Practical Nursing Program Semester 2 Faculty: Leslie Gifford Practical Nursing Diploma Program - Semester 2 Labs Start of Shift Assessment

Practical Nursing Program Semester 2 Faculty: Leslie Gifford

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


radiology or other tests booked diet IV therapy (solution, rate) fluid balance requirements (I&O) restrictions (diet, fluid, ambulation) O2 orders


presence of tubes, drains presence of bowel or bladder diversions cognitive status orders for restraints??? other safety measures positioning requirements


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


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

LISTEN, DON’T LABEL!!!!!!!!!!!!!


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



When you first walk into the room……...


Safety first...……... bedrails up if required and secure restraints on and intact if appropriate circulation check to restrained limb 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 intact???? respiratory status - is pt breathing???? O2 in use? - correct rate, check tubing

from pt to O2 source, correct delivery system (mask vs. prongs)

V/S assessment - include peripheral pulses if appropriate

check peripheral CSM if appropriate


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 DON’T WAKE UP JUST TO CHECK

THIS UNLESS NECESSARY!!!!!!!!!!


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

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Practical Nursing Program Semester 2 Faculty: Leslie Gifford Practical Nursing Diploma Program - Semester 2 Labs Start of Shift Assessment