How to give a thorough report?

[nrsgnerd]

Hello all. I am a newer nurse and just learning how to give change of shift report. I have tried to do so and found that I leave out information and was wondering if anyone, seasoned nurses, can help me with this. this is what I know to say and would appreciate any help or advice you can offer (what I'm leaving out). I'll just use the best case scenario for my example. I work in a cardiac unit so my example may be geared towards what I see there. Perhaps i just get nervous but i feel like I'm all over the place when I try to give report.

Example:

Mrs. Patient 55 yo F Dr. Ducky Surgeon, Dr. Lucky Cardiologist Allergies: Bananas/latex full code status

Admitted 8/22 thru ER with c/o CP, taken to cath lab, cath found multi vessel disease and consulted for Open heart surgery

OHS Surgery on 8/23 with triple vessel bypass with LIMA no complications, extubated evening of 8/23, pt now on pathway

neuro) A+O, afebrile, PEARLA-pupils 2+, moves all extremities

Cardiac) SR 80's, no rubs or clicks, CO 6, negative enzymes, no CP, no edema, upper and lower extremities pulses 2+, BP 110's/70's. RR 15, Sat is 93-95% on 2 L NC

Resp) clear and equal bilaterally, CT output 100 mL this 12 hr shift with total of 200 over last 24 hrs, serosanguineous and draining well, no airleaks, no SOB, CXR report clear

GI) BS in all quads, passing gas, tolerating cardiac diet, no N/V, no distention or complaints

GU) foley in place with 1200 UOP this shift, urine is yellow/clear

MS) pt is weak, muscles are symetric, no C/O of pain, full ROM, 1 person assist OOB or to bathroom

Skin) Sternal wound is approximated, closed with skin glue, pink and scab had formed, tender, no pus/oozing. all other skin is in tact, bottom looks fine, heels are fine

Pscych) Pt has supportive family, wife is in waiting room, pt seems motivated to get better and is cooperative.

Home Meds

synthroid 5 mcg daily

ASA 325 mg

Gtts

Heparin 12 units/hr theres a new bag of heparin in the med room if needed

NS at 20 mL/h carrier

Ancef 2g q 8 hrs

next Ancef is due at 2000, IV tubing is saved and on IV pole in pt. room

PO meds

Lopressor 25 mg bid lopressor is in med room and due again at 2000

Lortab q 6 hrs, last dose at 1400

IV access

20 ga in L FA, 20 ga in R wrist, CVL in R SC...all patent and flushing. Heparin is infusing in CVL along with NS. No redness or signs of infiltration

Labs

K+ 4.0

H/H 10/35

WBC's 8000

AntiXa therapeutic

Pt. has ambulated X2 today, IS reads at 1000, is now up in chair since 1500, one person assist to help with lines. pt was bathed and likes to have graham crackers and skim milk at bedtime.

See, this sounds good to me but I just know Im missing something so help me out if you don't mind and thank you so much in advance

Abbs

[madwife2002, BSN, RN]

Looks good to me

Mine normally is more condensed

example

room -999

name -Jo Blogs

age -33

DR -kildare

Consults -Renal, SS, GI

Admitting diagnoses -RI

Past medical History DM, HTN, RI,

Allergies -Pen

Activity -Bedrest

labs

K=

mg=

Neuro -A&O

Heart -SR

Lungs -Clear/Dim

O2 -Room air

GI - bowel sounds

GU -voids, BM yesterday

Pulses -3+

IV -20# LAC 1/2 N/S 100mls/hour

skin -intact

acuchecks- 6hourly

Misc- CT

MRI

Echo etc

[KBRN413]

do you have an sbar form?? at my facility we use an sbar form for report and throughout our day. it helps keep me organzied and allows me to give a very throuogh report. i also recommend that throughout your day, when things happen, write them down in the appropriate areas on the sbar form, that way you know exactly what has changed and what you did. much easier to give report and keep track of your day!

[CABG patch kid, BSN, RN]

Everything looks good to me, it may be a little too detailed even, for example you don't really have to go through a full assessment unless something is abnormal or has changed (like if lung sounds previously had crackles but are now clear or something like that). Maybe you feel like you're missing things because things happen throughout the shift that you forget to report off about? What helps me is that I have one section of my paper specifically for things that need to be passed on to the next shift. I work nights so I usually have a few nonemergent things that I wouldn't wake a doctor up for but need to be addressed and are important, so I need to make sure the next nurse follows up. It also helps if you write things like that in a different color or put little boxes next to things that need to be done to make it stand out more.

[miss81, BSN, RN]

CABG patch kid said:

Everything looks good to me, it may be a little too detailed even, for example you don't really have to go through a full assessment unless something is abnormal or has changed (like if lung sounds previously had crackles but are now clear or something like that). Maybe you feel like you're missing things because things happen throughout the shift that you forget to report off about? What helps me is that I have one section of my paper specifically for things that need to be passed on to the next shift. I work nights so I usually have a few nonemergent things that I wouldn't wake a doctor up for but need to be addressed and are important, so I need to make sure the next nurse follows up. It also helps if you write things like that in a different color or put little boxes next to things that need to be done to make it stand out more.

Sounds just like we do it. That was a good report by the OP, but a little too detailed for me too. Oh, I do the little box thing too... I also highlight stuff (like dressings, treatments, etc) after I have completed it and throughout the shift I write the stuff I have to pass on in red on my sheet. I hate when units have special sheets that you have to use to give report. That actually makes me forget more. We tape report and I like it much better than face to face actually. It is much more organized. Just my opinion...

[JulesRN10]

I work on a very busy med-surg floor, we are "allowed" approximately 1 minute per patient. i also float, so i have found that every floor wants different info, so i am never totally confident that i have given all of the pertinent info that everyone wants on the floor of the day...so...this report sheet was given to me by one of the cardiac nurses. their whole floor uses it in addition to the kardex. i tailor it a bit for different floors, and i copy it on both sides, so i can just flip it over and add on if i need more space for a patient, but you get the idea. hope it helps!!