Download RN Trauma Competencies Validation Tool Trauma

Sunrise Trauma Services
RN Trauma Competencies Validation Tool
Trauma ED RN
Registered Nurse: ______________________________________________
Preceptor Signature/Initials: ______________________________________
Self Assessment Code (SAC) Key:
0 = No knowledge or experience
1 = Need assistance
2 = Can perform independently
3 = Able to resource others
Validation Options (VO):
V = Individual verbalizes knowledge
and understanding of behavior
according to standard
O = Preceptor observes the individual
performing behavior or skill
according to standard
Notes:
1. Learning resources are listed below
a. Orientation to Trauma Resuscitation
b. TNCC / ATCN (circle one) Date taken: ___________ Date Expiration ___________
CRITICAL SKILLS TO BE VALIDATED
SAC
VO
COMPETENCY #1: Assessment
1. Performs head to toe assessment on every multiple
trauma patient presenting to the ED/Trauma Bay –
V
O
includes removal of clothing, re-warming measures appropriate
assessment of injuries, good patient care tactics
2. Demonstrates use of trauma flow-sheet
3. Documents the trauma assessment, including
appropriate subjective and objective data
4. Reassesses patient according to patient’s condition
and reassessment standards
V
O
V
O
V
O
DATE
INITIALS
COMPETENCY #2:
Able to recognize and activate the appropriate
Trauma Activation Level – bases on Sunrise Trauma
V
O
Activation Criteria
5. Prioritize interventions appropriately according to
patients presentation
6. Reprioritizes interventions appropriately according to
changes in patients condition
7. Identifies nursing diagnoses and or collaborative
problems
8. Identifies expected outcomes and interventions to
achieve those outcomes
9. Use of Trauma Activation Paging System
V
O
V
O
V
O
V
O
V
O
Competency #3: Implementation: Interventions
are implemented as identified in the plan of care
10. Initiates independent nursing measures
11. Identifies role of trauma team members in
Level 1 trauma
a. Trauma Surgeon
b. Trauma Anesthesia
c. Emergency Room Physician-Role in Class
III Traumas vs Class I/II
d. Scribe RN
e. Trauma RN #1
f. Trauma RN #2
g. Pediatric RN (PICU, Peds ED)
h. O.R. RN
i. O.R. Technician
j. Respiratory Therapist
k. Lab Technician
l. Radiology Technician
m. Social Worker
n. Security
o. Child Life Specialist for Pediatric Alerts
12. Identifies/Locates/Demonstrates equipment on
trauma cart
13. Identifies/Locates/Demonstrates familiarity with
procedure trays
a. Combo Tray
V
O
V
O
V
O
V
O
b. Open Thoracic Tray
c. Surgical Airway Tray
d. Closed thoracotomy Tray and Drainage
System set-up
Competency #4: Validates Technical Skills:
14. Demonstrates use of universal precautions
15. Spinal Precautions
A. Adult
B. Pediatric
16. Application of C-Collar-Aspen Vista and Pediatric
Aspen
17. Airway Maintenance
a. Opening airway while maintaining cervical
spine precautions
b. Oropharyngeal or Nasopharyngeal
c. Intubation
d. Surgical Airway
e. Pediatric Considerations
18. blanket and fluid warmer
19. Applies Splints:
1. Hare Traction
A. Adult
B. Pediatric
C. Indications vs Contraindications
20. Level I Rapid Infuser
21. Code Cart
22. Pediatric Trauma Cart
23. ECG Monitor
24. BAIR Hugger
25. Chest Tube Setup: Tray and Pleuravac – (chest tube
ties and dressing application)
26. Arterial line setup
27. Diagnostic Peritoneal Lavage
V
O
V
O
V
O
V
O
V
O
V
O
V
O
V
O
V
O
V
O
V
O
V
O
V
O
V
O
28. Cystogram-(for possible urethra injury-insert foley just
inside meatus, inject just enough saline to hold balloon in
place-instill 30cc of iodine solution)
V
O
29. Appropriate documentation when traveling with
trauma patient –Trauma RN travels to all diagnostic
procedures on Class I & II patients, as needed for Class
III trauma patients
30. Medication Administration
A. Steroid administration for spinal cord injury
B. RSI medication-Vec and Etomidate
C. Tetanus
D. Accu-dose and trauma drug kits-include
V
O
process for wasting drugs included in kit and
where unused drugs are returned
31. Blood Administration
1. Emergency un-crossmatched
blood/paperwork, type, administration
2. Hot line
3. Crossmatched Blood
32. Evidence Collection
33. Manage patient with spinal cord and vertebral
column trauma
34. Manages the emergent burn patient
35. Manages the emergent patient with Orthopedic
injuries
1. Pelvic fracture
2. Femur fractures
3. Extremity fractures
36. Manages the emergent patient with brain injury-mild,
moderate, severe
1. Skull fractures
2. Epidual Hematoma
3. Subdural Hematoma
37. Manages the patient with Cardiothoracic trauma
1. Rib and sternal fractures
2. Flail chest
3. Pneumothorax
4. Hemothorax
5. Blunt cardiac injury]
6. Pericardial Tamponade
7. Aortic injuries
8. Ruptured diaphragm
V
O
V
O
V
O
V
O
V
O
V
O
V
O
38. Manages the patient with penetrating injuries
1. Gunshot wounds
2. Stub wounds
3. Impalements
39. Manages the Emergent trauma patient with acute
abdominal injuries
1. Splenic Injury-may need Invanz
2. Lacerated Liver
3. Renal Injuries
4. Rupture of the bladder
40. Manages the pregnant patient who has sustained
trauma
1. Abruptio placenta
2. Uterine rupture
3. Fetal monitoring in the ED
4. Premature labor
5. Positioning of patient
41. Removal of patient following RN backboard removal
policy
42. Manages the patient in need of active re-warming
43. Evaluates effectiveness of discharge teaching as
evidenced by patient with family’s understanding of
instructions and appropriate follow-up plan of care –
V
O
V
O
V
O
V
O
V
O
V
O
includes appropriate dressings, cleansing of wounds;
patient needs are met as needed
44. Misc. –trauma panel should include obtaining U/A,
45. Must take manual B/P’s, Morphine means 2mg IVP
as needed for pain up to 10mg if not hypotensivestanding order!
46. L&D-has 30 minutes to respond unless pt is in
distress-read policy
V
O
V
O
V
O
Trauma Orientation Notes: