AM& PM UNIT ROUTINE

Receiving Assignments

1. Get patient assignment from the assignment board.

2. Obtain report on your patients from the night nurse at the nurses' station.
3. During report, focus on the patient's current problems, nursing care plan, vital signs, I&O,
Lab reports, daily weight, and chart.
4. Check the patient, IV, tubes, etc. Assure each patient has an armband and allergy band Label
pumps and lines.

Assessment & Reassessment

5. Complete a head to toe assessment on each patient--note on flow sheet in designated areas.
6. Measure VS and record it in medical records every 6 hrs. ( 4 times per day ).
7. Daily and when needed assist patients with oral care and personal Hygiene.
8. Prepare patients for breakfast and ensure that he received his meal.

Patient care

9. Freshen linens and straighten bedside as needed.

10. Do wound dressing as per physician order.
11. Assist patients back to bed and help them get comfortable.
12. Make rounds with physicians on your patients.
13. Ensure the patency of peripheral or central lines every shift.
14. Any patient on patient controlled analgesia (PCA) should have 2 peripheral lines .
15. Continuously monitor your patient's on going status--IV's and I&O, ECG, presence or absence
of pain.
16. Order supplies and equipment as needed for the patient..

Documentation & medical record review

17. Obtain and record the vital sings and assessments as ordered.
18. Complete a “focused” assessment and chart on Flow Sheet
19. .Record all observations; including activity tolerance, I & O, and percentage of meal taken in
designated forms and flow chart.
20. Compare the Physician’s Order sheets and the medication schedule for accuracy.
21. Prepare Medication and obtain Double check from the charge Nurse (CN).
22. Review medications and note /write down in the medical record Medication not given or hold
and notify MD.
23. Prepare patient for radiological studies or for special procedure.
24. Recording any change in patient condition.
25. Complete the preoperative checklist and sign both assigned nurse & CN or HN
26. Review physician order sheet every 2 hrs. in the medical record
27. Recording medical supplies correctly.
28. Medical record review every shift ( SN/CN and HN)

Reporting
 AM& PM UNIT ROUTINE

29. Immediate reporting abnormal values (critical value).

30. Immediate reporting of any change in patient condition.
31. Initiate code blue when needed.
32. Immediate reporting of any adverse drug reaction.
33. Immediate reporting of blood transfusion reaction and follow the policy.

Patient and Family Education

34. Encourage patient to move out of the bed as ordered and when needed
35. Encourage/instruct your patient on using incentive spirometer especially after open heart
Surgery.
36. Ensure that the patient received and answered for all needed inquiries.
37. Initiate patient education at the bedside for medication, nutrition and activity of daily living
(ADLs) before and after procedure or operation.

Dealing with new admission (preoperative patient)

38. Receive patient file with complete data from admission office.
39. Making sure that the patient wear ID.
40. Assess patient history for allergy and apply ID.
41. Measuring VS and do physical assessment.
42. Making sure that the patient is fasting at least 8 hrs.
43. Notify or call Anathesia/ medical / surgical registrar and record time for calling.
44. Drug reconciliation is a must.
45. Checking physician order for preoperative preparation.
46. Completion of preoperative checklist.
47. Follow up lab & Rad. Results considering critical value reporting.
48. Endorse patient with medical file to the OR.

Patient care after operation

49. Receiving patient from OR with operative details even blood transfusion and contraptions.
50. Ensure patient safety while transferring patient to his bed.
51. Ensuring patient contraptions and drains.
52. Measuring vital signs post operatively and record.
53. Checking physician order and start to proceed on it.
54. Informing related physician about availability of patient in the floor.
55. Ensure diet order / medication sheet.