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SYLLABUS HANDOUT FOR Summer 2012 Concepts of Health Assessment and Therapeutic Intervention II NURS 2520 9A & 9B INSTRUCTORS: Alex Winter, RN, MSN Diana Blum, RN, MSN WELCOME TO METROPOLITAN COMMUNITY COLLEGE Metropolitan Community College 1 Metropolitan Community College Course Syllabus – Summer 2012 COURSE IDENTIFICATION Title: Concepts of Health Assessment and Therapeutic Intervention II Prefix/Section: NURS 2520 9A Credit Hours: 1 Credit hours (Class hours 5.5, lab hours 20 for 10 weeks) Begins/Ends: Saturdays, June 9, 2012 through Saturdays, August 11, 2012 Meeting Day/Time: Saturdays 11:30am – 2:00pm Last Day to Withdraw Saturday, July 28, 2012 No Class: N/A Delivery Type: Classroom/ Simulation Laboratory/Demonstration Class Location: SOC, Mahoney RM 505 Lab Location: SOC, Mahoney RM 505 Course Web Address: http://www.mccneb.edu/healthcareers/ CONTACT INFORMATION Instructor Name: Office Location: Office Telephone: Facsimile: Office Hours: Email Address: Faculty Web Site: Alex Winter RN, MSN SOC-Mahoney Bldg, RM 513 402-738-4784 402-738-4552 Posted outside office [email protected] http://faculty.mccneb.edu/awwinter Instructor Name: Office Location: Office Telephone: Facsimile: Website: Metro Office Hours: Diana Blum, RN, MSN Mahoney Bldg. SOC Room 513 402-738-4651 402-738-4552 Faculty.mccneb.edu/Dblum3 Posted outside Office Academic Program Area: Tutoring: Health Careers Alice Ludwig, RN – SOC-Mahoney RM 513 COURSE INFORMATION Course Description: This course is designed to assist the student in developing assessment skills of the professional registered nurse. It introduces physical assessment skills related to light palpation, percussion, and the use of the ototscope/opthalmoscope. The therapeutic interventions related to intravenous therapy are presented. Comprehension of underlying principles and mastery of skills will be demonstrated in the lab setting. Course Prerequisites: Successful completion of the LPN program and licensure as an LPN. Co-requisites: NURS 2410: High Risk Family. Metropolitan Community College 2 Course Objectives: At the completion of this course, the student will be able to 1. Demonstrate the safe administration of IV therapies. 2. Demonstrate total parenteral nutrition administration. 3. Demonstrate safe blood administration. 4. Demonstrate chest tube management. 5. Demonstrate head to toe physical assessment of the adult client. 6. Demonstrate the use of the ophthalmoscope/otoscope in the assessment of the adult client. 7. Demonstrate the proper techniques for light palpation and percussion. 8. Assess abnormal heart sounds including S3, S4 sounds and murmurs. 9. Assess neurological reflex activity. Required & Supplemental Materials: Berman (2012) Kozier & Erb’s Fundamentals of Nursing, 9th Edition. Pearson. Osborne, K. et al (2010). Medical-Surgical Nursing Preparation for Practice. Pearson: Boston: Kaplan: Math for Nurses (2007) Gahart: IV Medications (2011) 27th edition Course Structure: a. Class activities will include lecture, discussion, demonstration, return demonstration, reading assignments, and application of content in the laboratory portions of the program. COURSE ASSESSMENT Types of Assessment/Assignments COURSE OBJECTIVES 1. Demonstrate the safe administration of IV therapies. ASSESSMENT MEASURES Lab activities Return Demonstration 2. Demonstrate total parenteral nutrition management. Lab activities Return Demonstration 3. Demonstrate safe blood transfusion. 4. Demonstrate nursing management of chest tubes. Lab activities Return Demonstration Lab activities Return Demonstration 5. Demonstrate head to toe physical assessment of the adult client.. Lab activities Return Demonstration 6. Demonstrate the use of the ophthalmoscope/otoscope in the assessment of the adult client. 7. Demonstrate the proper techniques for light palpation and percussion. Lab activities Return Demonstration 8. Assess abnormal heart sounds including S3, S4 sounds and murmurs. Lab activities Return Demonstration Metropolitan Community College Lab activities Return Demonstration 3 9. Assess neurological reflex activity. Lab activities Return Demonstration Final Exam 10. Objectives 1-9 EVALUATION: METHODS OF ASSESSING STUDENT PROGRESS: Classroom assessment techniques will be utilized periodically to determine the student’s understanding of the materials being studied. CRITERIA FOR DETERMINING FINAL COURSE GRADE: Test Out x 4 Final MNL (IV) Quiz Test #1 Test #2 Test #3 Test #4 100 pts. 100 pts 150 pts 25 pts 375 pts = = = = 70% 20% 5% 5% 100% Central Line Care IV start IVP meds 1o & 2o setup on pump Final course grades are based on the following letter scale: 93-100 = A 84-92 = B 78-83 = C 70-77 = D Below 70 = F There will be NO rounding of grades, i.e., a 75.8 = 75%. A final course grade of C (78%) is required to continue in the program. Unit examinations will be administered as indicated on the course calendar. A comprehensive final examination will be administered at the completion of the quarter. MAKE-UP TEST PROCEDURES: If it is necessary to be absent during an assigned test period, the student must make-up that examination within one week of the original test date (i.e., if the exam is given on Monday, it must be made up PRIOR to the next Monday). Failure to do so will result in a zero for the examination. The student may miss one examination without penalty, as long as the test is made up within the specific time period. If the student misses more than one examination, the exam may be made up, but the maximum score allowed is 80%. The final examination must be taken on the scheduled date and at the scheduled time. Metropolitan Community College 4 Students may not enter the classroom after the testing has begun. If the student is not in the classroom when tests are being distributed the student must follow the procedure for make up testing. When it is necessary to make up an examination, it will be placed in the testing center. It is the student’s responsibility to make an appointment and take the test within the specified period of time. Exceptions to these guidelines may be considered, but only if the student consults with the instructor in advance. LATE ASSIGNMENTS: The assignment for the teaching project is to be submitted at the time indicated. Failure to submit at the appropriate time will result in a zero. Maintenance of Student Records The tests will be reviewed in the following class period. All test papers are to be returned to the instructor at the completion of the review. Exams will be kept for one academic year. STUDENT EXPECTATIONS Required Expectations METHODS OF LEARNING: Students will be expected to read all assigned material, participate in the lecture-discussion classes, and participate in small group activities as assigned, and demonstrate lab skills. Objectives for each unit of study are provided in this syllabus. Students will be expected to prepare for activities related to the assigned objectives. ATTENDANCE STATEMENT: The student is expected to attend all classes. If it is necessary to be absent from class, the student is responsible for all assignments and materials covered in class. It will be necessary to obtain a fellow classmate’s notes or have a classmate tape-record the lecture for you. If there are questions or handouts see the instructor as necessary. Students who attend no class meetings up to and including the Section Census Date published in the Class Schedule at www.mccneb.edu/schedule/ may be disenrolled from the class. There is no appeal for this disenrollment. Attendance and participation in lab activities is mandatory. Any missed labs must be made up prior to the next scheduled lab time. Notice: This syllabus is written as an expectation of class topics, learning activities, and expected learning outcomes. However, the instructor reserves the right to make changes in this schedule that may result in enhanced or more effective learning for students. These modifications will not substantially change the intent or objectives of this course and will be done within the policies and guidelines of Metropolitan Community College. WX WX is an administrative withdrawal/disenrollment of a student who registered by never attended class. WX is not a grade or other transcript mark; it is only a code used by the instructor or the College. After the first class meeting and through the Section Census Date, the instructor may Metropolitan Community College 5 disenroll (WX) students who have not attended any classes. The Section Census Date is listed under the Important Dates for the course in the official Class Schedule at http://www.mccneb.edu/schedule/. There is no appeal for this disenrollment. FX The FX grade, an attendance-related failure, can be determined at any time during the quarter— that is, once it is earned according to the attendance policy as specified in the instructor’s syllabus. The actual posting of the FX grade will take place at the end of the quarter. Avoiding the FX Grade When a student has earned the FX grade prior to the end of the quarter, he or she may avoid receiving the failing grade by withdrawing from the course before the Last Date to Withdraw from Class. This date is posted under the Important Dates for the course on the official Class Schedule at http://www.mccneb.edu/scedule/. It is the student’s responsibility to maintain contact with the instructor to know if he or she may be subject to an FX grade and/or to drop the course in a timely manner. LEARNING SUPPORT Metro's Learning, Math, and Writing Centers can help you achieve educational success. The staff in these centers provide drop-in assistance with basic math, reading, writing and computer skills. We offer a friendly, supportive learning environment. Self-paced computer-assisted instructional support in reading, vocabulary, typing, English as a Second Language, and online course orientation is also available. Detailed information about these services are in the Student Handbook, College Catalog, and online. Links to these resources are located at http://www.mccneb.edu/learningcenter/. COLLEGE POLICIES College policies, such as student rights and responsibilities, academic standards, plagiarism, and etc. are outlined in the College Catalog and Student Handbook. This information can be accessed via the online catalog at http://www.mccneb.edu/academics/catalog.asp. STUDENT WITHDRAWAL: If you cannot participate in and complete this course, you should officially withdraw through WebAdvisor at http://webadvisor.mccneb.edu or by calling Central Registration at 402-457-5231 or 1-800-228-9553. Failure to officially withdraw will result in either an attendance-related failure (FX) or failing (F) grade. The last date to withdraw is noted in the CLASS IDENTIFICATION section of this syllabus. STUDENT CODE OF CONDUCT: The College has a standard code of conduct that involves consequences for specific academic and non-academic behavior that may result in a failing grade, probation, or suspension from the college. More complete information about the code of conduct is located in the Student Services portion of the online catalog (http://www.mccneb.edu/catalog/studentinformation.asp). ACCOMMODATIONS FOR STUDENTS WITH DISABILITIES: If you have a disability that may substantially limit your ability to participate in this class, please contact a Vocational Metropolitan Community College 6 Special Needs Counselor, located in the Student Services Office on each campus. Metropolitan Community College will provide reasonable accommodations for persons with documented qualifying disabilities. However, it is the student’s responsibility to request accommodations. For further information, please contact the Student Services Office at your campus. RECORDING IN THE CLASSROOM: Students may not video or audio record class sessions without the instructor’s knowledge and permission. If recording of class sessions is authorized as a reasonable accommodation under Americans with Disabilities Act (ADA), the instructor must have the appropriate documentation from College Disability Support Services. Permitted recordings are to be used only for the individual student’s educational review of the class session and may not be reproduced, posted, sold or distributed to others. Students who violate this policy are subject to disciplinary procedures as outlined in the Student Conduct Code. Other pertinent college policies are posted on the CDS website www.mccneb.edu/cds. Metropolitan Community College 7 2520 Calendar Summer 2012 SCHEDULE OF ASSIGNMENTS The schedule of assignments is listed below. The instructor reserves the right to modify this as necessary. Changes will be announced in class. DATE CLASSROOM ACTIVITY Week 1 June 9 Intro / Central line venipuncture / Lecture Demo Week 2 June 16 IVP / Pmeds/ PB / Lecture / Demo Week 3 June 23 Blood Admin, chest tubes / Lecutre / Demo Week 4 June 30 Head to toe otoscope/opthalmoscope/Lecture/Demo Week 5 July 7 Abnormal heart tones, lungs/ABD/Lecture/Demo Week 6 July 14 Checkouts/Quiz/MNL Week 7 July 21 Checkouts/Quiz/MNL Week 8 July 28 Checkouts/Quiz/MNL Week 9 Aug. 4 Checkouts/Quiz/MNL Week 10 Aug. 11 Final IMPORTANT DATES see Metro’s Academic calendar at www.mccneb.edu/academics/calendar.asp?Theme=2 Metropolitan Community College 8 Unit 1-3: Intravenous interventions Unit Objectives: At the completion of this unit of study, the student will be able to: 1. Explain the legal implications of intravenous therapy. 2. Apply the concepts of standard precautions in infusion therapy. 3. Discuss the risks, complications, and adverse reactions of intravenous therapy. 4. Identify central and peripherally placed vascular access devices utilized for various patient needs. 5. Identify the pharmacological principles and administration of intravenous medications. 6. Demonstrate peripheral venipuncture and discontinuation of IV push. 7. Demonstrate calculation of IV drip rates and IV dosages. 8. Demonstrate safe administration of medications and IV piggyback medications. REQUIRED LEARNING ACTIVITIES Required Readings: Kozier Chapter 35, 52 (pgs 1455-1471) Osborn Chapter 22 Lab activities: Demonstrate safety in delivering intravenous therapies. Complete the unit objectives. Demonstrate administration of IV medication, venipuncture, spike IV fluid bag and IVPB. Utilize Gahart 2009 for safe administration of IV medications. Metropolitan Community College 9 Unit 4-6: Total Parenteral Nutrition/Intralipids/Central Line Care Unit Objectives: At the completion of this unit of study, the student will be able to: 1. Demonstrate safe administration and discontinuing of TPN. 2. Demonstrate a sterile central dressing change and changing central line caps. 3. Discuss safe administration of intralipids. 4. Demonstrate safety and sterility in discontinuing a central IV line. 5. Identify types of central lines, safety issues, and cares. REQUIRED LEARNING ACTIVITIES Required Readings: Kozier Chapter 52; pg. 1277, 1234, Ch. 31 pgs. 700-711 Osborn: pgs 279-321, 515-516, and 526-527. Demonstrate safety in delivering TPN in simulation manikin IV arm. Demonstrate a central line dressing change and changing caps on simulation manikin. Demonstrate discontinuing a PICC line on simulation manikin (only performed by RN and only with physician order). Utilize the procedure checklist. Metropolitan Community College 10 Unit 7: Blood Transfusion Unit Objectives: At the completion of this unit of study, the student will be able to: 1. Discuss treatment with blood components. 2. Demonstrate safe nursing interventions in blood transfusions. 3. Assess transfusion reaction and safe interventions. REQUIRED LEARNING ACTIVITIES Required Readings: Kozier pgs 1472-1478 Osborn, Chapter 23. Simulation Utilize the procedure checklist in demonstrating blood administration. Utilize the procedure checklist in demonstrating procedure for transfusion reaction. Metropolitan Community College 11 UNIT 8: Head to Toe Assessment Review 1. Demonstrate head to toe assessment of the adult client. 2. Document findings by narrative charting. REQUIRED LEARNING ACTIVITIES Required Readings: Kozier chapter 30 Osborn: Chapters 6-7, Chapter 9, Chapter 14 (pgs 272-276), Chapter 15 (pgs 338-341.) Lab activities: be prepared to utilize procedure checklist to demonstrate head to toe assessment. Document by narrative charting. Complete the unit objectives. Unit grade evaluated by unit test. Evaluated by performance of head to toe assessment in lab setting. SUGGESTED LEARNING ACTIVITIES View the video on the complete physical assessment. Metropolitan Community College 12 UNIT 9: Physical Assessment Techniques for the Lungs, and Abdomen Unit Objectives: At the completion of this unit of study the student will be able to: 1. Demonstrate the assessment technique of light palpation and percussion to abdomen. 2. Demonstrate the assessment technique of percussion of the thorax and abdomen. REQUIRED LEARNING ACTIVITIES Required Readings: Kozier pgs 610-618, 631-639 Osborn: Chapters 33 and 44 Lab activities: Utilize procedure checklist. Complete the unit objectives. SUGGESTED LEARNING ACTIVITIES Review anatomy and physiology of thorax and abdomen. Metropolitan Community College 13 UNIT 10: Physical Assessment Techniques for the Eye, Ear, and Nose Unit Objectives: At the completion of this unit of study the student will be able to: 1. Demonstrate the proper use of the ophthalmoscope. 2. Demonstrate the proper use of the otoscope. 3. Assess the anatomical structures visible with the ophthalmoscope and otoscope. REQUIRED LEARNING ACTIVITIES Required Readings: Kozier pgs 586-601 Osborn: Chapter 69. Lab activities: Utilize procedure checklist. Complete the unit objectives. SUGGESTED LEARNING ACTIVITIES Practice using the otoscope and ophthalmoscope before the lab activities. Metropolitan Community College 14 UNIT 11: Assessment of Abnormal Heart Sounds Unit objectives: At the completion of this unit of study the student will be able to: 1. Identify the events in the heart that create normal heart sounds of S1 and S2. 2. Identify the abnormal heart sounds of S3 and S4 and murmurs. 3. Identify heart murmurs as systolic or diastolic. 4. Demonstrate auscultation of heart sounds. REQUIRED LEARNING ACTIVITIES Required Readings: Kozier pgs 619-624 Osborn: pages 1060-1072 Lab activities: Practice the assessment of the various heart sounds. Complete the unit objectives. Utilize the procedure checklist. SUGGESTED LEARNING ACTIVITIES Review normal and abnormal physiology of the heart. Metropolitan Community College 15 UNIT 12: Neurological Assessment Unit Objectives: At the completion of the unit of study each student will be able to: 1. Assess the components of the basic neurological assessment to include pupils, level of consciousness and mental status, reaction to external stimuli, and the Glasgow Coma Scale. 2. Demonstrate the proper technique for the assessment of reflex activity using a reflex hammer. 3. Demonstrate the assessment techniques employed in the assessment of the cranial nerves. 4. Demonstrate the complete assessment of the neurological system. REQUIRED LEARNING ACTIVITIES Required Readings: pgs 642-653 Osborn: pgs 698-711 Lab activities: Utilize the procedure checklist. Complete the unit objectives. SUGGESTED LEARNING ACTIVITIES Complete a neurological assessment on a client in the clinical setting. Review neurologic system. Metropolitan Community College 16 Unit 13: Chest Tubes Unit Objectives: At the completion of this unit of study, the student will be able to: 1. Demonstrate the role of RN in nursing intervention of chest tubes. 2. Perform therapeutic nursing interventions to clients with chest tubes. REQUIRED LEARNING ACTIVITIES Required Readings: pgs 1393-1395 Osborn: pgs 680, 990-991. Assess simulation of chest tube to manikin. Utilize the procedure checklist. Metropolitan Community College 17 Metropolitan Community College Procedure Checklist Peripheral Venipuncture Procedure Steps 1. Verify physician order. 2. Assess purpose of IV (Blood administration or IV fluids and/or antibiotics) and choose proper IV gauge. 3. Identify patient and explain procedure. Note any allergies. 4. Hand hygiene. 5. Obtain IV supplies and flush lock with saline. 6. Assess venipuncture site – use of tourniquet. 7. Remove tourniquet, put on gloves. 8. Prepare venipuncture with chloroprep. 9. Do Not Repalpate after prepping. 10. Reapply tourniquet. 11. Inform patient of needle stick. Introduce needle with bevel up. Angle to enter skin will depend on depth of vein. Once vein is entered then bring IV device flush with skin so able to thread into vein. 12. Observe for blood return in flash back chamber. a. When blood returns advance needle slightly further then hold needle still (do not advance needle) and advance only catheter into vein. b. Immediately release tourniquet. c. Connect hub of catheter to saline lock. d. Apply Tegaderm. e. Wipe saline lock port with alcohol and infuse 5-10 mL of sterile saline to assure patency and no infiltration noted. f. Discard supplies and sharp properly. g. Remove gloves and wash hands. h. Maintain patient comfort. Metropolitan Community College Yes 18 No Comments Peripheral Venipuncture – continued i. Documentation to include: - gauge used - how many attempts (limit to 2 per policy) - location of IV - saline lock or infusion as ordered. - any comments said by patient that relates to IV. Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 19 Metropolitan Community College Procedure Checklist Administering IV Push Medication Procedure Steps 1. Check physician order. 2. Verify Allergies. 3. Review information on the medication, including reason for, effects of proper dilution, rate of administration, reactions, compatibility with existing IV fluids/meds. 4. Explain procedure to patient. Yes No 5. Hand hygiene. 6. Select appropriate equipment needed. 7. Assure 6 rights to safe medication administrated. Rt Patient Rt Drug Rt Dose Rt Time Rt Route Rt Documentation 8. Perform the 3 checks while preparing the medication. maintain sterility and always use alcohol wipe before accessing on any IV ports. 9. Put on clean gloves. Flush peripheral saline port with 5-10 mL normal saline, observing IV site for infiltration. (Need to perform if port is locked). If central line capped port, flush with 10mL sterile saline and check of Blood return. 10. Give IV push medication properly diluted (if indicated) at recommended rate, timing with watch. 