Open Heart Nurses I need your help!

nurseabc123 · Jan 4, 2008

I am a new nurse working on a busy open heart unit and so far I am really enjoying it. I find it very exciting and mentally stimulating and as you all know it's impossible not to learn something new nearly every day.
However, being new, I am still not where I would like to be in terms of my practice. Of course I know that it will take a long time before I "get it" but there is one thing in particular that I am hoping you guys could help me with. Report. Some days I feel really confident when giving report and others I am stuttering and coming up blank.
I really want to develop a nice flow to my report and at this point I am struggling. How do you guys with experience do it? Any help would be GREATLY appreciated!!!

Take a few minutes before giving report to organize your thoughts. Make a quick list of things you must tell the oncoming nurse. I did this for a couple weeks when I first started, it seemed to help. Now while, I still hate giving report as I'm always so anxious to get the heck out of there, it's second nature. Good luck.

putmetosleep · Jan 8, 2008

It helps to make a list of things (actually write them down if you have to, that's what I do) that you absolutely need to pass on to the next nurse, whether it's assessment info/what to watch for, or tasks that need to be taken care of. It also helps to communicate the "plan" for the pt if you know what it is (ie, MD would like us to wean Dopamine first, then the Vasopressin, with goal to extubate in the morning) or whatever. Otherwise what I do is just go down the systems: start with hemodynamics/gtts, then your head to toe assessment. Hope that helps, it'll get easier with time :)

RNRao · Jan 8, 2008

Perhaps this will help.....

Start by giving pt's name, age, allergies, surgeon, admitting date then surgery performed. Continue report with pt's complaints that brought him/her to the OR, pt's history, Cath results and date of cath (LV function, EF%) ect, proceed with an OR semi-report(clamp time, was it uneventfull did they require alot of blood products, UO). After a brief history then maybe continue with hemodynamics and Vital signs that are most recent and pertinent and proceed to systems from head -toe; Neuro/safety, CV/skin( I always include skin with CV because of temp, pulses, etc), Resp, GU, GI, Endo, and then family dymanics and who's who's for their spokesperson(s).

I try to stick with my system for every pt. Also always ask if they have any questions regarding your report and if you don't get everything done r/t pt care pass it on in report afterall nursing is a 24hr job.

Good luck and I hope this gives you some ideas.

Daytonite, BSN, RN · Jan 9, 2008

if you do a search on the first year in nursing forum (https://allnurses.com/forums/f224/) using the word "report", you should find a whole bunch of threads on this subject.

Zookeeper3 · Jan 10, 2008

all excellent advise and I'd like to add... make a "wish list" as I call it for the doc the next day... thing's you anticipate needing but wouldn't call for. don't forget your Antibiotic timing as that is a new monitored criteria after 24 hrs.