Shift, SBAR, report

Report, assessments & reviewing vital signs (followed by notifying MD of any abnormal findings if unable to fix issue myself), med pass, and lastly charting. It helped me to have a routine, although, especially on a busy ortho floor it will be difficult to stick to a "routine" per se. Watch how your preceptor navigates through their day and take mental notes. Always remember to prioritize the care given (who will suffer if I don't do this right now & who can wait?), remember your ABCs, & remember to delegate (if you are a student? this might work a little differently for now). Also, keep a "brain sheet" to help you organized. Lots of examples on this site.

Important things to include in report include: Pain level, pain medications & last time of medication, neurovascular status of extremity involved and the opposing extremity, surgery date, any complications, PMH, allergies, pertinent labs (H&H, WBC, RBC, PT/INR) as most are usually on anticoag therapy).....so on and so forth. Does your preceptor use a report sheet that you might be able to copy? If not, tons of examples again on this website or even just on Google.

Lots to learn on an ortho floor. Be a sponge. Good luck.

Oct 16 by RN403

Report, assessments & reviewing vital signs (followed by notifying MD of any abnormal findings if unable to fix issue myself), med pass, and lastly charting. It helped me to have a routine, although, especially on a busy ortho floor it will be difficult to stick to a "routine" per se. Watch how your preceptor navigates through their day and take mental notes. Always remember to prioritize the care given (who will suffer if I don't do this right now & who can wait?), remember your ABCs, & remember to delegate (if you are a student? this might work a little differently for now). Also, keep a "brain sheet" to help you organized. Lots of examples on this site.

Important things to include in report include: Pain level, pain medications & last time of medication, neurovascular status of extremity involved and the opposing extremity, surgery date, any complications, PMH, allergies, pertinent labs (H&H, WBC, RBC, PT/INR) as most are usually on anticoag therapy).....so on and so forth. Does your preceptor use a report sheet that you might be able to copy? If not, tons of examples again on this website or even just on Google.

Lots to learn on an ortho floor. Be a sponge. Good luck.

She does use an SBAR sheet, but it doesn't really help me. I actually made my own which seemed to help.

I made my own too. We use a text paging system, so we are REALLY limited on what we have space to tell. Just the facts Jack.

I give whatever info is important to what the situation is. If it pain related, cardiac relates, DVT, resp, etc. Include VS and important symptoms. and pertinent negatives.