Skill Training

8/8/2019 Skill Training

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NO. TOPIC

1.

Uterine Massage

2.

Abdominal Examination(Maneuver)


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Intern ship skill training program

It is training customized to meet internships' specific needs, Training isdelivered to new or current internships at the work site or in a

classroom.It is a learning process that involvesthe acquisition of knowledge,sharpening of skills, concepts, rules, orchanging of attitudes and behaviors toenhance the performance of intern

ship

Vision:

The most Skillful intern ship student infaculty of nursing Ain shams

university all over the Middle East

Mission:


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Enable nurse internship through thisintern ship skill training program to bethe best skillful internship nurse.

:

Objectives:

The objectives of this programare:

This program designed to

provide:

Better recognition is designed torecognize and support the skills ofinternship who work alongsidemedical specialists in key areas of our

health system. A more satisfying career

pathway A career pathway withdiverse opportunities and theflexibility to accommodate bothpersonal career goals and the needsof intern ship.


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More training opportunities.Education resources and learningactivities. Excellent training means

high quality patient care. For intern ship The training

program ensures that training isaligned with the needs of the jobcreating a fit-for-purpose workforce.

Provide relevant groups and

individuals with information on skillsimplementation and progress;

Give relevant groups and individualsan opportunity to meet and networkideas.

Progress development for intern shipinvolved in the working group giventhe opportunity to provide feedback.

1. Uterine Massage

EQUIPMENT: o Disposable gloves

o


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NO. PROCEDURE/TECHNIQUE RATIONAL

Preparing for examination(pre procedure )

1. Prepare the necessary equipment andtake it into the bed side table2. Greet to the woman respectfully and

with kindly.3. Explain to the woman is going to be

done and obtain her consent toperform the procedure.

4. Ask the woman to empty her bladderbefore starting the procedure to avoiduterine displacement

5. Listen to her attentively, and respondto her questions and concerns.

6. Protect the woman from drafts andkeep her privacy throughout the

procedure.7. Wash hands thoroughly with soap andwater and dry with a clean dry towel orair drier

8. Put on clean examination gloves.

9. Assess woman's fundus and lochia incorrespondence with the period of

postpartum Fundus and lochia assessment steps

1. Ask the woman to lie on her back,uncover her abdomen and have herknees slightly bent to relax theabdominal muscles and to permit

accurate location of the fundus.


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2. Stand comfortably at the right side ofthe mother's bed.

3. Do fundal massage with one of your

hands while the other gloved handlower the perineal pad ; so that youcan determine the type ;odor;consistency and amount of lochia flow.

4. Ask the woman since how many hoursshe changed her perineal pad.

5. Observed the amount of lochia in the

pad. Conceder the lochia scanty if isless than 10ml /hourly; small or mild ifit is from 10 25 hourly; moderatefrom 25 50 ml hourly and large orsever if the perineal pad is hourlysaturated.

6. Assess the fundal level , position, size

and consistency first then do massageas needed

7. Support the uterus by cupping onehand against the lower uterinesegment (just above the symphysispubis )

8. Gently use the side of the other

cupped hand to determine the locationof fundus uteri between umbilicusand symphysis pubis

9. Measure by finger breadth how far thefundus from the umbilicus

10.

Determine its size , position (at themiddle or displaced to either sides )

and consistency (normally contractedand firm or boggy and require


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massage)11.

If the uterus is boggy and soft use theflat part of your fingers (not the

fingertips )to gently massage thefundus toward the lower uterinesegment till it become contracted andfirm

12.

Put new perineal pad after performingperineal care

Post Procedure Tasks

1. Remove gloves by turning them insideout , dispose them and wash hands

2. Inform the woman about the findingsand record it accurately in thewoman's file.

3. Help the woman to readjust her

clothes and to have any comfortableposition.

INTRODUCTION:

- After delivery of the placenta, theuterus normally contracts firmly, closingoff the open blood vessels whichpreviously supplied the placenta. Withoutthis contraction, rapid blood loss wouldlikely prove very problematic or worse.- A simple way to encourage firmuterine contraction is with uterinemassage. The fundus of the uterus (top


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portion) is vigorously massaged to keepit the consistency of a tightened thighmuscle. If it is flabby, the patient will

likely continue to bleed- Uterine massage given every 10minutes for 60 minutes after birtheffectively reduced blood loss, and theneed for additional uterotonics, by some80%. The number of women losing morethan 500 ml of blood also appeared to be

halved. Two women in the control groupand none in the uterine massage groupneeded blood transfusions.

OBJECTIVES:

- To determine the effectiveness ofuterine massage after birth and before orafter delivery of the placenta, or both, toreduce postpartum blood loss andassociated morbidity and mortality.


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2. Abdominal Examination

NO. PROCEDURE/TECHNIQUE RATIONAL

Preparing for examination(pre procedure )

EQUIPMENT: o de

o


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1. Explain the steps of the physicalexamination and obtain the woman'sconsent

2. Ask her to empty her bladder have herprovide a urine sample if indicatedand if urine testing is available

3. Have the woman undress in private.Ask her to remove only enoughclothing to complete the examination

4. Position the woman on the

examination couch , on her back withknees flexed and slightly separated

5. Provide her with a drape or cloth tocover the parts of her body that arenot being examined and uncover herabdomen

Abdominal Examination (Every visit)

1. Stand at the right side of the woman2. Inspect abdomen for scars

If there is a scar, ask if is from acaesarean section or other surgeryalso for hair distribution, skinpigmentation, edema, fetal movement,

shape & enlargement of the abdomen

3. Measure fundal height (palpate theabdomen to estimate the period ofgestation )

Place the palmer border of the lefthand just below the xiphisternum &

move it down the abdomen until the


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fundus is felt

Measure the number of fingers, whichcan fit between the fundus &

xiphisternum or measure the distancefrom the symphysis pubis to thefundus using tape measure (Fig2)Fig (2) Palpation of the abdomen toestimate the period of gestation

4. Carry out fundal palpation

Stand at the woman's right side, facing

her hand. Place both hands on the sides of the

fundus at the top of the abdomen

Using the pads of the fingers , applygentle but firm pressure to assessconsistency and mobility of the fetalpart & to determine which part of the

fetus is occupying the fundus .5. Carry out lateral palpation

Move hands smoothly down, sides ofuterus to feel for fetal back

Keep dominant hand steady againstthe side of uterus and use palm of thehand to apply gentle but deeppressure to explore opposite side ofuterus

Report procedure on other side ofuterus

6. Carry out suprabubic (pelvicpalpation )

Facing the women's feet , place bothhands on the uterus just below the


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umbilicus with fingers close to gather&pointing downwards to determinewhich part of the fetus is occupying

the lower part of the uterus7. Carry out pawlik grip ( done at 9th

month or 36 weeks )

Facing the women's head, use theright hand to grasp the lower part ofuterus between the thumb &fingers

Ask woman to take deep breathes outgently.

Allow fingers to sink gently &deeplyabove the symphysis pubis to feel thesize &mobility &engagement ofpresenting part

Fetal Heart Rate Evaluation

Listen to the fetal rateDetermine position of the fetus and

place fetal stethoscope on abdomen

on the same side that you palpated

the fetal back

Place your ear in close , firm contactwith fetal stethoscope

Remove hands from fetal stethoscopeand listen to fetal heart for a full

minute, counting beats against thesecond hand of a clock.


