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Bedside Shift Report Example

Nurse Lia is providing a bedside shift report to Nurse Mari for their patient Mrs. Janice du Terti, a 46-year-old Asian female admitted with nausea, vomiting, abdominal cramping, and weight loss. Lia updates Mari on the patient's history, vital signs, symptoms, IV hydration treatment, and the goal to increase nutritional intake and decrease pain. Mari verifies the patient's current condition and pain level is a 4-5 before both nurses take their leave.

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8lueCzarcasm
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271 views2 pages

Bedside Shift Report Example

Nurse Lia is providing a bedside shift report to Nurse Mari for their patient Mrs. Janice du Terti, a 46-year-old Asian female admitted with nausea, vomiting, abdominal cramping, and weight loss. Lia updates Mari on the patient's history, vital signs, symptoms, IV hydration treatment, and the goal to increase nutritional intake and decrease pain. Mari verifies the patient's current condition and pain level is a 4-5 before both nurses take their leave.

Uploaded by

8lueCzarcasm
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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  • Bedshift Report

Bedshift Report

Lia: *Knocks* *Enters the room* “Good day, Ma’am!”


Mama: Oh hello Nurse Lia.
Me: I would like to inform you that I’m going home now. I have here
with me Nurse Mari who will be your nurse for the next shift. Nurse
Mari is one of the most experienced nurses here and she’s going to take
good care of you.
Mari: Goo day Ma’am! I’m Mari, your nurse for the next shift. *while
holding the wristband* Can you state your name and age, ma’am?
Mama: Janice du Terti, 46 years old.
Lia: I’m about to give your report to nurse Mari. Please listen and you
may ask questions or fill any information that nurse Mari will need to
know to care for you during the shift.
Mama: Okay
Lia: Mrs. Janice du Terti, 46 years old Asian female, came in by
wheelchair from the Emergency department 9:00 in the morning on May
8, 2020 with the reason of having nausea and have been vomiting for 4
days. She’s been experiencing generalized abd cramping and decreased
in normal frequency of defecation and urinary output. Her weight
dropped 5 lbs since she got ill. No known allergies nor prescription
medications but she took Pepto-Bismol, an antidiarrheal that relieves
nausea and stomach discomfort.
For her Vital Signs, temperature is 37.2 degree Celsius which is
afebrile, pulse of 76 bpm, respiration of 20 bpm and blood pressure
which is on the normal level of 110/70 mmHg. She described her abd
cramping as sharp, intermittent and rated it as 6 on a 1 to 10 pain scale.
She has an IV for hydration and electrolyte replacement in her right arm.
Mari: How are you feeling currently, ma’am?
Mama: I still feel nauseated but its less severe now…
Mari: Oh do you want me to reposition you, ma’am?
Mama: Okay *Puts pillow under pt head*
Lia: So, the goal of the plan for today is for the pt to display nutritional
ingestion sufficient to meet metabolic needs as manifested by increased
desire to eat, decreased severity of nausea or vomiting, and lessen abd
pain. For the nursing interventions, we’ll need to further assess the pt to
determine the relationship of her eating habits to onset of nausea,
vomiting or abd pain. We also need to maintain the IV flow rate for her
hydration and electrolyte replacement and continue giving frequent,
small amounts of foods that appeals her to maintain nutritional status.

Lia: So, Mrs. Du terti do you have some questions or want to clarify
something before we leave the room?
Mama: I think you covered everything? No more questions right now.
Mari: Please do not hesitate to give us a call if you need anything and
btw this right here is a pain scale so I can keep track of how your pain is
doing, 0 being no pain and 10 being most painful. What do you say your
pain is at now?
Mama: About 4 or 5
Mari: Is that a tolerable pain for you?
Mama: It’s okay
Lia: Okay good. I’ll be back and Nurse Mari will now take over to take
care of you.
Mama: Okay.
Mari: Take care and we’ll be back!

Bedshift Report Lia: *Knocks* *Enters the room* “Good day, Ma’am!” Mama: Oh hello Nurse Lia. Me: I would like to inform you t
vomiting or abd pain. We also need to maintain the IV flow rate for her hydration and electrolyte replacement and continue g

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