Approval: Doctor to review patient's medical chart
6
Attend to patient's needs and comfort
7
Monitor for any changes in patient's condition
8
Report changes to supervising Doctor
9
Administer medical tests if necessary
10
Approval: Lab results by Lab Technician
11
Coordinate with other healthcare professionals
12
Educate patient and family
13
Prepare for and assist with medical procedures
14
Provide emotional support to patient and family
15
Proper clean-up and disinfection of patient's area
16
Document all provided care
17
Shift handover to next on-duty nurse
18
Plan for next day tasks
19
Approval: Nursing Supervisor for day's tasks
20
Restock medical supplies if necessary
Check patient's medical records and history
This task involves reviewing the patient's medical records and history to gain a comprehensive understanding of their health condition. It plays a crucial role in providing personalized care and treatment. By checking the medical records and history, nurses can identify any preexisting conditions, allergies, or previous treatments that may impact the current care plan. The desired result is to ensure accurate and safe care. Key questions to consider: What information should be included in the medical records? How can the nurse obtain the necessary medical records? How can the nurse verify the accuracy of the information?
1
Electronic
2
Paper
Check patient's vital signs
In this task, nurses assess the patient's vital signs to monitor their overall health and detect any abnormalities or changes. It is a critical component of patient care that helps identify potential medical issues and guides treatment decisions. By regularly checking vital signs such as blood pressure, heart rate, temperature, and respiratory rate, nurses can identify any signs of distress or improvement. The desired result is to ensure the patient's stability and timely intervention if needed. Key questions to consider: How often should vital signs be checked? What are the normal ranges for each vital sign? What actions should be taken if vital signs are abnormal?
1
Blood Pressure
2
Heart Rate
3
Temperature
4
Respiratory Rate
Administer medication as prescribed
Administering medication as prescribed by the doctor is a crucial responsibility of a nurse. This task ensures that patients receive the correct dosage, at the right time, and through the appropriate route. It requires the nurse to have knowledge of various medications, their indications, dosages, potential side effects, and administration techniques. Administering medication accurately and following proper protocols is essential to ensure patient safety and positive treatment outcomes. The desired result is the effective delivery of medication according to the prescribed plan. Key questions to consider: How can the nurse verify the medication order? What safety measures should be followed? What documentation is required for medication administration?
1
Oral
2
Intravenous
3
Intramuscular
4
Subcutaneous
Update patient's medical chart
This task involves updating the patient's medical chart with the latest information, including vital signs, medication administration, treatments, and any changes in the patient's condition. Keeping accurate and up-to-date medical charts is essential for effective communication among healthcare professionals and continuity of care. It ensures that everyone involved in the patient's care has access to the most current information. The desired result is a comprehensive and updated medical chart that captures all relevant details. Key questions to consider: What information should be included in the medical chart? How can the nurse ensure the accuracy and completeness of the documentation? How should the nurse organize and store the medical chart?
Approval: Doctor to review patient's medical chart
Will be submitted for approval:
Update patient's medical chart
Will be submitted
Attend to patient's needs and comfort
This task involves addressing the needs and ensuring the comfort of the patient. Nurses play a crucial role in providing physical and emotional support to patients, promoting their well-being, and enhancing their overall experience. This task includes activities such as assisting with personal care, providing pain relief, ensuring a safe and clean environment, and enhancing patient comfort. The desired result is patient satisfaction and improved quality of care. Key questions to consider: What are the common needs and comfort measures? How can the nurse individualize care to meet each patient's preferences? How can the nurse ensure patient privacy and dignity?
1
Assist with Personal Care
2
Provide Pain Relief
3
Maintain Clean Environment
4
Enhance Patient Comfort
Monitor for any changes in patient's condition
This task involves actively monitoring the patient's condition for any changes or deterioration. Nurses must be vigilant in observing and assessing various indicators such as vital signs, symptoms, pain levels, and overall well-being. Early detection of changes is crucial for timely intervention and preventing any complications. The desired result is the prompt identification of any changes in the patient's condition. Key questions to consider: What signs and symptoms should the nurse be alert for? How frequently should monitoring be performed? What actions should the nurse take if changes are identified?
1
Vital Signs
2
Symptoms
3
Pain Levels
4
Overall Well-being
Report changes to supervising Doctor
This task involves promptly reporting any changes or concerns regarding the patient's condition to the supervising doctor. Effective communication between nurses and doctors is crucial for coordinated and timely decision-making. Nurses must provide clear and concise information about the changes observed, their assessment, and any recommended actions. The desired result is the collaboration and involvement of the doctor in the patient's care. Key questions to consider: How should the nurse communicate the changes to the doctor? What information should be included in the report? How can the nurse prioritize urgent concerns?
Administer medical tests if necessary
If the patient's condition requires further investigation or monitoring, this task involves administering medical tests as prescribed. Nurses must follow the necessary protocols and procedures for conducting tests, collecting samples, and ensuring patient comfort and safety. They also play a role in preparing patients for the tests and providing appropriate instructions. The desired result is accurate and timely test results that assist in diagnosing and managing the patient's condition. Key questions to consider: What tests might be required in different situations? How should the nurse prepare the patient for the tests? What precautions should be taken during the testing process?
