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"Time out" immediately before starting the procedure General Information Sheet JCAHO Requirements: A time out should be conducted in the room before the procedure/incision for any procedure where instruments will be inserted in to a body orifice or the integrity of the skin will be compromised. Pre-Procedure Time-Out Patient safety during invasive procedures is of utmost importance in the medical center. This includes pre-procedure protocols to help ensure that all members of a procedural team, including the patient if applicable and able, are in agreement as to what is to occur. This is known as a “Time-Out” and should be performed prior to the start of any invasive or consent-necessary procedure. This should be viewed as an integral final safety stop before a procedure is to begin. Invasive Procedure- any procedure requiring insertion of an instrument or device into the body through the skin or a body orifice for diagnosis or treatment. All of these procedures should also require a written consent from the patient or surrogate Time-Out Protocol All members of the team present during the procedure should participate and verbally acknowledge each component Patient identity should be confirmed using a minimum of two identifiers Procedure to be performed confirmed Patient positioning verified Procedure location, including correct side Applicable pre-procedure medications, equipment, imaging set and confirmed Time-out should be documented If patient needs to be repositioned, procedure altered, or any other factor that leads in anyway to a gap in the planned procedure, a new Time-out should be performed Protocol may be abbreviated or by-passed in emergent situations providing appropriate documentation of such Review the Checklist on the Following page. The checklist will be used for all appropriate procedures during training sessions and assessments. Procedural Skills Instruction Time-Out Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED All steps must be verbalized for all applicable procedures. Please rate the examinee on the following items: 1. Written consent from patient or surrogate obtained. ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done ___Done __Not Done 10. If protocol is abbreviated or by-passed for an emergent ___Done situation, appropriate documentation is provided. __Not Done 2. All team members participated in time out. (Must verbalize if specific procedure may involve more than one caregiver.) 3. Patient identity confirmed w/minimum of two identifiers. 4. Procedure to be performed confirmed. 5. Patient positioning verified. 6. Procedure location, including correct side (or side being used is verbalized- as in right arm, left wrist, etc.) 7. Applicable pre-procedure medications, equipment, imaging set and confirmed. 8. Time Out documented 9. If any change in plan – time-out is performed again. 4/19/12 Graduating Class of 2014 Total Missed: ___N/A ___N/A ___N/A ___N/A Procedural Skills Instruction Arterial Blood Gas (ABG) Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Please rate the examinee on the following items: 1. Washed hands. 2. Check that all necessary equipment is available and ready to use. 3. Perform “Time Out” immediately before beginning procedure 4. Put on examination gloves. ___Done __Not Done ___Done __Not Done __Correct Technique __Incorrect Technique ___Done __Not Done 5. Identified location of radial artery (palpated pulse lateral to flexor carpi radialis tendon. Thumb may not be used in palpation) “Describe and demonstrate the steps in the Allen test” __Correct Technique __Incorrect Technique 6. Hold patient’s hand up and have patient clench and unclench hand several times to drain blood from the hand. 7. Compress the radial and ulnar arteries while patient is clenching the hand. 8. Lower hand and have patient relax the arm and hand to alleviate tension which can cause inaccurate results. (Must verbalize) 9. Release pressure on the ulnar artery and observe for brisk return of color to hand. (Must verbalize) 10. “Describe potential results” Participant answer need not be verbatim but must be complete: “Positive Test: Color returns to hand in 14 seconds or less and procedure can be done; Negative Test: Color returns to hand in 15 seconds or greater and procedure must be aborted. Assess the other hand.” 11. Prepared area with alcohol wipe to simulate CHG (chlorhexidine gluconate) or idophor. Must state that solution stays on site for 2 minutes until dry before puncturing the skin. 12. Using a Heparinized syringe, removed residual air from syringe. For credit, cap must be removed. Attach needle to syringe. 13. Palpated artery with index finger. of non-dominant hand proximal to (“above”) planned puncture site 14. Slightly adduct arm and dorsiflex the wrist approximately 30o. Inserted needle at a 60° angle to the skin and advanced to the artery with bevel side up. (This must be done proximal to model) *Prompt participant to verbalize proper positioning. __Correct Technique __Correct Technique __Correct Technique __Correct Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique 4/19/12 Graduating Class of 2014 __Not Done __Correct Response __Not Done __Not Done __Not Done __Not Done __Not Done __Incorrect Response __Correct Technique __Incorrect Technique __Correct Technique __Correct Technique __Incorrect Technique __Incorrect Technique __Correct Technique __Incorrect Technique Total Missed: __Not Done __Not Done __Not Done __Not Done 15. Assessed for flashback of blood into the syringe, then allowed syringe to fill. (about 1 cc - assessor should tell examinee that a smaller amount is sufficient for the purpose of the exam. Assessor may prompt for aspiration.) 16. Placed 2x2 gauze pad over puncture site and withdrew needle and syringe. Needle safety device is engaged. 17. Upon SI’s question, “How long should pressure be applied to puncture site?” Answered, “At least five minutes” or “Five Minutes.” 18. Slowly inverts the syringe 10 times, and then roll between palms to mix. 19. In the patient’s presence, labels the specimen and places in a biohazard bag. (NO ICE) 20. Ask: “What must you do once the procedure is completed?” Answer: “Document in the patient chart including location of puncture site, results of Allen test, and any complications”.” 21. Patient comfort was a priority. 4/19/12 Graduating Class of 2014 __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done ___Correct Response __Correct Technique __Correct Technique ___Incorrect Response __Incorrect Technique __Incorrect Technique __Not Done __Not Done ___Correct Response ___Incorrect Response ___Yes ___No Total Missed: Procedural Skills Instruction Basic Airway #1: Bag-Valve-Mask Ventilation ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Please rate the examinee on the following items: 1. Assessor Prompt: “What equipment should be set out and checked for the procedure?” Correct Response: “Oxygen, ambu bag, Oral & Nasal Airways, Suction, stethoscope.” 2. Washed Hands 3. Put on Gloves 4. Chooses appropriate sized mask and attaches to ambu bag.. 5. Checks patients’ mouth for foreign material and/or small or illfitting dental devices. (Good-fitting full dentures may be left in place to get a better seal.) 6. Oral or Nasal airways properly measured (Tip of lip to angle of jaw/Tip of nare to angle of jaw) and inserted. (If oral, curve up towards hard palate first, then rotated at soft palate - or used tongue blade; if nasal, lubricated generously and initially inserted with bevel tip toward the septum.) Ask: “When is a(n) oral/nasal airway used.” Answer: Indicates gag reflex uses nasal vs. no gag reflex uses oral. **Oral and Nasal Airways can be done in conjunction with BVM or as a separate task.** 7. Attaches Oxygen with tubing and adjusts regulator to at least 15 liters. 8. Head-tilt, Chin-lift performed. 9. Hand positioned– one-handed technique to fit and seal the bag against the face. (Proper hand placement: Thumb & Index finger on body of mask, 3rd & 4th digits on jawbone, 5th digit at the angle of the jaw. Little or NO pressure to the sub-mandibular soft tissue.) 10. Hand positioned– two-handed technique to fit and seal the bag against the face. Assessor should squeeze the bag for the participant. (Proper hand placements: Thumbs & Index fingers on body of mask, 3rd & 4th digits on jawbone, 5th digit at the angle of the jaw. Little or NO pressure to the sub-mandibular soft tissue.) 11. Assessor prompt “What needs to be checked now?” Correct Response: “Auscultation of chest.(By a second person)” 12. Ask: “What must you do once the procedure is completed?” Answer: “Document in the patient chart.” 4/19/12 Graduating Class of 2014 __Correct Response __Incorrect Response __Done __Not Done __Done __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Correct Technique __Incorrect Technique __Incorrect Technique __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Response __Correct Response Total Missed: __Not Done __Not Done __Incorrect Response __Incorrect Response Procedural Skills Instruction Basic Airway #2: Oxygen Delivery (NC, Simple Mask, NRB) Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED All Items MUST be done in the correct order per the checklist. Participant MUST verbalize full range of oxygen liter flow for each device. NASAL CANNULA 1. Connect end of tubing to Oxygen regulator (flowmeter). 2. Turn on Oxygen from 2 to 6 liters. (states range) 3. Place nasal cannula on patient w/prongs correctly placed in nares and tubing gently looped over ears. 4. Patient comfort was a priority. ___Done ___Not Done ___Done ___Not Done ___Correct Technique ___Incorrect ___Not Done Technique ___Yes ___No ___Done ___Not Done ___Done ___Not Done SIMPLE MASK 1. Connect end of tubing to Oxygen Regulator (flowmeter) 2. Turn on Oxygen from 6 to 12 liters. (states range) 3. Place mask over patients’ face and gently place elastic strap around the back of the head. 4. Patient comfort was a priority. ___Correct ___Incorrect Technique Technique ___Not Done ___Yes ___No ___Done ___Not Done ___Done ___Not Done NON-REBREATHER MASK 1. Connect end of tubing to Oxygen Regulator (flowmeter) 2. Turn on Oxygen to 12 -15 liters. (states range) 3. Place thumb over vent until reservoir bag is full. 4. Place mask over patients’ face and gently place elastic strap around the back of the head. 5. Patient comfort was a priority. 