after change of shift report which patient should the nurse assess first

What is a change of shift report in nursing?

Change of Shift Report in Nursing 1 Change in Practice Assignment: Shift Report. Nurses communicate information about their assigned client at the end of each shift to the nurse working on the next shift. 2 Evidence Supporting the Proposed Change. ... 3 Evaluating the Change. ...

What is the evidence for bedside shift report?

The first research study that supports the evidence for bedside shift report is Translating an Evidence-Based Protocol for Nurse-to-Nurse Shift Report (Dufault et al., 2012).

When should the nurse notify the health care provider?

After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done 9 The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a.

What are the different ways to give end-of-shift reports?

The different ways to give the end-of-shift report vary among institutions, and especially among different units in the same hospital. It constitutes a problem for nurses, particularly when they float from unit to unit (Dufault et al., 2012). Some common types of reports are orally in person, by audiotape, and walking- planning rounds.

Which patient would the nurse need to assess first after change of shift report?

The nurse has received the shift report. Which client should the nurse assess first? Assess the client for abnormal bleeding.

Which client would the newborn nursery assess first after receiving shift report?

The newborn who has chignonYou can view your scores and the answers to all the questions by clicking on the SHOW RESULT red button at the end of the questions. 1. Which client would the newborn nursery nurse assess first after receiving shift report? The newborn who has chignon.

Which of the following should be included in the change of shift report?

Change-of-Shift Report Should: Include significant objective information about the client's health problems. Proceed in a logical sequence. Include no gossip or personal opinion.

Which of the following clients should the nurse assess first?

Which of the following clients should the nurse assess first? *When using the acute versus chronic approach to client care, the nurse should place the priority on the client who has a chest tube and has asymmetrical chest movement because this can indicate a tension pneumothorax.

Who should the nurse see first?

Again, that goes airway, breathing, circulation, safety, then pain, education, and feelings. If we refer to test taking or working on the four, whatever option, whatever patient care, whatever plan you need to implement that becomes closest to a, to airway, is the most important thing. That's what you need to do first.

How do you prioritize nursing questions?

Client safety should take priority, so when analyzing NCLEX questions, think about first meeting the client's basic needs (e.g., oxygen, nutrition, elimination). The answer to many priority questions is often the option that will benefit the client the most, even if it doesn't involve direct nurse-to-patient treatment.

What is included in a nursing change-of-shift report?

It should include the patient's medical history, current medication, allergies, pain levels and pain management plan, and discharge instructions. Providing these sorts of details about your patient in your end of shift report decreases the risk of an oncoming nurse putting the patient in danger.

What happens during nurse shift change?

Change-of-shift report is the time when responsibility and accountability for the care of a patient is transferred from one nurse to another. The communication that ensues during this process is linked to both patient safety and continuity of care giving.

Who is responsible for giving the end of shift report on the unit?

The LPN/LVN is responsible for giving end-of-shift reports. There are several types of reporting systems.

In what order should the nurse assess assigned clients following shift Report place in priority order?

Terms in this set (59) In what order should the nurse assess assigned clients following shift report? Place in priority order.

How do you prioritize patient care in nursing?

Nurses should apply the concept of ABCs to each patient situation. Prioritization begins with determining immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as priority, moving to breathing, and circulation (Ignatavicius et al., 2018).

What is priority in nursing?

Priority setting can be defined as the ordering of nursing problems using notions of urgency and/or importance, in order to establish a preferential order for nursing actions.

After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

ANS: D The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as...

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Milk the chest tube gently to remove any clots. b. Clamp the chest tube momentarily to check for the origin of the air leak. c. Assist the patient to deep breathe, cough, and use the incentive spirometer. d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.

ANS: D The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the fir...

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Review hemoglobin and hematocrit values.

ANS: A Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as...

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. Oxygen saturation is 88%. b. Blood pressure is 145/90 mm Hg. c. Respiratory rate is 22 breaths/minute when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

ANS: A Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax...

