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: ◦

DemographicsROOM #, Pt name, sex, age DiagnosesPrimary, Secondary, Nrsg and medical dx, admission date, surgical date Pt statusDNR 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 toleration Oxygen rate, route; Other tubes: eg: chest tubes, NG tubes, foley (type and drainage Abnormal lab and test values Labs and tests to be done on oncoming shift Treatments done on your shift (dressing changes) and other procedures Identify treatments to be done during next shift

Expected shift outcomesPriority outcomes for one or two nursing diagnoses Patient learning outcomes Plans for dischargeExpected date of discharge Referrals needed Progress toward self-care and readiness for home Care supportAvailability of family or friends to assist in ADL Priority interventionsInterventions 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