Download Taking a 12 Lead ECG

Al al-Bayt University
Faculty of Nursing
Medical – surgical Nursing-II
Skills Competency Checklist
Student_______________ Instructor ______________
Course _______________ semester________________ Date: __________
Procedure
number
A2/1
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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 ………………
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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)
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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 …………………