4/19/12 ___Correct ___Incorrect Technique Technique ___Correct ___Incorrect Technique Technique Graduating Class of 2014 ___Not Done ___Not Done ___Yes ___No Total Missed: Procedural Skills Instruction Advanced Airway Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Please rate the examinee on the following items: 1. Washed hands. 2. Assessor prompt: “What equipment should be set out and checked for the procedure?” Correct Response: O2, ambu bag, mask, induction drugs, oral airway, suction, Endotrachial tube, 10cc syringe, laryngoscope handle & blades, stylette, CO2 detector, stethoscope. 3. Perform “Time Out” immediately before beginning procedure 4. Put on gloves, eye protection, and mask. 5. Oral airway placed (curved up toward hard palate first, then rotated – or – inserted with tongue blade). Should verbalize that someone is bagging patient before and after insertion. Ask student: “If patient has a positive gag reflex, what would you consider next?” Correct Response: “Induction agents and paralytics” 6. Checked light on laryngoscope (a size #3 MacIntosh [curved] blade is used on task trainers). 7. Checked cuff of ET tube by inflation with 10cc syringe (syringe should be removed to ensure no leak in cuff); deflates cuff. 8. Placed stylette into ET tube (in such a way that the tip does not protrude). 9. Verbalizes lubrication of ET tube. (Instructor will spray manikin.) 10. Remove Oral Airway 11. Head-Tilt, Chin-Lift performed. 12. Assessor prompt: “How long should you persist in the attempt to place the ET tube before bagging again?” Correct response: “As long as I can hold my breath.” [Once ventilation stops, hold your breath to intubate, stop when breathless.] 4/19/12 Graduating Class of 2014 ___Done ___Not Done ___Correct Response ___Incorrect Response ___Correct Technique ___Incorrect Technique ___Done ___Not Done ___Not Done ___Correct Technique ___Incorrect Technique ___Not Done ___Correct Technique ___Incorrect Technique ___Not Done ___Correct Technique ___Incorrect Technique ___Not Done ___Correct Technique ___Incorrect Technique ___Not Done ___Done ___Correct Technique ___Not Done ___Incorrect Technique ___Not Done ___Done ___Not Done ___Correct Response ___Incorrect Response Total Missed: 13. Opened mouth with right hand while using scissor technique, inserted laryngoscope using the left hand, swept tongue from right to left. 14. Assessor prompt: “What direction do you give to the team?” Correct response: “Direct assistant to perform cricoid pressure – selleck maneuver.” 15. Tip of Mac (curved) blade placed into valecula. Assessor Prompt: “Where is the tip?” Correct response: “At the velecula.” If Miller (straight) blade is used, placed at epiglottis. 16. Lifted handle up and away from operator (without touching the teeth). 17. Right hand placed the ET tube, through vocal cords. Assessor prompt: “Where is the end of the tube?” Correct response: “1-2 cm below cords” 18. Asked assistant to release the cricoid pressure. 19. Inflated cuff. 20. Removed stylette while securing the tube with the other hand. 21. Checked that ambu bag was connected to O2 source. (Can be done anytime prior to bagging through ET tube.) 22. Attached ambu bag to CO2 detector, then to ET tube. 23. Firmly held ET Tube while ventilating patient. 24. Assessor prompt: “What do you see that suggests proper intubation?” Correct response: (any of the following) “Chest Rise,” “condensation on the tube,” or “CO2 detection” 25. Listened for proper placement by auscultating epigastrium, then bilateral axilla while pt is being ventilated. 26. If proper placement, secured ET tube and noted depth of placement w/marking on ETT 27. When asked “What would you do next, after you finished the procedure with a real patient?” Answer: “Document the procedure in the patient chart including depth of ET tube noted at teeth” 4/19/12 Graduating Class of 2014 ___Correct Technique ___Incorrect Technique ___Correct Response ___Not Done ___Incorrect Response ___Correct Technique ___Incorrect Technique ___Not Done ___Correct Technique ___Incorrect Technique ___Not Done ___Correct Technique ___Incorrect Technique ___Not Done ___Done ___Correct Technique ___Correct Technique ___Not Done ___Incorrect Technique ___Incorrect Technique ___Done ___Correct Technique ___Not Done ___Not Done ___Not Done ___Incorrect Technique ___Not Done ___Done ___Not Done ___Correct Response ___Incorrect Response ___Correct Technique ___Correct Technique ___Incorrect Technique ___Incorrect Technique ___Correct Response ___Not Done ___Not Done ___Incorrect Response Total Missed: Procedural Skills Instruction 12-Lead EKG Placement Skills Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Participant must be able to find the correct anatomical position for each lead on the model Please rate the examinee on the following items. 1. Clean hands. 2. Placement of V1 electrode - Fourth intercostal space at the right sternal border, right chest 3. Placement of V2 electrode - Fourth intercostal space at the left sternal border, left chest. 4. Placement of V4 electrode - Fifth intercostal space on the midclavicular line, left chest. (Must be placed before V3) 5. Placement of V3 electrode - Midway between locations V2 and V4, left chest. 6. Placement of V5 electrode - Anterior axillary line on the same horizontal level as V4, left chest. **Leads V5 & V6 can be placed in either order.** 7. Placement of V6 electrode - Mid axillary line on the same horizontal level as V4 and V5, left chest **Leads V5 & V6 can be placed in either order.** 8. Placement of LA electrode - Left deltoid or wrist, fleshy area (not on bone). 9. Placement of RA electrode - Right deltoid or wrist, fleshy area (not on bone). 10. Placement of LL electrode - Left inner thigh or above ankle, fleshy area (not on bone) 11. Placement of RL electrode - Right inner thigh or above ankle, fleshy area (not on bone). 12. Application of electrodes was done in correct order - V4 and V2 before V3. 13. Electrodes applied with tabs pointing in correct direction (toward waist; chest electrodes should point down, LL and RL should point up.) 14. EKG machine placed in a convenient location with ample room to apply wires. 15. Lead wires properly placed on the correct corresponding electrode. 16. Advised patient to lie still during test. 17. Can correctly run and identify an acceptable 12-Lead printout. 4/19/12 Graduating Class of 2014 __Done __Not Done __Correct Technique __Correct Technique __Correct Technique __Correct Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Correct Technique __Correct Technique __Correct Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Not Done __Not Done __Not Done __Not Done __Not Done __Not Done __Not Done __Not Done __Done __Not Done __Done __Not Done __Done __Not Done __Done __Not Done __Done __Not Done __Yes __No Total Missed: Procedural Skills Instruction Injections ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Instructor: Hand cleaning MUST be done at start of session, but must re-clean OR verbalize hand cleaning for other two injections. INTRADERMAL (3/8” to 5/8” small gauge needles should be used: 25g–27g) 1. Wash Hands 2. Prepare all equipment. ___Done ___Not Done ___Done ___Not Done 3. Perform “Time Out” immediately before beginning procedure 4. Put on gloves ___Correct Technique 5. States needle length and gauge ranges for Intradermal Injections 6. Find and clean an appropriate injection site ___Correct Response ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique 7. Open vial and clean w/alcohol 8. Inject amount of air equivalent to amount of med needed 9. Withdrew correct amount of meds & removed air from syringe. 10. Insert needle superficially with bevel side up at a 15o angle. 11. Entered just under epidermis and injected .1cc fluid to form ‘bubble’ under the skin. 12. Remove needle using a 2 x 2 gauze pad – without applying pressure. 13. Disposed of supplies safely and appropriately. 14. Gave follow-up instructions to patient. (ID injections are generally used for TB tests and the patient should be instructed to return in 48 to 72 hours to have the test read by a nurse or physician.) 15. Document on patient chart: date, time, needle gauge, location of injection, complications, instructions given. 4/19/12 Graduating Class of 2014 ___Incorrect Technique ___Done ___Not Done __Not Done ___Incorrect Response ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Done ___Not Done ___Done ___Not Done ___Done ___Not Done Total Missed: SUBCUTANEOUS (1/2” to 1” needles should be used w/ smallest appropriate needle: 22g – 24g) 1. Wash Hands (or verbalize) 2. Prepare all equipment. ___Done ___Not Done ___Done ___Not Done 3. Perform “Time Out” immediately before beginning procedure 4. Put on gloves (if not using same ones from 1st injection) ___Correct Technique 5. States needle length and gauge ranges for Subcutaneous Injections 6. Find and clean an appropriate injection site ___Correct Response ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique 7. Open vial and clean w/alcohol 8. Inject amount of air equivalent to amount of med needed 9. Withdrew correct amount of meds & removed air from syringe. 10. Hold tissue gently between thumb & fingers to raise subcutaneous tissue above the muscle. 11. Insert needle at a 45o angle and inject fluid. 12. Remove needle using a 2 x 2 gauze pad with slight pressure. 13. Disposed of supplies safely and appropriately. 14. Cover site with band aid. 15. Give patient instructions to check for signs of infection. 16. Document on patient chart: date, time, needle gauge, location of injection, complications, instructions given 4/19/12 Graduating Class of 2014 ___Incorrect Technique ___Done ___Not Done __Not Done ___Incorrect Response ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Done ___Not Done ___Done ___Not Done ___Done ___Not Done ___Done ___Not Done Total Missed: INTRAMUSCULAR (1” or larger needle using at least a size 20g) 1. Wash Hands (or verbalize) 2. Prepare all equipment. ___Done ___Not Done ___Done ___Not Done 3. Perform “Time Out” immediately before beginning procedure 4. Put on gloves (if not using same ones from 1st injection) ___Correct Technique 5. States needle length and gauge ranges for Intramuscular Injections 6. Find and clean an appropriate injection site ___Correct Response ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique 7. Open vial and clean w/alcohol 8. Inject amount of air equivalent to amount of med needed 9. Withdrew correct amount of meds & removed air from syringe. 10. Hold skin taught with thumb & fingers to compress subcutaneous tissue and ensure needle enters muscle. 11. Insert needle at 90o angle. 12. Draw back slightly on plunger to ensure needle is not in a blood vessel. Inject medication. 13. Remove needle using a 2 x 2 gauze pad and apply slight pressure. 14. Disposed of supplies safely and appropriately. 15. Cover site with band aid. 16. Give patient instructions to check for signs of infection. 17. Patient comfort was a priority. 18. Document on patient chart: date, time, needle gauge, location of injection, complications, instructions given 4/19/12 Graduating Class of 2014 ___Incorrect Technique ___Done ___Not Done __Not Done ___Incorrect Response ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Not Done ___Done ___Not Done ___Done ___Not Done ___Done ___Not Done ___Yes ___No ___Done ___Not Done Total Missed: Procedural Skills Instruction IV Insertion Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Please rate the examinee on the following items: 1. Checked that all necessary equipment is available and prepared to use. 2. Washed hands 3. Perform “Time Out” immediately before beginning procedure 4. Put on gloves __Not Done ___Done __Not Done __Correct Technique __Incorrect Technique ___Done 5. Cleaned insertion point. Must use at least 3 wipes, as shown on the training video, for credit. 6. Applied tourniquet (may be done prior to cleaning if necessary to locate appropriate site.) 7. Inserted needle superficially with bevel side up; if blow-out occurred, removed needle and starts procedure over in a different vein with a clean needle 8. Removed tourniquet to release pressure in vein. 9. Advanced catheter over needle up to hub and using one finger to put pressure at the end of the catheter to stop blood flow, removed the needle. (If using needleless device, retracted needle first.) 10. Disposed of needle in Sharps container without recapping. 11. Attached IV tubing to hub of catheter and opened IV line to ensure proper flow of fluids. 12. Thoroughly secured cannula and tubing with tagaderm & tape. At least two pieces of tape must be used with the tagaderm for credit. 13. Labeled work with the minimum of initials, date, and size of needle. For credit, information must be recorded on piece of tape or on the tagaderm before it is placed on patients’ hand. 14. Used proper removal technique: removed tape, applied 2x2 gauze pad with pressure at removal point, disposed of cannula and attached one band-aid. Note: All steps required for credit; if any are missing or incorrect, item is to be marked “incorrect technique” 15. Placed biohazard materials in proper containers. 16. Patient comfort was a priority 17. Ask: “What must you do once the procedure is completed?” Answer: “Document in the patient chart.” 4/19/12 ___Done Graduating Class of 2014 __Correct Technique __Not Done __Incorrect Technique ___Done __Correct Technique __Not Done __Not Done __Not Done __Incorrect Technique ___Done __Not Done __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Done __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Done __Not Done ___Yes ___No ___Correct Response ___Incorrect Response Total Missed: Procedural Skills Instruction Lumbar Puncture Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Instruct the Examinee: You are permitted to re-adjust by retracting the needle to the subcutaneous tissue. If no fluid is present on the second attempt or if the needle is completely removed while trying to readjust the angle, you must begin process over at a new insertion site starting with sterilization. Please rate the examinee on the following items: 1. Wash Hands. 2. Checked that all necessary equipment is available and ready to use. 3. Perform “Time Out” immediately before beginning procedure 4. Put on Mask. 7. Open sterile glove package. 8. Put on sterile gloves maintaining sterile environment. 9. Prepped “skin” over proposed puncture site. ___Not Done ___Done ___Not Done ___Correct ___Incorrect Technique Technique 5. Identified correct puncture site (midline at L4-L5-S1. L4 is at the level of the iliac crest). 6. Open LP kit carefully to maintain sterility. ___Done ___Not Done ___Done ___Not Done ___Done ___Not Done ___Correct Technique ___Correct Technique ___Correct Technique ___Correct Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Incorrect Technique ___Not Done ___Not Done ___Not Done ___Not Done 10. Place sterile drapes around site maintaining sterile environment. ___Correct ___Incorrect Technique Technique ___Not Done 11. Properly administered a local anesthetic. Must anesthetize four different tissue levels using smaller needle for initial levels and larger needle for deeper levels. ___Correct ___Incorrect Technique Technique ___Not Done 12. Verified proper fit of the stylette in the spinal needle. 13. Inserted the spinal needle with stylette into the puncture site w/bevel toward the iliac crest and at the proper angle. (10 degrees toward the umbilicus). 