Phase 1: Foundation
Hospital admission journey
Knowing what happens during admission can reduce anxiety and help you participate more fully in your care.
Before coming to the hospital or healthcare facility, taking a few minutes to prepare can make your arrival easier and help prevent delays.
Confirm your appointment details.
Make sure you know the date, time, and location of your appointment or procedure. If you are unsure about where to go or when to arrive, contact your care team before leaving home.
Review your pre-admission instructions.
You may receive specific instructions about when to stop eating or drinking, which medications to take or hold, and when you should arrive. These instructions can be different depending on the procedure, so follow the directions provided by your healthcare team.
Bring important information with you.
Have your identification, insurance information, current medication list, and any required paperwork ready. If you have advance directives or other important healthcare documents, bring those as well.
Plan for transportation and support.
If you are receiving sedation or a procedure that may affect your ability to drive, arrange for someone to take you home. You may also want a family member or support person available to help you understand instructions or assist you after the procedure.
How a nurse checks you head to toe
Total Body Assessment
During your hospital stay, your nurse will perform a head-to-toe assessment to check how your body is doing and look for changes that may need attention.
This may include checking your vital signs, breathing, heart, neurological status, skin, IV site, movement, pain, and other areas based on your condition.
Your nurse may also take or document pictures when appropriate to help monitor skin integrity, wounds, or changes over time.
Head to Toe Assessment
Step by step, in order
- Overall look and alertness. Your nurse checks whether you are awake, know where you are, and can answer simple questions, and checks your name band.
- Head, eyes, and mouth. Pupils are checked with a small light. Your nurse looks at your mouth, teeth, and dentures, and asks about headaches or dizziness.
- Neck. A quick look and feel for swelling or stiffness, and a check of any IV line placed in the neck.
- Heart and pulses. Your nurse listens to your heart and feels pulses in your wrists, feet, or groin to make sure blood is flowing well.
- Lungs and breathing. You may be asked to take slow deep breaths while your nurse listens to your front and back, and checks your oxygen level.
- Belly. Your nurse listens for bowel sounds, presses gently to check for tenderness or firmness, and asks when you last ate.
- Skin. A look at your back, hips, heels, and elbows for redness, bruises, rashes, or open areas. Redness that does not fade is an early sign of a pressure sore.
- Arms and legs. You may be asked to squeeze your nurse's fingers, wiggle your toes, and say whether you feel touch. Your nurse also checks for swelling and warmth.
- Bladder and bowels. Questions about urinating, your last bowel movement, leaking, or a catheter.
- Pain. Where it is, what it feels like, how bad it is from 0 to 10, and what makes it better or worse.
- Lines, tubes, and drains. IV sites, oxygen tubing, catheters, feeding tubes, and drains are checked for redness, leaking, or pain.
- Safety items. Bed low and locked, call light in reach, non-skid socks on, bed alarm set if you need one, and side rails set the way your plan says.
What your nurse watches for
- New confusion, more sleepiness, or trouble waking up.
- New shortness of breath, chest pain, or a drop in oxygen.
- New or worse pain, or pain in a new place.
- New weakness, numbness, or trouble moving one side.
- Redness, warmth, swelling, or drainage around an IV, wound, or drain.
- Not urinating, or a belly that is getting firm or bigger.
Questions you can ask
- What did you find during my assessment today?
- Did anything change from the last shift?
- How do my lungs and my heart sound?
- Is my skin healthy, or do you see any red areas?
- How is my IV site looking, and when does it need to be changed?
- What should I report to you right away?
White Board Simply Explained
How to use your room whiteboardA Nurse’s Shift — What to Expect
Have you ever wondered what your nurse is doing throughout the shift? Let me walk you through some of the things that may happen during your day or night in the hospital.
Vital Signs
One of the first things your nurse may do is check your vital signs. This can include your blood pressure, heart rate, temperature, breathing rate, and oxygen level. Your nurse looks at these numbers along with how you are feeling to help identify changes in your condition.
Nursing Assessment
Your nurse will also perform an assessment. This may include listening to your heart and lungs, checking your neurological status, looking at your skin, checking movement and circulation, reviewing your IV or other equipment, and asking questions about how you are feeling.