11. Slowly flush with 10 mL saline when completed. Again observing IV site for infiltration for peripheral lines. Metropolitan Community College 20 Comments Administering IV Push Medication- continued 12. If IV fluids are infusing, assure compatibility. May need to stop infusion (if safe for patient) and flush with 10 mL saline then give IV medication then flush with IV 10 mL saline slowly to clear tubing of medication. 13. Observe for side effects. 14. Dispose of equipment properly and hand hygiene. 15. Document med given, dose, route, time, signature. Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 21 Metropolitan Community College Procedure Checklist Primary IV Fluid and Tubing Procedure Steps 1. Check physician order. 2. Verify Allergies. 3. Assess if IV fluid appropriate for this patient. 4. Gather equipment. 5. Explain procedure. 6. Hand hygiene. 7. Assure 6 rights to safe medication administrated. 8. Spike IV bag to primary tubing. fill drip chamber approximately ½ full. Prime this tubing carefully. Remove all fluid, even in parts along tubing, inverting these ports so fluid will fill and air will move out. 9. Place tubing in pump (if using) assure proper mL/hour and volume setting into pump. 10. Flush a peripheral saline lock or central heparin lock to assure patency. Then attach aseptically with gloves on. Always wipe lock connector with alcohol before attaching. 11. Assure clamps open; proper rate, proper volume are set in pump. 12. Maintain patient comfort. Yes No Comments Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 22 Metropolitan Community College Procedure Checklist Administering IV Piggy Back Medication with Existing IV Line and Without Procedure Steps 1. Check physician order. 2. Wash your hands. 3. Verify any allergies. 4. Review information on the medication, medical reason for, effects of proper dilution, rate of administrating, reactions, compatibility with existing IV fluids/meds. 5. Assess IV access. If IV fluids are infusing, assure compatibility. May need to stop infusion if safe for patient and flush with 10 mL saline, then attach IV piggyback tubing then flush with 10 mL saline slowly to clear tubing of medication. Always use alcohol wipe prior to accessing any IV port. 6. Explain procedure to patient. 7. Select appropriate equipment. 8. Assure the 6 rights and 3 checks: Rt Patient Rt Drug Rt Dose Rt Time Rt Route Rt Documentation * With piggyback meds assess the label attached by pharmacy as well as the label on the bag itself to assure proper dilution and proper med. 9. If using pump and existing IV line a. Assure compatibility b. Spike piggyback IV bag to secondary tubing (clamp is closed at this time) c. Fill drip chamber approximately ½ full d. Slowly open clamp and flush secondary tubing so do not waste any medication. e. Prime tubing Metropolitan Community College Yes No 23 Comments Administering IV Piggy Back Medication with Existing IV Line and Without – continued f. Attach to existing tubing above pump. Remember to hang what you want to be infusing the highest. g. Enter correct infusion rate and volume into pump and start (make sure clamp is open or pump will alarm “occlusion”). h. Always date tubing. Good for 24-48 hour (check policy) 10. If using pump but no existing IV line a. Some agencies use long Continu-flo tubing for piggyback medication. But medication is wasted in this long tubing. Best to prime Continu-flo with saline (or compatible fluid) then spike piggyback med with secondary tubing and run through pump (follow the steps in #8 above). 11. Tubing may be revised for 24 hours (check policy). Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 24 Metropolitan Community College Procedure Checklist Changing IV Fluid With Existing IV Tubing Procedure Steps 1. Check physician order for type of fluid and infusion rate. 2. Hand hygiene. 3. Select correct fluid IV bag. 4. Examine solution for clarity. 5. Assemble supplies. 6. Perform 6 rights to safe medication administration. Rt Patient Rt Drug Rt Dose Rt Time Rt Route Rt Documentation 7. Close regulator on tubing. Verify existing tubing date (tubing change usually every 72 hours) 8. Remove cover from entry port of new IV bag. 9. Remove old IV bag from connector and insert connector into new solution IV bag without touching the portion of connector that is going into the bag. 10. Invert new container and hang it up. 11. Fill drip chamber approx. ½ full. 12. Open clamp, start, and regulate flow rate through IV pump as ordered. 13. Secure client’s environment and comfort. 14. Dispose of used IV bag. 15. Reassess entire IV, including rate and IV site. 16. Hand hygiene. 17. Document the procedure. Yes No Comments Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 25 Metropolitan Community College Procedure Checklist Changing the Central Intravenous Dressing Procedure Steps 1. Check date and time of last dressing change. PICC lines 7 days (Check policy) 2. Wash your hands. 3. Assemble supplies. 4. Check clients’ identification. 5. Explain procedure to patient. 6. Clean overbed table and allow to dry. 7. Place client in supine position if patient can tolerate, with head turned away from site. 8. Put on face mask and also on patient if necessary. (PICC line patient does not need to put on mask (unless patient is watching the procedure.) 9. Set up supplies on overbed table. Open sterile field. Maintain sterile field. Do not contaminate during procedure. 10. Put on clean gloves and remove old dressing. 11. Dispose of dressing in plastic bag or contain in glove. 12. Remove gloves and wash hands. (make sure patient is safe if moving away from patient) 13. Visually inspect site carefully. 14. Put on sterile gloves. Maintain sterility. 15. Cleanse area with chloroprep, moving in a spiral direction moving inside to outside. Keeping both gloves sterile. Cleanse area the size of the dressing that will cover the site. 16. Dispose of used articles away from sterile field. 17. Allow antiseptic solution to dry. 18. Apply new dressing and secure tube if needed. Metropolitan Community College Yes No 26 Comments Changing the Central Intravenous Dressing- continued 19. Remove gloves and mask. 20. Label dressing with date and time. Do not cover site, place on edge of dressing. 21. Reposition client for comfort and safety (call light, side rails up). 22. Dispose of packages and wastes. 23. Wash your hands. 24. Assure proper IV flow rate. 25. Document site appearance and procedure. Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 27 Metropolitan Community College Procedure Checklist Changing the Central Line Caps (this is usually done with Central Line Dressing) Procedure Steps 1. Hand hygiene. 2. Explain procedure to patient. 3. Assemble supplies: If triple lumen, need: 3 sterile caps sterile saline syringe alcohol pads x 3 4. Use 1 saline syringe to remove air from each cap. 5. Put on clean gloves and place patient in supine position. 6. Assure all lumens are clamped. Yes No Comments 7. Wipe around existing central caps with alcohol prior removal to decrease bacteria count. 8. Make sure line is clamped or kinked prior to removing cap so air will not enter. 9. Remove 1 cap and quickly and keeping end sterile, apply new cap that has been flushed with saline. 10. Continue these steps until all 3 lumens have new caps. 11. Keep lumens clamped when not in use to decrease incidence of air emboli. Assure caps are secure. 