Records

Nurses keep accurate records of all care and observations for many purposes. The patient's record is how the different members of the health care team communicate with each other. The chart is a legal document that serves as evidence of care provided. Since the maintenance of records is a legal responsibility, the charts have to meet certain standards, e.g. records must be permanent, accurate, complete, and kept for years after the care was given.

Medication

Medications are typically dispensed during nursing care. In some countries a nurse is only responsible to administer medication as prescribed by a doctor. In other countries nurses are legally responsible to ensure that the medication is appropriate for the patient and have the authority to interpret the order. Administration of medication by nurses generally requires the nurse to apply advanced knowledge and critical thinking to determine the safety of the administered medication. Advanced practice nurses (Nurse Practitioners, Nurse Midwives, Clinical Nurse Specialists and Certified Registered Nurse Anesthetists) prescribe medications as regulated by the state boards of nursing. Advanced practice nursing requires additional education, generally at the master's level. Advanced practice nurses, depending on specialty and state regulations may assess, order and interpret diagnostic tests, diagnose and treat medical conditions and evaluate the results. Advance practice varies in the different states from supervised (by a physician) to completely independent practice. Multiple research studies indicate patients treated by advanced practice nurses have the same outcomes as patients treated by physicians. Patient satisfaction has been equal to treatment by physicians. Advanced practice nurses may be part of the solution to an overburdened and costly health care system. Advanced practice nurses retain the holistic and preventative framework of nursing, and are ideally suited to wellness care.

Diet

Diet is important for people to stay healthy. A dietitian, or physician may place the patient on a regular, light, soft, or liquid diet. A person on a regular diet can eat any type of food; on a light diet the patient may have such foods as ground meat, chicken, fish, potatoes, rice, strained vegetables, custards, and puddings. Raw fruit and vegetables, rich, spicy or fried foods are not allowed on this diet. A soft diet includes such foods as bread, cereal, eggs, potatoes, custards, and ice cream. A liquid diet may consist only of clear liquids, such as soup, tea, and juices. People with certain illnesses may have other diet restrictions for example people with diabetes or on dialysis.

Vital Signs

Nurses may take a person's vital signs several times a day. Vital signs include taking and recording a patient's temperature, blood pressure, respirations, pulse, and pain level. Other things recorded in vital signs may be weight (especially for renal patients), bowel movements, and blood pressure measurements which are taking in different positions (in heart patients, for example, it is common to do a lying then standing measurement to assess the cardiovascular system's ability to compensate).

Vital signs are usually done with an electronic machine (commonly called a Dynamap) in modern first world countries, however nurses are usually trained to also use manual equipment. These include a sphygmomanometer for blood pressure and a thermometer for temperature. Nurses are also trained in use of a stethoscope to hear heart, lung and bowel sounds on patients of all ages.

Infection control

Nurses must observe the principles of asepsis at all times to prevent the spread of infection. They wash their hands thoroughly with soap and warm water before and after caring for patients, after handling any waste, before and after eating and drinking, after smoking, coughing, touching clothes, and after wearing gloves. Alcohol gel has come into common use to sanitize the hands in place of washing hands that are not visibly soiled. Infection control regulations state that hand washing must be done after the third instance of using hand sanitizer. Gloves are generally worn when patient care is given, especially when exposure to patient bodily fluids is likely.

Nurses also observe aseptic technique. This speciality is used for procedures such as wound cleaning and any insertion or removal of appliances into or out of the patient's body. Examples are insertion of an intravenous or urinary catheter, or feeding (nasogastric) tube.

Surgical scrub techniques are also taught to nurses. This speciality is used for operating room technique, where nurses are an important part of any procedure.