Clinical Focus: Shift Assessment

Learning Objectives:

  1. Identify the data to collect the day prior to care and the source of the data.
  2. Identify methods of preparation for nursing care.
  3. Describe the components of a daily shift assessment.
  4. Correlate the elements of the shift assessment with decision-making and planning for the patient's care.
  5. Describe the data to be collected in each category of PERSON or Functional Health Patterns.
  6. Compare the data in the shift assessment to the data in the nursing admission assessment.
  7. Compare the physician's history and physical exam to the nursing physical exam.
  8. Describe how NAMC implements problem oriented nursing records.
  9. Use the computer to document the patient's daily shift assessment.
  10. Use critical thinking skills to make decisions about assessment.
  11. Identify teaching needs related to assessment.
  12. Work effectively with the health care team to communicate assessment data.
  13. Discuss the use of material and human resources to assure effective, comprehensive assessment.
  14. Discuss ethical principles and legal guidelines for the collection and discimination of assessment data.

Learning Activities:

Review module objectives.
Read: Assigned patient's chart
  • Use your text to identify the expected signs and symptoms of your patient's illness, signs and symptoms of complications.
  • Plan for a head to toe shift assessment

Clinical Homework will vary depending on your instructor. Check with your clinical instructor about requirements for paperwork.

Each category of PERSON should have history, current assessment, medications, diagnostic tests.

Diagnostic tests should include:

    • P: none; might be a blood level for psyche drugs; CT scan of the head
    • E: BUN and Creatinine (even if normal; or say not done on this admission)
    • R: Pain scale, liver function tests
    • S: cultures, blood level for seizure meds
    • O: Na, K, EKG, Chest xray, H&H, pulse oximetry
    • N: BMI , blood glucose for diabetics
Review module objectives and check for knowledge gaps.
In post conference share information about your patient with other students. Clarify concepts. Review diagnostic tests that were done on your patient.