Begin your shift by receiving the handover report from the previous nurse. This report will provide you with important information about each patient, including their current condition, any changes in medication or treatment plans, and special instructions. Use this information to ensure a smooth transition and continuity of care for the patients.
Check patient's vital signs
Regularly check the vital signs of each patient to monitor their overall health and detect any abnormalities. This includes measuring their temperature, blood pressure, pulse rate, and respiratory rate. Pay close attention to any significant changes and report them immediately to the nurse in charge.
Record patient's health condition
Accurately record the patient's health condition during each shift. Take note of any symptoms, changes in vital signs, medication administration, and nursing interventions. This information is crucial for the healthcare team to provide appropriate care and make informed decisions regarding the patient's treatment plan.
Administer morning medication
Administer the prescribed morning medications to each patient according to their individual medication schedule. Ensure accuracy in dosage and delivery method. Follow proper medication administration protocols and document the administration in the patient's medical records.
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Patient A
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Patient B
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Patient C
Provide personal care services
Assist patients with their personal care needs, such as bathing, grooming, toileting, and dressing. Respect and maintain their privacy and dignity throughout the process. Use appropriate infection control measures and provide emotional support to promote the patient's well-being.
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Bathing
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Grooming
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Toileting
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Dressing
Update care plan based on patient's condition
Regularly update the patient's care plan based on their current health condition. Collaborate with the healthcare team to incorporate any changes in treatment or interventions. Document the updates in the patient's care plan to ensure continuity of care and improve patient outcomes.
Approval: Update on Care Plan
Will be submitted for approval:
Update care plan based on patient's condition
Will be submitted
Monitor patient's nutrition intake
Regularly assess and monitor the patient's nutrition intake, including their dietary preferences and restrictions. Ensure that patients receive appropriate meals according to their dietary needs and follow any specific instructions from the healthcare team.
Conduct patient health education
Educate patients and their families about their health condition, medications, and self-care techniques. Provide clear and understandable explanations, answer their questions, and address any concerns they may have. Empower patients to actively participate in their own care and make informed decisions.
Assist doctors during rounds
Accompany doctors during their rounds and assist them with any necessary tasks, such as retrieving patient files, providing information on patients' conditions, and facilitating communication between the doctors and patients. Be prepared to answer questions and provide any required assistance.
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Retrieve patient files
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Provide information on patient conditions
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Facilitate communication
Perform wound dressing if necessary
If there are patients with wounds or dressing changes required, perform the necessary wound care procedures according to the healthcare team's instructions. Follow proper aseptic techniques, ensure proper wound healing, and document the procedures performed in the patient's medical records.
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Patient A
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Patient B
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Patient C
Prepare for any surgical procedures
If there are scheduled surgical procedures, ensure the necessary preparations are made. This includes confirming the patient's identity, verifying surgical consent, preparing the surgical site, and ensuring all required equipment and supplies are available.
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Confirm patient identity
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Verify surgical consent
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Prepare surgical site
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Ensure availability of equipment and supplies
Manage equipment inventory
Regularly check and manage the inventory of medical equipment and supplies. Ensure that all necessary equipment is available, in good working condition, and properly stored. Report any discrepancies or deficiencies to the appropriate personnel to ensure seamless patient care.
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Check equipment availability
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Ensure working condition
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Proper storage
Review patient's lab results
Review and interpret the patient's lab results to identify any abnormalities or changes in their health condition. Follow the appropriate protocols to report critical findings to the healthcare team and document the results in the patient's medical records.
Approval: Changes in Patient's Lab Results
Will be submitted for approval:
Review patient's lab results
Will be submitted
Administer evening medication
Administer the prescribed evening medications to each patient according to their individual medication schedule. Ensure accuracy in dosage and delivery method. Follow proper medication administration protocols and document the administration in the patient's medical records.
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Patient A
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Patient B
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Patient C
Comfort patients during their sleep
Provide comfort and support to patients during their sleep. Ensure a relaxing and conducive environment by adjusting lighting, temperature, and noise levels. Offer assistance with positioning, pain management, and any other necessary comfort measures.
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Adjust lighting
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Control temperature
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Manage noise levels
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Assist with positioning
Prepare reports for the shift
Prepare comprehensive reports summarizing the events, observations, and interventions that occurred during your shift. Include any significant findings, changes in patient condition, and actions taken. Ensure accuracy, confidentiality, and timely submission of these reports to the appropriate individuals or departments.
Handover the charge to incoming nurse
Effectively communicate the patient's condition, ongoing care plan, and any relevant information to the incoming nurse during the shift handover. Ensure a smooth transition to maintain continuity of care and patient safety.
End shift
Complete all necessary documentation, ensure the cleanliness and organization of the work area, and prepare for the handover to the incoming nurse. Reflect on the shift, ensuring all tasks were completed, and communicate any outstanding issues or concerns to the appropriate personnel.