14. Advanced the needle into the subarachnoid space; if bony resistance was felt, backed needle out to the subcutaneous tissue, changed angle and re-advanced the needle. Ask: If boney tissue is felt, what would you do? Response should be as stated above. 4/19/12 ___Done ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done Graduating Class of 2014 Total Missed: 15. Tested for presence of spinal fluid. Note: Credit given even if no fluid present. Ask: “How much fluid is collected?” Answer: “3 – 4 ml” 16. If no fluid seen, examinee states they would back needle out to the subcutaneous tissue, changed angle and re-advanced the needle. 17. Stylette placed into needle. Placed gauze over puncture site and removed needle. (Must use gauze every time needle is removed for credit and stylette MUST be reinserted into needle before removal.) 18. Disposed of needle assembly in Sharps container 19. Disposed of soiled or bloodied gauze into biohazard container. 20. When asked “What would you now advise the patient to do?” Correctly answered, “Rest: Decrease activity for at least several hours.” 21. Ask: “What must you do once the procedure is completed?” Answer: “Document in the patient chart.” 22. Patient comfort was a priority. ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Done ___Not Done ___Done ___Not Done ___Correct Response ___Incorrect Response ____Correct Response ____Incorrect Response ___Yes ___No ____Done ___Not Done 23. Maintained sterility appropriately throughout the procedure. 4/19/12 Graduating Class of 2014 Total Missed: Procedural Skills Instruction Nasogastric Tube Insertion ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED FACE MASK, EYE PROTECTION & GOWNS AND GLOVES MUST BE WORN. Please rate the examinee on the following items: 1. Wash Hands 2. Prepare all equipment. 3. Perform “Time Out” immediately before beginning procedure 4. Participant dons full protective equipment (listed above). 5 Have the patient breathe in through each nostril to assess which side is more patent 6 Premedicate the nasal cavity with a vasoconstricting spray (such as phenylephrine or oxymetazoline). 7. Anesthetize the nasal cavity with a topical anesthetic such as 4 percent lidocaine or topical lidocaine jelly. 8. Anesthetize the posterior oropharynx with lidocaine or topical benzocaine spray. 9. Approximate the proper depth of tube insertion by measuring the distance from the xiphoid process to the angle of the mandible and then to the nostril. 10. Lubricate the distal tip of the nasogastric tube with surgical jelly or viscous lidocaine. 11. Position the patient sitting upright, in the "sniffing" Position (neck flexed slightly) 12. Insert the tip of the nasogastric tube into the nasal cavity and slowly advance it posteriorly, parallel to the floor of the nasal canal. (The tube should not be directed upward. When the tube is passed parallel to the nasal floor, it reaches the posterior nasopharynx without difficulty.) 13. Continue to pass the tube posteriorly. (The patient may gag when the tube reaches the larynx.) 14. Temporarily halt the advancement of the tube, and ask the patient to begin swallowing sips of water through a straw. (Coordinate advancement of the tube with the swallowing mechanism to facilitate advancement of the NG tube into the esophagus and to prevent entry into the trachea.) 15. Check the black markings on the tube to confirm proper depth of insertion 4/19/12 ___Done ___Not Done ___Done ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Done ___Not Done ___Done ___Not Done ___Correct ___Incorrect Technique Technique ___Correct ___Incorrect Technique Technique ___Correct ___Incorrect Technique Technique ___Correct ___Incorrect Technique Technique ___Not Done ___Not Done ___Not Done ___Not Done ___Done ___Not Done ___Done ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done Graduating Class of 2014 ___Done ___Not Done Total Missed: 16. Ensure that the patient is in no respiratory distress and is able to speak. (If the patient is unable to talk, is in respiratory distress, or if respirations can be heard through the tube, it should be removed immediately as tracheal intubation has likely occurred.) 17. Attach the catheter-tip syringe to the main port of the NG tube and insufflate 30 cc of air while auscultating over the epigastrium. (A gurgling noise should be clearly audible.) 18. Using the same syringe, aspirate the NG tube and ensure that it fills with gastric contents. 19. Secure the tube to the patient. To do this, take a 5-to-7cm strip of adhesive tape and tear it vertically for one half of its length. Place the wide section across the patient's nose, and wrap the two tails in opposite directions around the NG tube. 20. Order an X-Ray to confirm proper placement. (Participant must state that the tube is below the diaphragm.) 21. Now connect the nasogastric tube to suction. 22. Turn on the suction and adjust the vacuum force as desired. 23. Ask: “What must you do once the procedure is completed?” Answer: “Document in the patient chart.” 24. Patient comfort was a priority throughout the procedure. 4/19/12 ___Done ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Done ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Done ___Not Done ____Correct Response ____Incorrect Response ___Yes ___No Graduating Class of 2014 Total Missed: Procedural Skills Instruction Venipuncture (Phlebotomy) Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Please rate the learner on the following items: 1. Washed hands. 