NURS 3362-Daily Clinical Checklist for Faculty

(Circle any portion not completed)

Professionalism: Uniform/shoes clean, pressed, patch sewn in place, id tag visible and placed above waist; hair/nails/jewelry according to policy, punctual, proper demeanor and attitude Equipment: Stethoscope, pen light, black ink pen, scissors, watch with second hand, measuring device, med books-including IV med book Beginning of shift: Checks chart for new orders, gets report from night staff, selects/notifies instructor if patient discharged, meets day nurse, gets report, discusses patient care for the day with staff nurse Preconference: Thoroughly presents HOPI, CSA, FOC, patho, dx/lab results, identifies correct priority diagnosis and interventions, modifies care as needed Clinical care: VS taken 7a/11a, instructor/nurse notified immediately of abnormal findings Assessment: Thorough head to toe assessment completed, identifies correct IV site and fluids, reports amount remaining, instructor/nurse notified immediately of abnormal findings AM care: Hand care provided before/after meals, mouth care provided before/after meals, patient fed or assisted, bath completed, linen change completed, dressing changes done, turned every 2 hours, glucose check completed before meals Medications: Checks MAR with MD orders, obtains meds correctly, prepares meds correctly comparing with MAR, calculates correct dose, has completed med cards, checks 2 pt identifiers, checks allergies, checks meds with MAR at bedside, places meds in medicine cup, proper technique for injections, maintains asepsis, wears gloves Ongoing assessment: Focused assessment completed every 2 hours, full reassessment every 4 hours, IV site/pain/elimination assessment every 2 hours, chart checked for new orders every 2 hours Teaching: Meds use and side effects, illness management, prevention management, discharge care Safety: Environment of care, bed low position, call light in reach, phone in reach, assistive devices in reach, environment neat and tidy-waste baskets not overflowing Documentation: VS documented on clipboard and graphic sheet by 8a/12n, documents opening assessment by 9a, ongoing assessment documented every 2 hours, completes final documentation by 1p, glucose/SSI amount recorded on diabetic record Organization: Ready to begin on time, completes care on assigned patient by end of clinical time, charting completed when specified, medications given in timely manner, promptly treats patient problems (high BP, pain) Offgoing report: Comprehensive report given to nurse, report given to CNA including I&Os Care Plan: Turned in on time, legible, neat, correct spelling, contains complete information, evaluation completed and modified from one day to next Date and students initials when reviewed Day 1 Day 2 Day 3 Day 4 Day 5

Student________________________________
Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12

DS-draft #1-October 4, 2010

NURS 3362-Daily Clinical Checklist for Faculty

Student________________________________

DS-draft #1-October 4, 2010