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……….
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allergies
specimens to be collected
lab work (??fasting??)
medication times
dressing times
treatment times
Practical Nursing Program Semester 2 Faculty:
Leslie Gifford
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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
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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
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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……...
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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
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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……….
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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…..
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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...……...
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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
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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
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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……….
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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………...
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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……….
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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……..
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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
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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
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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……..
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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……...
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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
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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
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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
Practical Nursing Program Semester 2 Faculty:
Leslie Gifford