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Discussion

Nursing Shift Report

Hi all..I'm a new MedSurg RN, started in March. I work on a great floor and everyone is great and helpful, but I seem to be struggling with shift report. I always feel like I am fumbling or not giving enough information. I haven't received any poor feedback, but I always feel like it's an inadequate report. Any advice? ?

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    Do you use an organized brain sheet? Be sure to update the sheet as you go throughout your shift that way you have the most and the most accurate information to give without forgetting anything.

    It all gets better with time.

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    My report, most done at the bedside....

    This is Mr. Smith, 55yo male.

    Admitted for chest pain, CA

    Pmh: HTN, HPL, hypothydroid, smoker x 15 years

    Dr. Johnson is attending

    Procedures:

    LHC: yesterday, 3 vessel disease

    Cardiothoracic surgery consult for Bypass

    Pt is currently free of CP with 1 inch of nitro 2% on left chest wall

    AOX4, MAEW

    2 Lnc

    SB on Tele

    Good pulses

    Voiding

    Nausea intermittent treated with Zofran prn

    Last BM this morning

    Up with standby to ad lib

    20G left AC

    CATH access: Right groin soft with small amount of bruising

    Syvek patch and tegaderm c/d/i

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