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1 STUDENT NURSE PRECEPTORSHIP HEMODIALYSIS SKILLS CHECKLIST Name: _________________________ Clinic: ___________________ Date Started Training: ________________ Date Completed Training: _____ Instructions for use: All hemodialysis procedure skills listed in the first column will be explained and/or demonstrated to the student nurse by the preceptor. After completion of the demonstration, the trainer will initial and date the second column. The student nurse will then explain and demonstrate the procedural skill to the preceptor while being corrected and reinstructed as needed. After completion, the third column will be initialed and dated by the preceptor. After sufficient guidance and practice of the procedure, the student nurse will be rated on the performance of the procedure by the preceptor. All procedures must receive a satisfactory rating or will be repeated until a satisfactory rating is obtained. After a satisfactory performance of the skill, the trainer will date and initial the fourth column. Skills determined by the _________ as not assigned to the student nurse by the clinic will be indicated by a "N/A" (not authorized) placed by the procedure in column 2 and initialed and dated by the Facility Manager and a representative of the school of nursing. Upon satisfactory completion of the preceptor program, the student nurse will be eligible to work as a dialysis technician. Preceptor Name: ____________________________ Preceptor Initials: _________ Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. 2 INFECTION CONTROL UNIVERSAL PRECAUTIONS 1. Demonstrates appropriate use of barrier precautions 2. Recalls and demonstrates sharp instrument and needle precautions 3. Recalls high risk procedure precautions 4. Recalls appropriate use of respiratory resuscitation equipment during cardiac and respiratory arrests 5. Properly demonstrates appropriate cleaning and disinfecting of surfaces and equipment 6. Properly performs body fluids spill disinfection procedure 7. Properly disposes of contaminated or infectious waste 8. Recalls isolation procedure 9. Properly demonstrates appropriate hand washing technique 10. Properly performs isolation procedure for patient care during dialysis 11. Properly obtains and handles isolation blood specimens 12. Properly performs and/or verbalizes airborne precautions 13. Properly performs and/or verbalizes contact precautions 14. Properly performs and/or verbalizes Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. Preceptor Initials 3 INFECTION CONTROL Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials UNIVERSAL PRECAUTIONS general infection control measures 15. Demonstrates aseptic technique 16. Verbalizes understanding of Post exposure follow up policy 17. Verbalizes understanding TB Exposure Control Plan Operation of Delivery System 1. Properly performs system start up procedure 2. Properly performs alarm systems function test 3. Properly performs manual conductivity test 4. Properly performs manual temperature test 5. Properly performs manual pH test 6. Properly performs manual pressure holding test (IF APPLICABLE) 7. Properly performs basic operator troubleshooting Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. 4 Operation of Delivery System Cont’d Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee 8. Properly cleans and disinfects exterior of machine 9. Properly initiates chemical disinfect procedure and labels machine with RTK sign (Right to Know label for chemical) 10. Properly tests for residual disinfectant after disinfectant dwell 11. Properly initiates heat disinfect procedure 12. Properly initiates standard rinse procedure 13. Properly initiates acetic acid rinse procedure 14. Properly initiates bleach rinse procedure 15. Documents procedures performed and results 16. Properly demonstrates using the Sodium Variation system 17. Properly demonstrates using the Ultrafiltration Profiling System Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. Preceptor Initials 5 DIALYSIS DELIVERY SYSTEM Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials Properly operates the Fresenius 2008 H Properly operates the Fresenius 2008 K Properly operates the Cobe C 3 Properly operates the Baxter 1550 Properly operates the Baxter SPS 550 Properly operates the Althin “Tina” Other: Other: VASCULAR ACCESS PROCEDURES Properly assesses access for function and lack of pathology Properly cleans needle site with appropriate disinfectant Properly cannulates fistula at 25 angle Properly cannulates an AV graft at 45 angle Properly performs pre-dialysis CVC care (as allowed by state nursing practice) Properly changes CVC dressing (as allowed by state nurse practice act) Properly performs post dialysis vascular access care Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. 6 VASCULAR ACCESS PROCEDURES Cont’d Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials Properly uses safety guard provided on needles Properly demonstrates butterfly taping Properly discontinues dialysis with CVC (as allowed by state nurse practice act) Properly initiates treatment with internal vascular access Properly discontinues treatment with internal vascular access Properly initiates treatment with CVC (as allowed by state nurse practice act) Properly assesses access for function and cessation of bleeding from needle sites ADMINISTRATION OF MEDICATIONS (AS ALLOWED BY STATE NURSE PRACTICE ACT) PREPARATION AND ADMINISTRATION OF MEDICATIONS Properly verifies the medication prescription and patient Obtains appropriate supplies/correct needle and syringe Properly reads and checks medication label three times Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. 7 ADMINISTRATION OF MEDICATIONS (AS ALLOWED BY STATE NURSE PRACTICE ACT) Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Properly recalls the five rights of administering medications Properly documents the administration of medications on flow sheet Demonstrates proper aseptic technique preparing and administering medications ADMINISTRATION OF LIDOCAINE Recalls signs and symptoms of adverse reactions Properly administers ID xylocaine Proper angle of needle insertion 15 Aspirates prior to injection ADMINISTRATION OF HEPARIN Recalls signs and symptoms of adverse reactions Recalls methods of heparin administration Recalls types of heparin protocols ADMINISTRATION OF HEPARIN Properly administers heparin bolus through venous line Waits 3 minutes after bolus administration prior to treatment initiation Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. Preceptor Initials 8 ADMINISTRATION OF MEDICATIONS (AS ALLOWED BY STATE NURSE PRACTICE ACT) Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials ADMINISTRATION OF NORMAL SALINE Recalls indications for use during hemodialysis Properly administers normal saline per procedure Properly follows precautions during normal saline administration Recalls the signs and symptoms of fluid volume overload Properly recalls the systemic effects of normal saline RISKS AND HAZARDS OF HEMODIALYSIS COMMON OCCURENCES Recalls and/or responds properly to hypotension Recalls and/or responds properly to patient complaints of chest pain Recalls and/or responds properly to patient cramps Recalls and/or responds properly to patient complaints of nausea and vomiting Recalls and/or responds properly to pruritis Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. 9 RISKS AND HAZARDS OF HEMODIALYSIS Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee UNUSUAL OCCURENCES Recalls and/or responds properly to an air embolism Recalls and/or responds properly to anaphylactic reactions Recalls and/or responds properly to cardiac/resp. arrest Recalls and/or responds properly to hemolysis Recalls and/or properly performs infected access care Recalls and/or responds properly to an allergic reaction due to a medication Recalls and/or properly performs identifying fever source Recalls and/or responds properly to a pyrogen reaction Recalls and/or responds properly to angina Recalls and/or responds properly to arrhythmias Recalls and/or responds properly to back pain Recalls and/or responds properly to a blood loss Recalls and/or responds properly to crenation Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. Preceptor Initials 10 RISKS AND HAZARDS OF HEMODIALYSIS Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee UNUSUAL OCCURENCES – Cont’d Recalls and/or responds properly to difficulty with needle insertion Recalls and/or responds properly to disequilibrium syndrome Recalls and/or responds properly to hypertension Recalls and/or responds properly to hypoglycemia Recalls and/or responds properly to a reaction of undetermined cause Recalls and/or responds properly to a rising venous pressure Recalls and/or responds properly to shortness of breath Recalls and/or responds properly to a dialyzer reaction Recalls and/or responds properly to transfusion reaction Recalls and/or responds properly to a seizure Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. Preceptor Initials 11 TECHNICAL PROBLEMS Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee 1. Recalls and/or properly evaluates a clotted dialyzer 2. Recalls and/or properly evaluates a dialyzer blood leak 3. Recalls and/or properly changes an arterial blood line 4. Recalls and/or properly changes a venous blood line 5. Recalls and/or properly replaces a dialyzer 6. Recalls and/or responds properly to hematoma formation or infiltration 7. Recalls and/or responds properly to blood flow problems 8. Recalls and/or properly performs the emergency termination of dialysis 9. Recalls and/or properly performs the hand crank during a power failure 10. Knows the contents of the emergency evacuation kit Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. Preceptor Initials 12 Emergency Procedures Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials Recalls and/or responds properly to a bomb threat Demonstrates or verbalizes disaster and emergency readiness Recalls and/or responds properly to a disaster Recalls and/or responds properly to patient evacuation procedure Recalls and/or responds properly to the fire drill procedure Demonstrates proper use of the fire extinguisher Recalls and/or responds properly to a facility fire Recalls and/or responds properly to emergency transfer of patients to the hospital from the clinic LABORATORY PROCEDURES Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Properly obtains blood specimens per procedure Properly obtains blood specimens for URR and KT/V determinations Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. Preceptor Initials 13 LABORATORY PROCEDURES Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Demonstrates proper basic laboratory skills: A. Demonstrates acceptable aseptic and isolation technique B. Properly labels specimens C. Properly fills out forms D. Demonstrates good technique collecting specimen E. Properly obtains specimen from arterial blood line port F. Properly obtains specimen from venous bloodline port G. Properly obtains specimen from vascular access port H. Properly obtains specimen for blood cultures (as allowed by state nurse practice act) I. Properly obtains blood specimen for transfusion J. Properly packs and prepares specimens for transport Blood glucose monitoring A. Properly performs blood glucose QC calibration B. Properly performs blood glucose monitoring Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. Preceptor Initials 14 LABORATORY PROCEDURES Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials C. Properly performs operator maintenance procedures Demonstrates use of the hemoccult slide (as allowed by state nurse practice act) OPERATION AND USE OF ANCILLARY EQUIPMENT Properly operates, maintains, and inspects EKG Machine Knows location and contents of crash cart Properly operates, standardizes and maintains conductivity meter Properly demonstrates use of the AED MEDICAL RECORDS Verbalizes understanding of confidentiality of medical records Demonstrates proper documentation in the medical record Demonstrates proper completion of the Incident Reporting system Verbalizes understanding of release of information from patient medical record Properly uses ESRD lab system Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. 15 DIALYSATE BATH PROCEDURES Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee Preceptor Initials Properly prepares bicarbonate concentrate with bicarbonate mixer Properly cleans and disinfects bicarbonate mixer and containers Familiar with storage and distribution of acid concentrate Properly performs manual conductivity test of dialysate Properly obtains manual temperature of dialysate Properly performs manual pH testing of dialysate Properly performs presence test for bleach Properly performs bacterial culturing of dialysis delivery system (if applicable) Properly performs bacterial culturing of bicarbonate mixer (if applicable) WATER TREATMENT PROCEDURES 1. Properly performs RO System start up procedure 2. Properly performs the water hardness test Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. 16 WATER TREATMENT PROCEDURES Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Date of Satisfactory Performance by Trainee 3. Properly performs the chlorine/chloramine test 4. Properly reads the total dissolved solutes meter (TDS Test) 5. Properly reads pressure drops 6. Properly records RO rejection and product flow rates 7. Properly documents performance and operating parameters 8. Properly performs RO System shut down procedure 9. Properly performs manual RO bypass procedure 10. Properly performs bacterial culturing of water treatment system 11. Properly performs water treatment system disinfect procedure 12. Properly rinses water treatment system free of disinfectant 13. Properly reports to the charge nurse/administrator and technical water treatment deviations and abnormal quality test results Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658. Preceptor Initials 17 OTHER PROCEDURES Properly endorses over patient assignment before leaving the floor in a consistent manner. Completed extra assignments in a timely manner. Completed all inservices. Effectively communicates with patients, families, and multidisciplinary team members. Refers problems/issues to appropriate multidisciplinary team member. The above individual has received training and has demonstrated competency at performing procedures listed above. Date of Demonstration by Preceptor Preceptor Initials Date of Return Demonstration by Trainee Preceptor Initials Preceptor Signature: _______________________________________ Date of Satisfactory Performance by Trainee Preceptor Initials Date: ________________ ___________________________________ has received training in the above procedures satisfactorily as indicated above by a check. Signature of Employee: _____________________________ Date: ___________ Signature of Medical Director: _______________________ Date: ___________ Signature of Education Coordinator ___________________ Date: ___________ Signature of Clinic Manager: ________________________ Date: ___________ Copyright 2005, American Nephrology Nurses' Association (ANNA). Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.
