Skills Test 1

1. Assess if the bed/ matress needs to be cleaned before applying clean linens

2. Assess if the client has any special needs while the bed is being changed

• 1. The client will have clean linens on the bed
• 2. The clean linens will be appropriate for the clients needs or condition
• 3. Linens will be changed with a minimal amount of disruption to the client

• fitted sheet
• flat sheet
• draw sheet
• pillowcase
• waterproof pad (if needed)
• blanket (if not on bed)
• plastic laundry bag or linen hamper

• 1. Check for order or need
• 2. Gather supplies
• 3. Identify Client
• 4. Wash Hands
• 5. Assist client out of bed
• 6. Put on gloves, flatten bed, raise to workable height, lower side rail
• 7. Loosen all linens, remove call button & personal items from bed
• 8. Remove blanket & fold (put on clean surface - NOT on other bed)
• 9. Remove pillow case & set pillow on clean surface
• 10. Remove all linens - roll up - put in laundry bag
• 11. Wash matress if needed
• 12. Remove gloves & WASH HANDS
• 13. Place fitted sheet, draw sheet, & pad (if using) on first half of bed & fanfold other side
• 14. Put top sheet & blanket on first half of bed and fanfold other side
• 15. Walk to other side and put fitted sheet, draw sheet & pad on bed (be sure to remove wrinkles)
• 16. Pull top sheet & blanket over & miter corners at foot of bed
• 17. Fold blanket & topsheet over 6 inches & Fanfold blankets at end of bed
• 18. Put new pillowcase on pillow & place on bed
• 19. Put up siderail
• 20. Lower bed
• 21. Put overbed table & call button within reach
• 22. Assist client back into bed
• 23. Dispose of equipment, wash hands, document

• Changing bed not normally documented -
• document any abnormalities - pus/ drainage on sheets
• docutment assessment data - client's physical status, pulse & respiratory rate before and after getting out of bed if necessary

Chart:

• 1. Assess if client has special needs while bed is being changed (comfort needs, movement restrictions, incontinence, wound drainage)
• 2. Assess for IV lines, tubing & drains that require special precautions while moving client & changing linens

• Bedside:
• 1. Assess if bed/ matress needs to be cleaned before applying clean linens
• 2. Assess of client can assist or move self during procedure
• 3. Assess clients skin condition when rolling on side (reddened boney prominences or skin breakdown)

• 1. Client will have clean linens on bed
• 2. Clean linens will be appropriate to meet the clients needs/ condition
• 3. Linens will be changed with minimal amount of discomfort
• 4. Client will systain no injury while linens are being changed

• 1. Assess for orders or need, gather supplies
• 2. Wash hands, Identify client, explain procedure, PROVIDE PRIVACY
• 3. Flatten bed, raise to working height, PUT ON GLOVES
• 4. Loosen linen, remove personal items, move call device
• 5. Remove blanket & fold (place on clean surface)
• 6. Lower siderail & assist client to roll to side of bed - place pillow under head ( make sure siderail is up)
• 7. Roll soiled linens & place under client
• 8. Put bottom sheet & draw sheet on your side of bed & roll other half under soiled linens - use barrier if necessary
• 9. Raise railing on that side & go around bed - assist client to roll to other side - advise that they will roll over "lump"
• 10. Remove soiled linen & place in laundry bag
• 11. Pull clean linen from under client & tuck in
• 12. assist client to supine position & cover with top sheet
• 13. Put top sheet & blanket on bed & miter corners
• 14. Pull up on linens at clients feet to allow foot movement
• 15. Fold over top sheet & blanket 6 inches
• 16. Change pillowcase
• 17. RAISE SIDERAIL, LOWER BED
• 18. Place over the bed table & call button in easy reach of client
• 19. Dispose of equipment, remove gloves, wash hands
• 20. Document

• Changing of bed is not normally documented
• assessment should be noted if unusual

• Chart:
• 1. Assess fluid status - I &O
• 2. Baseline Weight
• 3. Baseline Labe Values
• 4. Bowel Movement status
• 5. Allergies

• Bedside:
• 1. Fluid status - skin turger, edema, ausc, lungs
• mucous membranes
• 2. Ausc, bowel sounds b/4 beginning & q 4-8 hrs
• 3. Allergy Band

• 1. Client will recieve the correct volume and formula over the correct amount of time
• 2. Client's nutritional status will improve
• 3. Client's nutritional needs will be met
• 4. Client will maintain a patent airway
• 5. Client will not have diarrhea due to NG feeding
• 6. Mouth mucous membranes will remain moist and intact
• 7. Client will maintain normal fluid volume
• 8. Clien's comfort level will increase
• 9. Skin around the tibe will reamin intact

• 1. Tube feeding formula
• 2. Graduated container
• 3. Stethoscope
• 4. Administrations set (if not inserted)
• 5. Connector
• 6. Pump & IV Pole
• 7. Chux pad
• 8. Gloves
• 9. Irrigation set
• 10. pH strips

• 1. Identify Client
• 2. Provide Privacy
• 3. Explain procedure
• 4. Wash Hands & Glove
• 5. Turn off clamp on feeding tube bag
• 6. Pour tube feeding into bag
• 7. Insert drip chamber into pump
• 8. Purge Tube & insert tube into pump
• 9. Turn on Pump - clear dose & volume
• 10. Set dose - total amt in bag
• 11. Set volume - mL/ hr
• - Raise bed to working height
• - Fowlers Position
• 12. CHECK placement of feeding tube - line at nose
• 13. Insert 20 mL of air while listening over stomach
• 14. Check residual volume - note amount & color/ consistency
• 15. Check pH & replace fluids
• 16. Flush tube with 30 mL of water
• 17. Attach tubing to feeding tube
• 18. Open clamp
• 19. Press start
• - lower bed
• - raise siderail - put call button within reach
• 20. Check resudual q8h or by facility procedure
• 21. Check placement/ irrigate & check bowel sounds q4h or by facility procedure
• 22. Document

• Document the feeding
• - kind and amount of formula taken
• - duration of feeding
• - assessment of client
• - how you checked placement - auscultation & pH
• - Amt & color of residual contents

Record volume of feeding & water administered on clients I & O

11/5/06 1330 Aspirated 20 ml pale yellow fluid from NG tube, pH 5. Pt in Fowler's Position. 1 L room-temperature ordered formula begun @ 60 mL/ hour on pump. No nausea reported. C. Swett, STN

• 1. Assess client's level of conciousness/ ability to cooperate with procedure
• 2. Assess client's history for nasam trauma or surgery
• 3. Assess nares for size, patency have client blow nose one side at a time (listen for patency)
• 4. Assess client's comfort level (medicate if necessary)
• 5. Determine presence of gag reflex

• 1. Review client's medical record & physician's orders
• 2. Sanitize hands - Introduce self & Identify patient
• 3. Check allergy band
• 4. Provide privacy
• 5. Explain procedure & develop hand signal
• 6. Prepare the equipment - set up suction & ensure that it is working)
• 7. Place cleint in high fowler's position & lower side rail
• 8. Cover client's chest with towel & offer emesis basin
• 9. Apply Gloves
• Assessment - nasal patency & Gag reflex
• 10.Measure NG tube - mark measurement
• 11. Lubricate NG tube with water soluble lubricant
• 12. Have client hyperextend neck
• 13. Instruct client to continue to breathe during procedure
• 14. Gently insert tube into the nare until distance to estimated oropharynx distance is reached or until client begins to gag - in the event of gagging pull back one ince and pause
• 15. Have client flex neck
• 16. Instruct client to swallow sips of water while passing tube
• 17. Advance catheter forward as the client swallows intil desired length has been inserted
• 18. Secure the tube with tape or tube holder
• 19. Check for placement
• - - ascultate - 30 ml air & ascultate stomach
• - asperate - 30 ml stomach - check color & pH
• - replace stomach contents
• - Flush with 30 ml water
• 20. Secure the tube to the clients gown using safety pin
• 21. Connect NG tube to suction (if ordered)
• 23. Verbalize instructions to patient
• - notify nurse of any nausea/ vomiting
• - Reinforce that HOB cannot be lowered below 30 degrees
• -Rationale - NG tube is holding stomach sphincter open so if you lay flat, stomach contents could come up into asophagus, or go into lungs
• 24. Dispose of soiled items & put equipment away
• 25. Remove gloves & perform hand hygene
• 26. Lover bed & endure patient comfort
• 27. Place bedside table & call button within reach

