B. Shift Hand Off Report, Assignments, Making Patient Care Rounds

BEFORE A PLAN is made for the shift, THE SHIFT HAND-OFF REPORT can lead to a smooth and effective start to the new shift.

WORST CASE SCENARIO: leaves the oncoming shift with inadequate or old data on which to base their plan

JOINT COMMISSION included a standardized approach as one of it’s patient safety goals as far back as 2006

Given face to face seated or walking

How will you collect data differently? How will you organize your data differently? In the precepted clinical you will be using

the Data Collection Form found on the NRS 240 course information part of the following web site:◦ http://www.mccc.edu/~martinl/

Demographics ROOM #, Pt name, sex, age

Diagnoses Primary, Secondary, Nrsg and medical dx, admission date, surgical date

Pt status DNR status, current VS, problem with ABC’s, LOC, or safety, oxygen sat, pain score, skin condition, activity, fall risk, suicide risk, presence/absence of S&S of potential complications, new orders/changes in tx plan

Fluids/tubes/oxygen/laboratory tests and treatments

IV fluid, rate, site;Tube feedings – type of tube, solution, rate, and pt tolerationOxygen rate, route;Other tubes: eg: chest tubes, NG tubes, foley (type and drainageAbnormal lab and test valuesLabs and tests to be done on oncoming shiftTreatments done on your shift (dressing changes) and other proceduresIdentify treatments to be done during next shift

Expected shift outcomes Priority outcomes for one or two nursing diagnosesPatient learning outcomes

Plans for discharge Expected date of dischargeReferrals neededProgress toward self-care and readiness for home

Care support Availability of family or friends to assist in ADL

Priority interventions Interventions that must be done this shift

Oncoming nurse needs to make initial rounds on the patients at risk for life threatening conditions or complications first performing rapid assessments

CHANGES COME UP: eg: a pt with asthma who had been calm and without respiratory distress on the previous shift may have experienced a visitor who wrote perfume and delivered bad news. As the nurse makes a quick ABC’S assessment it is determined that the pt has suddenly developed respiratory distress. Nurse has to be flexible and change priorities from providing comfort needs to providing life threatening nursing interventions