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.
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.
synthroid 5 mcg daily
ASA 325 mg
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
Lopressor 25 mg bid lopressor is in med room and due again at 2000
Lortab q 6 hrs, last dose at 1400
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
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