Final answer:
Upon noticing unrecorded medications from the previous shift, the PN should verify if the medications were administered, correct documentation or determine the next steps with healthcare providers, and ensure all actions prioritize resident safety.
Step-by-step explanation:
Initial Steps for a Practical Nurse:
The first step the Practical Nurse (PN) should take upon noticing that several medications were not recorded as given in the previous shift is to check with the nurse from that shift to confirm whether the medications were administered. If the medications were administered but not documented, the documentation should be corrected immediately. If the medications were not administered, the PN should assess the resident to ensure there are no adverse effects from missed doses, and then communicate with the prescribing healthcare provider or their supervisor to determine the appropriate action for administering the missed medications.
Confirming Medication Administration:
Meticulous documentation in healthcare is crucial, especially with medication administration. Proper protocol dictates that a thorough review of the situation must be conducted, including verifying with the team involved in the previous care. The PN should also review the medication administration records (MAR) and resident's current condition before proceeding with any additional medication administration.
Importance of Clear Communication:
In collaboration with the healthcare team, the PN should strive for clear communication to prevent medication errors. Proper handoff communication techniques are essential to ensure that medication administration is accounted for in a resident's care. Addressing issues with documentation and ensuring that all care team members have accurate information are paramount for safe and effective resident care.