12. Heparin flush 100 units is infused once a day for each lumen to keep these lumens from clotting. (Power Piccs are flushed with saline) complete all the 6 safe administration rights if infusing the Heparin flush. 13. Document. Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 28 Metropolitan Community College Procedure Checklist Blood Administration Procedure Steps 1. Verifies blood administration consent has been signed. 2. Verifies physician order, note type of blood, number of units, rate of infusion, any premedication orders. 3. Verify that the patient has been typed and cross matched. 4. Notify lab if patient has not been typed/cross matched. 5. Inquire to blood bank as availability of blood. 6. Explain procedure to patient. 7. Obtain blood tubing and IV of normal saline. 8. Assess IV administration site, state proper gauge of peripheral IV catheter appropriate for infusion. 9. Wash hands, put on gloves. 10. Prime blood administration tubing with IV saline, squeeze drip chamber to ½ full, prime tubing, so no air in tubing including “Y” tubing to where blood unit will be connected. (make sure clamp closed to “Y” tubing awaiting blood product). 11. Flush IV lock with saline first to assure patency. 12. Use aseptic technique and connect to IV. 13. If using pump, or gravity, turn rate to keep open – usually 20 ml/hour. 14. Remove gloves – wash hands. 15. Administer any pretransfusion medications if prescribed depending on the order (make sure the 6 administration rights have been completed for any pretransfusion meds) Metropolitan Community College Yes No 29 Comments Blood Administration - continued 16. Obtain the blood product from the blood bank according to agency policy. May need to take a form that has the patients infusion number from wrist band to take to blood band. 17. Put on gloves when handling blood products. 18. Recheck physician order for any possible changes. 19. Obtain pre-transfusion vitals. 20. Verify the patient and blood product with another nurse following agencies policy/procedure. a. Have patient state name/birthdate and nurse compares to blood bank form. b. Compare patient name and hospital ID number to patient name and hospital ID number on blood bank form attached to blood product. c. Compare blood unit ID number located on blood bank form with the ID number printed on blood product. d. Compare patient’s blood type on the blood bank form with blood type on blood product. e. Obtain signatures of both nurses if no discrepancies to blood bank form attached to blood product. f. Document on blood bank form the date/time transfusion began. g. Keep blood bank form attached to blood product until administration is complete. 21. Observe blood bag for bubbles, cloudiness, clots, sediment, and if present, notify blood bank, then gently invert blood product several times. 22. Carefully spikes blood product through blood port “Y”. Do not touch the connector that is going inside the blood bag. Open clamp. Metropolitan Community College 30 Blood Administration - continued 23. Using roller clamp, adjust to prescribed drip rate (blood administration sets have drop factor of 10 drops/mL) or set pump. 24. Remain with patient the first 15 minutes (or according to policy/procedures) and then obtain vitals, assess for signs/symptoms of transfusion reaction. 25. Assure patient has call light. 26. Then vitals hourly until transfusion is complete, always assess for transfusion reaction and fluid status. 27. After infusion is complete, close rollerclamp to “Y” transfusion bag and allow normal saline to flush the administrator set. 28. State tubing is used for no more than 2 units and blood unit/tubing not hanging longer than 4 hours. 29. Discard empty blood bag and tubing per policy. 30. Obtain post transfusion vitals. Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 31 Metropolitan Community College Procedure Checklist Transfusion Reaction Procedure Steps 1. Upon assessment of reaction, stops transfusion immediately. 2. Do not flush blood administration set with saline. 3. Disconnects administration set from IV catheter. 4. Obtains vitals, assesses patient including auscultating heart and lungs. 5. Notify physician. 6. Hang new IV 0.9% with primed new tubing TKO or saline lock IV catheter. 7. Administer prescribed medications as ordered. 8. Places administration set and blood product with blood bank form attached and place all inside biohazard bag, notify blood bank, and return it to blood bank regarding policy. 9. Obtain blood and urine specimen according to policy. 10. Continue to assess patient and monitor vitals frequently – notify physician of any changes immediately. 11. Complete transfusion reaction record. Yes No Comments Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 32 Metropolitan Community College Procedure Checklist Head-to-Toe Assessment Procedure Steps 1. Hand hygiene. 2. Introduce self. Explain procedure to patient, provide privacy. 3. Demonstrate therapeutic communication during assessment. 4. The following are to be noted: -Appears stated age -Level of consciousness -Oriented to person, place, time - Skin color - Obvious physical deformities - Mobility, gait - ROM - Facial expressions - Mood and affect - Speech - Vision (glasses?) - Hearing (hearing aid?) - Personal hygiene - Pain assessment - Allergies - Unexplained weight loss 5. Skin -Inspect nails -Inspect for presence of dryness, rashes, discolorations, any abnormalities -Note general texture and color -Inspect in regions as exam progresses 6. Vital Signs -Radial pulse/apical pulse -Respirations -Blood pressure -Temperature - Pulse ox if necessary Metropolitan Community College Yes No 33 Comments Head-to-Toe Assessment – continued 7. Head - Inspect face, scalp, hair, cranium - Observe facial expression for symmetry, appropriate affect - Test pupils for size, reaction to light and accommodation - Note sclera, conjunctiva, cornea, any redness, drainage, swelling. - Palpate sinus areas for tenderness if appropriate. -Inspect outer ear - Observe hearing ability - Note presence of hearing aides -Inspect nose for symmetry, drainage, lesions. -Inspect mouth for moist mucous membranes, note any abnormalities, any difficulty swallowing. - Note presence of dentures, lesions, loose teeth - Inspect neck, note any swelling, limited range of motion. - Palpate for tenderness, nodules. 8. Lungs assessment: Cough present, difficult breathing? Posterior chest: - Inspect, note symmetry, configuration - Palpate for symmetrical expansion, fremitus, tenderness - Auscultate over all lung field in a consistent pattern Anterior chest: -Inspect respiratory pattern, symmetry, symmetry of breasts -Palpate, note fremitus, lumps -Auscultate over all lung fields in a consistent pattern. Metropolitan Community College 34 Head-to-Toe Assessment – continued 9. Cardiovascular -Inspect precordium, note any pulsations or heaves -Auscultate apical rate and rhythm, - Capillary refill - Listen to all areas of precordium with diaphragm, including traditional valve areas. Note S1 and S2, as well as other sounds (murmurs). -Assess for peripheral edema, assess peripheral pulses, assess capillary refill, assess Homan’s sign or any tenderness to calves. 10. GI -Inspect -Auscultate all four quadrants -Palpate all quadrants, noting tenderness/guarding. -Soft, firm, distension, flat 11. Extremities -inspect, noting any swelling, lesions, discoloration, hair pattern -palpate for swelling, tenderness -palpate pulses, compare quality side to side -test hand grasp strength and foot push strength. Note equality 12. GU: Assess voiding changes or problems 13. Maintain patient comfort. 