1
Blood Tests
2
Urine Tests
3
Imaging Tests
4
Diagnostic Procedures
Approval: Lab results by Lab Technician
Will be submitted for approval:
Administer medical tests if necessary
Will be submitted
Coordinate with other healthcare professionals
In this task, nurses collaborate and coordinate with other healthcare professionals involved in the patient's care. Effective teamwork and communication contribute to the overall quality and success of the patient's treatment plan. Nurses may need to discuss the patient's condition, interventions, and progress with doctors, pharmacists, therapists, or social workers. The desired result is seamless coordination and a holistic approach to patient care. Key questions to consider: Which healthcare professionals should the nurse coordinate with? How can the nurse ensure effective communication and collaboration? What information should be shared during coordination?
1
Doctor
2
Pharmacist
3
Therapist
4
Social Worker
Educate patient and family
This task involves educating the patient and their family about their condition, treatment plan, medications, and self-care practices. Nurses play a crucial role in empowering patients and their families with the knowledge and skills necessary for managing their health and well-being. Effective education improves treatment adherence, fosters self-management, and enhances patient outcomes. The desired result is an informed and engaged patient and family. Key questions to consider: What information should be included in the patient and family education? How can the nurse evaluate the effectiveness of the education provided? How can the nurse address language or cultural barriers?
Prepare for and assist with medical procedures
In this task, nurses prepare for and provide assistance during medical procedures. This may involve setting up equipment, preparing the patient, assisting the doctor or other healthcare professionals, and ensuring patient safety and comfort throughout the procedure. Nurses must have a comprehensive understanding of the procedure, its purpose, potential risks, and required precautions. The desired result is a well-prepared and smoothly executed medical procedure. Key questions to consider: What preparations are required for different procedures? How can the nurse anticipate and address potential complications? What role does the nurse play during the procedure?
1
Surgical Procedure
2
Diagnostic Procedure
3
Specialized Treatment
Provide emotional support to patient and family
This task involves providing emotional support to the patient and their family members. Nurses play a vital role in creating a compassionate and supportive environment that addresses the emotional needs of patients facing illness, stress, or significant life changes. This may involve active listening, empathy, therapeutic communication, and providing reassurance. The desired result is improved emotional well-being and coping abilities of the patient and family. Key questions to consider: How can the nurse establish rapport and trust with the patient and family? What are effective techniques for active listening and therapeutic communication? How can the nurse recognize signs of emotional distress?
Proper clean-up and disinfection of patient's area
This task involves cleaning and disinfecting the patient's area according to proper protocols and guidelines. Maintaining a clean and hygienic environment is crucial for preventing the spread of infections and ensuring patient safety. Nurses should follow recommended practices for cleaning surfaces, disposing of waste, and handling contaminated materials. The desired result is a clean and sanitized patient's area that minimizes the risk of infection. Key questions to consider: What cleaning agents and equipment should be used? How frequently should cleaning be performed? How can the nurse ensure proper waste disposal?
1
Clean Surfaces
2
Dispose of Waste
3
Handle Contaminated Materials
Document all provided care
This task involves accurately documenting all care provided to the patient, including medications administered, treatments performed, observations made, and any changes in the patient's condition. Documentation serves as a crucial record for monitoring the patient's progress, facilitating communication among healthcare professionals, and ensuring continuity of care. Nurses should follow established protocols for documentation, including the use of standardized formats and terminology. The desired result is complete and comprehensive documentation that reflects the patient's care journey. Key questions to consider: What information should be included in the documentation? How can the nurse ensure accuracy and timeliness in documentation? How should the nurse store and organize the documents?
Shift handover to next on-duty nurse
In this task, nurses provide a shift handover to the next on-duty nurse, ensuring a smooth transition of care. Effective handover communication is critical for maintaining patient safety, continuity of care, and informed decision-making. Nurses should provide a summary of the patient's condition, recent events, ongoing treatments, and any pending tasks or concerns. The desired result is a comprehensive handover that provides the next nurse with a clear understanding of the patient's status and care requirements. Key questions to consider: What information should be included in the handover? How can the nurse ensure effective communication during the handover? What tools or formats can be used for handover documentation?
Plan for next day tasks
This task involves planning and organizing the tasks and responsibilities for the next day. Nurses should review the patient's care plan, pending tasks, appointments, and any anticipated changes or events that may affect the upcoming shift. Planning ahead ensures preparedness, efficient time management, and a smooth workflow. The desired result is a well-prepared and organized plan for the next day's tasks. Key questions to consider: What tasks and appointments should be prioritized? How can the nurse anticipate and address potential challenges or contingencies? What tools or resources can help in planning for the next day?
Approval: Nursing Supervisor for day's tasks
Will be submitted for approval:
Plan for next day tasks
Will be submitted
Restock medical supplies if necessary
This task involves reviewing and restocking medical supplies to ensure availability for patient care. Nurses should regularly check the inventory of essential supplies such as medications, dressings, equipment, and other consumables. By restocking supplies in a timely manner, nurses prevent disruptions in patient care and maintain a well-equipped healthcare setting. The desired result is a well-stocked inventory that meets the needs of patient care. Key questions to consider: What supplies should be regularly checked and restocked? How can the nurse track and manage the inventory? What should the nurse do if certain supplies are not available?