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Feel the women's pulse at wrist ,simultaneously to ensure that fetalheart tones , and not maternal pulse ,

are being measured (see LGauscultation of fetal heart )After the Examination

1. Drape the exposed abdomen.2. Remove gloves by turning them inside

out.3. If disposing gloves , place in leak proof

container or plastic bag4. Help the woman off the examination

table5. Share your findings with the woman.6. Record the findings & woman's

reaction


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Infection Prevention & Control in ICU: A Self Learning Package for ICU Nurses

INDEX1.1 Introduction &learning objectives

About This Package

Infection Prevention & Control in ICU package is intended toprovide staff working in ICU settings with the core, or basic informationneeded for staff who work in intensive care unit

Infection Prevention & Control in ICU includes information about: \

How Do Infectious Agents Spread? The Means of Transmission


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ICU patients

Increased risk is associated with:

ICU Care is Invasive

Sources of Cross-Infection in the ICU

Some Health-Care Associated Infections that May OccurUTIassociated with Foley catheters

Strategies to Reduce Infection Risk

I- Patients needing ICU care should be assessed for:

II- Hand hygiene:

III- Procedures requiring aseptic technique (Intravenous Therapy, UrinaryCatheterization & Equipment Respiratory Care /Practices)

IV- ICU Personnel

1 Hand Hygiene

2 Personal Protective Equipment

3 Elements of Routine Practices Respiratory Etiquette

4 Routine Practices Patient/Client/Resident Management

5 Infection Prevention & Control and the Healthcare Worker

Environment Factors and Design

Issues for the ICU

Unit Design should consider the following

Patient Care Equipment

6 Routine Practices Competencies Skills Checklist

7 Routine Practices Q/A

8 Reference List

Intensive Care Unit

Did You Know.1 About 220,000 Canadians (or one patient in nine) admitted to ahospital every year pick up healthcare associated infections (HAI) as aconsequence of their hospital stay?


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1 8,000 patients die annually from those infections (about the samenumber annually as the number of deaths from breast cancer and motorvehicle accidents).

1 Most healthcare facilities report less than 50% adherence to handhygiene.

1 The evidence supporting hand hygiene with soap and water oralcohol-based hand rub is nothing short of overwhelming.BUTit is notthe only answer. What is needed is a multi-faceted approach.

1 15 seconds: thats all the time thats needed to destroy almost allpotentially harmful microorganisms using a squirt of alcohol-based handrub and rubbing it into your hands until they are dry.

1 Healthcare associated infections (HAI) were the eleventh leadingcause of death two decades ago but are now the fourth leading cause of

death in Canadians after cancer, heart disease and stroke.

1 While most healthcare providers believe they are already practicingappropriate hand hygiene, one Canadian study found actual compliancewas less than 40%.

Source: adapted from www.justcleanyourhands

ICU patientsoSickest patients (multiple diagnoses,

multi-organ failure,


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immunocompromised, septic andtrauma)oMove less

oMalnourishedoMore obtunded (Glasgow coma scale)

oDiabetics and Heart failure

Increased risk is associatedwith:

oThe severity of the patients illness

and underlying conditions.oThe exposure to multiple invasive

devices and procedures.oIncreased patient contact with

health-care personnel.oA longer ICU stay which prolongs the

risk of exposure.oSpace limitations that increase therisk of contaminating equipmento Since patients in the ICU are likely tohave multiple devices fortreating ormonitoring their care it is notsurprising care, that the most commonnosocomial infections are pneumonia

(endotracheal tubes),urinary tract infections (urinarycatheters) and catheter-related bloodstream infections.o Urinary catheter, ventilator-associated, and catheter-associatedbloodstream infection are common


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complications of care provided in theICU.o Attributable mortality for pneumonia

occurring in the ICU population isbetween 5 14%.

ICU Care is Invasive: More invasive lines and proceduresincluding surgeries

Longer length of stay

More IV and parenteral drugs

More tube feeding and Parenteralnutrition

More ventilation

Sources of Cross-Infection in

the ICU Hands of staff and attendants (via two-bow) hand washing and communal towels orno hand washing);

Assisted ventilation equipment;

Suction and drainage bottles;

I.V. lines central and peripheral;Urinary catheters;

Wounds and wound dressings;

Disinfectant containers;

Dressing trolleys (on which disinfectantsjars/bottles are stored)

Understaffing

Lack of isolation facilities


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No separation of clean and dirty AREAS

Excessive antibiotic use

Inadequate decontamination of items &

equipments Inadequate cleaning of environment

Some Health-Care Associated Infectionsthat May OccurUTI associated withFoley catheters

Lower respiratory tract infection (post-op

and ventilator dependent)Skin necrosis (skin breakdown)

Blood stream infection (and lineassociated)

Surgical-site infection

Nutrition-related and malnutrition

Strategies to Reduce InfectionRisk

I- Patients needing ICU care should beassessed for.

