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Home
About Us
Our Official Charity Partner
Meet the Team
Clients
Testimonials
Acquired or Traumatic Brain Injury
Spinal Injury
Other Medical Conditions
Live Vacancies
Register CV
Candidates
Apply online
Supporting Our Official Charity Partner
Subject Access Requests
Refer a Friend Scheme
Care Packages for Brain and Spinal injury
Contact Us
Submit a Daily Record
Daily Record Form NM Night Shift Log
Step 1 of 12
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User's Email
Username
Client Name
*
Name(s) of all Support Workers on shift today?
*
Date of Shift
*
Date Format: DD slash MM slash YYYY
If you are undertaking night shifts, please remember to enter the correct date the shift started.
Shift Start Time
*
:
HH
MM
Shift End Time
*
:
HH
MM
Have you recieved a detailed handover at the start of your shift?
*
Yes
No
Please give a brief overview of the handover received
*
Mobility
Specific prompts and sequencing are needed to help NM adhere to his bedtime routine, (including mobilising from recliner, using the stairs, mobilising to bathroom and bedroom and sitting/lying on bed). Were these prompts/sequences and guidelines followed?
Yes
No
Please confirm the time this routine started
*
:
HH
MM
NM needs a Zimmer frame and hands on support from staff when mobilising at night. Was this support given to NM?
*
Yes
No
Please summarise mobility and support given, including correct prompts and support when getting up and returning to bed
*
Please confirm specific occupational therapy guidelines were followed, when mobilising in morning ?
*
Yes
No
Including to bathroom for morning hygiene programme, correct positioning of handling belt and mobilising to come downstairs, use of the stairs and correct prompts for sitting at breakfast table
Please comment on mobility and support given?
*
Hygiene
Please confirm hygiene needs were met before NM went to bed?
*
Yes
No
This includes hand washing (after going to the toilet) and oral hygiene
Please confirm hands were washed after going to the toilet overnight?
*
Yes
No
Were you responsible for NM morning hygiene programme?
*
Yes
No
Please detail what were you responsible for?
*
In the morning, one staff member assists with NM’s hygiene programme while another staff member sets up the bathroom and bedroom to enable NM to initiate and carry out as many tasks as independently as possible during the morning hygiene programme.
Please confirm that the programme set by the occupational therapist was followed and the chart completed?
*
Yes
No
Please confirm that you supported NM to attend to his hygiene needs, including showering, oral hygiene, shaving and hair combing?
*
Yes
No
Please provide brief details below
*
Please comment on issues such as levels of NM’s independence, prompting required (especially during teeth brushing and shaving to prevent redness and soreness due to perseveration) and motivation
If you were responsible for setting up bathroom and bedroom, please confirm the set up was completed and both rooms were left tidy and hygienically clean, with bedding, towels, flannels, and clothing washed when required.
*
Yes
No
Skin
Please confirm that skin checks took place and if applicable provide summary of any issues noted as well as confirming this has been recorded on body map?
*
Yes
No
NM’s skin should be checked when getting ready for bed and when the opportunity arises overnight. Any skin breaks/dry patches/ irritation, scratches and non-blanching areas should be identified and recorded on a body map.
Please confirm creams were applied in the evening on face, elbows, legs, and ankles to prevent dryness and redness due to eczema.
*
Yes
No
A full body check should be carried out by the support worker during the morning hygiene programme. Please confirm that this took place ? Please write N/A if you were not responsible for this tasks during the morning double up..
*
Yes
No
N/A
Please provide a summary of any issues identified and if applicable recorded on a body map
Please confirm NM (during the morning hygiene programme) was assisted to apply Cerave moisturising face cream to the face and Cerave body moisturiser to his body, including arms, torso, legs, and feet. Please write N/A if you were not responsible for this tasks.
*
Yes
No
N/A
Please confirm that the support worker applied Cerave body moisturiser to NM’s back.
*
Yes
No
Please confirm that NM’s feet were thoroughly dried, checked for signs of athlete’s foot and daktarin spray was applied if necessary. Please write N/A if you were not responsible for this task.
