Help with research/report

[KrCmommy522, BSN, RN]

Hello! I'm a senior in the BSN program. I'm started my practicum. With so many patients, I'm not able to do the same research I did during clinicals with just two patients. I am wondering is there anything specific I should look for in each patients chart to write down. I am trying out different report sheets to see which one I like but some have a lot, some have a little, and some have just boxes to fill in information. I am just so overwhelmed with all the information I'm never sure what I should look for and write down when first looking into my patient in the morning.

Also, when you give report at the end of a shift. What should you always be sure to tell the oncoming nurse?

I've asked my preceptor this but she was busy and she said it depended on the patient and if she's had the patient already and for report if the oncoming nurse had the patient before. I said what if the oncoming nurse hadn't had the patient before and she said just describe what brought the patient in and about your care for the day and how the patient did. So I guess I kind of get what to report. I guess it's more not knowing what to look for when first researching each patient.

Also, I just don't understand how my preceptor is able to remember so much about each patient! It's amazing! If I don't write it down I never remember. Like I checked a patient's blood sugar and I looked at the result and then got interrupted and forgot and had to dock it and wait for it to go in the computer to see the result! How do all of you guys remember everything?

As usual, thanks for any advice you guys can give!!

[Esme12, ASN, BSN, RN]

((HUGS)) I'm sorry she isn't making time for you...that is why she is the preceptor. Sigh.

Giving report and what is important will get easier...as well as your recall of information. Right now you are just barely keeping your head above water.

You will develop a routine and your report may vary a little as each patient has a different diagnosis.

Report:

Name

Age

Diagnosis/History

CODE status

Isolation (if applicable)

Allergies

Activity

Daily weight

IV fluid rate and site

I/O (if necessary) Fluid restrictions (if necessary) Diet. NPO status. Stool (last BM, diarrhea, constipation, guiac) Foley (if present)

daily labs: glucose, capillary glucose, lytes etc and was MD notified or was coverage given and when

Other testing (CT scan, x-ray etc)

Assessment: color, mental status, resps, lungs, edema, skin, wounds (dressings)

If your patient is a diabetic....glucose. Heart failure...weight, I/O, lytes lungs.

I have attached a few brain sheets that I have collected over time the first sheet you might find useful. As you get organized...the 5 patient report sheet is good too.

mtpmedsurg.doc

1 patient float.doc‎

5 pt. shift.doc‎

finalgraduateshiftreport.doc‎

horshiftsheet.doc‎

report sheet.doc‎

day sheet 2 doc.doc

ICU report sheet.doc‎

‎critical thinking flow sheet for nursing students

student clinical report sheet for one patient

[KrCmommy522, BSN, RN]

I like my preceptor a lot and she has helped me learn so far. I just think it's a bad time sometimes when I ask questions. I thought about it watching her chart and asked. I should have waited until we had a minute or after the shift was over and I think she would have been able to help more. Hopefully!

Thank you so much for your help!! It helps to know that I'll get better at it and its not something I should already be able to do! Thank you so much for all the brain sheets! I'm going to try them out!!!

[Esme12, ASN, BSN, RN]

I like my preceptor a lot and she has helped me learn so far. I just think it's a bad time sometimes when I ask questions. I thought about it watching her chart and asked. I should have waited until we had a minute or after the shift was over and I think she would have been able to help more. Hopefully!

Thank you so much for your help!! It helps to know that I'll get better at it and its not something I should already be able to do! Thank you so much for all the brain sheets! I'm going to try them out!!!

If you think of questions when you are home or don't want to ask come here and we will try to help. You can also PM me.

[KrCmommy522, BSN, RN]

Thank you very much!! I appreciate it!

[KrCmommy522, BSN, RN]

If you think of questions when you are home or don't want to ask come here and we will try to help. You can also PM me.

Thank you so much!!! I really appreciate it!!