Basic Standard Nursing Report by Nurse Howie

Basic Nursing Report

These are just the basics of nurse reporting

DEMOGRAPHICS

• help us focus on which patient and what room we’re talking about
  • name
  • age
  • gender
• code status
• allergies
• attending
  • specialists are extra
• isolation

EVENTS

• how did the patient get here
• what have we done so far?

MEDICAL HISTORY

• relevant info pertinent to this visit
• don’t bother w/hypertension or hyperlipidemia (personal thoughts)
  • you’ll also be talking about blood pressure later

HEAD to TOE

Systematic review

• Neuro
  • alertness & orientation, what is their baseline?
  • temperature
  • behavior
  • PERRL
  • moves all extremities?
  • pain, pain meds
    • (sedation is for ICU)
    • controlled meds are important to note (often a source of license removal)
  • seizure precautions?
• Cardiac
  • rhythm
    • (not all are going to be on a cardiac monitor)
  • rate
  • blood pressure
  • pulses
  • any heart failure? (common)
• Respiratory
  • how are they breathing generally?
  • are they on a breathing apparatus or use O2 support?
  • are they doing better, the same, or worse after getting breathing treatments (if applicable)?
  • If they are getting worse, is there a risk or are you planning to intubate?
• GI
  • diet & provisions
  • swallowing issues
  • appetite
  • last bowel movement
  • diabetes & insulin requirements, if any!
• GU
  • how do they urinate? Via purewick or Foley?
  • how much do they urinate?
    • oliguric, anuric, good output?
• Skin
  • any previous skin issues? (did they come from a SNF, etc)
  • have pictures been taken of the wound
  • was skin inspected by two RNs
  • how many wounds are there
  • can they turn themselves or do you need help to clean them
• Musculoskeletal
  • ambulation: can they walk safely?
    • if so, how much assistance do they need
    • if not, how long are they going to be on bedrest?
      • how is ambulation going to be advanced (PT, OT, rehab)?
  • are they a huge fall risk?
    • how are we adjusting for this fall risk and maintaining safety
• Labs
  • abnormal labs
  • labs you have to draw during this shift
• IV Meds & Access
  • which part of the body
  • do you need to insert a new one?
  • are there any continuing infusions or drips running? (You’ll check for yourself if an IV bag is running out)
  • are there high-risk medications that have to be handed off and verified between the two shift change nurses?
• Family
  • is family involved?
  • are any of them going to be a problem to patient care?
  • are they anxious, in denial, accepting?
  • are the social workers, case managers, discharge planners involved in issues that may affect your care (such as DNR, advance directives, financial issues, DRAMA, who you can divulge information to)
  • know which family members are not allowed to visit or not allowed to divulge info to, if this is what the patient requests

EXTRA

• Know which patient may be able to downgrade
  • where are they transferring?
  • do you think they can be discharged?
    • if so, where