Embed Size (px)
Citation preview
Skills Quick View
Nursing School Made Simple Guaranteed © 2014 SimpleNursing.com All Rights Reserved.
Page 2 of 10
Table of Contents
1 Moving patient up in bed ....................................................................................................................................... 3
2 Applying restraints ................................................................................................................................................ 3
3 Applying and removing personal protective equipment ........................................................................................ 3
4 Administering an Enema ....................................................................................................................................... 3
5 Bed bath ............................................................................................................................................................... 3
6 Positioning of a patient.......................................................................................................................................... 4
7 Ambulating a patient ............................................................................................................................................. 4
8 Applying bandages ............................................................................................................................................... 4
9 Applying binders ................................................................................................................................................... 4
10 Applying antiembolism stockings .......................................................................................................................... 4
11 Intermittent and continuous tube feeding administration ....................................................................................... 5
12 Critical Thinking Question ..................................................................................................................................... 5
13 Safety and security ............................................................................................................................................... 5
14 Standard Precautions ........................................................................................................................................... 5
15 Comfort ................................................................................................................................................................. 6
16 Documentation ...................................................................................................................................................... 6
17 Occupied bedmaking ............................................................................................................................................ 6
18 Range of Motion ................................................................................................................................................... 7
19 Transfer of patient from bed to chair ..................................................................................................................... 7
20 Nasogastric tube insertion +/- suction ................................................................................................................... 7
21 Sterile Wet to moist dressing change ................................................................................................................... 7
22 Foley catheter insertion......................................................................................................................................... 8
23 Medication Administration ..................................................................................................................................... 8
24 Primary IV administration ...................................................................................................................................... 8
25 Secondary IV administration ................................................................................................................................. 8
26 IV flush with Saline ............................................................................................................................................... 8
27 Colostomy Emptying ............................................................................................................................................. 9
28 Colostomy Bag change ......................................................................................................................................... 9
29 Trach Suctioning ................................................................................................................................................... 9
30 Trach Care ............................................................................................................................................................ 9
31 CVP dressing change ......................................................................................................................................... 10
Skills Quick View
Nursing School Made Simple Guaranteed © 2014 SimpleNursing.com All Rights Reserved.
Page 3 of 10
1 Moving patient up in bed
Critical Elements:
1. Assess the patient’s ability to assist
2. Position a draw sheet under the patient appropriate
3. Use proper body mechanics
4. Properly instruct the patient how to assist
2 Applying restraints
Critical Elements:
1. Assess CSM or any contradictions to use
2. Explain rationale to patient and/or family
3. Apply restraint properly
4. Secure restraint t proper location on bed or wheelchair as appropriate
5. Assess at frequency dictated by agency policy
3 Applying and removing personal protective equipment
Critical Elements:
1. Identify needed equipment
2. Apply appropriate equipment on proper order
3. After use, remove protective equipment in proper in order to prevent contamination
4 Administering an Enema
Critical Elements:
1. Use warm water
2. Regulate flow of water to appropriate rate
3. Offer and place patient on bedpan after instillation
5 Bed bath
Critical Elements:
1. Prepare supplies using medical asepsis
2. Maintain proper body positioning of the patient and good body mechanics of the nurse; minimizing
movements of the patient and nurse
3. Keep patient covered to maintain modesty and prevent chilling
4. Clean from head to toe; perineal area last
5. Change water when appropriate
Skills Quick View
Nursing School Made Simple Guaranteed © 2014 SimpleNursing.com All Rights Reserved.
Page 4 of 10
6 Positioning of a patient
Critical Elements:
1. Maintain use of body mechanics by the nurse
2. Use pillows appropriately for support
3. Support body during position changes as appropriate
7 Ambulating a patient
Critical Elements:
1. Assess patient’s ability to ambulate
2. Correctly position self and arms to provide for assistance and safety
3. Evaluate patient’s gait, distance and tolerance of exercise
8 Applying bandages
Critical Elements:
1. Assess CSM
2. Position body part in neutral, elevated position if possible
3. Apply bandage using equal distance and equal pressure
4. Wrap the extremity distal to proximal
5. Secure appropriately
9 Applying binders
Critical Elements:
1. Choose proper sized binder for the patient
2. Position the binder appropriately
3. Assess for potential breathing or skin impairment
10 Applying antiembolism stockings
Critical Elements:
1. Measure patient for proper fit
2. Apply the stocking appropriately
3. Assess CSM and presence of wrinkles in stockings
Skills Quick View
Nursing School Made Simple Guaranteed © 2014 SimpleNursing.com All Rights Reserved.
Page 5 of 10
11 Intermittent and continuous tube feeding administration
Critical Elements:
1. Position HOB at least 30° unless contradicted
2. Check placement and patency of tube
3. Perform residual check; hold if residual > 100mL
4. Using the correct port, administer (TF or water) correct type and amount at prescribed rate
5. Keep HOB at least 30° for at least 1 hour after feeding for intermittent feedings and maintain HOB always
at least 30° for continuous feedings
12 Critical Thinking Question
Demonstrates applicant of knowledge obtained in current and previous courses related to the skill and patient
situation
13 Safety and security
Critical Elements:
1. Identify assigned patient by reading ID bracelet before initiating care
2. Protect the patient from physical harm at all times, such as the following:
Siderails are raised when indicated
Bed is left in low position appropriately
Patient’s ability to ambulare safely is assessed before beginning ambulation
Restraints are secure, when required, without injuring patient
3. Protect the patient and significant other from psychological harm by following actions:
Refer to the patient by designated or preferred name
Communicate verbally and non-verbally in professional manner
Communicate verbally and non-verbally in a manner that does NOT express anger, distrust, abuse,
familiarity or demeaning behaviors to the patient and/or significant others
Provide accurate information to patient and/or significant others
Keep all patient-related information professionally confidential
Maintain patient’s personal privacy at all times
Explain procedure to patient prior to initiating skill
14 Standard Precautions
Critical Elements:
1. Wash hands before initiating direct contact with patient and whenever hands are contaminated by
patient’s body secretions or substance
Skills Quick View
Nursing School Made Simple Guaranteed © 2014 SimpleNursing.com All Rights Reserved.