II- Hand hygiene.

III- Procedures requiring aseptic

technique (IntravenousTherapy, Urinary Catheterization &Respiratory Care Equipment/Practices).

IV-ICU Personnel

I- Patients needing ICU care should be assessed for:

Diarrhea,

Rashes or skin conditions;


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Recognized communicable disease;

Known carrier of an epidemic strain ofbacterium;

Isolation: Patients suspected or known tohave communicable

diseases should be admitted directly toan isolation cubicle in the ICU or referred to a Fever Hospital.

II- Hand hygiene:

Hands are the most common vehicle oftransmission of organisms and thereforesinks should be provided for handwashing. All visitors and staff should wash theirhands before direct contact with patients.

Aseptic hand wash or alcohol based hand

rub should be performed:-Before entering the ICU.- Before performing any invasive

procedure including peripheralcannula Insertion and removal.

- Before use of multi dose vials.- Before administration of iv fluids or

medications/drugs-Routine hand wash should be performed:-Before and after any contact with the

patient-After touching environmental surfaces-Whenever soiled.

III- Procedures requiring aseptic technique(Intravenous Therapy, Urinary Catheterization


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& Equipment Respiratory Care /Practices)

A) IV care practices.

B) Respiratory care - Patient-Based

Interventions. C) Personal protective equipment forroutine patient care.

A) IV care practices Clean injection ports with 70% alcohol oran iodophor before accessing the system.

Cap all stopcocks when not in use. Use aseptic technique including a cap,mask, sterile gown, sterile gloves, and alarge sterile sheet for the insertion ofcentral venous catheters (including PICCs)or guide wire exchange. Do not routinely replace central venous

catheters, hem dialysis catheters, orpulmonary artery catheters. Do not remove CVCs or PICCs on thebasis of fever alone. Use clinical judgment regarding theappropriateness of removing the catheterif infection is evidenced elsewhere or if a

noninfectious cause of fever is suspected.Do not routinely replace peripheralarterial catheters.

B) Respiratory care - Patient-Based

Interventions:


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If there is no medical contraindication,elevate the head of the bed of a patient athigh risk for aspiration pneumonia, e.g., a

person receiving mechanically assistedventilation and/or who has an eternal tubein place, at an angle of 30-45 degrees. Periodically drain and discard anycondensate that collects in the tubing of amechanical ventilator, taking precautionsnot to allow condensate to drain toward

the patient. Decontaminate hands with soap andwater or a waterless antiseptic agent afterperforming the procedure or afterhandling the fluid. If available, use an endotracheal tubewith a dorsal lumen above the

endotracheal cuff to allow drainage (bycontinuous suctioning) of trachealsecretions that accumulate in the patient'ssubglottic area. Use sucralfate, H2-blockers, , , and/orantacids interchangeably for stress-bleeding prophylaxis in a patient receiving

mechanically assisted ventilation (H2-blockers alone decrease gastric acidityand increase gastric colonization andincreases the susceptibility to respiratoryinfections). Instruct preoperative patients, especiallythose at high risk of contractingpneumonia, regarding taking deep breaths


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and ambulating as soon as medicallyindicated in the postoperative period. High-risk patients include those who will

have an abdominal, thoracic, head, orneck operation Follow manufacturers' instructionsmanufacturers for use and maintenance ofwall oxygen humidifiers . Between patients, change the tubing,including any nasal prongs or mask used

to deliver oxygen from a wall outlet. Small-volume medication nebulizers: "in-line" and hand-held nebulizers: Betweentreatments on the same patient, disinfect;rinse with sterile or pasteurized water; andair-dry small-volume in-line or hand-heldmedication nebulizers or who have

substantial pulmonary dysfunction. Use only sterile or pasteurized fluid fornebulization and dispense the fluid intothe nebulizer aseptically. If multidose medication vials are used,then handle, dispense, and store themaccording to manufacturers' instructions

using sterile techniques.

