practical nursing program semester 2 faculty: leslie gifford practical nursing diploma program -...
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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
Prior to or during report……...
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
Check the Kardex for………. allergies specimens to be collected lab work (??fasting??) medication times dressing times treatment times
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
radiology or other tests booked diet IV therapy (solution, rate) fluid balance requirements (I&O) restrictions (diet, fluid, ambulation) O2 orders
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
presence of tubes, drains presence of bowel or bladder diversions cognitive status orders for restraints??? other safety measures positioning requirements
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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.
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
review doctors notes from past few days check back at least one week check fluid balance if pt on I&O
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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!!!!!!!!!!!!!
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
When you first walk into the room……...
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
call bell within reach floor area dry and uncluttered necessary items within reach - kleenex,
bedpan,urinal,water etc. as appropriate
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
Now for the assessment in 5 minutes or less…….
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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!!!!!!!!!!
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
Feeding tubes - correct solution
- correct rate
- connected to pt???
- requires flushing???
- pump plugged in and
programmed correctly
- correct TBA from report
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
Catheters - intact
- insitu
- draining
- colour/clarity
- amount in drainage bag
- not twisted or kinked
- drainage bag closed
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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.
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
Before you move on to your next patient……..
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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
Practical Nursing Program Semester 2 Faculty: Leslie Gifford
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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