14. Hand Hygiene 15. Document – report any abnormal findings to physician. Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 35 Metropolitan Community College Procedure Checklist Physical Assessment of Lungs Utilizing Light Palpation and Percussion Procedure Steps 1. Explain Procedure to patient. 2. Lung Visual: a. Sitting position if patient can tolerate. b. Inspect shape of thorax: 1. Estimate visually transverse diameter of thorax then anteroposterior diameter. 2. Inspect for superficial veins on thorax. 3. Estimate angle at which ribs articulate with sternum. 4. Assess for retractions, use of accessory muscles. 5. Assess rate of respirations, depth, pattern, audibility, mode of breathing (nose or mouth breathing). 6. Any sputum. 7. O2 needed? Trach tube? Any other assistive devices? 3. Lungs: Light palpation: posterior a. Carefully palpate any area where pain is reported or lesions evident as last portion of exam, for patient comfort. b. Place your thumbs at level to 10th ribs, your hands grasping the lateral rib cage. Slide hands medially slightly to raise loose skin. fold between thumbs and spine. Have patient inhale deeply and feel for symmetry of respiratory movement. c. Palpate posterior for fremitus with ball of hand (palm side of hand at base of fingers); ask patient to repeat words “ninety nine”. Can use both hands at once comparing bilaterally. d. Identify, describe, and localize any areas of increased or decreased fremitus. Metropolitan Community College Yes No 36 Comments Physical Assessment of Lungs - continued 4. Lungs: Percussion Posterior to determine underlying tissues are airfilled, fluid-filled, or solid. a. Press only distal phalanx and joint of middle finger firmly on surface. b. Quick strikes (one or two) when move on with opposite hand, middle finger to the distal phalanx that has firm pressure on surface. Compare one part chest to another. 5. Assess and identify 5 percussion notes: a. Flatness: soft intensity, high pitch, short duration (thigh). b. Dullness: medium intensity, medium pitch, medium duration (fluid in lungs) c. Resonance: Loud intensity, low pitch, long duration (example normal lung) d. Hyper Resonance: Very loud intensity, lower pitch, longer duration. (emphysematous lung, hyperinflated) e. Tympany: loud intensity. (gastric air bubble, puffed out chest.) 6. Percussion lungs: Posterior: Percuss across top of each shoulder – to identify lung apex with arm folded across chest. a. Percuss symmetrical areas of lung moving down chest. b. Below scapulae, percuss areas along sides of chest and medially. 7. Identify level of diaphragmatic dullness bilaterally during respiration. a. Slightly higher level on right than left. (sound is dull below diaphragm.) b. Abnormally high “dull” suggests pleural effusion or a high diaphragm from paralysis or atelectasis. Metropolitan Community College 37 Physical Assessment of Lungs - continued 8. Lungs: Anterior Light Palpation a. Identify areas of tenderness. b. Respiratory symmetry. - place thumbs along each costal margin - hands along lateral rib cage. - slide in to raise loose skin fold between thumbs. - ask patient to inhale deeply c. Tactile Fremitus: compare symmetrical areas of lungs using ball of hand. Have patient say “ninety-nine”. Fremitis is decreased or absent if bronchus obstructed or fluid in pleural space. Fremitus is increased near large bronchus and over consolidated lung such as pneumonia. 8. Lungs: Anterior: Percussion: a. Compare symmetrical points. - supraclavicular (above clavicle) - infraclavicular (below clavicle) move down chest wall. Heart: dullness to left of sternum from 3rd to 5th interspaces. b. Dullness replaces resonance when fluid or solid tissue replaces air. c. Only large pleural effusion detected anteriorly since pleural fluid displaces posterior in supine patient. d. Identify upper border of liver dullness to right. e. Identify tympanic gastric air bubble to left. Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 38 Metropolitan Community College Procedure Checklist Physical Assessment of Abdomen Utilizing Light Palpation and Percussion Procedure Steps 1. Explain procedure to patient. 2. Provide for privacy. 3. Hand hygiene. 4. Assess abdomen using light palpation. a. Identify abdominal tenderness, superficial masses. b. Use pads of your fingertips with finger together in a light, gentle motion. c. Move smoothly in all 4 quadrants. d. Identify involuntary rigidity of abdominal muscles (indicates peritoneal inflammation.) 5. Percussion : a. Percuss lightly in all 4 quadrants. b. Tympany most prominent. Dullness over distended bladder. c. Percuss liver for dullness in right, midclavicular line. d. Percuss stomach: identify tympany of gastric air bubble of left lower anterior rib cage. e. Percuss spleen: small oval area of splenic dullness near left 10th rib posterior to mid axillary line. Yes No Comments Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 39 Metropolitan Community College Procedure Checklist Assessing Eye With Use of Opthalmoscope Procedure Steps 1. Explain Procedure to patient. 2. Darken room 3. Switch on opthalmoscope light and turn lens disc to zero. Keep your index finger on lens disc so as to be able to refocus the scope during examination. a. Large round beam (0) for large pupils b. Small round beam for small pupils the green (or red) beam used to detect small red lesions) 4. Use right hand for patient’s right eye. Use left hand for patients left eye. 5. Place thumb of opposite hand on patients eyebrow to give guidance as you move in closer and may use thumb to gently elevate patients upper lid if necessary. 6. Ask patient to look straight ahead and look at a specific point on the wall. 7. Hold scope firmly against your face with your eye directly behind the sight hole. 8. From about 15 inches away and about 15 degrees lateral to patient’s line of vision, shine the light beam on the pupil, keep both your eyes open. a. Note orange glow (red reflex) b. Absence of red reflex suggests: - cataract - detached retina - artificial eye 9. Keep the light beam focused on red reflex as you move opthalmoscope very close to pupil. Your forehead is on or very close to your thumb. Metropolitan Community College Yes No 40 Comments Procedure Checklist – continued 10. Identify optic disc, note: yellowish orange, oval or round, may need to follow a blood vessel centrally until visualized. There is much branching away from optic disc and progressive enlargement of vessel size as approach disc. 11. Identify arterioles and veins: Arterioles are light red, smaller, bright light reflex, veins are dark red, larger, absent light reflex. 12. Adjust lens disc to focus on optic disc. a. Normal patient eye usually “O” diopters (clear glass) b. Near sighted patient: use lens with longer focus – rotate lens disc counterclockwise (red numbers indicates minus diopters) c. Farsighted patient or lens has been removed: rotate disc clockwise to plus diopters (black numbers). 13. Assess for normal white or pigmented rings or crescents around disc. Disc outline clear. 14. Note abnormalities of retina. a. Flame-shaped hemorrhages (may indicate hypertension) b. Tiny red spots (may indicate diabetic retinopathy) c. Small, slightly irregular red spots (diabetes) d. Large, horizontal line (preretinal hemorrhage) 15. Identify macular area (responsible for central vision). Shine light beam laterally or have patient look directly into light. a. A vascular area, somewhat larger than disc, has no distinct margins. Shimmering light reflection common in younger patients. Metropolitan Community College 41 Procedure Checklist - continued 16. Rotate lens disc progressively to +10 to +12 diopters to focus on anterior structures of eye. a. Lens: should be transparent - cataract symptoms of impaired vision, annoying glare from bright lights, distortion of vision. Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 42 Metropolitan Community College Procedure Checklist Assessing Ears With Use of Otoscope Procedure Steps 1. Explain Procedure to patient. 2. Obtain otoscope and use correct size speculum (the largest speculum that the canal will accommodate). 3. Have patient tilt head to side not being examined. 4. For adult: pulls Helix up and back. For preschool child: Pulls Helix down and back. Assess for ear pain with this movement (maybe painful with acute otitis externa) 5. Inserts speculum slowly, only into outer 1/3 of canal. 6. Identify if wax, discharge, or foreign bodies, redness or edema in ear canal. 7. Identifies location of cone of light and bony landmarks. a. Normal drum is pearly grey/with good cone of light. b. The handle and short process of the malleus are readily identifiable. 8. Gently move speculum to observe entire drum. 9. Examine bilaterally. 10. Dispose of speculum used. 11. Hand hygiene. Yes No Comments Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 43 Metropolitan Community College Procedure Checklist Assessing the Nose With Use of Otoscope Procedure Steps 1. Explain Procedure to patient. 2. Assess nose for deformity, asymmetry, inflammation. 3. Using otoscope, use wide, short nasal speculum. 4. Assess lower portions of nose then upper portion. 5. Move your own head and otoscope to view upper nasal cavity. 6. Assess: a. Nasal mucosa: note color (normally slightly redder than oral mucosa) edema, exudates, bleeding. b. Nasal septum: note any bleeding, deviation. c. Inferior and middle turbinates and middle meatus: note color, edema, exudates, polyps. 7. Dispose nasal speculum after use. 8. Hand hygiene. Yes No Comments Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 44 Metropolitan Community College Procedure Checklist Assessment of Abnormal Heart Sounds Procedure Steps 1. Explain Procedure to patient. 2. Position patient supine or sitting. 3. Provide privacy. 4. Hand hygiene. 5. Identify head piece of the stethoscope a. Diaphragm transmits highfrequency sounds b. Bell transmits low – pitched sounds (rest only lightly on skin or will act like the diaphragm.) 6. Identify S1: Use diaphragm of stethoscope a. S1 loudest in mitral area (left 5th ICS at midclavicular line) “lub” sound from “lub-dub”. b. Caused by closure of mitral and tricuspid valves. c. Palpate carotid lightly as you will hear S1 with each carotid pulse beat. 7. Identify S2: Use diaphragm of stethoscope a. S2 loud in aortic area (identify angle of Louis, move your finger laterally to right of sternum, this is: 2nd ICS to right of sternum) b. “Dub” in “lub-dub” c. Caused by closure of semilunar valves. Metropolitan Community College Yes No 45 Comments Assessment of Abnormal Heart Sounds - continued 8. Identify S3: Use bell of stethoscope a. Auscultate mitral and tricuspid area (Tricuspid area left of sternal border with 5th ICS) b. “Gallop” or extra heart sound just after S2. c. Indicated rapid ventricular filing, CHF and fluid overload. S1 S2 S3 Ken tuc ky d. Use mitral landmark for left rapid ventricular filling. e. Use tricuspid landmark for right rapid ventricular filling. 9. Identify S4 heart sound: Use bell of stethoscope. a. Best in mitral or tricuspid area. b. Late diastolic filling and occurs right before S1. c. S4 (left-sided) louder on expiration. S4 (right-sided) louder on inspiration. S4 S1 S2 Ten nes see d. Increased resistance to filling from poorly compliant ventricle from MI, CAD, CHF, cardiomyopathy, HTN, aortic stenosis. 10. Auscultate patient for the following concerning murmurs: a. Location: Note area where murmur is loudest. Aortic and pulmonic areas, with diaphragm of stethoscope. Mitral and tricuspid areas, with diaphragm and bell of stethoscope. b. Timing: Systolic murmur: between S1 and S2. Diastolic murmur: between S2 and S1 c. Intensity: Grade I very faint. Grade II faint, heard immediately. Grade III moderate intensity. Grade IV loud, may be associated with palpable thrill. Grade V loud, thrill palpable, audible with stethoscope partially off chest Metropolitan Community College 46 wall. Grade VI very loud, heart with stethoscope off chest wall, thrill palpable. d. Identify quality: harsh, rumbling, blowing, musical. e. Identify pitch: high, medium or low. Low pitched with bell of stethoscope. High pitched with diaphragm of stethoscope. f. Identify configuration: Crescendo: soft to loud. Decrescendo: loud to soft. Plateau: sound is sustained. g. Identify if murmur radiates to another area such as neck, axilla. Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 47 Metropolitan Community College Procedure Checklist Neurological Assessment Procedure Steps 1. Explain Procedure to patient. 2. Provide privacy. 3. Hand hygiene. 4. Consider patient’s language, education and culture during examination. 5. Assess behavior, facial expression, posture, affect, grooming. 6. Determine level of arousal, as needed, in this order: verbal stimuli, tactile stimuli. 7. Correctly describe altered level of consciousness using Glasgow Coma Scale. 8. Determine level of orientation. a. Checks orientation to time, person, and place. 7. Assess recent memory – “How did you get to the hospital?” 8. Assess remote memory – “What is your birth date?” 9. Checks cranial nerves. a. CN I – identify the smell of common substances. b. CN II – tests visual acuity and visual fields. c. CN III, IV, and VI Tests Extraoculor movement by having patient move eyes through the 6 cardinal fields of gaze with the head held steady. Tests papillary reaction to light and accommodation. d. CN V – motor function – move jaw from side to side, clenching jaw, and biting down on a tongue blade. e. CN V – sensory function – close eyes and identify when nurse touches patients face at forehead, checks, and chin bilaterally. Metropolitan Community College Yes No 48 Comments Neurological Assessment - continued f. Tests corneal reflex by puffs air from a syringe over cornea. g. CN VII motor function – make faces such as smile, frown, whistle. h. CN VII taste – test taste on anterior portion tongue by placing sweet (sugar) salty (salt) or sour (lemon) substance on tip on tongue. i. CN VIII use – watch: the tictoc for hearing; Weber and Rinne test for air and bone conduction; Romber test for balance. j. CN IX and X observe ability to talk, swallow and cough. k. CN IX and X motor function: patient to say “ah” while depressing tongue with tongue blade and observing soft palate and uvula rise. l. CN IX and X sensory function: induce gag reflex (we will not perform but be aware these nerves responsible for this reflex). m. CN IX and X taste: (sweet, salty, sour) tests on posterior portion of tongue. n. CN XI place hands on patient’s shoulders and patient to shrug his/her shoulders against resistance. Have patient turn head from side to side against resistance. o. CN XII - Say “d, l, n, t”. - Protrude tongue and move it from side to side. 10. Tests superficial sensations: a. Begin with most peripheral part of limb, test with light touch. b. If patient does not perceive touch, determine boundaries by testing about every inch to determine sensory loss area. Metropolitan Community College 49 Neurological Assessment - continued 11. Use correct procedure to test each reflex: Uses the following scale to grade reflexes: O – no response detected +1 – Diminished response +2 – Response normal +3 – Response somewhat stronger than normal +4 – Response hyperactive with clonus. a. Biceps reflex (spinal cord level C5 and C6) Rests the patients elbow in nondominant hand, with thumb over the biceps tendon. Strikes the percussion hammer to own thumb. b. Triceps reflex (spinal cord level C8 and C8) abducts patient’s arm at the shoulder and flexes it at the elbow. Supports the upper arm with non dominant hand, letting the forearm hang loosely. Strikes the triceps tendon about 1-2 inches above the olecranon process. c. Brachioradialis reflex (spinal cord level C-3 and C-6) Rests patients arm on patients leg. Strikes with the percussion hammer 1-2 inches above the bony prominence of the wrist on the thumb side. d. Patellar reflex (spinal cord level L-2, L-3, L-4) Patient sits with legs dangling. Strikes the tendon directly below the patella. e. Achilles reflex (spinal cord level S1, S2) Patient lies supine or sits with legs dangling. Holds the patients foot slightly dorsiflexed and strikes the Achilles tendon about 2 inches above the heel with the percussion hammer. f. Test Plantar superficial reflex with end of reflex hammer. Strokes sole of foot in an arc from the lateral heel to medially across the ball of the foot. Metropolitan Community College 50 Neurological Assessment - continued Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 51 Metropolitan Community College Procedure Checklist Preparing for Chest Tube Insertion Procedure Steps 1. Insertion: Assure consent signed. 2. Reinforce procedure explanation to patient. 3. Obtain pre-insertion vitals and inquire as to pre-procedure pain medication. 4. Obtains prescribed chest tube drainage system. - Water seal - Dry seal 5. Hand hygiene 6. Prepare water seal system without suction as prescribed a. remove cover on water-seal chamber and fill the second chamber with sterile water or normal saline to 2 cm mark, then replace cover on water-seal chamber. 7. Prepare water seal system with suction as prescribed. a. remove cover on water-seal chamber and fill second chamber with sterile water or normal saline to 2 cm mark. b. Add sterile water or normal saline to suction – control chamber. Add amount of fluid as specified by physician – usually 20 cm. c. Attach tubing from suction – control chamber to connecting tube to suction source. 8. Position patient to semi-fowlers to high fowlers according to indicated insertion site. 9. Assist physician with mask, sterile gown, sterile gloves and put on mask to self. 10. Provide support to patient while physician prepares sterile field, local anesthetic is administered and insertion and suturing of chest tube. Metropolitan Community College Yes No 52 Comments Patient with Chest Tubes – continued 11. As soon as CT inserted, attach to drainage system using a connector (from sterile field). 12. Assist physician with occlusive dressing around C.T., physician may use petroleum gauze, - pre-cut drain-dressing over petroleum gauge - Abd (lg dressing) over the 2 precut drain dressings - Secure dressing with 2 inch silk tape or elastoplast to cover dressing site completely. Must be air occlusive dressing. 13. If suction is prescribed, adjust suction source (on wall) until gentle bubbling occurs in suction – control chamber. If suction not prescribed, leave the suction tubing on the drainage system open. 14. Assure drainage tube has no kinks and no dependent drainage tube. (tubing coiled up on bed). 15. Post insertion x-ray 16. Place Vaseline type dressing to bedside in case chest tube becomes dislodged. 17. Make sure chest tube unit is cleared from bed and make sure there will be no damage when bed changes position. 18. Position patient for comfort. 19. Assess lung sounds/vitals. 20. Chart procedure. 21. Assure drainage system is located below insertion site. Recommendation: Pass____________________ Needs more practice_____________________ Student______________________________________________Date______________________ Instructor____________________________________________ Metropolitan Community College 53 2012 Summer Quarter Important Dates Classes Begin for 10-week/first five-week sessions ................................................ June 6 W ***Census Date/Tenth Day* Date for first-five week session .................................. June 12 W ***Census Date/Tenth Day* Date for 10 week session ........................................... June 19 Tu Student Withdrawal Deadline to “drop” a class ............................................ Varies by Class** Independence Day Recess/College Closed ................................................................... July 4 W Classes end: First-five week session ....................................................................... July11 W Classes begin for Second five week session ........................................................... July 12 Th Summer grades for first five week session due and posted by 11:59 p.m ................. July 18 W ***Census Date/Tenth Day* Date for second five week session ............................... July 18 W Spring Quarter Term Incomplete “I” Grades Due ................................................... August 1 W Classes end for second five week/10 week sessions .......................................... August 15 W Summer grades for second five week/10 week sessions due and posted by 11:59 p.mAugust 17 F * Tenth Day is the date on which your enrollment level is checked. **To view the last day to withdraw “drop” a class, go to the class schedule found on line at http://www.mccneb.edu/schedule/classschedule.asp . Then, find the course section and click on the Important Dates link on the same line as the course title. The refund dates for each course section are automatically calculated based on the start and end dates and the number of sessions for a course. A student must withdraw by this date to avoid an “F” grade. Note: Schedule changes may have implications for students on Financial Aid. Check with the Financial Aid Office prior to any schedule changes at 402-457-2330. The Census Date*** is the date on which Financial Aid Student’s enrollment is checked to determine the type and amount of funds authorized for the quarter. Payment is based on enrollment as of that date. REFUND POLICIES for Credit Courses A student is responsible for withdrawing “dropping” from a course(s) if unable to attend. Nonattendance or non-payment does not relieve a student from the obligation to pay. To withdraw “drop” from a course, log on to WebAdvisor https://webadvisor.mccneb.edu and click “Register and Drop Sections”. An official schedule change that reduces or terminates a student’s academic credit load may entitle the student to a refund. The eligibility and amount of a refund is automatically calculated by the date of the withdrawal. A student may see the refund percentage received through midnight of the same day by logging into WebAdvisor and clicking on the Tuition Refund Calculator A link to the Student Information Calendar is available once logged in on WebAdvisor. Metropolitan Community College 54