nurses understand it just takes time for you to get your bearings, especially in the ICU. You'll come up with your own way to get the job done, very few things absolutely must be done in a certain way. You'll learn what makes you the most efficient and best nurse you can be through trial and error and watching your experienced nurses and seeing how they do things.