2. Checked that all necessary equipment is available and ready to use. 3. Perform “Time Out” immediately before beginning procedure 4. Put on exam gloves. 5. Applied tourniquet. 6. Cleansed “skin” with 3 dry wipes to simulate alcohol pads. Note: Must use at least 3 wipes, as shown in the training DVD, for credit. 7. Held needle securely by wings or by plastic vacutainer connector. Note: For credit, must not let go of wings, though s/he may switch hands. 8. Inserted needle bevel up at approximately 30° angle to skin surface 9. Pressed the evacuated glass tube onto the piercing needle using connector and collected sample (If no blood returned to tube, examinee removed and reinserted needle in a new site.). 10. Removed tourniquet. 11. Tube was removed from vacutainer connector before needle was removed from task trainer 12. Placed 2x2 gauze over puncture site and withdrew needle, then applied pressure.. 13. Upon being asked by instructor “How long would you tell the patient to apply pressure?” Answered “2 minutes.” 14. Placed needle in Sharps container. 15. Inverted tubes 6 – 8 times. 16. Disposed of all soiled supplies into proper containers (“bloodied” supplies into biohazard). 17. Labeled samples with full name, ID #, location, date, time, initials and test name. Prompt (without specifics) if not done; if then done correctly, rate as correct technique. 4/19/12 Graduating Class of 2014 ___Done ___Done ___Done __Not Done __Correct Technique __Incorrect Technique __Not Done ___Done __Not Done ___Done __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done ___Done __Correct Technique __Correct Technique __Not Done __Incorrect Technique __Incorrect Technique __Not Done __Not Done __Correct Response __Incorrect Response ___Done __Not Done ___Done __Not Done ___Done __Not Done __Correct Technique __Incorrect Technique Total Missed: 19. Ask: “What must you do once the procedure is completed?” Answer: “Document in the patient chart.” 4/19/12 Graduating Class of 2014 ___Correct Response ___Incorrect Response Total Missed: Procedural Skills Instruction Sutures Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Please rate the learner on the following items: 1. Wash Hands 2. Checked that all necessary equipment is available and ready to use. 3. Perform “Time Out” immediately before beginning procedure 4. Anesthetized wound area. 5. Irrigated wound. 6. Opened suture kit in a sterile manner; open sutures and drop into sterile field. 7. Put on sterile gloves in a sterile manner and sterile prepared wound area w/sterile drape(s). 8. Examinee held needle correctly (2/3 of distance from point when starting insertion into tissue, needle and holder at right angles to each other). 9. Examinee performed a simple interrupted stitch. Grasp cut edge of wound near insertion site of the needle. (Both single flap and double flap insertion will be credited.) 10. Place the needle in the skin at 90o angle; press forward with slight turn (wrist motion) through the skin. 11. Grasp the contra-lateral edge; press the skin over the needle and move it forward with slight turn (wrist motion) through skin. (If double flap was done, credit can be given for this step.) 12. Carefully release needle and grab it from the other side; pull through skin leaving a small amount of suture as a ‘tail’ for making knot. 13. Insertion Knot: Two forward rolls over needle driver. Grasp on the edge of the free tie (‘tail’) and bring knot down squared. Pull tissues together and turn to 90 o to lock in place. 14. One backward roll over needle driver, grasp end, and place second knot. 15. One forward roll over needle driver, grasp end, place third knot down on skin. Suture must be cut when completed. 16. Stitch was properly sized. 4/19/12 ___Done ___Not Done ___Done ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Done ___Not Done ___Done ___Not Done ___Correct ___Incorrect Technique Technique ___Correct ___Incorrect Technique Technique ___Not Done ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done Graduating Class of 2014 ___Yes ___No Total Missed: 17. Stitch was perpendicular to wound and properly aligned with knot on one side of wound. 18. Stitch was acceptably taut (“Wound” edges touching each other, but not buckled or overlapping 19. Patient comfort was a priority. 20. When asked, “What would you do next, after you finished the procedure with a real patient?” Answered, “Document the procedure in the patient chart.” 21. Suture removal: Grasped suture by knot. 22. Cut stitch under knot without cutting knot, on side closest to skin without allowing contaminated suture to go through tissue. 23. Patient comfort was a priority. 24. Maintained sterility appropriately throughout the procedure. 4/19/12 ___Yes ___No ___Yes ___No ___Yes ___No ___Correct Response ___Incorrect Response ___Correct ___Incorrect Technique Technique ___Not Done ___Correct ___Incorrect Technique Technique ___Not Done ___Yes ___No ___Done ___Not Done Graduating Class of 2014 Total Missed: Procedural Skills Instruction Urethral Catheterization Checklist ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Please rate the examinee on the following items. 