Download Procedural Skills Instruction

"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.
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10. If protocol is abbreviated or by-passed for an emergent
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situation, appropriate documentation is provided.
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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
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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.
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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”
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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.
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4/19/12
Graduating Class of 2014
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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
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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
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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.
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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.
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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
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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
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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
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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
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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.
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3. Perform “Time Out” immediately before beginning
procedure
4. Put on gloves
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5. States needle length and gauge ranges for Intradermal
Injections
6. Find and clean an appropriate injection site
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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
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SUBCUTANEOUS (1/2” to 1” needles should be used w/ smallest appropriate needle: 22g – 24g)
1. Wash Hands (or verbalize)
2. Prepare all equipment.
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3. Perform “Time Out” immediately before beginning
procedure
4. Put on gloves (if not using same ones from 1st injection)
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5. States needle length and gauge ranges for Subcutaneous
Injections
6. Find and clean an appropriate injection site
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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
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INTRAMUSCULAR (1” or larger needle using at least a size 20g)
1. Wash Hands (or verbalize)
2. Prepare all equipment.
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3. Perform “Time Out” immediately before beginning
procedure
4. Put on gloves (if not using same ones from 1st injection)
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5. States needle length and gauge ranges for Intramuscular
Injections
6. Find and clean an appropriate injection site
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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
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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
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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
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___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: