Nursing

By angelac4531 on Feb 26, 2007 | Reply

Student nurse here, graduating in Dec, ‘07, but I can tell you what I want to know when I get a patient. First of all, are your patients adult or peds? It may be important to know, if peds, when the patient was last changed and fed.
I may miss a few things, but these are the highlights.
- VS schedule
- I/O schedule
- Any drains
- Any dressings needing changed and location
- Activity schedule
- Diet schedule/NPO?
- IV location
- IVFs running and what rate
- Family situation- at bedside, arriving soon, etc.
- Any special information regarding recent surgery or upcoming tests/surgery, what prep is needed (if any), etc.
- Labs needing drawn
- When pain meds last given and when they can be given again (NA wouldn’t be administering, but would be able to alert the RN as to pt need; also NA can remind pt that the pain med may not yet be available if they know the schedule).

As far as how much space is needed on a report sheet, I’d say one half sheet per patient with the information on front would be more than plenty. That would give NAs the chance to take extra notes on the back.

You may want to employ this type of sheet as a “Safe Handoff” for every nurse so that if you are giving your assignment to another nurse or splitting them between several, OR if your patient is leaving your unit and being transferred to another, you can give the same information to everyone. I’m not sure the purpose of not sharing the same information with the Nursing Assistants that you would share with your fellow nurses is, to be honest. I like to know everything that is going on with my patients as a student nurse so that I can be ready for whatever is going on. I can double check the patient’s fluids, the tubing, the rate, etc., and make sure they’re getting the right things and if not, I can alert my RN and she can take care of it so that the patient either gets what they are supposed to get or not get something that they aren’t. Why is there a need to differentiate the given information between the different levels of practice if you’re going to rely on their help and their attention to detail to help you through your shift? I realize that RNs, LPNs, NAs, student nurses, techs, etc., all have different roles and have different capabilities, but the information shared could be the exact same, thereby alleviating the need to create different forms for different folks.

If you already have that type of sheet available for RN to RN or unit to unit transfers, you may save yourself some time by gathering the information for your NA report sheet from there, or just using that particular sheet instead of reinventing the wheel.
Personally, I keep my patients’ kardexes in my pocket with report notes on it at all times and fold them so that I can put my VS/I&O schedules, diet, activities, etc. on the flip side so that I can see everything at a glance, or open it up and get more details from the notes. Just my personal preference, but your facility may not allow that sort of thing… I don’t know.

I think it’s great that you’re trying to make your unit more efficient and helping out your NAs/student nurses. Wish I worked with you.
Good luck!!

By zzzzz on Mar 1, 2007 | Reply

Nursing assistant assignment sheet- that I have used for 40 years in both hospitals and nursing homes
pt. name
dx.
room and bed #
primary language spoken
needed for dentures glasses or hearing aids
allergies
diet
any fluid restrictions
specific assistance in adl’s- dressing-feeding-bathing- toiletting etc.
siderails in bed Y-1or2 –N
continent or incontinent- diaper needed?
foley - foley care
# of staff need for transfer- or assistive devices need for transfer
any assistive devices used in wheel chair or ambulating or if patient needs assistance to ambulate or to propel wheel chair
any splints braces or prosthesis
Ted stockings or ace bandages application when oob
if patient is on falls precautions
if patient has any skin breakdown or redness due to immobility
need for positioning devices in wheel chair or bed
head of bed to be elevated at__ degrees when in bed
if on isolation which type
if pt. is prone to choking on foods or liquids
presence of any wounds-sutures-drains or dressings and care of same
if present any redness drainage or odor present and color of drainage
pt. resistive or combative with care Y or N
if pt. can verbalize needs

info on any active or passive R.O.M. with number of times a day and # of repetitions ( include site i.e. uext-lext or all ext.)
if pt. goes to P.T.or O.T. what time they are scheduled for
# of times B/P, T.P.R. per shift and if any site is restricted for B/P (as in a shunt site)
I&O as ordered
turning and positioning schedule
and anything else that is specific or unique to the care of that pt.
it can be a standard form with general information either checked off or written in
with room on back for anything else either you or they need to write in