Skills Test 1

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Author:
cswett
ID:
100652
Filename:
Skills Test 1
Updated:
2011-09-11 23:04:19
Tags:
Nursing Skills Test
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Description:
Checklists for first skills test
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  1. Making an Unoccupied Bed
    Assessment
    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
  2. Making an Unoccupied Bed
    Planning
    • 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
  3. Making an Unoccupied Bed
    Supplies Needed
    • fitted sheet
    • flat sheet
    • draw sheet
    • pillowcase
    • waterproof pad (if needed)
    • blanket (if not on bed)
    • plastic laundry bag or linen hamper
  4. Making an Unoccupied Bed
    Procedure
    • 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
  5. Making an Unoccupied Bed
    Documentation
    • 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
  6. Making an Occupied Bed
    Assessment
    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)
  7. Making an Occupied Bed
    Planning
    • 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
  8. Changing an Occupied Bed
    Implementation
    • 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
  9. Changing An occupied bed
    Documentation
    • Changing of bed is not normally documented
    • assessment should be noted if unusual
  10. Feeding Pump
    Assessment
    • 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
  11. Feeding Pump
    Planning
    • 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
  12. Feeding Pump
    Supplies
    • 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
  13. Feeding Pump
    Implementation
    • 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
  14. Feeding Pump
    Documentation
    • 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
  15. Inserting Nasogastric Tube Checklist
    Assessment
    • 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
  16. Inserting Nasogastric Tube
    Implementation
    • 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
  17. CGI- WIPE
    Start with Goals

    • Chart - assessment
    • Gather Equipment
    • Identify Client
    • Wash Hands
    • Identify Self
    • Provide Privacy
    • Explain Procedures
  18. Inserting NG tube
    Planning
    • 1. Place NG tube per Doctors Orders
    • 2. Clients comfort will be maintained
  19. Inserting NG Tube
    Supplies
    • 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
  20. Inserting NG Tube
    Documentation
    • 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
  21. Bed Bath
    Planning
    • 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
  22. Bed Bath
    Assessment
    • 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
  23. Bed Bath
    Supplies
    • Bath Basin
    • Soap
    • Washclothes 2-3
    • Towels 3
    • Bathsheet
    • Gloves
    • linen bag
    • hospital gown
    • deodorant, powder, lotion as desired
  24. Bed Bath
    Assessment
    • 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
  25. Bed Bath
    Documentation
    • Type of bath completed
    • How client tolerated bath
    • Note any areas of skin breakdown
  26. Assisting with ambulation
    Planning
    • 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
  27. Assisting with ambulation
    Assessment
    • Chart;
    • P/B history for hypotension & orthostatic hypotension
    • Assess Hemoglobin - WNL - within normal limits

    Bedside:

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