*
Yes
No
N/A
Medication and Clinical Observations
Was all medication listed on the E Mar given as prescribed prior to going to bed?
*
Yes
No
Please confirm what time the medication was administered?
*
:
HH
MM
Was the prescribed steroid inhaler (Soprabec) given prior to going to bed using the spacer and a small amount of water given after the inhaler to prevent thrush?
*
Yes
No
Was any PRN medication required?
*
Yes
No
Please provide further details
*
Did you check whether there were any signs of wheeziness or hay fever symptoms?
*
Yes
No
If symptoms present was this discussed with NM’s wife and PRN medication given such as Salbutamol (blue inhaler) for wheeziness (no spacer required) or Beclomethasone Nasal spray for hay fever).
*
Yes
No
N/A
Were the inhaler levels checked prior to administering?
*
Yes
No
N/A
6. Was the early morning medication administered as per Mar chart?
*
Yes
No
Please state time morning medication was administered
*
:
HH
MM
Safety
NM’s high low-profile bed needs to be lowered to the floor and a crash mat placed on the floor at the side of the bed to reduce the risk of injury from impulsive and unpredictable behaviours. Confirm this took place.
NM requires constant and uninterrupted supervision using the monitor provided and using direct visual observation. This helps to prevent injury and to reassure when agitated or in discomfort. Please confirm this uninterrupted supervision took place.
Please confirm that NM used the Zimmer frame when mobilising overnight and was fully supported with hands on upper back, due to high risk of falls from muscle and joint stiffness, left side weakness especially in lower left limb and dizziness when standing up (postural hypotension).
Were any safeguarding concerns noted or any incident reports completed?
Yes
No
If yes, briefly summarise below.
Continence
What times did NM visit the toilet to pass urine overnight? Record times, colour and use the following code to provide further details (** = successful urine: * = unsuccessful: I = initiated W = Wet). Please also detail any incidents of incontinence of urine.
Did NM open his bowels overnight?
Yes
No
If yes, record time and result, refer to Bristol Stool Chart to categorise any output. Please also include any incidence of incontinence of bowel.
Has the toileting programme chart been completed?
Yes
No
Sleep
What time did NM settle down to sleep?
:
HH
MM
AM
PM
Please state times when NM was awake during the night, how long he was awake and care needs required. Please also include information about quality of sleep, interventions needed to reassure/reorientate, reduce anxiety, overheating, issues relating to restless legs or general comfort and any other care requirements.
Please state time NM woke up in the morning.
:
HH
MM
AM
PM
Any intervention required to ensure X remained settled in bed and what time he got up.
Blood pressure
Confirm blood pressure recording before getting up and starting early morning exercises and include time this was taken.
If applicable, comment on any recordings close to NM’s baseline readings of 105/69/69 and possible reasons for this and confirm any abnormal readings have been reported to NM’s wife for potential escalation. Associated symptoms such as dizziness due to postural hypotension can also be recorded here.
Behaviour/psychological and Emotional Wellbeing
Please comment on any incidents or changes to behaviour, mood, or anxiety overnight and possible reasons for this. Please state any interventions required.
Exercise
NM’s physiotherapist has a prescribed early morning physiotherapy exercise programme to mobilise stiff joints, to provide a gentle stretch with movement for tight muscles and to prepare the body for functional tasks such as rolling, transfers, personal care and walking. Please confirm the programme has been followed and support was given to facilitate the movements in a smooth and controlled way, and within a comfortable range of movement, without pain or excessive effort If you were not the person supporting NM with this task, please state n/a
Yes
No
N/A
Provide details/times of exercises NM completed
Consider adding details about range of movement of the stretches in the upper and lower limbs on both the left and right side, muscle strength, posture, core strength and any difficulties encountered with the stretches (please indicate the specific exercise this related to).
Summary
Provide a brief summary of night, including any issues encountered and confirm a handover was completed at 07.30 when the day support worker arrived.
Do you have any safeguarding concerns?
Signature
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