Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Al al-Bayt University Faculty of Nursing Medical – surgical Nursing-II Skills Competency Checklist Student_______________ Instructor ______________ Course _______________ semester________________ Date: __________ Procedure number A2/1 A2/2 A2/3 A2/4 A2/5 A2/6 A2/7 A2/8 A2/9 A2/10 Procedure name Intra Venous Fluids Administration Finger Stick Capillary Blood Glucose Testing Collecting Blood Specimen Medication Administration Nasal- gastric Tube caring , feeding ,and removing Pre operative checklist Post operative checklist Cast Care Applying sterile dressing Taking a 12 lead ECG Done under observation Done independently Al al-Bayt University Faculty of Nursing Medical – surgical Nursing-II Skills Checklist Intra Venous Fluids Administration A2/1 Student_______________ Instructor ______________ Course _______________ semester________________ Date: __________ Item Checks selected IV fluid for: Proper Fluid Type Expiry date Indications Contra indications Clarity Selects appropriate catheter Selects proper administration set Connects IV tubing to the IV bag Prepares administration set (fills drip chamber and flushes tubing) Cuts or tears tape (at any time before venipuncture) Applies tourniquet Performs veinpuncture Inserts stylette Notes flashback Occludes vein proximal to catheter Removes stylette Connects IV tubing to catheter Performs vein puncture Inserts stylette Notes flashback Occludes vein proximal to catheter Removes stylette Connects IV tubing to catheter Releases tourniquet Set IV to proper drip rate Adjust flow rate as appropriate ,formula calculation Critical Criteria( infection control ) Failure to establish a patent and properly adjust IV Failure to take body substance isolation precautions prior to performing venipuncture Contaminates equipment or site without appropriately correcting situation Performs any improper technique resulting in the potential for uncontrolled hemorrhage, catheter shear, or air embolism Failure to successfully establish IV within 3 attempts Failure to dispose of needle/equipment in proper containers Instructor recommendations Total mark ……………… 0 1 2 3 4 5 Comments Student signature …………………………… Al al-Bayt University A2/2 Faculty of Nursing Medical – surgical Nursing-II Skills Checklist Finger Stick Capillary Blood Glucose Testing Student_______________ Instructor ______________ Course _______________ semester________________ Date: __________ Item 0 1 2 3 4 Assemble the equipment and supplies based on agency protocol: Example: a. cotton ball b. alcohol swab c. test strip d. finger lancing device e. latex glove (universal precautions use throughout the procedure) f. blood glucose monitoring machine r fingerstick rly Document according to policy and procedure Instructor recommendations Total mark ……………… Student signature ………………………………. 5 Comments Al al-Bayt University Faculty of Nursing Medical – surgical Nursing-II Skills Checklist Collecting Blood Specimen A2/3 Student_______________ Instructor ______________ Course _______________ semester________________ Date: __________ Criteria Always should follow the principle steps as the following: Label specimen tubes or bottles with the client’s name, age, sex, date, time, inpatient no. and other data if needed before collecting the specimen. Always perform hand hygiene before and after collecting any specimen. Always observe body substance precautions when collecting specimens Collect the sample according your hospital/agent policy and procedure. Clean the area involved for sample collection Maintain the sterile technique if needed for sample or culture. Transport the specimen to laboratory immediately Be sure specimen is accompanied by specimen form or appropriate order form Record the collection and forwarding of the sample to laboratory on the client’s record 1. Identify the patient 2. Reassure the client that the minimum amount of blood required for testing will be drawn 2. Reassure the client that the minimum amount of blood required for testing will be drawn 4.Explain to the client about the purpose and the procedure 5.Perform hand hygiene and put on gloves if available 6. Positioning 1)Make the client to be seated comfortably or supine position 2) Assist the client with the arm extended to form a straight-line from shoulder to wrist. 3) Place a protective sheet under the arm. 7. Check the client’s requisition form, blood collection tubes or vials and make the syringe-needle ready. 8. Select the appropriate vein for venipuncture. 9.Applying the tourniquet: 1) Apply the tourniquet 3-4 inches( 8 - 10 cm)above the collection site. Never leave the tourniquet on for over 1minute. 2) If a tourniquet is used for preliminary vein selection, release it and reapply after two minutes. 10. Selection of the vein: 1) Feel the vein using the tip of the finger and detect the direction, depth and size of vein. 2) Massage the arm from wrist to elbow. If the vein is not prominent, try the other arm. 11.Disinfect the selected site: 1) Clean the puncture site by making a smooth circular pass over the site with the spirit swab, moving in an outward spiral from the zone of penetration. 2) Allow the skin to dry before proceeding. 3)Do not touch the puncture site after cleaning 0 1 2 3 4 5 Comment s 4)After blood is drawn the desired amount, release the tourniquet and ask the client to open his/her fist. 5) Place a dry gauze over the puncture site and remove the needle. 6) Immediately apply slight pressure. Ask the client to apply pressure for at least 2minutes. 7)When bleeding stops, apply a fresh bandage or Gauze with tape. 12. 1) Transfer blood drawn into appropriate blood specimen bottles or tubes as soon as possible using a needless syringe . 2)The container or tube containing an additive should be gently inverted 5-8 times or shaking the specimen container by making figure of 8. 13.Dispose of the syringe and needle as a unit into an appropriate sharps container 14. Label all tubes or specimen bottles with client name, age, sex, inpatient no., date and time. 15.Send the blood specimen to the laboratory immediately along with the laboratory order form. 16. Replace equipments and disinfects materials if Needed 17. Put off gloves and perform hand hygiene Instructor recommendations: Total mark ……………… Student signature ………………………………. Al al-Bayt University Faculty of Nursing Medical – surgical Nursing-II Skills Checklist Medication Administration A2/4 Student_______________ Instructor ______________ Course _______________ semester________________ Date: __________ Item 1. Check the accuracy of the medication order. 2. Assess for any contraindications to client receiving medications (NPO, hypotension, heartrate, allergies, labs, etc.) 3. Perform the 6 rights of medication administration a. patient (verbal, ID: name and mr#) b. drug/indication c. dose (including correct computation) d. route e. time f. documentation 4. Med knowledge: a. Generic and trade names b. Classification (non critical) c. Indication including your patients d. Therapeutic dose range and your pt dose e. Significant side effects f. Nursing implications 5. Prepare meds a. Wash hands b. Take medications/MAR to patient’s room c. Check each medication against MAR d. Check medication expiration date e. Tell patient name, dose, indication as appropriate f. Open medication and place in med cup g. Repeat procedure until all meds are in cup h. Administer meds according to patient preference/condition 6. Never leaves medication unattended 7. Remain with patient until medication is ingested 8. Document according to policy and procedure 0 1 2 3 4 Instructor recommendations Total mark ……………… Student signature ………………………………. 5 Comments Al al-Bayt University Faculty of Nursing Medical – surgical Nursing-II Skills Checklist Nasal- gastric Tube caring, feeding, and removing A2/5 Student_______________ Instructor ______________ Course _______________ semester________________ Date: __________ Item 0 1 2 3 Care for Nasal-Gastric Tube Wash hands Verify the tube’s placement in the stomach. a. Aspiration of a small amount of stomachcontents: Attach the syringe to the end of the tube and aspirate small amount of stomach contents. Visualize aspirated contents, checking for color and consistency. b. Auscultation: Inject a small amount of air( 10- 15 ml)into the nasogastric tube while you listen with a stethoscope approximately 3 inches ( about 8 cm) below the sternum. 2. Secure the tube with tape to the client’s nose 3. Putt off and dispose the gloves, Perform hand hygiene Administering a Nasal- gastric Tube Feeding 1. Assemble all equipments and supplies after checking the Dr.’s prescription for tube feeding 2. Prepare formula: a. in the type of can: Shake the can thoroughly. Check expiration date b. in the type of powder: Mix according to the instructions on the package, prepare enough for 24 hours only and refrigerate unused formula. Label and date the container. Allow formula to reach room temperature before using. c. in the type of liquid which prepared by hospital or family at a time: Make formula at a time and allow formula to reach room temperature before using. 3. Explain the procedure to the client 4. Perform hand hygiene and put on disposable gloves if available 5. Position the client with the head of the bed elevated at least 30 degree angle to 45 degree angle 6.Determine placement of feeding tube by: a. Aspiration of stomach secretions ①Attach the syringe to the end of feeding tube & Gently pull back on plunger ③Measure amount of residual fluid ④Return residual fluid to stomach via tube and proceed to feeding. ❖Nursing Alert❖ If amount of the residual exceed hospital protocol or Dr.’s order, refer to these order b. Injecting 10- 20mLof air into tube: ①Attach syringe filled with air to tube ②Inject air while listening with stethoscope over left upper quadrant 7.Using the syringe Feeding as follows 1) Clamp the tube. Insert the tip of the large syringe with plunger, or bulb removed into the gastric tube. 2) Pour feeding into the syringe 3) Raise the syringe 12 to 18 inches above the Stomach .Open the clamp. 4) Allow feeding to flow slowly into the stomach. 4 5 Comments Raise and lower the syringe to control the rate of flow. 5)Add additional formula to the syringe as it empties until feeding is complete 8. Termination feeding: 1) Terminate feeding when completed. 2) Instill prescribed amount of water 3)Keep the client’s head elevated for 20-30minutes 10. Clean and replace equipments to proper place 11. Remove gloves and perform hand hygiene 12. Document date, time, amount of residual, amount of feeding, and client’s reaction to feeding. Sign the chart Removal a Nasal-Gastric Tube 1.Assemble the appropriate equipment, such as kidney tray, tissues or gauze and disposable gloves, at the client’s bedside 2. Explain the client what you are going to do. 3. Put on the gloves 4. Remove the tube 1) Take out the adhesive tape which holding the nasal-gastric tube to the client’s nose 2) Remove the tube by deflating any balloons 3) Simply pulling it out, slowly at first and then Rapidly when the client begins to cough. 4) Conceal the tube . 5) Be sure to remove any tapes from the client’s face. Acetone may be necessary. 6. Provide mouth care if needed. 7. Put off gloves and perform hand hygiene. 8. Record the date, time and the client’s condition on the chart. And be alert for complains of discomfort, distension, or nausea after removal. Sign the Signature 9. Dispose the equipments and replace them. Instructor Recommendations: Total mark ……………… Student signature …………………. Al al-Bayt University Faculty of Nursing Medical – surgical Nursing-II Skills Checklist Preoperative Care A2/6 Student_______________ Instructor ______________ Course _______________ semester________________ Date: __________ Item 1-Mention the objective of the procedure 2- Explain procedure to the patient 3-Assess level of comfort of the patient 4- Provide privacy for the pt 5-check the physician order for the surgery 6-check the operation room if informed or not 7-Check for surgical informed consent if signed or not 8- check the anesthesia form if filled or not 9-fill the preoperative checklist as hospital policy 10-keep pt NPO and explain to him the reason 11- Take Vital signs and document it 12- Give preoperative medication if ordered 13- Shower or bath the pt before and prepare him to surgery, shave if needed the area of surgery 14- Instruct/ assist pt to : -remove all clothes and Jewelries and wear gown -to void and defecate 15- Documentation 0 1 2 3 Instructor Recommendations: Total mark ……………… . Student signature …………………. 4 5 Comments Al al-Bayt University A2/7 Faculty of Nursing Medical – surgical Nursing-II Skills Checklist Post Operative Assessment Student_______________ Instructor ______________ Course _______________ semester________________ Date: __________ Item 0 1 2 3 Check the patient’s airway is patent, that the patient is breathing adequately and they have good peripheral perfusion. 1. Check if the patient has been prescribed oxygen therapy. If so, ensure the patient receives the correct amount of oxygen to ensure the target saturation is maintained for the prescribed period of time and that it is documented. 2.Assess the patient’s overall condition e.g. degree of orientation, comfort and their colour and respiratory pattern and any nausea and vomiting. 3.Record the patient’s temperature, pulse and blood pressure manually. Compare to readings taken in the recovery room and also to their baseline observations. Report any significant discrepancies or early warning triggers to the medical staff 4.Check the operation notes for specific instructions. 5. Ask and assess the patient to determine if they are in pain using the pain assessment tool. Check the type of analgesia that has been prescribed on the prescription chart. If the patient has analgesia via infusion pump, check and record the present infusion rate. Also note the infusion dosage scale, the analgesic doses and check that the equipment is working correctly. Otherwise, administer analgesia as required by the patient and as prescribed. Throughout the post-operative period assess the effectiveness of the analgesia. 6.If there is an intravenous infusion ensure that it is infusing according to the prescription. Observe the infusion site for patency, swelling and redness and record this. 7.When the patient passes urine, the time should be noted, the amount may need to be measured and recorded. If the patient is catheterised establish how often the urine output needs to be measured. 8.Observe the wound. Check any drains that may be present; record their position, the type and amount of drainage and check that they are secure and patent. 9.If present, the wound dressing should ideally be left in place for at least 48 hours unless otherwise instructed by the medical staff. 10.If the patient is allowed to eat and drink they should be given fluids and food as tolerated.If they are nil per OS or on oxygen they will require oral hygiene to be carried out. 11.Assist the patient to find a comfortable position, that also optimises respiratory capacity 12.The patient should be encouraged to perform breathing, supported coughing and leg exercises at frequent intervals until they are ambulant, with advice from the ward physiotherapist. 13.Establish a balance between encouraging the patient to move as much as able whilst ensuring that they have adequate periods of rest. 14.Explain the nursing procedures undertaken post-operatively and their rationale and ensure that the call bell is within easy reach. Instructor recommendations: Total mark ……………… Student signature ………………… 4 5 Comments Al al-Bayt University A2/8 Faculty of Nursing Medical – surgical Nursing-II Skills Checklist Cast Care Student_______________ Instructor ______________ Course _______________ semester________________ Date: __________ Item 1-Mention the objective of the procedure 2- Explain procedure to the patient 3-Assess level of comfort of the patient 4- Provide privacy for the pt 6- Hand washing 7-Assessment of the cast(Clean ,Dirty) 8- Assessment of the affected part : -skin assessment(irritation ,lesions, discoloration ,ausing ) -assess if any bad odor -ask pt if he feel (pain ,discomfort, pressure, numbness ,or loss of sensation ) -assess temperature, texture , moisture -assess pulses of affected extremities with comparison with the other not affected one -assess capillary Refilling 9-Patient teaching : -explain complication might happen with casting -explain how to clean the cast (by dry clothing) -explain how to clean the area around the cast to keep cast dry -teach pt to never put anything inside cast or use any object to itch under it -if ordered: instruct pt to elevate the affected part -End the procedure 10-Handwashing 0 1 2 3 Instructor Recommendations: Total mark ……………… Student signature ………………… 4 5 Comments Al al-Bayt University A2/9 Faculty of Nursing Medical – surgical Nursing-II Skills Checklist Applying Sterile Dressing Student_______________ Instructor ______________ Course _______________ semester________________ Date: __________ Item 1- Assess size and location of wound to be dressed 2- Assess patients’ level of comfort. Apply prescribed analgesic , if needed 3- Review orders for dressing change procedure 4- Explain procedure to the patients and instruct him not to touch wound area or sterile supplies 5- provide privacy 6- Assist patients to comfortable level 7- Place disposable bag within reach of work area fold top of bag to make cuff 8- Prepare needed equipments: a. Trolley b. Sterile dressing set contains kidney shape receiver, 1-2 gallipots, one artery, one dissecting forceps, cotton balls square gauze 2x2. c. Antiseptic solution. d. Disposable gloves. e. Sterile gloves. 9- Wash hands 10- Apply disposable gloves 11- Remove tape , bandage , or ties from wound site 12- With gloved hand, carefully remove gauze dressing’s one layer at a time, taking care not to dislodge drains or tubes. Keep soiled undersurface away from patient’s sight. If dressing sticks on , gently free dressing and alert patients of potential discomfort 13- Observe character and amount of drainage on dressing and appearance of wound 14- Dispose of soiled dressing in disposable bag 15- Remove and dispose of gloves 16- Open sterile dressing tray place on bedside table 17- Open bottle of cleansing solution and pour into sterile basin 18- Apply sterile gloves 19- Inspect wound for appearance , drains, drainage , and integrity 0 1 2 3 20- Cleans wound with solution use separate swab for each cleansing stroke clean from least to more contaminated area 21- Use dry gauze and dry wound in same matter as step20 22- Apply dry sterile gauze to incision 23- Apply tape over dressing 24- Remove and dispose gloves 25- Assist patients to comfortable position and assess level of comfort and presence of pain 26- Return equipments 27- Wash hands 28- Documentation for wound appearance and patients responses Instructor recommendations : Total mark ……………… Student signature ………………… 4 5 Comments Al al-Bayt University Faculty of Nursing Medical – surgical Nursing-II Skills Checklist Taking a 12 Lead ECG A2/10 Student_______________ Instructor ______________ Course _______________ semester________________ Date: __________ Item Wash hands Communication with patient Introduce self to patient/check identity Acquires verbal consent with explanations of procedure The patient should ideally lie at between 30 & 45 degrees though exception can be given for those patients who cannot tolerate this position The patient is encouraged to lie still and breath as normally as possible Applying electrodes Locations are described below Electrodes should be fully in contact with the skin. If there are gross problems (e.g sweating or hairy) appropriate measures should be taken Care must be taken to rule out interference (e.g. pressure mattresses) Limb Lead Application Red Right arm Yellow Left arm Green Left leg Black Right leg Chest Lead Application V1 Right of the sternum (4th intercostal space) V2 Left of the sternum (4th intercostal space) V4 Left mid clavicular line (5th intercostal space) V6 Left mid axillary line (5th intercostal space) V3 Midway diagonally between leads V2 & V4 V5 Left anterior axillary line (midway between V4 & V6) ECG Machine You must have received appropriate training on the medical device to use it Some machines require you to enter patient details Some machines also require you to enter an access code You must ensure that the following have been checked: The machine is plugged in or that the battery has been fully charged All leads are secured correctly, are clean and in good working order There is paper in the device Also ensure the following: Filter is used (to help rule out interference) Ensure that speed is set to 25mm/sec Ensure that calibration is set to 10mm/sec Press to acquire/record the ECG You must be able to troubleshoot/resolve problems with lead contact/interference Observe the ECG quality and decide if another recording is necessary Remove leads Consider whether or not to leave electrodes in place (a repeat ECG may be necessary) 0 1 2 3 4 5 Comments Ensure patient comfort/thanks patient Clean the leads with an approved solution Document his notes and calculate heart rate Instructor Recommendations: Total mark ……………… Student signature …………………