Page 6 of 10
2. Wear gloves whenever coming in contact with human secretions
3. Protect patient from contamination.
4. Protect self and others from contamination
5. Confine contaminated material to contaminated areas.
6. Dispose of contaminated materials in designated containers
7. Implement any designated special precautions as required
15 Comfort
Critical Elements:
1. Assess the patient’s comfort level before, during and after a potentially uncomfortable procedure.
2. Provide interventions to increase the patient’s comfort level
16 Documentation
Critical Elements
1. Document patient care using the following methods, as designated: assessment forms, flow graphs, or
other standard clinical forms, narrative process recording
2. Document patient changed and responses to care in designated records
3. Use language, terms, and abbreviations that are consistent with professional standards, agency protocols,
and other specific guidelines
4. Record data so that entries are: clear, accurate, precise, pertinent/relevant Handwashing: Critical
Elements:
5. Regulate water temperature and flow
6. Lather with soap covering all aspects of hand and wrists for appropriate length of time
7. Dry hands
8. Maintain medical asepsis and does not contaminate self
17 Occupied bedmaking
Critical Elements:
1. Making medical asepsis of linen
2. Place bed at working level for height
3. Keep patient covered at all times
4. Maintain proper positioning of patient and body mechanics of nurse
5. Create mitered corner and foot tent
6. Center top sheet and bedspread to hand equally on both sides
7. Place clean pillowcase on pillow
Skills Quick View
Nursing School Made Simple Guaranteed © 2014 SimpleNursing.com All Rights Reserved.
Page 7 of 10
18 Range of Motion
Critical Elements:
1. Proceed systematically from head to toe
2. Support joint being exercised
3. Perform exercise 3-5 times
19 Transfer of patient from bed to chair
Critical Elements:
1. Assess patient’s ability to assist; presence of weakness or paralysis; cognitive function
2. Maintain use of good body mechanics by the nurse
3. Maintain proper body alignment of the patient during
4. Position bed at working level for height
5. Demonstrate appropriate use of gait belt
6. position wheelchair at appropriate angle and locked continuous feedings
20 Nasogastric tube insertion +/- suction
Critical Elements
1. Measure tube for appropriate positioning
2. Lubricate the tube
3. Instruct the patient regarding procedure and patient participation
4. Facilitate chin tuck when appropriate
5. Insert the tube to the appropriate place
6. Check placement
7. Secure the tube
8. Attack the tube to suction appropriately
21 Sterile Wet to moist dressing change
Critical Elements
1. Remove old dressing
2. Assess wound and drainage
3. Establish sterile field
4. Apply sterile gloves
5. Apply dressing using sterile technique
6. Secure dressing
Skills Quick View
Nursing School Made Simple Guaranteed © 2014 SimpleNursing.com All Rights Reserved.
Page 8 of 10
22 Foley catheter insertion
Critical Elements:
1. Establish sterile field
2. Apply sterile gloves
3. Check foley balloon
4. Cleanse perineum correctly
5. Insert catheter maintaining sterile technique
6. Inflate foley bulb at appropriate location
23 Medication Administration
Critical Elements:
1. Correct calculation dose
2. Medication preparation using aseptic technique
3. Utilizes “5 Rights”
4. Appropriate drug knowledge
5. Correct needle, syringe and site selection
6. Correct administration
24 Primary IV administration
Critical Elements:
1. Maintain asepsis
2. Minimal loss of fluid
3. Correct titration of drop rate if gravity or correct mL/hr if using infusion pump
25 Secondary IV administration
Critical Elements:
1. Maintain asepsis
2. Correct connection to primary line
3. Backflush method
4. Correct titration to drop rate if gravity or correct mL/hr is using infusion pump
26 IV flush with Saline
Critical Elements:
1. Assess for complications
2. Cleans injection port
Skills Quick View
Nursing School Made Simple Guaranteed © 2014 SimpleNursing.com All Rights Reserved.
Page 9 of 10
3. Assess for blood return
4. Infuse saline while assessing for complications
27 Colostomy Emptying
Critical Elements
1. Assess stoma and contents of bag
2. Empty bag with minimal mess
3. Proper cleaning
4. Reattach clamp
28 Colostomy Bag change
Critical Elements:
1. Remove bag with minimal trauma
2. Assess stoma and surrounding skin
3. Measure for new pouch
4. Prep skin
5. Apply new pouch
29 Trach Suctioning
Critical Elements
1. Assess need for suctioning
2. Preoxygenate
3. Maintain asepsis
4. Correct method for insertion and removal of secretions
5. Assess tolerance
30 Trach Care
Critical Elements
1. Remove inner cannula
2. Maintain asepsis
3. Clean reusable cannula or replace with disposable cannula
4. Clean skin and trach plate
5. Replace ties as needed
Skills Quick View
Nursing School Made Simple Guaranteed © 2014 SimpleNursing.com All Rights Reserved.
Page 10 of 10
31 CVP dressing change
Critical Elements
1. Don mask
2. Remove dressing without dislodging catheter
3. Maintain asepsis throughout procedure
4. Clean site using technique
5. Apply tegaderm dressing with sterile technique and no air bubbles