Your assessment may be repeated during the shift because your condition can change.
Pain Assessment
Your nurse will ask about your pain and may ask you to describe where it is, how severe it feels, and what makes it better or worse.
After pain medication or another intervention, your nurse may reassess your pain to see whether the treatment helped. You can also let your nurse know if your pain changes or if you are uncomfortable.
Treatments and Medications
During the shift, your nurse may give medications, provide treatments, change dressings, manage IV therapy, assist with procedures, or carry out other parts of your plan of care.
Your nurse is also monitoring how you respond to your treatments and watching for changes that may need to be reported to the healthcare team.
Breaks
Your nurse may take scheduled meal or rest breaks during the shift. Another qualified member of the healthcare team may provide coverage while your nurse is away.
If you need assistance, use your call light as you normally would. Your care team has systems in place to help maintain your care while your nurse is on break.
Intake and Output — I&O
Your healthcare team may keep track of what goes into your body and what comes out.
Intake can include things such as fluids you drink, IV fluids, or certain tube feedings.
Output can include urine, drainage, or other fluids that your healthcare team needs to measure.
Tracking I&O can help your healthcare team understand your fluid balance and monitor your condition.
Final Rounds
As the shift comes to an end, your nurse may make final rounds, reassess you, check your comfort and safety, make sure important treatments are completed, and review anything that needs to be communicated to the next nurse.
The incoming nurse then receives a report about your condition, care, medications, treatments, and anything that needs continued attention.
And remember — if something changes or you have a concern, don't wait for the next scheduled round. Let your healthcare team know.
Medication Administration
Medications in the hospital are scheduled based on your individual treatment plan. Depending on the medication, your nurse may give medications during different medication passes, such as morning, noon, evening, and bedtime. Some medications may be scheduled at other specific times or more frequently depending on your needs.
Before giving a medication, your nurse uses a scanner to scan your identification wristband and the medication. The scanning system helps verify that the medication matches your electronic medication record, including the correct patient, medication, dose, route, and scheduled time.
Your nurse may also explain what the medication is for and answer any questions you have before it is administered.
Before You Arrive
Before coming to the hospital or healthcare facility, taking a few minutes to prepare can make your arrival easier and help prevent delays.
Confirm your appointment details.
Make sure you know the date, time, and location of your appointment or procedure. If you are unsure about where to go or when to arrive, contact your care team before leaving home.
Review your pre-admission instructions.
You may receive specific instructions about when to stop eating or drinking, which medications to take or hold, and when you should arrive. These instructions can be different depending on the procedure, so follow the directions provided by your healthcare team.
Bring important information with you.
Have your identification, insurance information, current medication list, and any required paperwork ready. If you have advance directives or other important healthcare documents, bring those as well.
Plan for transportation and support.
If you are receiving sedation or a procedure that may affect your ability to drive, arrange for someone to take you home. You may also want a family member or support person available to help you understand instructions or assist you after the procedure.
Check-In and Registration
Once you arrive at the hospital, registration is usually your first step. This is where the hospital officially begins your visit and makes sure the information they have about you is correct.
Understanding Consent Forms
You may be given several forms to review and sign. These can include permission to receive treatment, financial or insurance-related forms, and other hospital policies.
Take your time. If you don't understand a form, it is okay to ask the registrar to explain it before you sign. You should feel comfortable knowing what you are agreeing to.
Your Privacy and Communication
The hospital will also provide information about your privacy rights under HIPAA, which helps protect your health information. You may be asked who the hospital is allowed to communicate with about your care, such as a family member or caregiver.
You may also be asked about your preferred language or whether you need assistance with hearing, vision, reading, or communication. These questions are designed to help the healthcare team communicate with you and provide care in a way you can understand.
Advance Directives
If you have an advance directive, living will, or medical power of attorney, let the hospital know and provide a copy if requested. These documents can communicate your healthcare wishes and identify who may make healthcare decisions for you if you become unable to make or communicate those decisions yourself.
Before You Leave Registration
This is also a good time to ask practical questions.
Find out where the waiting area, restrooms, cafeteria, and other important locations are. If you are being admitted, ask how your family or support person can contact your unit and how they can receive updates about your care.