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every eight hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

ANS: A UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nurs...

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH) who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse? a. The oxygen saturation is 94%. b. The blood pressure is 98/56 mm Hg. c. The patient's central IV line is disconnected. d. The international normalized ratio (INR) is prolonged

ANS: C The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deteri...

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site

ANS: B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediat...

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the oxygen saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider

ANS: A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first ac...

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

ANS: D Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and cou...

How often should you reposition a patient?

b. Reposition the patient every 1 to 2 hours.

What is the pH of a patient's blood gas after mechanical ventilation?

Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to

What does it mean when your respiratory rate increases?

The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An oxygen saturation of 93% is acceptable and does not suggest that immediate suctioning is needed

What is the oxygen saturation of a patient?

a. The patient's oxygen saturation is 93%.

Why do family members want to remain in the room during CPR?

Research indicates that family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient

Should ICU visitation be individualized?

ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.

When should a patient assessment be scheduled?

scheduled routinely, but it should be done only when patient assessment data indicate the need for

What is the head position of a patient's bed?

The head of the patient's bed should be positioned at 30

What technique does a RN use to suction a patient?

b. The RN uses a closed-suction technique to suction the patient.

How long after mechanical ventilation is initiated for chronic obstructive pulmonary disease?

Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease

What is the temperature of a patient who was extubated in the morning?

a. Patient who was extubated in the morning and has a temperature of 101.4° F (38.6° C)

What is shift report in nursing?

In resume, nurse shift reports are one of the most crucial processes in patient care were patient safety can be improved to reduce medical errors in the U.S.

How to give change of shift report?

It constitutes a problem for nurses, particularly when they float from unit to unit (Dufault et al., 2012). Some common types of reports are orally in person, by audiotape, and walking- planning rounds. Oral reports are given in conference rooms, with staff members from both shifts participating. It has the advantage that they allow staff members to ask questions or make clarifications face to face. By audiotape recording question and clarifications have to be made after listening to the tape report.

What does the evidence say about bedside shift reports?

This study summarizes a systematic literature review of BSRs and serves as a mechanism to relate the support for improving quality of care and patient safety. After strong evidence supporting the benefits of BSR, sustainability is still an issue. As a result, many studies recommend assessing staff attitudes before and after implementation to identify if periodic interventions are needed to sustain desired change in practice. Models of bedside report incorporating the patient into the triad have been shown to increase patient engagement and enhance caregiver support and education. This study analyzed Thirty-three titles divided into six categories: team-based variables, dynamic relationships, individual benefits, confidentiality concerns, accountability and cost efficiency.

What is the first research study that supports the evidence for bedside shift report?

The first research study that supports the evidence for bedside shift report is Translating an Evidence-Based Protocol for Nurse-to-Nurse Shift Report (Dufault et al., 2012). The purpose of this study was standardizing communication practices to reduce the risk of patients in an acute care environment as a result of a gap in communication at the time of the shift report. It focuses on how to translate research into practice model to generate the best-practice-protocol for nurse-to-nurse shift handoffs in a Magnet designated community hospital in U.S.

What is shift report?

The purpose of this assignment is to analyze the effectiveness of the change-of-shift-report at bedside and the implementation of evidence-based practice for an accurate and relevant report.

What is the proposed standardized protocol for the report?

The proposed standardized protocol for the report will use the SBARP format: Situation will review admitting information, problem list, and diagnosis. Background will include a review of past medical history, social history, resuscitation status if any, current orders and medication list. Assessment will be together with the oncoming nurse including validating progress notes and verification of the most recent vital signs. This step will be with nurses already in the patient room. Recommendation will be in front of the patient to discuss what the care plan for the shift is. Patient participation will consider patient concerns and questions.

What does an oncoming nurse do?

The oncoming nurse will review assignment sheet and read information on the computerized reports. At the time of meeting with the off-going nurse, it is necessary to review the information and to add what is not on the computerized report.