1. Washed hands 2. Opened all equipment in a sterile manner and prepared for use. 3. Perform “Time Out” immediately before beginning procedure 4. Place first drape at buttocks carefully to maintain sterile area. 5. Put on sterile gloves 6. Tested Foley catheter balloon – injected 10cc sterile water into the balloon port to assess the integrity of the balloon 7. Lubricated the distal portion of the Foley catheter including the balloon portion 8. Draped the genital area with a fenestrated drape 9. Maintained a sterile [dominant] hand and a contaminated [nondominant] hand 10. Cleansed site Female Held labia open with non-dominant hand (this hand is now contaminated) Cleansed vulva using antiseptic soaked cotton balls or sponges held with forceps in dominant [sterile] hand Prepped the vulva using a circular motion Male Retracted foreskin (if present) and held shaft of penis, near the base, with non-dominant hand (this hand is now contaminated) Cleansed using antiseptic soaked cotton balls or sponges held with forceps in dominant [sterile] hand Started at urinary meatus and worked outward 11. Inserted Catheter Inserted the lubricated catheter into the urinary meatus with dominant [sterile] hand In male, gently stretched the penis to straighten the urethra lifting it away from the body or stretching slightly cranial. 12. Advanced the catheter - overcoming slight resistance indicates passage past the urinary sphincter. In female, inserted approximately 4 inches In male, inserted to the balloon’s sidearm 4/19/12 Graduating Class of 2014 ___Done __Not Done __Correct Technique __Correct Technique __Correct Technique __Correct Technique __Correct Technique __Correct Technique __Correct Technique __Correct Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Incorrect Technique __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done Total Missed: __Not Done __Not Done __Not Done __Not Done __Not Done __Not Done __Not Done __Not Done 13. Confirmed position of the catheter tip Return of urine occurred - indicates successful entry into the bladder 14. Inflated catheter balloon with 10 cc of sterile water 15. Gently withdrew catheter (Resistance signifies the balloon resting on the bladder neck) *In male, gently return foreskin to original position 16. Attached catheter to drainage system 17. Secured tubing to medial thigh with appropriate device. (This step must be verbalized.) 18. Disposed of supplies appropriately 19. When asked “What would you do next, after you finished the procedure with a real patient?” Answered, “document the procedure in the patient chart.” 20. Patient comfort was a priority. 21. Maintained sterility appropriately throughout the procedure 4/19/12 Graduating Class of 2014 __Incorrect Technique __Not Done Technique __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Correct Technique __Incorrect Technique __Incorrect Technique __Not Done __Correct __Not Done ___Done ___Not Done ___Correct Response ___Incorrect Response ___Yes ___No ___Done ___Not Done Total Missed: Procedural Skills Instruction Metered Dose Inhaler / Peak Flow Meter ASSESSORS: PLEASE DO NOT LEAVE ANY ITEM UNRATED Ask Learner: “How would you instruct a patient to use a metered dose inhaler?” Please rate the examinee on the following items: 1. Remove the cap and hold the inhaler upright __Correct Technique 2. Shake inhaler __Correct Technique 3. Breathe out slowly __Done 4. Position the inhaler (open mouth with inhaler 1– 2 inches away in a spacer; or directly in the mouth) 5. Press down on the inhaler as you breathe in through your mouth (3 – 5 seconds) 6. Hold breath for up to 10 seconds 7. Wait one minute between puffs before repeating 8. Performed all of the above steps in the correct order (as listed here) 10. Skill was completed in the time allotted 4/19/12 __Not Done __Not Done __Not Done __Correct Technique __Incorrect Technique __Not Done __Correct Technique __Incorrect Technique __Not Done __Done __Not Done __Done __Not Done __Done __Not Done __Yes __No __Yes __No __Done __Not Done 11. Student demonstrated as well as explained 12. Student asked patient to demonstrate __Incorrect Technique __Incorrect Technique Graduating Class of 2014 Total Missed: Ask Learner: “How would you instruct a patient to use a peak flow meter?” Please rate the examinee on the following items: 1. Explained the need to use peak flow meter to __Correct monitor success of medications Explanation 2. Explained the danger zone of the peak flow meter: When the blue marker does not pass the __Correct red indicator on the meter – less than 50% of Explanation their personal best; Indicates need for immediate medical attention. 3. Demonstrated how to use the peak flow meter: Set blue marker on zero (at top), Take a deep __Correct breath in; seal lips around spacer, exhale quickly Technique and forcefully, note the number at the blue marker 4. Student asked patient to demonstrate __Done 4/19/12 Graduating Class of 2014 __Incorrect Explanation __Not Done __Incorrect Explanation __Not Done __Incorrect Technique __Not Done __Not Done Total Missed: