Nursing faculty teaching resource
Outgoing nurse case brief
A shift handoff
It is 7:00 p.m. on 5 West. You are Casey Nolan, RN, giving report to Dana Whitfield, RN, at the nurses' station. An item of care is still due after your shift ends.
- Patient
- Diane Foster, 68 years; fictional MRN 730516
- Location
- 5 West, room 521
- Admission
- Postoperative day 1 after laparoscopic cholecystectomy for acute cholecystitis. Observation continues after nausea and limited oral intake; discharge awaits intake and mobility review.
- History / status
- Hypertension; no known medication allergies; full code
- Latest assessment
- At 6:15 p.m.: alert, oriented, no nausea or dizziness; incisions clean and dry. Pre-dose pain 4/10 at the incision with movement; patient goal 3/10 or less.
- Recent medication
- Acetaminophen 650 mg orally at 6:15 p.m., administered under the existing order.
- Mobility / intake
- Tolerating oral fluids. Fall precautions and one-person assistance for walking under the current care plan.
| Observation | Recorded at 6:15 p.m. |
|---|---|
| Blood pressure | 128/76 mmHg |
| Heart rate | 82/min |
| Respiratory rate | 16/min |
| Oxygen saturation | 97% on room air |
| Temperature | 98.6 °F (37.0 °C) |
Reassess pain at 7:15 p.m., one hour after the oral dose. Assist with toileting when requested; check pain and dizziness before standing and provide one-person assistance. If pain remains above the goal, reassess and contact the covering surgical clinician for review of the pain plan. Promptly report new or increasing abdominal pain, fever, vomiting or changed vital signs; use the emergency pathway for deterioration.
The patient requests help to the bathroom when needed. A daughter asked about visiting tomorrow. This excerpt is not the complete medication record.