Your first day on a unit
About Your Care
Once you arrive on your hospital unit, you become part of a healthcare team. Your care may involve nurses, nursing assistants, doctors, therapists, and other healthcare professionals. Each person has a different role, but they work together to support your care and recovery.
Your Daily Plan of Care
Your nurse will usually explain what is planned for your care. This may include medications, treatments, vital signs, tests, walking, eating, breathing exercises, or other activities that support your recovery.
Your plan can change as your condition changes, test results become available, or your doctor or specialist evaluates you.
Simply Explained: Think of your plan of care as a roadmap. It gives you an idea of what is planned, but the roadmap can change as your healthcare team learns more about your condition.
Who Is Caring for You?
Your unit may use different approaches to organize nursing care, such as primary nursing or team nursing.
Primary Nursing: One RN may have primary responsibility for coordinating your nursing care, while other healthcare workers may assist.
Team Nursing: Several healthcare workers share responsibility for caring for a group of patients. The team may include RNs, CNAs, and other healthcare professionals.
The exact roles and responsibilities can vary by hospital and unit.
Understanding Your Healthcare Team
Your care may include:
- RN: Provides nursing care, medications and treatments, monitors your condition, and communicates important changes.
- CNA: May assist with bathing, toileting, repositioning, walking, vital signs, and other patient-care activities within their role.
- Doctor or Specialist: Evaluates your condition and develops or changes the medical plan of care.
- Physical or Occupational Therapist: Helps with movement, strength, balance, and daily activities when needed.
- Respiratory Therapist: Helps with breathing treatments, oxygen therapy, airway care, and other respiratory needs.
- Case Manager: May help coordinate discharge planning, equipment, medications, rehabilitation, or services after leaving the hospital.
When Your Plan Changes
Your plan of care can change during your hospital stay. A test result, change in symptoms, or response to treatment may cause your healthcare team to adjust the plan.
If something sounds different from what you were told earlier, it is okay to ask:
“Has my plan of care changed, and can you explain what changed?”
If you receive information that seems different from another member of your healthcare team, ask your nurse or another appropriate team member to help clarify it.
Staying Informed
You are an important part of your healthcare team. Ask questions, listen to explanations, and let your healthcare team know when something is unclear.
Some hospitals may use bedside tablets, patient portals, apps, or other technology to provide information about your care. Ask your nurse how your hospital communicates updates and where you can find your information.
Questions You Can Ask
- What is the plan for my care today?
- Who is involved in my care, and what is each person’s role?
- Has anything changed in my plan of care?
- What can I do to help with my recovery?
- Which therapists may be involved in my care?
- If I have a question my nurse cannot answer, who should I ask?
- Who can help me understand my plan if I am confused?
- How will I be told if my plan of care changes?
- Does this hospital use a tablet, app, or patient portal where I can see information about my care?
How a nurse checks you head to toe
Total Body Assessment
During your hospital stay, your nurse will perform a head-to-toe assessment to check how your body is doing and look for changes that may need attention.
This may include checking your vital signs, breathing, heart, neurological status, skin, IV site, movement, pain, and other areas based on your condition.
Your nurse may also take or document pictures when appropriate to help monitor skin integrity, wounds, or changes over time.
Head to Toe Assessment
Step by step, in order
- Overall look and alertness. Your nurse checks whether you are awake, know where you are, and can answer simple questions, and checks your name band.
- Head, eyes, and mouth. Pupils are checked with a small light. Your nurse looks at your mouth, teeth, and dentures, and asks about headaches or dizziness.
- Neck. A quick look and feel for swelling or stiffness, and a check of any IV line placed in the neck.
- Heart and pulses. Your nurse listens to your heart and feels pulses in your wrists, feet, or groin to make sure blood is flowing well.
- Lungs and breathing. You may be asked to take slow deep breaths while your nurse listens to your front and back, and checks your oxygen level.
- Belly. Your nurse listens for bowel sounds, presses gently to check for tenderness or firmness, and asks when you last ate.
- Skin. A look at your back, hips, heels, and elbows for redness, bruises, rashes, or open areas. Redness that does not fade is an early sign of a pressure sore.
