Priorities: Airway, Breathing, Circulation & Pain
Introduce Name: “Hi, good morning I’m Donn, your student nurse for today. So, how are
you doing?
“I’ll just adjust the bed to my working level, is that okay?” (SIDE RAIL DOWN,
ADJUST BED TO WORKING LEVEL)
***WASH HANDS***
Ask for two identifiers: “Can I check your arm band please?”
-Can you tell me your name? Your date of birth?”
Oriented x4
‘She is oriented to person, place, time, and self.”
-Do you know where you are right now?
-Do you know what season is it?
-Do you know who I am?
-Do you know your last name?
Medication- “Are you currently taking any medication right now?” (OTC, prescribed,
herbal remedies, mood-altering drugs)
Allergies- “are you allergic to any medication, food, environment, contact with latex?”
I’ll be taking your vitals, okay”
***WASH HANDS***
What are my findings and my descriptors?” (Pulse, Resp, temp, 02 Sat, BP)
DEPENDING ON THE PRIORITY, YOU MAY, DO THE SKILL IF IT REQUIRES
OXYGEN**
Do interventions for MED AND SKILL: “So, I’m going to do a ___________ assessment,
EXPLAIN THE PROCEDURE then ask, “Is it okay if I touch you?”
MAKE SURE TO DO NURSING CARE INTERVENTIONS IN ORG PLAN
***WASH HANDS*** Assessment: Right reason for assessment prior to med admin + special
skill
Do you assessment for med admin + special skill: GI Assessment, Respiratory Assessment,
Cardiovascular Assessment especially (Apical for a full minute), Skin Assessment, Checking
Site.
-If giving med by PO: Assess swallowing ability (give water and ask to take a sip).
Getting the med: “Okay so I’m just going to prepare your medication and I’ll be back in a few
minutes”.
-“Is there anything I can do for you?”
LOWER THE BED TO LOWEST POSITION, PUT SIDE RAILS UP AND CALL BELL IN
REACH
***WASH HANDS***
Going to the medication cart: *WASH HANDS*
VERIFICATION: Verify MAR with Physician Order: Compare it before doing rights.
-Name, Patient ID, DOB, Drug, Dose, Time/Frequency, Route, ALLERGIES, EXPIRATION
DATE.
-INSULIN AND HEPARIN (High alert): ALWAYS COMPARE WITH MAR AND OR
ORDERS.
Pull the med:
-Right patient, drug, dose, time/frequency, route, EXPIRATION DATE, ALLERGIES.
If Oral: put it in a cup & label with NAME, DOB, NAME OF MED AND DOSE.
If Parenteral Medication: label at cover of syringe, don’t touch plunger.
Pulling the medication down after drawing up except for insulin.
SWAB VIAL
Use filter needle for (heparin, ampule) then change needle after.
Use blunt needle for vials then change needle after.
Pull Med Away:
-Don’t put away the vial or container. Do the 3 checks before putting it away.
***GO BACK TO PT’S ROOM***
Introduce again: Hi, Mr. and Mrs. ____ It’s Donn again the student nurse from a while ago and
I’m back with your med.
Provide privacy: close curtains.
Proper Body Mechanics: Raise the bed to working height, side rail down.
***WASH HANDS***
Identifiers: “Can you tell me your name? & Date of Birth?” W/MAR.
4th check in the bedside: “I’m just going to do my 4th check, just give me a few seconds”.
- Right patient, right drug, right dose, right time/frequency, right route.
DO 5 REMAINING RIGHTS
Right reason: This med helps__ to relieve/make it better, to make urinate/void…(etc)
Right Education: “tell the patient that “This can cause (adverse effects)”.
-Do some necessary teachings and ask back what you just told him/her.
-USE LAYMAN TERMS
-ASK “Do you have any other questions”
Right to Refuse: “Are you taking this medication?’
-If PO: Raise the head of the bed (SEMI FOWLER POSITION)
-Administer it with GLOVES If doing parenteral injections.
-Do LANDMARKS (SAY IT)
Right Documentation:
-SIGN THE MAR!!!
Leaving the Client:
***If doing the skills, tell the patient, you are going to come back and grab the equipment
needed***
-LOWER THE BED IN LOWEST POSITION, SIDE RAILS DOWN, CALL BELL IN
REACH.
-Ask: “Do you need anything before I go?”
***WASH HANDS***
Right Evaluation: Can do assessments again, respiratory, GI, Skin assessment, pain assessment
(O, P, Q, R, T, S, U, V) ETC.
-Evaluate the nursing care (skills), medication administration, teaching
-How client-centred outcome would be achieved
-Do Vital Signs
-If Insulin, Check glucose again.
