THE SHIFT ASSESSMENT

PROCESS
Shift Assessment (Nursing)
At the commencement of every shift an assessment must be completed on
every patient and this information should be used to develop a plan of care.
The Assessment includes:

 Airway: The nurse should look out for the following; noises, secretions,
cough and the use of an artificial airway.
 Breathing: The nurse should look out for the following; bilateral air
entry and movement, breath sounds, respiratory rate, rhythm, work of
breathing, oxygen requirement and delivery mode.
 Circulation: The nurse should check the following; pulses (rate, rhythm
and strength); blood pressure, peripheral temperature, capillary refill
time; skin, lip, oral mucosa and nail bed colour, edema.
 Hydration/Nutrition (In-put): Assess this indicator by determining the
following; appetite, food intolerance, nausea or vomiting, dietary
requirements, route of nutrition (oral, nasogastric, gastrostomy, Jejunal,
fasting/nil per os, special diet, IV fluids).
 Output/Elimination: Assess this indicator by collecting data on the
following; urine, bowel movement, drains and other losses.
 Skin: Assess this indicator by determining the following; Colour, turgor,
lesions, bruising, wounds and pressure injuries.
 Pain: Assess this indicator by determining pain using the pain scale.
 Disability: Assess this indicator by determining the level of
consciousness, and power in limbs.
 Focused assessment: This should be done by carrying out an
assessment of patient’s problem(s) on the shift or any other identified
issues, e.g. Cardiovascular, respiratory, gastrointestinal, renal, eye, etc.
 Risk: The nurse must conduct a risk assessment to determine whether
the patient or client could be potentially at risk of developing adverse
outcomes in care.
 Wellbeing: Assess this indicator by determining the following; Mood,
sleeping habits, coping strategies, reaction to admission
 Social support: family/ guardian, preparations towards discharge.
 Review the medical record: The nurse must at all times read the
patient’s folder to understand the progress of the disease and the
human response to the disease.
Shift Assessment (Nursing)
At the commencement of every shift an assessment must be completed on
every patient and this information should be used to develop a plan of care.
The Assessment includes:

 Airway: The nurse should look out for the following; noises, secretions,
cough and the use of an artificial airway.
 Breathing: The nurse should look out for the following; bilateral air
entry and movement, breath sounds, respiratory rate, rhythm, work of
breathing, oxygen requirement and delivery mode.
 Circulation: The nurse should check the following; pulses (rate, rhythm
and strength); blood pressure, peripheral temperature, capillary refill
time; skin, lip, oral mucosa and nail bed colour, edema.
 Hydration/Nutrition (In-put): Assess this indicator by determining the
following; appetite, food intolerance, nausea or vomiting, dietary
requirements, route of nutrition (oral, nasogastric, gastrostomy, Jejunal,
fasting/nil per os, special diet, IV fluids).
 Output/Elimination: Assess this indicator by collecting data on the
following; urine, bowel movement, drains and other losses.
 Skin: Assess this indicator by determining the following; Colour, turgor,
lesions, bruising, wounds and pressure injuries.
 Pain: Assess this indicator by determining pain using the pain scale.
 Disability: Assess this indicator by determining the level of
consciousness, and power in limbs.
 Focused assessment: This should be done by carrying out an
assessment of patient’s problem(s) on the shift or any other identified
issues, e.g. Cardiovascular, respiratory, gastrointestinal, renal, eye, etc.
 Risk: The nurse must conduct a risk assessment to determine whether
the patient or client could be potentially at risk of developing adverse
outcomes in care.
 Wellbeing: Assess this indicator by determining the following; Mood,
sleeping habits, coping strategies, reaction to admission
 Social support: family/ guardian, preparations towards discharge.
 Review the medical record: The nurse must at all times read the
patient’s folder to understand the progress of the disease and the
human response to the disease.
Shift Assessment (Midwifery Pre-natal )
At the commencement of every shift an assessment must be completed on
every patient and this information should be used to develop a plan of care.
The Assessment includes:

