Practical Nursing Diploma Program - Semester 2 Labs

Start of Shift Assessment

Prior to or during report……...

Check the Kardex for……….

• allergies

• specimens to be collected

• lab work (fasting??)

• medication times

• dressing times

• treatment times

Check the Kardex for…..

• radiology or other tests booked

• diet

• IV therapy (solution, rate)

• fluid balance requirements (I&O)

• restrictions (diet, fluid, ambulation)

• O2 orders

Check the Kardex for…..

• presence of tubes, drains

• presence of bowel or bladder diversions

• cognitive status

• Isolation measures

• other safety measures

• positioning requirements

Check the Kardex For….

• religion

• DNR status

• V/S requirements (how often)

• activity level

• any scheduled events/visit for that day/shift ie. sutures to be removed, physio, chaplain visits etc.

Check the Chart for……...

• recent orders

• changes to meds

• new tests ordered

• review charting for last few shifts

• review multidisciplinary notes

• review recent lab work

• review recent radiology reports

Check the chart for….

• review doctors notes from past few days

• check back at least one week

• check fluid balance if pt on I&O

During report……….

• listen for changes from previous

• note significant information

• don’t be afraid to ask questions but make sure the info isn’t in the Kardex or chart already!!!!!

• write down last vital signs, TBA in IV, any concerns from previous shift

• Cluster information

Use or create a worksheet…..

• standard forms on some units• if not, create one that works for you• use it to note information gathered during

report and information that you collect during the shift ie. Vital signs, PRN meds given, concerns or problems encountered, samples collected etc.

• this help when you chart and give report at end of shift

Be Prepared

• Be organized and take equipment with you

Safety first...……...

• bedrails up if required and secure

• name over bed matches armband

• allergies noted above bed and on armband if appropriate

• call bell within reach

• floor area dry and uncluttered

• necessary items within reach - kleenex, bedpan,urinal,water etc. as appropriate

• restrictions noted above bed ie.NPO

• bed at appropriate height

• no sharps (needles etc.) in bed or at bedside

• no meds at bedside

• lighting appropriate and safe

Comfort second……….

• bed dry and intact

• bed alarm on if appropriate

• pt warm/cool enough

• sheets not wrinkled under pt

• pt in comfortable position (not left on bedpan………)

• pt states is comfortable or if unable to verbalize, at least appears comfortable

Now for the assessment in 5 minutes or less…….

ABC’s………...

• Airway

• Breathing

• O2 in use? - correct rate, check tubing from pt to O2 source, correct delivery system (mask vs. prongs)

• Chest assessment

• Circulation - check peripheral CSM and pulses

LOC……….

• if pt awake, is he oriented?

• drowsy, alert, confused?

• does your observation match what you heard in report

• remember some people are slow to wake up

Focused Assessment

Depends on the diagnosis• Surgical

– Orthopedic vs abdominal?

• Medical– Pneumonia vs stroke?

• Mental health– Depresssed vs manic?

• Maternity• Child

Tubes, Tubes, Tubes……..

• IV - correct solution & rate

- check label for additives

- correct TBA from shift report

- site intact

- check tubing from container to pt

- check that pump is plugged in and

programmed correctly if in use

• Feeding tubes - correct solution

- correct rate

- connected to pt???

- requires flushing???

- pump plugged in and

programmed correctly

- correct TBA from report

• Catheters - intact

- insitu

- draining

- colour/clarity

- amount in drainage bag

- not twisted or kinked

- drainage bag closed

Dressings and Drains……..

• dressing dry and intact

• drains attached to appropriate equipment

• hemovac or other suction devices intact and compressed if ordered

• ostomy bags intact and not overfull

• sutures/staples intact if observable

• drainage tubes not kinked or twisted

Other things to observe……...

• if pt in traction, is it correct and intact?, are weights hanging freely?

• is pt positioned according to guidelines if required (ie.post hip replacement)

• pain?

• bowel sounds/flatus

• any other tubes - chest tubes etc intact, connected, not kinked etc.

Before you move on to your next patient……..

• INTRODUCE YOURSELF AND EXPLAIN WHAT YOU WILL BE DOING WITH/FOR THE PATIENT THAT SHIFT!

• determine if there is anything you must do for this patient prior to leaving

• explain the plan for the morning if appropriate

• set pt up to wash self if able

• tell pt when you will be back and STICK TO THE PLAN!

• let the patient know who his/her other caregivers might be for the shift

• let the patient know if blood work is being drawn and if he/she needs to be NPO