Shift Handoff Report — Medical-Surgical Unit 4B
Date: March 18, 2025
Shift Transition: Day Shift (0700–1500) to Evening Shift (1500–2300)
Outgoing Nurse: RN Taylor Briggs
Incoming Nurse: ________________________
Shift Start Time: 1500
Unit Context
This handoff is conducted on Medical-Surgical Unit 4B at Lakeside Medical Center, a Joint Commission accredited facility. All handoffs follow I-PASS protocol implementation per NPSG.02.05.01. Unit 4B is currently under Patient Safety Committee performance improvement monitoring following a 2024 sentinel event review that identified communication failures during shift transitions. A recent audit found 40% of handoffs lacked structured documentation. This report uses the I-PASS framework (Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver) to ensure standardized communication of critical patient information.
Patient Handoff Summary
Room 312: Mr. David Kowalski
Illness Severity: Moderate to high acuity
Patient Summary:
- Age: 68
- Diagnosis: COPD exacerbation, admitted 3/16
- Vital Signs (0600): BP 148/92, HR 98, RR 24, SpO2 91% on 3L O2
- Vital Signs (1400): BP 152/94, HR 104, RR 26, SpO2 89% on 3L O2
- Respiratory Status: Increased work of breathing noted at 1400, using accessory muscles
Action List:
- Monitor respiratory status closely; oxygen saturation has declined from 91% to 89% despite supplemental oxygen
- Assess for signs of respiratory distress (nasal flaring, retractions, tripod positioning)
- Notify provider if SpO2 drops below 88% or respiratory rate exceeds 28
Situation Awareness:
Mr. Kowalski's condition shows signs of deterioration over the course of the day shift. His increased work of breathing, rising heart rate, and declining oxygen saturation suggest worsening respiratory compromise. He has a history of multiple COPD exacerbations requiring ICU admission in the past year. Family is aware of his current status and expressed concern during afternoon visit.
Room 313: Ms. Angela Torres
Illness Severity: Low to moderate acuity
Patient Summary:
- Age: 52
- Diagnosis: Cellulitis, left lower leg, admitted 3/17
- Medication Due: Vancomycin 1g IV due at 1600
Action List:
- Administer scheduled antibiotic on time to maintain therapeutic levels
- Monitor IV site for patency before administration
- Assess left lower leg for changes in erythema, warmth, or edema
Situation Awareness:
Ms. Torres is responding well to IV antibiotic therapy. Erythema margins were marked at admission and have not advanced. She is afebrile and reports decreased pain in the affected leg. She is ambulatory with steady gait and has been independent with activities of daily living throughout the shift.
Room 314: Mr. Samuel Okafor
Illness Severity: Low acuity
Patient Summary:
- Age: 59
- Diagnosis: Pneumonia, admitted 3/16
- Vital Signs (1400): BP 118/72, HR 82, RR 18, SpO2 96% on 2L O2
- Status: Stable, ambulating in hallway with assistance at 1300
Action List:
- Continue current plan of care
- Encourage incentive spirometry every 2 hours while awake
- Monitor for changes in respiratory status or fever
Situation Awareness:
Mr. Okafor is progressing well. He completed his antibiotic course this morning and is being transitioned to oral antibiotics. His oxygen requirement has decreased from 4L to 2L over the past 24 hours. He is motivated to ambulate and has been compliant with respiratory therapy. Provider discussed potential discharge planning for tomorrow if he remains stable overnight.
Room 315: Mr. Jerome Patterson
Illness Severity: Moderate acuity
Patient Summary:
- Age: 71
- Diagnosis: Post-op day 1 s/p right total knee replacement, admitted 3/17
- Pain Level: Pain 7/10 at 1300, medicated with oxycodone 10mg PO
- Medication Due: Enoxaparin 40mg subQ due at 1700
Action List:
- Administer scheduled DVT prophylaxis on time
- Reassess pain level 1 hour after last dose of oxycodone
- Assist with first physical therapy session scheduled for 1800
- Monitor surgical site for bleeding, swelling, or signs of infection
Situation Awareness:
Mr. Patterson is post-operative day 1 following right total knee replacement. He has required frequent pain medication throughout the day shift, with pain levels ranging from 5/10 to 7/10. He has not yet ambulated but is scheduled for his first physical therapy session this evening. He has been using the incentive spirometer as instructed and has no signs of respiratory compromise. Surgical dressing is clean, dry, and intact with minimal serosanguinous drainage noted on last assessment.
Contingency Plan: [blank]
Room 318: Mrs. Linda Huang
Illness Severity: Low to moderate acuity
Patient Summary:
- Age: 64
- Diagnosis: Type 2 diabetes, hyperglycemia management, admitted 3/15
- Glucose (0900): 182 mg/dL
- Glucose Trend: Trending down from 210 mg/dL at 0600
- Vital Signs (1400): BP 128/78, HR 76, RR 16, SpO2 98% on room air
- Medication Due: Metformin 1000mg PO due at 1730
Action List:
- Administer scheduled oral hypoglycemic agent with evening meal
- Monitor blood glucose per sliding scale protocol (next check at 2100)
- Reinforce diabetic diet education and carbohydrate counting
Situation Awareness:
Mrs. Huang's blood glucose levels are improving with medication adjustments made by the endocrinology consult team. She has been compliant with diabetic diet and has attended two diabetes education sessions with the certified diabetes educator. She is eager to learn self-management strategies and has been practicing blood glucose monitoring independently. No signs of hypoglycemia or hyperglycemia noted during day shift. She is hemodynamically stable and has been ambulating independently without assistance.
Action List Summary — Medications Due Within Next Hour
| Time | Patient | Room | Medication |
|---|---|---|---|
| 1600 | Ms. Angela Torres | 313 | Vancomycin 1g IV due at 1600 |
| 1700 | Mr. Jerome Patterson | 315 | Enoxaparin 40mg subQ due at 1700 |
| 1730 | Mrs. Linda Huang | 318 | Metformin 1000mg PO due at 1730 |
Synthesis by Receiver
[This section is to be completed by the incoming nurse after receiving the handoff. Use this space to summarize your understanding of patient priorities, clarify any questions, and confirm the action plan for the evening shift.]
Confidentiality Notice: This document contains protected health information under HIPAA regulations. Unauthorized disclosure is prohibited. This handoff report is intended solely for clinical communication between healthcare providers involved in direct patient care on Medical-Surgical Unit 4B.
Outgoing Nurse Signature: ________________________ Date/Time: ____________
Incoming Nurse Signature: ________________________ Date/Time: ____________