Download Skills and Procedures for Student Nurses

NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Skills and Procedures for Student Nurses
Student Nurses may perform the following procedures (from the GHS Nursing Policy and Procedure Manual) “Under the DIRECT SUPERVISION of an RN”.
Student Nurses are considered “Unlicensed Assistive Personnel”. Refer to the South Carolina Board of Nursing: Delegation of Nursing Tasks to Unlicensed
Assistive Personnel:
•
Determine competency by review of training, review of instructions and rationale for task, etc.
The RN will consider:
•
•
•
•
the client’s condition and stability
the nature / complexity of the task
potential risk if the task is done inappropriately
competency of the individual performing the task
The safe and effective delegation of selected tasks remains the responsibility of the licensed nurse who is authorized by law to practice nursing. The Nurse
Practice Act holds the licensed nurse responsible for the competency assessment and supervision of the person to whom nursing tasks are delegated.
Senior Nursing Practicum Students are allowed to actively participate in all nursing skills and procedures, under the direct supervision of the GHS
primary RN, with the exception of administration of blood products, IV push medications, chemo meds, narcotics/controlled substances, mixing
medications, and urinary catheter insertion. The GHS preceptor is encouraged to engage the student in all available learning opportunities, subject to the
precpetor’s evaluation of the student’s competency.
Nursing Faculty will be responsible for rotating and “checking on” each student and assigned primary nurse (preceptor) on a regular basis. Faculty are also
responsible for meeting with the student and assigned primary nurse (preceptor) to review skills performed by the student in the clinical site.
Section
Documentation
Policy #
Document 1
Document 4
Document 9
Under direct
supervision
X
X
X
Title
Critical Care Flow Sheet
Focus® Charting
Discharge Summary
Page 1 of 16
NOTES
Students to be added to procedure.
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
Eye, Ear, Nose,
Throat
GI Tract
Policy #
Document 11
Title
Interdisciplinary Plan of Care (POC)
EENT 1
Obtaining a Nasal or Pharyngeal Culture
EENT 2
EENT 3
EENT 4
EENT 5
EENT 6
GITract 2
GITract 3
GITract 7 & 11
GU-Dialy 5
Ear Drops, Instillation
Ear Irrigation
Eye Drops, Instillation
Eye Irrigation
Nasal Drops, Instillation
Colostomy / Ileostomy
Fecal Incontinence, Management of
N/G tube – irrigation, suction – intermittent
and continuouas
Enemas, Cleansing, Retention, Milk and
Molasses Carminative
Nasoduodenal Feeding Tube (Adult),
Insertion and Maintenance of Weighted
Tip
Bladder Irrigation Using 3-Way Foley
Bladder Retraining
(Bladder Scanner- only RN with
demonstrated competency)
Catheterization, In and Out
GU-Dialy 6
Catherization, Foley & Coudé
IVDevice 1
IVDevice 2
IV Therapy, Insert, Maintain, Discontinue
Central Venous Catheter, Assisting with
Placement, Maintenance and Removal
GITract 12
GITract 13
GU-Dialysis
IV Device
Under direct
supervision
X
GU-Dialy 3
GU-Dialy 4
Specimens
Not by a student
X
X
X
X
X
X
X
X
NOTES
Students contribute to the PoC. PoC must be signed
by RN
Lab specimens –
Employee responsible for patient ID and labeling of
any specimen at the bedside – RN to ID and label
X
X
X
X
Insertion Not by a
Student/Faculty
Insertion Not by a
Student/Faculty
X
Only sterile
dressing changes
by student
Page 2 of 16
The Bladder Scanner competency video may be
available to faculty for viewing. Bladder scanning for
RN’s only.
Removal only, maintenance, and urinary retention
protocol
A student nurse with appropriate theoretical
instruction, under the direct supervision of a RN, may
perform sterile dressing changes only.
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
Medications /
Drugs
Medication
Procedures
Policy #
IVDevice 3
Title
AV Fistula Access for IV Therapy
IVDevice 4
Alaris IV Infusion Pump Guidelines
IVDevice 5
(This does not include specialty fluids,
medications, blood products – see note)
Culturing IV Catheters
Under direct
supervision
Student may assess
& report only
ONLY under direct
supervision of RN
Lab specimens Not
by a student
NOTES
Physically assess for presence of thrill and bruit;
verbalize to RN what this means.
NOT blood products or PCA (controlled substance)
that require 2 RNs for heparin infusion (see MedDrugs
15).
Employee responsible for patient ID and labeling of
any specimen at the bedside – RN to ID and label
All medication administration by a student nurse must be under the direct supervision of an RN. The supervising RN must co-sign
the medication record with the student at the time the medication is given. All high risk medications must be verified by two (2)
licensed nurses.
MedDrugs 3
Subcutaneous Heparin Injection
X
MedDrugs 5
Insulin Administration
Glucomander Not by
(includes Glucomander System protocols a student
in specialty areas)
MedDrugs 12
Intradermal - PPD Skin Testing
X
MedDrugs 13
IV Insertion – Use of Local Anesthetic
X
MedDrugs 16
Pneumococcal Screening and Vaccine
X
Important screen, document and administer—All Care
measure
MedDrugs 17
Influenza Vaccine, Screening and
X
Important All Care measure
Administration
Nursing students can administer medications, per GHS policies and guidelines, only under the direct supervision of a Registered
Nurse. This Registered Nurse may be a credentialed school of nursing faculty member, GHS RN preceptor, or other Registered
Nurse involved in the care of the patient. Nursing students are not given a sign-on to the Omni cell med. cabinet or the electronic
Medication Administration Check (MAC)*. Medications removed from the Omni cell must be removed by the nursing faculty or an
RN preceptor. The documentation of medication administration in MAC is done under the faculty member’s sign-on or the RN
preceptor’s sign-on and requires that the faculty member or RN preceptor remain with the student during the entire process. Both
the RN and student co-sign in the medical record.
(*Special Circumstances – Nursing Practicum Students are issued a temporary MAC sign on for the practicum experience only. Medication
administration must be witnessed and co-signed by the RN preceptor at the time the medication is administered.)
Page 3 of 16
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
Policy #
MedProc 1 & 2
MedProc 5
MedProc 6, 7
and 8
NursCare 1
Title
Administration of Medication & Guidelines
Suppositories, Rectal and Vaginal
Medication Administration
Intradermal, Intramuscular, IM Z-track
method
IV Medication – Intermittent Doses
(formerly Piggyback)
Linen Use
NursCare 2
NursCare 3
Vital Signs
Patient Assessment
NursCare 4
NursCare 5
NursCare 6
NursCare 7
Fall Prevention
Cold Application
Wound Drainage Device, Care of
Hypoglycemic Protocol
NursCare 8
NursCare 11
NursCare 12
Post Mortem Care
Latex Precautions
Admission of the Inpatient to an Acute
Care Unit
Nursing Summary Hand Off Report
Discharge of the Inpatient
Sitz Bath
Restraints – refer to GHS policy directive
S-50-2A.
Cardiac Catheterization, Nursing Care
Pre- Procedure
Code Stat Response
Refer to GHS policy directive S-50-20
MedProc 9
Nursing Care
NursCare 13
NursCare 14
NursCare 15
Cardiovascular
CardVas 1
Code
Code 1
Under direct
supervision
X
X
X
NOTES
UNDER DIRECT SUPERVISION OF AN RN
UNDER DIRECT SUPERVISION OF AN RN
UNDER DIRECT SUPERVISION OF AN RN
X
UNDER DIRECT SUPERVISION OF AN RN
X
Students need awareness of linen usage procedures
to support patient comfort and cost containment.
Report v/s to the primary nurse.
Report assessment and any changes in condition to
the primary RN.
X
X
X
X
X
Lab specimens Not
by a student
Page 4 of 16
X
X
X
X
X
X
X
Employee responsible for patient ID and labeling of
any specimen at the bedside – RN to ID and label.
In collaboration with primary nurse
SBAR format used
In presence of the primary RN; may assist in process.
X
X
S-50-20: Cardiopulmonary Resuscitation (CPR) will
be initiated using American Heart Association
Guidelines for Basic Life Support where trained
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
Diagnostics
Policy #
Diagnost 1
Diagnost 2
Diagnost 3
Oncology
Oncology 3
Title
Should a student nurse find a patient
pulseless or breathless, they should
immediately summon help and begin CPR
if appropriate – anticipating the arrival of
the Code Stat Team.