 Airway: The midwife should look out for the following; noises,
secretions, cough and the use of an artificial airway.
 Breathing: The nurse should look out for the following; bilateral air
entry and movement, breath sounds, respiratory rate, rhythm, work of
breathing, oxygen requirement and delivery mode.
 Circulation: The nurse should check the following; pulses (rate, rhythm
and strength);blood pressure; peripheral temperature, capillary refill
time; skin, lip, oral mucosa and nail bed colour.
 Vital indicator: The midwife must assess the fundal height, fetal heart
rate and the kick rate.
 Hydration/Nutrition (In-put): Assess this indicator by determining the
following; appetite, food intolerance, nausea or vomiting, dietary
requirements.
 Output/Elimination: Assess this indicator by collecting data on the
following; urine, bowel movement, drains and other losses.
 Skin: Assess this indicator by determining the following; Colour, turgor,
lesions, bruising, wounds and pressure injuries.
 Pain: Assess this indicator by determining pain using the pain scale.
 Disability: Assess this indicator by determining the level of
consciousness, and power in limbs.
 Focused assessment: This should be done by carrying out an
assessment of patient’s problem(s) on the shift or any other identified
issues, e.g. Cardiovascular, respiratory, gastrointestinal, renal, eye, etc.
 Risk: The nurse must conduct a risk assessment to determine whether
the patient or client could be potentially at risk of developing adverse
outcomes in care.
 Wellbeing: Assess this indicator by determining the following; Mood,
sleeping habits, coping strategies, reaction to admission
 Social support: family/ guardian, preparations towards discharge.
 Review the medical record: The nurse must at all times read the
patient’s folder to understand the progress of the disease and the
human response to the disease.
Shift Assessment (Midwifery Pre-natal )
At the commencement of every shift an assessment must be completed on
every patient and this information should be used to develop a plan of care.
The Assessment includes:

 Airway: The midwife should look out for the following; noises,
secretions, cough and the use of an artificial airway.
 Breathing: The nurse should look out for the following; bilateral air
entry and movement, breath sounds, respiratory rate, rhythm, work of
breathing, oxygen requirement and delivery mode.
 Circulation: The nurse should check the following; pulses (rate, rhythm
and strength);blood pressure; peripheral temperature, capillary refill
time; skin, lip, oral mucosa and nail bed colour.
 Vital indicator: The midwife must assess the fundal height, fetal heart
rate and the kick rate.
 Hydration/Nutrition (In-put): Assess this indicator by determining the
following; appetite, food intolerance, nausea or vomiting, dietary
requirements.
 Output/Elimination: Assess this indicator by collecting data on the
following; urine, bowel movement, drains and other losses.
 Skin: Assess this indicator by determining the following; Colour, turgor,
lesions, bruising, wounds and pressure injuries.
 Pain: Assess this indicator by determining pain using the pain scale.
 Disability: Assess this indicator by determining the level of
consciousness, and power in limbs.
 Focused assessment: This should be done by carrying out an
assessment of patient’s problem(s) on the shift or any other identified
issues, e.g. Cardiovascular, respiratory, gastrointestinal, renal, eye, etc.
 Risk: The nurse must conduct a risk assessment to determine whether
the patient or client could be potentially at risk of developing adverse
outcomes in care.
 Wellbeing: Assess this indicator by determining the following; Mood,
sleeping habits, coping strategies, reaction to admission
 Social support: family/ guardian, preparations towards discharge.
 Review the medical record: The nurse must at all times read the
patient’s folder to understand the progress of the disease and the
human response to the disease.
Shift Assessment (Midwifery Post -
natal)
At the commencement of every shift an assessment must be completed on every
patient and this information should be used to develop a plan of care.
The assessment of the mother includes:

 Breast: the midwife must assess the mother’s breast for the secretions of
colostrum, breast engorgement (pain, tenderness, warmth, dilated veins etc.)
nature of the nipples (inverted, retracted, fissures, cracks etc.). She must also
assess the knowledge and practice of breast feeding of the mother and the
physical and physiologic capabilities of the mother to breastfeed.
 The abdomen: the midwife must assess the uterus by palpating the uterine
height, position and tone.
 The Perineum: the midwife must assess for cleanliness of the area including
the episiotomy wound, tears etc.
 Lochia: the midwife must assess for amount of bleeding, the colour, the odor
and the clots present.
 Blood loss: the midwife must assess for blood loss from either the caesarean
section wound, episiotomy wound or from tears (cervical, perineal, and
vaginal).
 Vital signs: assess this indicator by monitoring the blood pressure,
temperature, pulses and respirations; and random blood sugar for clients
with diabetes.
 Hydration/Nutrition (In-put): Assess this indicator by determining the
following; appetite, food intolerance, nausea or vomiting, dietary
requirements and fluid requirements (IVF).
 Pain: Assess this indicator by determining pain using the pain scale.
 Disability: Assess this indicator by determining the level of consciousness,
and power in limbs.
 Focused assessment: This should be done by carrying out an assessment of
patient’s problem(s) on the shift or any other identified issues, e.g.
Cardiovascular, respiratory, gastrointestinal, renal, eye, etc.
 Risk: The nurse must conduct a risk assessment to determine whether the
patient or client could be potentially at risk of developing adverse outcomes
in care.
 Wellbeing: Assess this indicator by determining the following; Mood, sleeping
habits, coping strategies, bonding with baby and the mental status
(depression, puerperal psychosis, etc.)
 Output/Elimination: Assess this indicator by collecting data on the following;
urine, bowel movement, drains and other losses.
Shift Assessment (Midwifery Post -
natal)
At the commencement of every shift an assessment must be completed on every
patient and this information should be used to develop a plan of care.
The assessment of the mother includes:

 Breast: the midwife must assess the mother’s breast for the secretions of
colostrum, breast engorgement (pain, tenderness, warmth, dilated veins etc.)
nature of the nipples (inverted, retracted, fissures, cracks etc.). She must also
assess the knowledge and practice of breast feeding of the mother and the
physical and physiologic capabilities of the mother to breastfeed.
 The abdomen: the midwife must assess the uterus by palpating the uterine
height, position and tone.
 The Perineum: the midwife must assess for cleanliness of the area including
the episiotomy wound, tears etc.
 Lochia: the midwife must assess for amount of bleeding, the colour, the odor
and the clots present.
 Blood loss: the midwife must assess for blood loss from either the caesarean
section wound, episiotomy wound or from tears (cervical, perineal, and
vaginal).
 Vital signs: assess this indicator by monitoring the blood pressure,
temperature, pulses and respirations; and random blood sugar for clients
with diabetes.
 Hydration/Nutrition (In-put): Assess this indicator by determining the
following; appetite, food intolerance, nausea or vomiting, dietary
requirements and fluid requirements (IVF).
 Pain: Assess this indicator by determining pain using the pain scale.
 Disability: Assess this indicator by determining the level of consciousness,
and power in limbs.
 Focused assessment: This should be done by carrying out an assessment of
patient’s problem(s) on the shift or any other identified issues, e.g.
Cardiovascular, respiratory, gastrointestinal, renal, eye, etc.
 Risk: The nurse must conduct a risk assessment to determine whether the
patient or client could be potentially at risk of developing adverse outcomes
in care.
 Wellbeing: Assess this indicator by determining the following; Mood, sleeping
habits, coping strategies, bonding with baby and the mental status
(depression, puerperal psychosis, etc.)
 Output/Elimination: Assess this indicator by collecting data on the following;
urine, bowel movement, drains and other losses.
Shift Assessment (Newborn )
All mothers and their babies must receive active and ongoing assessment in
the immediate postnatal period, regardless of the context around their birth.
During this time, the mother and baby should not be left alone. Ongoing
assessment is for a minimum of one hour. Assessment will be longer than one
hour if the mother or baby has experienced factors that increase their risk of
adverse outcomes. Care during this time supports the physiological processes
of the mother’s transition to motherhood and the baby’s transition to
independent life. To assist these transitions there is ongoing observation of
both the mother and baby’s wellbeing, promotion of skin-to-skin contact, and
support and oversight of the first breastfeed.

The assessment of the baby includes;

 Colour: assess the colour of the infant to determine the state of the
neonate’s health.
 Vital signs: heart rate, respiratory rate, temperature, SpO2.
 Breathing: The nurse should look out for the following; bilateral air
entry and movement, breath sounds, rhythm, work of breathing and
airway integrity.
 Warmth: assess this indicator by observing extremities for bluish
discoloration.
 Personal Hygiene: assess this indicator by observing the general head to
cleanliness of the neonate (including the cord).
 Breast Feeding: assess this indicator by determining the physical and
physiologic capabilities of the neonate to breastfeed.
 Hydration/Nutrition (In-put): assess this indicator by determining the
hydration status of the neonate and hypoglycemia.
 Output/Elimination: Assess this indicator by collecting data on the
following; urine and bowel movement.
Shift Assessment (Newborn )
All mothers and their babies must receive active and ongoing assessment in
the immediate postnatal period, regardless of the context around their birth.
During this time, the mother and baby should not be left alone. Ongoing
assessment is for a minimum of one hour. Assessment will be longer than one
hour if the mother or baby has experienced factors that increase their risk of
adverse outcomes. Care during this time supports the physiological processes
of the mother’s transition to motherhood and the baby’s transition to
independent life. To assist these transitions there is ongoing observation of
both the mother and baby’s wellbeing, promotion of skin-to-skin contact, and
support and oversight of the first breastfeed.

The assessment of the baby includes;

 Colour: assess the colour of the infant to determine the state of the
neonate’s health.
 Vital signs: heart rate, respiratory rate, temperature, SpO2.
 Breathing: The nurse should look out for the following; bilateral air
entry and movement, breath sounds, rhythm, work of breathing and
airway integrity.
 Warmth: assess this indicator by observing extremities for bluish
discoloration.
 Personal Hygiene: assess this indicator by observing the general head to
cleanliness of the neonate (including the cord).
 Breast Feeding: assess this indicator by determining the physical and
physiologic capabilities of the neonate to breastfeed.
 Hydration/Nutrition (In-put): assess this indicator by determining the
hydration status of the neonate and hypoglycemia.
 Output/Elimination: Assess this indicator by collecting data on the
following; urine and bowel movement.
 THE NEW DOCUMENTATION
FORMAT
 For every shift, the shift assessment tool will be the
standard tool for assessment. This will be the
responsibility of the charge nurse on duty for the shift
with support from the subordinates on duty.
 Assessment; Using the problem focus approach,
assessment finding must be listed in the nurses’ notes.
 Problems; from the assessment findings, the problems
must be listed according the order of priority.
 Patients Strengths; the strengths which must be
related to the problems must also be listed as the next
indicator.
..

 Nursing Orders; the next point is the nursing

orders, the plans of intervention must be listed
under this section. Nursing orders must read by
all nurses on duty especially those assigned to
the patient or Ibe written at the end of the shift.
 Sorting out which interventions were successful,
partially successful or unsuccessful; stating
reasons why some were not successful, then the
in-charge for the shift will sign.
 This will form the basis of the handing over.
 SAMPLE OF NURSMID DOCUMENTATION PROCESS

 A fifty (50) year old patient/client is

brought to your medical ward for further
management. He has a provisional
diagnosis of Chronic Kidney Failure
(CRF). You have come on duty on the
ensuing shift; the nursing management
process you are expected to follow is
elaborated as follows.
 Using the shift assessment (Nursing), the
plan has been developed as follows;
 SAMPLE
 Assessment
 Breathing- Use of accessory muscles
 Vital signs- P-110, R-40, B/P-90/50mmhg, SpO2-89%
 Circulation- generalized edema (anasarca)
 Hydration/Nutrition- Food intolerance, nausea
 Out-put/Elimination- No urine, no bowel movement
 Skin- Pallor
 Pain- generalized, (pain scale 9)
 Risk- Impaired skin integrity, fluid volume excess
 Wellbeing-Insomnia
 Social support- a nephew
 SAMPLE

 Patient/Clients Problems
 Ineffective breathing pattern
 Impaired gaseous exchange
 Excess fluid volume
 Impaired urinary elimination
 Imbalanced nutrition-less than body
requirements
 SAMPLE
 Patient/Client Strengths
 Client is conscious and communicating.
 Client is mobile.
 Care Plan goals
 Client will display improve outcomes of
care by breathing normally, displaying
normal oxygen saturation values,
decrease in generalized edema,
improvement in urine out-put, absence
of pain and by eating more calories.
.

 Nursing Orders
 Establish rapport
 Monitor and record vital signs
 Record occurrence of dyspnea. Change position of
client hourly.
 Provide safe environment, calm activities and enforce
adequate rest.
 Administer oxygen at prescribed dosage.
 Note amount of fluid intake from all sources and
record; and compare at the end of the shift to out-put.
 Note presence and level of edema.
 Restrict sodium and fluid intake.
 Weigh daily.
 Assess description of pain.
 .

 Nursing Interventions
 It should contain all activities
carried out in the nursing orders
 Evaluation
 Care plan goals were
met/partially met/not met and
explain.
THANK YOU