Nursing - Shift Report Forms

RN Shift Report Sheets - New Grad
July 8, 2017 – 01:25 pm

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Congratulations on your new position! Welcome to the world of SICU nursing!
Actually, shift reports are the end product of what you did and accomplished for the past 8-16 hrs. with a brief history of how and why your patient got to the ICU.

I found it helpful to write down the following at the beginning of my shift, and added on info throughout my day. This ended up as my shift report:

-Med hx. of patient. Physical findings. i.e, Head to toe assessment ..heart, lungs, etc.
-Labs (past, present, and future labs to be done) their values, and what you did to correct them.
-IV drips, and if you titrated up or down and why? (Its always nice to have another drip mixed up and ready to go for the oncoming shift if you are running low.)
-Vent mode and settings, and any changes throughout your shift.
-Blood gasses (ABGs) and what you did to correct them.
-Lines- art lines, PA caths, cordis, bladder pressures, TLCs, peripheral IVs sites, etc. - where they are located, the condition of them, and when the dressings were last changed.
-Tubes and drainage from JP bulbs, hemovacs, foley caths, penrose drains, colostomies, iliostomies, wound vacs, chest tubes, rectal bags/tubes, etc. And their drainage amount and complications, clots?.
-I&Os .. any abnormal values? Are we on the right track with fluid balances?
-Sedation- what titration worked? Was a daily awakening done? How did that go?
-What are the CVPs, PA pressures, BPs, ICPs ..What are the goals?
-Skin condition- especially in trauma patients..rashes, incisional sites, trach sites, road rashes, stab sites, gunshot wounds etc. and the dressing changes you have done and what time you did them.
-Family- Who is the primary decision maker, any issues?
-CRRT? What are the replacement fluids, settings, dialysate, any issues with the machine clotting off?
-Surgeries- When they last had surgery, when are they due to do again. SICU pts may have surgeries every day or every other day.
-Road trips- CT scans, MRIs, Nuclear med scans, xrays, angiograms, ultrasounds, etc. Let the oncoming nurse know what the results were, when they were done, and when they are due to do again.
-Supplies- If your patient has an open abdomen, or any complicated wound with a washout due every day or every other day, your room will need plenty of supplies. I always let the oncoming shift know what supplies I have on hand and what I ordered. Its difficult to go scrambling for stuff when you are in a hurry.
-Fluids, blood products given, how much and why?
-What is the plan? What was discussed at rounds?

See also:


Source: allnurses.com
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