Live Bedside Report Medsurg (Medical surgical)

This is Mr. Thompson he is a 65-year-old patient of Dr. Smith. He is a full code with no known allergies. He was admitted 2 days ago for pneumonia. He is incontinent for urine at times when he gets into coughing spells but aware and will let you know if he needs to be cleaned up and given a new pad for the bed. He has a history of hypertension and usually takes metroprolol for this. He is slightly tachypneic at 22, oxygen is 96%, and he has 2L of oxygen through the nasal cannula. All other vitals and assessments are within normal limits. He is receiving ceftriaxone 1g IV q24h in his left hand IV, which will be due at 1800. He is also receiving LR at 125 through that same 20G IV. He has a cough suppressant ordered PRN if needed. I called the doctor and left a message because he has no medication ordered for his hypertension so if he doesn’t return the call in the next 30 minutes I would try to call again. Do you have any questions?
This is Mr. Blakely and he is a 62-year-old patient of Dr. Cringle. He is a full code with allergies to Sulfa and Zithromax. He is here for a lower left leg amputation postop day 1. He is a Type 2 diabetic and has orders for blood sugars before meals and at bedtime. There is a sliding scale ordered should you need that. His blood sugar has been well controlled in the hospital and hasn’t needed the sliding scale. His blood guar at 1800 was 102. He is continent and using a bedpan or bedside commode with assistance. He is a fall risk and knows not to get out of bed without assistance. He is receiving norco for pain every 4 hours and last had that at 1800 for pain of 6/10. He also has metformin scheduled for 2000. He has an IV in the left AC with LR at 125ml/hr. His vitals are stable and within normal limits. Physical and occupational therapy have been seeing him daily. He is a possible discharge for tomorrow afternoon and has routine CBC ordered for the morning. Do you have any questions?

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Transcript

All right guys. In this lesson, we’re going to go over live bedside report for the med surge unit. What we’re going to do is first watch the scenarios all the way through. Then we’re going to go back and break it down. And then what we don’t want you to do is go watch them again and see if you can figure it out. Then finally at the end, we’re going to go over another scenario all on your own. So let’s get started.

Okay. Chance, this is Mrs. Thompson. She’s going to be your next patient. So she is a 65-year-old female, no known drug allergies and she’s a full code. She’s admitted for pneumonia. The admin was two days ago, so she’s been here for two days. She does have a past medical history of hypertension and no past surgical history. And then her doctor is Dr. Smith. For IVs. She has a 20 gauge in the left hand and she’ll have, LR running through that at one 125, I believe. Yep. So LR at one 125. And then we’ll also be giving her the Cephatriaxone, one gram IV every 24 hours. So the next dose is for you and it’s at eight o’clock tonight. So she’s alert and oriented times four. Her history, as I said, is hypertension and she takes Metoprolol for that.

Her pressures had been running a little high. She was 170 over 88 at my last check. Um, and I actually called the doctor because she doesn’t have any PRN blood pressure meds, so I’m just worried she’s going to spike tonight for you. So hopefully Dr. Smith calls back, but if not, you should probably call in about 30 minutes. All right. So she is 96% on two liters, but right now we’re doing a room air challenge. So I took her off her nasal cannula. She has been slightly tachypnic at 22. Her respiratory rate’s been 22. Let’s see what else I have. Um, she does have some stress incontinence, so when she gets into her coughing spells, she tends to have accidents, but she’ll let you know and it’s easy to clean up. So yeah the only PRN med she has right now is a cough suppressant for the cough. So other than waiting for that return call from Dr. Smith, do you have any questions for me?

Pain? None. No pain. Yeah, pretty good.

Are you okay? Yes. All right. I’m gonna go check on my other patients and I’ll be back to check on you. Okay. Thanks. Bye. You’ve been a great patient. Have a good shift.

All right, let’s break it down and review this report from start to finish.

Okay. Chance, this is Mrs. Thompson. She’s going to be your next patient. So she is a 65 year old female, no known drug allergies and she’s a full code.

All right guys, you want to start with the patient history and the code status. That’s so important. Also getting a little bit of a demographic background has helped.

For IVs. She has a 20 gauge in the left and she’ll have LR running through that at one 125 I believe. Yep. So LR at 125 and then we’ll also be giving her the Cephatrixone, one gram IV every 24 hours. So the next dose is for you and it’s at eight o’clock tonight.

The next thing you should think about is what are your immediate plans of care and things that are going on with the patient. So for this patient, they’re getting fluids and they are getting antibiotics.

Her pressures had been running a little high. She was 170 over 88 at my last check. I actually called the doctor because she doesn’t have any PRN blood pressure meds.

Anytime you’re giving a reporter taking report, if you can help out your fellow nurse in advocating for your patient, like for this, for instance, this patient may need blood pressure medications to regulate her high blood pressure. So talking to that oncoming nurse or talking to the offgoing nurse about any concerns that you have for the patient is imperative.

All right. So she is 96% on two liters, but right now we’re doing a room air challenge so I took her off her nasal cannula and then she has been slightly tachypneic at 22.

The thing you want to do here at this point in a report is to do a review of the systems. You want to do them systematically starting with neuro cardio-respiratory, skin and musculoskeletal. We have lessons on how to give report and how to take report in reviewing the report sheet, which is really, really important. So check those out. But here is where you review all those systems.

Other than waiting for that return call from Dr. Smith, do you have any questions for me?

Here is your opportunity to ask questions. This is the most important time for you to address questions with the patient and also the opportunity to do any followup that you need to with that nurse. The other thing that you can do at this point is also to review the chart. That’s a great opportunity to go over the chart and find any sort of discrepancy or questions and answer them before you even get started with your day.

Pain? None. No pain. Excellent. Alright. Are you good? Are you okay? Yes. All right, I’m gonna go check on my other patients and I’ll be back to check on you.

Okay, thanks. Bye. You’ve been a great patient. Have a good shift.

Now it’s your turn. Watch the following scenario and figure out what you need to make sure that you start your day off right with a successful report.

I’m just going to go over everything that’s going on and then we’ll go over your plan of care and if you have any questions then we can go over that. Okay? All right. So this is Mrs Blakely. She’s a 62 year old female. She’s a full code and she has allergies to sulfa and Zithromax. The doctor is Kringle. Her main issue is that she was here for a left above the knee amputation. She status post op day one. Her history, she’s got a type two diabetes. She does have a sliding scale. We haven’t had to use it cause her last sugar at 1800 was 102. Nice. Okay. neuro, she’s alert and oriented. Her cardiac concerns is that she’s got the only thing there is she’s got LR at 125 going to a 20 gauge in the left AC. Alright, everything is fine in terms of skin.

So she has the stump dressing, it’s clean, dry, intact. There’s an order for the surgeon to take it down tomorrow. Perfect. So her pain is moderately controlled. The last uh, pain rating she gave us six out of 10 and she’s getting oral Norco at five and she got the last one she got was like an hour ago. Okay. Sounds good. Do we have anything IV to give her or no? I don’t. We would have to call him if we need that. The plan for her is PT and OT are coming by tomorrow to work with her. She does have a do not get out of bed order and she knows that because she understands that we’ve got to get used to moving out of bed. Okay. But the plan is discharge tomorrow. Perfect. Cool. All right. Do you have any questions? No, I don’t think so. All right. I’ll be back in a little bit. Okay, thank you. Bye.