C) Personal protective equipment forroutine patientcare

Gloves: should be selected according toneed.(e.g., sterile for procedures usingaseptic technique such as insertion ofcentral venous catheter and non sterile for


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procedures non-such as emptying urinarydrainage bags, insertion of peripheral IVcatheters, contact with contaminated

surfaces or equipment); Wear gloves for handling respiratorysecretions or objects contaminated withrespiratory secretions of any patient. Change gloves and decontaminatehands, as above: Between contacts with different patients.

After handling respiratory secretions orobjects contaminated with secretions fromone patient. Before contact with object, orenvironmental surface. Between contacts with a contaminatedbody site and the respiratory tract of, or

respiratory device on, the same patient. Wear a gown :When exposure torespiratory secretions from a patient isanticipated, and change after soilingoccurs and before providing care toanother patient. Plastic aprons may be worn when contact

with patient body fluids is anticipated;Disposable high-efficiency filter masksmay be used for wound care.

Shoe and head coverings are notrequired for routine care

IV- ICU Personnel


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All staff working on the unit should beoffered hepatitis B vaccine beforebeginning work on the unit .

Orientation to the unit should includebasic infection control concepts thatinclude hand hygiene, management ofsharps, p yg , g p , and associated risks ofdisease transmission.Training and education should includeformal and informal infection control

lectures and assessment of practicesthrough periodic observations.

Environment Factors andDesignIssues for the ICUUnit Design should consider

the followingSpace

Ventilation

Traffic flow

Visitors

Non-ICU Staff

I- SpaceBeds


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The beds should be 2 5 -3 meters (7-9 feet) apart to allow free movementof staff and equipment, reducing risk

of cross contamination. Ideally, a sharps container shouldbe within easy access of each bed.

PartitionsPrivacy partitions should be ofmaterial that is easily cleaned and

should be cleaned weekly and anytime that it becomes soiled orcontaminated. If curtains are used,they should be changed weekly andbetween patients.

Toilets

May be located outside the ICU.Medication preparation

Medication prep areas should beseparate from patient care areas andshould be maintained as a clean area.

Clean storageAn area should be identified and

maintained for clean storage andshould be separate from care andwaste disposal areas.

Soiled and waste storageAn area should be identified forstoring collected bedside waste andshould be maintained separate from

direct care and clean medication


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areas. Ideally, this area should have aclinical sink for the disposal of bloodand body fluid waste. The area should

include storage of filled sharpscontainers until these containers canbe removed.

II- VentilationType

The source of clean air should be

determined including central orthrough the wall through-airconditioning units.

WindowsWindows should remain closed inorder to control all airborne risks;plants and flowers should be kept

outside the ICU.

Sinks and Waterless Hand rub DispensersSinks should be placed near the ICUentrance and If this is not feasible,waterless hand rub dispensers shouldbe available at the ICU entrance and

at each bedside. If the design permitsscrub sinks.An adequate number of easilyaccessible Elbow/Foot operated sinksshould be available. Sinks should notbe plugged or used for storage.Sinks assigned for hand washing

should not be using for washinginstruments.


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III- Traffic flowThe unit may be situated close to the

operating theatre and to the emergencydepartment for accessibility, but should beseparate from the main ward areas. Policies should consider controlling trafficflow to and from the unit in order toreduce sources of contamination fromvisitors, staff and equipment.

IV- Visitors Design of the unit should permit staff toassess visitors for communicable disease(eg, rash, respiratory infection) beforepermitted to enter unit.They should be instructed in washing

their hands if assisting the patient.

V- Non-ICU StaffStaff not assigned to the ICU should follow thefollowing protocol:

Street coats and white coats must beremoved;

Hands should be washed on entering theICU and before leaving the unit.

The proper procedure should be followedwhen attending the patient


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Patient Care Equipment

Equipment And

patient-care articles

Reprocessing Method

1. Ventilator circuits Ventilator Disposable tubingdoes not routinely need to bechanged for a single circuits

patient unless it becomesvisibly contaminated,malfunctions or within 3-4

days.Multiple-use tubing must beheat-disinfected for a at least76C for 30 minutes orsterilized

If properly maintained, aventilated patient may use

the same circuit for 3-4 daysbefore reprocessing becomesnecessary.

Use a heat-moistureexchanger (HME) to preventpneumonia in a patientreceiving mechanically

assisted ventilation. Changethe HME when it malfunctionsmechanically or becomesvisibly soiled.

Do not routinely change anHME more frequently thanevery 48 hours.

Install filters, e.g. heat-


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moisture exchangers withfilters (HMEF) on theexpiratory and in spiratory

ends of the ventilator toprevent contamination

Endotrachealsuction catheters

Closed suction catheters thatincorporate a protectivesleeve do not need to bechanged every 24 hours.Studies have demonstrated

these can safely be used onthe same patient until thedevice is contaminated ormalfunctions.

More often, disposablesuction catheters are used forrespiratory tract suctioning.

This device should bediscarded after each use ormay be used maximum for upto 6 hours on the samepatient.

The water used for flushingthe catheter after each

suction must be sterile andchanged every time.

Suction catheters must notbe shared between patients.

3. Endotracheal tubes These may be recycled afterthorough cleaning andautoclaving tubes

autoclaving.


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Disposable endotrachealtubes are available but aremore expensive

thanrecyclable ones.4. Ambu-bags These are used for

resuscitation. Ambu-bags areextremely difficult to disinfectand become contaminatedvery quickly:

Heat is the most reliable

method of disinfection; 2%glutaraldehyde is a lessacceptable method.

The bags must be rinsedthoroughly in sterile waterafter immersion inglutaraldehyde. This will

reduce the risk of chemicalirritation, which can itselfprecipitate respiratoryinfection.

5. Oxygendelivery masks

These can be disposable orreusable;

oWash thoroughly.

oSoak in alcohol for10 minutes or soak inchlorine (500 ppm),rinse, dry and store.

6. Suction anddrainage bottles

These are usually disposable,with a self-sealing innercontainer held in a clear plastic

outer container.


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Non-disposable bottles:

Must be changed every 24hours (or sooner if full).

The contents may beemptied down the toilet.

Must be rinsed andautoclaved.

Do not leave fluids standingin suction bottles.

7. Resuscitaires Disconnect all connections.Wash thoroughly with a softbrush and autoclave.

Low temperature ETO gas (15 h) andhydrogen peroxide gasplasma (50 min) for Heat-sensitive Patient CareEquipment

Liquid immersion Chemical sterilants :a 2.4%glut (10h), 1.12% glut and1.93% phenol(12 h), 7.35%HP and 0.23% PA (3h), 7.5%HP (6 h), 1.0% HP and0.08%PA (8h), and 0.2% PA(50 minat 50C56C)for (respiratory-therapy equipment)& (GIendoscopes andbronchoscopes)

High temperature Steam (40 min) and dry heat(16 h, depending ontemperature) For (surgical


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instruments)

Environmental Cleaning

DailyCleaning must be done daily with thehospital approved cleaner. All surfaces

must be wiped with a damp cloth toremove dust and dirt;Cleaner/disinfectants should beidentified by the IC- team and used asindicated. High level disinfectants(HLD) are not used for environmentalcleaning.

Cleaner/disinfectants should bekept closed when not in use.

TerminalWhen patients are discharged fromthe unit, a thorough cleaning of thebed and bedside equipment must becompleted before admitting new

patients.Scheduled

A total cleaning of all areas, includingthe store clean and soiled storageareas , should be done at least every1-2 weeks.


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Separate mops, and cleaningutensils should be used for cleaning ofthe unit.

Cleaning equipment should bewiped and properly stored when not inuse.

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