Angiogram, Care of the Patient Pre- and
PostAssisting the Physician with a Diagnostic
Procedure:
• Lumbar Puncture
• Throacentesis
• Paracentecesis
• Bone Marrow Aspriation
• Signmoidoscopy
Myelogram, Care of the Patient Pre- and
PostChemotherapy Precautions
(No administration of chemotherapy
medications by students or faculty)
OB/GYN
OBGYN 2
Breast Milk, Collection and Storage of
Pain
Management
PainMgt 3
End tidal CO2 Monitoring During Infusion
by PCA Pump
PainMgt 4
PainMgt 6
Transdermal Administration of Analgesics
Pain Assessment
Under direct
supervision
NOTES
providers are available. Student must have current
CPR card.
X
X
Assist the primary RN.
X
No chemo by
students – chemo
requires special
nurse eval. And
education
X
Students may be
involved in
monitoring along
with the RN
(instructor or staff
RN)
X
X
Page 5 of 16
Students are to review chemo precautions for safety
measures.
Also refer to on-Line Women’s Hospital policy and
procedure manual. Departments included:
-Labor and Delivery -Mom-Baby Unit -Newborn Nursery
Great learning experience- to be completed with the
RN (instructor or staff RN).
Controlled substance in most cases
Report assessment to primary RN
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
Respiratory
Skin
Surgery
Policy #
PainMgt 7
Title
Variable Range Orders for Medications
Respirat 1
Chest Tube Insertion: Assist Physician
Respirat 2
Respirat 6
Chest Suction & Drainage, Initial Set Up
Tracheostomy Care, Adult
Respirat 8
O2 Saturation Measurement by Pulse
Oximetry
Pressure Ulcer Assessment
Wound Cleansing or Irrigation
Surgical Site Dressing – Dry, Sterile
Wound Dressings – Wet to Dry
Wound Culture
Skin 1
Skin 3
Skin 4
Skin 5
Skin 6
Surgery 2
Surgery 3
Surgery 4
Post Op Care
Preparation and Preoperative Care
Documentation Guidelines – Pre Op
Assessment
Under direct
supervision
Under direct
supervision to
determine rationale
X
X
Students provide
care only for well
established trach
(48+ hours old)
X
X
Not by a student
X
X
Lab specimens Not
by a student
X
X
X
NOTES
Report patient response to dose to primary RN
Can assist set up of equipment under direct
supervision of RN
Can perform under direct supervision of RN
Well established trach student under direct
observation of an RN (instructor or staff RN) or Resp.
Therapist.
Good experience to observe & assess
Employee responsible for patient ID and labeling of
any specimen at the bedside – RN to ID and label
Refer to Nursing Policy NS-1-9, Supervision of Student Nurses, for any questions; or contact the Nurse Manager, Clinical Educator, or Student Liaison.
Page 6 of 16
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
THE FOLLOWING PROCEDURES MAY BE PERFORMED ONLY BY A LICENSED REGISTERED NURSE and MAY NOT be performed by a student nurse at
GHS. Students are encouraged to observe all of the following to gain knowledge of the process.
Section
Blood Products
Policy #
BloodPro 1
Title
Blood Bank Collections
RN ONLY
RN ONLY
BloodPro 2
Autotransfuser - Reinfuse Blood from
Surgical Wound
Administration of Cryoprecipiate
RN ONLY
Administration of Fresh Frozen Plasma
(FFP)
Administration of Platelets
Administration of Whole Blood or Packed
Red Blood Cells (PRBC)
Emergency Cart & Defibrillator, Routine
Operational and Equipment Checks
RN ONLY
BloodPro 3
BloodPro 4
BloodPro 5
BloodPro 6
RN ONLY
RN ONLY
RN ONLY
Codes
Code 5
GU-Dialysis
GU-Dialy 7
Catheter Irrigation, Manual
RN ONLY
IV Device
IVDevice 4
RN ONLY
MedDrugs 6
Alaris IV Infusion Pump
(Blood Products or PCA–Controlled
Substances; Heparin infusion (see
MedDrugs 15)
Implanted Peritoneal / Vascular Devices
(e.g. Port)
Peripherally Inserted Central Catheter
(PICC), Insertion and Sheath Exchange
Insulin Pump Therapy
MedDrugs 7
MedDrugs 9
Parenteral Nutrition Administration, Adult
Alteplase (Activase) Administration
RN ONLY
RN ONLY
IVDevice 7
IVDevice 18
Medications /
Drugs
RN ONLY
RN ONLY
RN ONLY
RN ONLY
Page 7 of 16
NOTES
Employee responsible for patient ID and labeling of any
blood specimen at the bedside – RN to ID and label – or
lab tech
Great experience to observe
Good experience to observe and research reason given
– rationale
Good experience to observe and research reason given
Good experience to observe & monitor for transfusion
reaction
ONLY Licensed personnel only may check and “sign off”
cart. GREAT opportunity for students review contents of
cart with instructor or preceptor.
RN only. Irrigation not recommended r/t infection
control ; ordered in specific cases.
Blood and PCA require check by 2 RNs
Special education and documented competency
required for RN.
Special education and documented competency
required for RN.
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
Medication
Procedures
Policy #
MedDrugs 15
MedProc 4
Muscock 1
IV Push Medications Through IV Tubing or
Heparin Well
Medicinal Leech Therapy
RN ONLY; student
may observe
RN ONLY
PainMgt 1
Epidural Infusion of Analgesics
RN ONLY
PainMgt 2
IV PCA (Patient Controlled Analgesia)
RN ONLY
PainMgt 8
Respirat 5
Epidural Catheter, Removal of
Suction – Nasotracheal
RN ONLY
RN ONLY
Respirat 6
Traceostomy Care: Adult
RN ONLY
MedProc 10
MusculoSkeletal
Pain
Management
Respiratory
Title
RN ONLY
(For declotting of central catheters)
Heparin Infusion Protocol
RN ONLY
Compounded Sterile Products
RN ONLY; student
(Admixtures), Preparing at Locations Other may observe
Than Pharmacy
Respirat 7
(ONLY RN or RT for the first 48 hours.
Student may perform care after 48 hrs.
with direct supervision)
Endotracheal / Tracheostomy Tube –
Closed/ In-Line Suction
RN ONLY
Page 8 of 16
NOTES
Only RN with special education and demonstrated
competency may perform.
(Limited admix at GHS outside pharmacy. Best
practice recommends admix under “hood” in pharmacy
r/t infection control and patient safety.)
Also refer to <edProc 13A, Levels of care for medication
administration.
RN with additional education & training. Requires 2
RNs to check and verify.
RN with additional education & training. Requires 2
RNs to check / verify.
RN with additional education & training
Only RN or Respiratory Therapist may perform
nasotracheal suctioning with additional training.
Well established trach student under direct observation
of an RN (instructor or staff RN) or Respiratory
Therapist.
RN or Respiratory Therapist with adequate training and
competency. (Students may ONLY suction oral cavities)
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Specfic Skills and Procedures for Student Nurses in CRITICAL CARE
The grid below outlines procedures specific to critical care and the skills that students can perform under direct supervision of the GHS primary RN. Key
learning points applicable to students are also outlined. Please refer to the unit-specific critical care policy/procedure manual located in each area for the full
procedure. Procedures are adopted from the AACN Procedure Manual for Critical Care.
NOTE: Patient care experiences for student nurses in critical care are contingent upon patient acuity, changes in patient condition, nursing judgment/accountability
and time available.
All skills are to be performed only under the direct supervision of the GHS primary RN.
Section
Airway
Management
AACN
Proc. #
3
Title
Endotracheal
intubation,
assisting with
Exceptions
Skills
•
•
•
•
•
•
•
4
ET tube and oral
care / ventilator
management /
VAP initiatives
•
•
•
•
Refer to GHS
Nursing
procedures:
•
Assembles laryngoscope
blade/handle
Setup of bag/mask device
Setup of suction
Auscultates lung fields
Ensures that ETT is secured
Notes position of ETT and
markings
Monitors O2 saturation
Suctions oral cavity (not ETT)
Performs oral care
Confirms settings on ventilator
Assesses pt for pain using BPS;
sedation using RASS and delirium
using KuDAT;
Assesses / monitors patient
response to ventilator changes
Page 9 of 16
Learning Points
Indications for intubation
Role of RN in assisting with intubation
Coordination of care with Respiratory Care /
Anesthesia
• Differentiates curved / straight blades
• Checking tube for air leak prior to insertion
• Confirmation of ETT placement (auscultation /
CO2 detector / PCXR)
• Medications used (sedatives vs. paralytics),
indications, side effects, monitoring
(Refer to GHS Nursing procedure Respirat 7 –
Suction, ET and Trach Tubes)
•
•
•
RN or RT with adequate training and
competency.
•
•
Discusses incidence of VAP/VAP bundle
Assesses proper cuff inflation
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
AACN
Proc. #
Title
Exceptions
Respirat 4, 5, 6
Skills
•
Learning Points
Assesses ABG results; monitors for •
potential skin breakdown from ETT
tube
•
•
•
•
6
Extubation /
Decannulation,
Assisting with
Assist only
•
•
•
•
Special
Pulmonary
8, 9
Nasopharyngeal
airway and
ororpharyngeal
airway insertion
10
Suctioning- ET or
trach
15
Refer to GHS
Nursing procedure
Respirat 7
O2 saturation
monitoring / pulse
•
•
•
•
Exception:
Trach less than
48 hours old
•
•
•
•
Monitors respiratory pattern/effort
pre/post extubation
Suctions patient pre- and postextubation as needed
Monitors trends in 02 saturation /
Arterial Blood Gases
Assists with application of
supplemental O2 post extubation
Measure for airway
Insertion of airway
Verifies patency of airway
Assesses patient’s respiratory
status
Sets up suction canister / tubing /
suction regulator
Uses closed-line suction
Monitors patient status during
suctioning
Sets up O2 saturation monitor on
bedside monitor
Page 10 of 16
•
•
•
Discusses different modes of ventilation,
ventilator alarms
Reviews pain / sedation / delirium orders
Differentiates importance of pain mgmt along
with sedation
Identifies rationale for daily awakening and
reviews criteria for daily awakening (DA)
eligibility
Collaboration with Respiratory Care in care
/management of ventilated patient
Discusses criteria for readiness to wean /
extubate
Discusses O2 saturation vs. Arterial Blood Gas
results
Role of RN/RT in extubation – coordination of
care
Discusses indications for Nasopharyngeal / oral
airway insert
Discusses effects of suctioning on oxygenation
status of patient
(Refer to Resp. 7 suction ET tube – only)
RN or RT with adequate training and
competency.
• Discusses values obtained from pulse oximetry
- trending of values
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
AACN
Proc. #
Procedures
Title
Exceptions
oximetry
Skills
•
•
Thoracic
Cavity
Management
Ventilatory
Management
16
Pronation therapy
19, 21,
22
Chest tube
Placement
(Assist); Removal,
Closed Chest
Drainage System
29
•
•
•
May not remove
•
•
•
•
•
Ambu bag
•
Cardiac
36
Emergencies
Cardioversion
May not deliver
shock
•
•
•
•
37
Defibrillation/
External
Connects O2 saturation probe to
patient/monitor
Assesses trends in O2 saturation
and notes significant changes
Assists with positioning of patient
Protects patient airway/ ETT tube
Monitors patient response to
therapy
Performs dressing change to chest
tubes insertion sites
Sets-up chest tube drainage
system
Monitors drainage from chest tube:
amount, characteristics of drainage
Troubleshoots problems
Assembles and connects ambu
bag
Administers ventilations with ambu
bag
Applies pads to chest for elective
cardioversion
Assists with assessment/
monitoring of patient pre- and postsedation
Monitors airway patency
Ensures IV patent pre- procedure
May not deliver
shock
Learning Points
•
Discusses indications/contraindications and
potential benefits of pronation therapy
•
•
•
Discusses indications for chest tube insertion
Differentiates mediastinal vs. pleural chest
tube (Post-op CVICU patient)
Discusses nursing interventions for increased
drainage, sudden change to bloody drainage,
etc.
Identifies situations in critical care where "ambuing"
is needed (code, transport, problems with vent )
•
•
•
•
•
•
Page 11 of 16
Identifies alternate locations for O2 sensor
probes
Identifies rhythms that can be treated with
cardioversion
Discusses emergency vs. elective
cardioversion
Discusses pad placement for cardioversion of
atrial rhythms
Discusses safety of shock delivery
Identifies non-synch vs. synch mode, possible
need for external pacing post cardioversion
Identifies rhythms that can be treated with
defibrillation
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
Cardiac
Pacemakers
Circulatory
Assist
Devices
ECG Leads
and Cardiac
Monitoring
AACN
Proc. #
Title
41, 77
Pericardiocentesis
(Assist) and
pericardial drain
management
46
Implantable
Cardioverter /
Defibrillator (ICD)
48, 50
Temporary
Pacemaker
(External,
transvenous,
epicardial)
51
IABP therapy
(CCU/CVICU)
54
ECG leads
Exceptions
Skills
Observes drainage for amount and
characteristics
• Assists with site care to sutured
drains
• Auscultates and notes differences
in heart sounds pre- and postprocedure
• Option to observe procedure in EP
lab
• Assists with pre-procedure prep
• Post procedure monitoring of
patient (inicisional care, activity,
post sedation)
• Patient/family education
Observes temporary pacer
settings/setup
•
May not: Adjust
settings, perform
dressing
change,
change battery,
remove or
manipulate wires
Observation
Observation Only
Only
•
•
Preps skin and places ECG leads
in correct location and connects to
bedside monitor
Collaborates with primary RN in
interpretation of cardiac rhythm
Page 12 of 16
Learning Points
•
•
•
Discusses safety of shock delivery (all clear)
Discusses indications for pericardiocentesis
Identifies monitoring required during and post
procedure
•
•
Discusses indications for ICD
Reviews programmed settings for pacer/ICD
•
•
Discusses indications for temporary pacer
Differences in external, transvenous and
epicardial pacing
Discusses capture and sensing and pacer
settings
•
Discusses indications for IABP therapy; discusses
hemodynamic effects of IABP
•
•
•
Discusses lead placement and
uses/indications for different monitoring leads;
Discusses trends in ST monitoring in cardiac
patients
Notes changes in rhythm and monitors patient
response
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
Hemodynamic
Monitoring
AACN
Proc. #
59
Title
Exceptions
Arterial catheter:
Insertion (Assist),
care and removal
May not remove
femoral arterial
line
May not obtain
blood sample
from radial
arterial line
60
63
64, 65
66
Blood sampling
from arterial line
May not obtain
blood sample
from closed
system
Cardiac output
measurements
May not obtain
injectable
cardiac outputs
Central Venous
Catheter
Removal/Site
Care/
May not
remove central
line
CLABSI initiatives
May not obtain
blood
specimens
CVP/RAP
monitoring
May not
manipulate
Skills
Learning Points
Observes insertion/Set up of
bedside monitor
• Levels and zeroes line
• Fast flush only with verification of
waveform with primary RN
• Ensures maintenance of line
• Monitors/interprets waveform
• Remove radial arterial line only
• Dressing change for sutured lines
only
Fast flushes line only with verification of
waveform with primary RN
•
•
•
Discusses indication for insertion of arterial line
Risks with arterial line
Discusses characteristics of waveform and
troubleshooting of line
•
Setup system for cardiac output
(injectable or continuous);
Observes cardiac output (CO)
values and monitors trends
•
•
Performs and documents dressing
change
Assesses site for signs of infection
Assesses dressing for intactness /
date / time of dressing change
•
•
Discusses precautions with blood draw (i.e.
Clearing line of possible contaminants);
Employee responsible for patient ID and
labeling of any specimen at the bedside – RN
to ID and label or lab
Discusses indication for CO monitoring
Discusses differences in injectable vs.
continuous cardiac output
Evaluates CO readings and indications based
on clinical presentation of patient
Discusses incidence/impact of CLABSI
Identifies elements of CLABSI bundle to
reduce rates of infection
Employee responsible for patient ID and
labeling of any specimen at the bedside – RN
to ID and label
Set-up pressure transducer
•
•
•
•
•
•
•
•
Page 13 of 16
•
•
•
Discusses indications for hemodynamic
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
AACN
Proc. #
Title
Exceptions
position of line
72
Special
Cardiac
Procedures
PA catheter
insertion: assist
and monitoring
73
PA catheter
removal
74
PA and pressure
linestroubleshooting
75
Single and Multiple
Transducer
Systems
76
Arterial and
venous sheath
removal
May not inflate
balloon to
obtain PCWP
May not
manipulate
position of line
May not
remove PA
catheter or
introducer
Observation
Only
May not
remove
•
•
•
•
Skills
Learning Points
system/monitor;
Obtains/measures readings for
CVP/RAP/ PA
Interprets/ monitors waveforms
Levels/zeroes lines
Fast flush only with verification of
waveform by primary RN
monitoring
Reviews different types of lines and
parameters obtained from each
Differentiates ScVO2 vs. SVO2 readings
Discusses significance of values obtained
Discusses waveform as indication of line
position
Observation Only
•
•
•
•
•
•
•
Neurologic
Monitoring
88
Intracranial Bolt
•
•
Monitor patient’s neurological status
Leveling and zeroing only with
Page 14 of 16
•
Discusses pre-procedure preparation of patient
Discusses proper placement for manual
pressure to control arterial bleeding
(Cont’d)
Identifies potential post procedure
complications (i.e. hematoma,
pseudoaneurysm; retroperitoneal bleed; AV
fistula)
Discuss rationale, patient preparation, and
procedure for insertion.
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
AACN
Proc. #
Title
Exceptions
Skills
primary RN present
Assist holding the patient’s head still
for insertion.
Calculate Ceribral Profusion
Pressure (CPP)
Monitor patient’s neurological status
Assist holding the patient’s head still
for insertion
Leveling drip chamber, zeroing
transducer and draining Ceribral
Spinal Fluid (CSF) only with primary
RN present
Calculate Ceribral Profusion
Pressure (CPP)
Same as with Intraventricular
Catheter
•
•
Same as with Intraventricular Catheter
Same as with Intraventricular
Catheter
•
Discuss different wave patterns
•
•
Monitor patient’s neurological status
Encourage patient not to strain or
blow his/her nose
•
•
•
Discuss causes for CSF drainage
Discuss assessment used to identify CSF
Discuss signs of meningitis and
pnemocephalus
•
•
Pin care
Assist with repositioning and
monitoring traction devices
Maintain body alignment in traction
with the supervision of the primary
RN
•
•
•
Assess pin sites for infection
Assess the 5 P’s
Assess pressure points for ulcers
•
•
89
Intraventricular
Catheter (Assist,
Monitoring, Care,
Troubleshooting,
Removal
May not draw
samples for lab
work
•
•
•
•
91
92
Special
Neurologic
Procedures
94
Traction
Management
99
Lumbar
Subarachnoid
Catheter
Neurologic
drain/pressure
system
Ceribral Spinal
Fluid (CSF)
drainage
assessment
External Fixation
Device
Learning Points
May not draw
•
samples for Lab
work
•
•
Page 15 of 16
•
•
•
•
•
•
•
Evaluate site and Ceribral Spinal Fluid (CSF)
clarity and consistency
Identify Intracranial Pressure (ICP), causes
and ways to decrease
Discuss significance of CPP
As with bolt
Discuss troubleshooting when pressure
consistently high
Discuss significance of CPP
Discuss use of medications to decrease
Intracranial Pressure (ICP)
Discuss assessment of insertion site after
removal of the catheter
NS-1-9, Supervision of Student Nurses
Appendix B: Skills and Procedures for Nursing Students
Section
Pain
Management
AACN
Proc. #
Title
Exceptions
Skills
Learning Points
100
Halo traction
•
•
Pin care
Maintain head and neck alignment
•
•
101
Tong and Halo pin
site care
Peripheral Nerve
Stimulator/Train Of
Four (TOF)
•
Pin care
•
•
Observes use of Train Of Four
(TOF) with neuromuscular blocking
agents (NMBA's); Records readings
obtained with TOF
•
•
•
104
•
Drip
Titration
NA
Vasoactive drips
May not
actively titrate /
change rates
on drips
•
•
Checks drip/ concentration against
order
Verifies programming of drip in
pump
Date: September, 2013
Revised: August, 2015
Page 16 of 16
•
Assess pin sites
Assess neurologic status: sensation and
movement of extremities.
Assess site for infection
Reviews order set
Identifies locations for electrodes
Discusses titration of NMBA based on results
of TOF
Discusses pain/sedation control with use of
NMBA’s
Discusses indications, monitoring guidelines,
lab values and titration parameters for
vasoactive drips