{"id":3233,"date":"2025-03-06T01:45:28","date_gmt":"2025-03-06T01:45:28","guid":{"rendered":"https:\/\/nursehowie.net\/?p=3233"},"modified":"2025-03-06T02:02:46","modified_gmt":"2025-03-06T02:02:46","slug":"3233","status":"publish","type":"post","link":"https:\/\/nursehowie.net\/?p=3233","title":{"rendered":"Basic Standard Nursing Report by Nurse Howie"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Basic Nursing Report<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">These are just the basics of nurse reporting<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">DEMOGRAPHICS<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>help us focus on which patient and what room we&#8217;re talking about \n<ul class=\"wp-block-list\">\n<li>name<\/li>\n\n\n\n<li>age<\/li>\n\n\n\n<li>gender<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>code status<\/li>\n\n\n\n<li>allergies<\/li>\n\n\n\n<li>attending\n<ul class=\"wp-block-list\">\n<li>specialists are extra<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>isolation<\/li>\n\n\n\n<li><\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">EVENTS<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>how did the patient get here<\/li>\n\n\n\n<li>what have we done so far?<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">MEDICAL HISTORY<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>relevant info pertinent to this visit<\/li>\n\n\n\n<li>don&#8217;t bother w\/hypertension or hyperlipidemia (personal thoughts)\n<ul class=\"wp-block-list\">\n<li>you&#8217;ll also be talking about blood pressure later <\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">HEAD to TOE<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Systematic review<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Neuro\n<ul class=\"wp-block-list\">\n<li>alertness &amp; orientation, what is their baseline?<\/li>\n\n\n\n<li>temperature<\/li>\n\n\n\n<li>behavior<\/li>\n\n\n\n<li>PERRL<\/li>\n\n\n\n<li>moves all extremities?<\/li>\n\n\n\n<li>pain, pain meds\n<ul class=\"wp-block-list\">\n<li>(sedation is for ICU)<\/li>\n\n\n\n<li>controlled meds are important to note (often a source of license removal)<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>seizure precautions?<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Cardiac\n<ul class=\"wp-block-list\">\n<li>rhythm\n<ul class=\"wp-block-list\">\n<li>(not all are going to be on a cardiac monitor)<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>rate<\/li>\n\n\n\n<li>blood pressure<\/li>\n\n\n\n<li>pulses<\/li>\n\n\n\n<li>any heart failure? (common)<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Respiratory\n<ul class=\"wp-block-list\">\n<li>how are they breathing generally? <\/li>\n\n\n\n<li>are they on a breathing apparatus or use O2 support?<\/li>\n\n\n\n<li>are they doing better, the same, or worse after getting breathing treatments (if applicable)?<\/li>\n\n\n\n<li>If they are getting worse, is there a risk or are you planning to intubate?<\/li>\n\n\n\n<li><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>GI\n<ul class=\"wp-block-list\">\n<li>diet &amp; provisions<\/li>\n\n\n\n<li>swallowing issues<\/li>\n\n\n\n<li>appetite<\/li>\n\n\n\n<li>last bowel movement<\/li>\n\n\n\n<li>diabetes &amp; insulin requirements, if any!<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>GU\n<ul class=\"wp-block-list\">\n<li>how do they urinate? Via purewick or Foley?<\/li>\n\n\n\n<li>how much do they urinate? \n<ul class=\"wp-block-list\">\n<li>oliguric, anuric, good output?<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Skin\n<ul class=\"wp-block-list\">\n<li>any previous skin issues? (did they come from a SNF, etc)<\/li>\n\n\n\n<li>have pictures been taken of the wound<\/li>\n\n\n\n<li>was skin inspected by two RNs<\/li>\n\n\n\n<li>how many wounds are there<\/li>\n\n\n\n<li>can they turn themselves or do you need help to clean them<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Musculoskeletal\n<ul class=\"wp-block-list\">\n<li>ambulation: can they walk safely?\n<ul class=\"wp-block-list\">\n<li>if so, how much assistance do they need<\/li>\n\n\n\n<li>if not, how long are they going to be on bedrest?\n<ul class=\"wp-block-list\">\n<li>how is ambulation going to be advanced (PT, OT, rehab)?<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>are they a huge fall risk?\n<ul class=\"wp-block-list\">\n<li>how are we adjusting for this fall risk and maintaining safety<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Labs\n<ul class=\"wp-block-list\">\n<li>abnormal labs<\/li>\n\n\n\n<li>labs you have to draw during this shift<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>IV Meds &amp; Access\n<ul class=\"wp-block-list\">\n<li>which part of the body<\/li>\n\n\n\n<li>do you need to insert a new one? <\/li>\n\n\n\n<li>are there any continuing infusions or drips running? (You&#8217;ll check for yourself if an IV bag is running out)<\/li>\n\n\n\n<li>are there high-risk medications that have to be handed off and verified between the two shift change nurses?<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Family\n<ul class=\"wp-block-list\">\n<li>is family involved?<\/li>\n\n\n\n<li>are any of them going to be a problem to patient care?<\/li>\n\n\n\n<li>are they anxious,  in denial, accepting?<\/li>\n\n\n\n<li>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)<\/li>\n\n\n\n<li>know which family members are not allowed to visit or not allowed to divulge info to, if this is what the patient requests<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">EXTRA<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Know which patient may be able to downgrade \n<ul class=\"wp-block-list\">\n<li>where are they transferring?<\/li>\n\n\n\n<li>do you think they can be discharged?\n<ul class=\"wp-block-list\">\n<li>if so, where<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Basic Nursing Report These are just the basics of nurse reporting DEMOGRAPHICS EVENTS MEDICAL HISTORY HEAD to TOE Systematic review 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