- Arms and legs. You may be asked to squeeze your nurse's fingers, wiggle your toes, and say whether you feel touch. Your nurse also checks for swelling and warmth.
- Bladder and bowels. Questions about urinating, your last bowel movement, leaking, or a catheter.
- Pain. Where it is, what it feels like, how bad it is from 0 to 10, and what makes it better or worse.
- Lines, tubes, and drains. IV sites, oxygen tubing, catheters, feeding tubes, and drains are checked for redness, leaking, or pain.
- Safety items. Bed low and locked, call light in reach, non-skid socks on, bed alarm set if you need one, and side rails set the way your plan says.
What your nurse watches for
- New confusion, more sleepiness, or trouble waking up.
- New shortness of breath, chest pain, or a drop in oxygen.
- New or worse pain, or pain in a new place.
- New weakness, numbness, or trouble moving one side.
- Redness, warmth, swelling, or drainage around an IV, wound, or drain.
- Not urinating, or a belly that is getting firm or bigger.
Questions you can ask
- What did you find during my assessment today?
- Did anything change from the last shift?
- How do my lungs and my heart sound?
- Is my skin healthy, or do you see any red areas?
- How is my IV site looking, and when does it need to be changed?
- What should I report to you right away?
White Board Simply Explained
How to use your room whiteboardA Nurse’s Shift — What to Expect
Have you ever wondered what your nurse is doing throughout the shift? Let me walk you through some of the things that may happen during your day or night in the hospital.
Vital Signs
One of the first things your nurse may do is check your vital signs. This can include your blood pressure, heart rate, temperature, breathing rate, and oxygen level. Your nurse looks at these numbers along with how you are feeling to help identify changes in your condition.
Nursing Assessment
Your nurse will also perform an assessment. This may include listening to your heart and lungs, checking your neurological status, looking at your skin, checking movement and circulation, reviewing your IV or other equipment, and asking questions about how you are feeling.
Your assessment may be repeated during the shift because your condition can change.
Pain Assessment
Your nurse will ask about your pain and may ask you to describe where it is, how severe it feels, and what makes it better or worse.
After pain medication or another intervention, your nurse may reassess your pain to see whether the treatment helped. You can also let your nurse know if your pain changes or if you are uncomfortable.
Treatments and Medications
During the shift, your nurse may give medications, provide treatments, change dressings, manage IV therapy, assist with procedures, or carry out other parts of your plan of care.
Your nurse is also monitoring how you respond to your treatments and watching for changes that may need to be reported to the healthcare team.
Breaks
Your nurse may take scheduled meal or rest breaks during the shift. Another qualified member of the healthcare team may provide coverage while your nurse is away.
If you need assistance, use your call light as you normally would. Your care team has systems in place to help maintain your care while your nurse is on break.
Intake and Output — I&O
Your healthcare team may keep track of what goes into your body and what comes out.
Intake can include things such as fluids you drink, IV fluids, or certain tube feedings.
Output can include urine, drainage, or other fluids that your healthcare team needs to measure.
Tracking I&O can help your healthcare team understand your fluid balance and monitor your condition.
Final Rounds
As the shift comes to an end, your nurse may make final rounds, reassess you, check your comfort and safety, make sure important treatments are completed, and review anything that needs to be communicated to the next nurse.
The incoming nurse then receives a report about your condition, care, medications, treatments, and anything that needs continued attention.
And remember — if something changes or you have a concern, don't wait for the next scheduled round. Let your healthcare team know.
Medication Administration
Medications in the hospital are scheduled based on your individual treatment plan. Depending on the medication, your nurse may give medications during different medication passes, such as morning, noon, evening, and bedtime. Some medications may be scheduled at other specific times or more frequently depending on your needs.
Before giving a medication, your nurse uses a scanner to scan your identification wristband and the medication. The scanning system helps verify that the medication matches your electronic medication record, including the correct patient, medication, dose, route, and scheduled time.
Your nurse may also explain what the medication is for and answer any questions you have before it is administered.
Questions to ask about the unit caring for you
Hospitals organize nursing care differently. In a primary care model, one nurse is responsible for all your care during a shift. In a team nursing model, several caregivers (such as CNAs and RNs) share responsibility, each carrying out different tasks. Knowing the model helps you understand who to ask for what.
Care Models: Primary Care vs. Team Care
Healthcare can be delivered in different ways, and two common models are primary care and team care.
In a primary care model, one primary healthcare professional takes the lead in coordinating and managing much of a patient’s care.
In a team care model, multiple healthcare professionals work together, with each person bringing their own knowledge and skills to the patient’s care.
Both models are designed to provide safe, coordinated care. The approach may vary depending on the patient, the healthcare setting, and the services needed.
Let’s take a closer look at these two care models.
- Does this unit use a primary care model or a team nursing model?
- Who is my assigned nurse or care team during this shift?
- What is each person's role (RN, CNA, technician, therapist)?
- What is the current CNA-to-patient ratio on this unit?
- If I need help quickly, should I use the call button, ask the CNA, or ask the nurse?
- Who should I call first if I need pain medicine, help getting to the bathroom, or have a safety concern?
- When does the shift change, and how will I learn the name of the next caregiver?
Patient Checklist
Before your hospital stay, a little preparation can make the experience feel less overwhelming. In this checklist, we'll go over some helpful things to bring, information to have available, and questions to think about before you arrive. Let's get prepared for your hospital journey — Simply Explained.
Daily Hospital Care Checklist
Use this checklist to help you understand who is caring for you and what to expect during your hospital stay. You can fill it out at the beginning of each shift, use it on your phone, or print a copy.
Your Care Team
Tip: If you are not sure who is caring for you, it's okay to ask. Knowing who is part of your care team can make it easier to know who to talk to when you have a question.
How Is My Care Organized?
Primary Care — One nurse is primarily responsible for coordinating your care during the shift.
Team Care — Several nurses and other caregivers share responsibilities for your care.
Not sure? Ask your nurse or charge nurse how your care is organized.
Understanding Staffing
You can ask your care team about the staffing structure on your unit.
Staffing can vary depending on the hospital, unit, patient needs, and shift.
What Can My CNA Help With?
Depending on the hospital and your care needs, a CNA may assist with:
Your RN remains an important resource for questions about your condition, medications, treatment plan, and changes in how you are feeling.
Therapy Visits
If therapy is part of your care, you can ask when they usually visit.
Physical Therapy
Occupational Therapy
Respiratory Therapy
Therapy schedules can change based on your condition, hospital needs, and the therapist's schedule.
My Notes & Questions
Use this space to write down questions you want to ask your healthcare team.
What a typical hospital room looks like
Most hospital rooms are set up the same basic way. Knowing what each item is makes the room feel less overwhelming on your first day.
Other Ways You May Be Admitted
Not every hospital stay begins with a planned check-in. You may enter through the Emergency Room (ER) or be sent directly to a hospital unit by your doctor or another healthcare facility.
If you come to the ER because of an urgent or unexpected problem, a triage nurse will first assess how quickly you need care.
You may have your vital signs checked, answer questions about your symptoms, and receive tests such as blood work or imaging. If you need to stay in the hospital, the ER team will arrange your admission and hand off your care to the hospital team.
Code status: what it means
Your code status is the plan for what the care team should do if your heart stops or you stop breathing. It is your choice. You will usually be asked about it when you are admitted, and you can change it at any time by telling your nurse or doctor.
Do everything to try to restart your heart and breathing.
- CPR (pushing hard and fast on the chest).
- Electric shocks to the heart if needed.
- A breathing tube and a ventilator (breathing machine).
- Emergency medicines given through an IV.
This is what happens by default if no other choice is written down.
Questions to ask about your code status
- What is my code status right now?
- Where is it written down, and who can see it?
- Who on the team talked with me or my family about it?
- Can I change my mind later, and how do I do that?
- What happens if my family does not agree with my choice?
Hospital codes you may hear
Hospitals use coded announcements to quickly alert staff to an emergency. If you hear one over the speaker, stay in your room unless a staff member tells you otherwise, keep pathways clear, and follow any instructions you are given.
Means: Cardiac or respiratory arrest — someone needs immediate life support.
What to do: Stay in your room. Staff will respond; clear hallways if asked.