Start with Goals

• Chart - assessment
• Gather Equipment
• Identify Client
• Wash Hands
• Identify Self
• Provide Privacy
• Explain Procedures

• 1. Place NG tube per Doctors Orders
• 2. Clients comfort will be maintained

• 1. NG Tube
• 2. Water-suluble lubricant
• 3. Irrigation kit
• 4. Tape
• 5. Sterile water
• 6. Cup & straw
• 7. Chux pad
• 8. Towel
• 9. Safety pin
• 10. Tongue depressor
• 11. Pen light
• 12. Emesis basin
• 13. Marking Pen
• 14. Gloves

• 1. Size and type of tube inserted (french) & placement (side of nare)
• 2. Date & time of insertion
• 3. Type of suction & pressure setting used (if ordered)
• 4. Character & amount of withdrawn stomach contents
• 5. Two methods of verification
• 6. Client assessment - vital signs

11/5/06 1030 #8 Fr feeding tube inserted without difficulty through R nare. Checked placement -ausculatated stomach, Aspirate is greeenish-brown with pH 3.5. Tube secured at nose. Pateint verbilized understning of need to not pull on tube and not lay HOB below 30 degrees. C. Swett, STN

• The client's mosedty will be preserved
• Client will not become chilled during bath
• Client will not become injured during the bathing process
• Client will feel relaxed and comfortable after bathing is complete

• Chart:
• 1. MD restriction for activity or positioning
• 2. Personal or cultural issues regarding bathing
• 3. Assess needs for special soaps or lotions

• Bedside:
• 1. Assess client's ability to bath self
• 2. Assess any lines/ tubes that must be considered when bathing client

• Bath Basin
• Soap
• Washclothes 2-3
• Towels 3
• Bathsheet
• Gloves
• linen bag
• hospital gown
• deodorant, powder, lotion as desired

• 1. Identify self, Provide Privacy, Identify Client,
• 2. Wash hands
• 3. Fill basin w/ warm water & place on surfce near patient
• 4. Adjust bed to working height, lower rail
• 5. Remove blanket & fold - apply bath blanket & remove top sheet w/o exposing client
• 6. Remove gown
• 7. Put on gloves & fold washcloth - clean eyes with plain water - use different part of washcloth for each eye
• 8. Wash pace & pat dry
• 9. Lay towel under farthest arm & wash hand and arm - distal to proximal - DRY
• 10. Wash chest & dry
• 11. Place towel under close arm, wash & dry arm
• 12. Cover chest with towel, fold back bath towel, wash abdomen & Dry
• 13. Place towel under far leg - wash leg & dry
• 14. Change Water, roll patient on side - wash & dry back
• 15. Wash buttocks & dry - CHANGE WATER & WASH CLOTH
• 16. Give patient clean wash closth & allow to wash private area & dry
• 17. Put clean gown on client
• 18. Put sheet over client & remove bath sheet -MAKE SURE NO TOWELS ARE LEFT IN BED
• 19. Lower bed & raise side rail
• 20. Put soiled towels in laundry bag & clean out basin
• 21. Wash hands & document

• Type of bath completed
• How client tolerated bath
• Note any areas of skin breakdown

• Client will understand the procedure
• Client will ambulate w/o pain or injury
• Client will assist in any way possible
• Client's tubes. IV's etc will remain intact

• Chart;
• P/B history for hypotension & orthostatic hypotension
• Assess Hemoglobin - WNL - within normal limits

Bedside: