Nursing 121 Supplemental Packet

Imperial Valley College Division of Nursing Education and Health Technologies Medical/Surgical Skills NS121 I.V. Procedure

Skill Demonstrated Not Demonstrated 1. Checks orders

2. Identifies patient

3. Assembles equipment and identifies correct patient and order 4. Positions patient and adjusts lighting

5. Washes hands and applies gloves

4. Prepares equipment

6. Selects and prepares venipuncture site 7. Applies tourniquet

8. Enters skin with cathelon needle either next to or directly over vein 9. Observes for “pop” and flashback

10. Advances cathelon carefully

11. Releases tourniquet and applies pressure above site 12. Opens clamp on I.V. tubing or instills saline flush after checking for patency 13. Observes for swelling at I.V. site and patient for reactions 14. Applies appropriate dressing

15. Tapes the needle and tubing

16. Sets flow rate on pump

17. Labels I.V. site

18. States the difference between catheter and saline lock set-up 19. Uses universal precautions throughout procedure Imperial Valley College Division of Nursing Education and Health Technologies

Skills Demonstration I.V. Medications

Student’s Name Skill Demonstrated Not Demonstrated A. IV Push with continuous infusion

1. Checked physician’s order & allergies

2. Checked compatibility

3. Washed hands

4. Prepared medication

5. Identifies patient

6. Explained procedure to patient and correctly identified patient 7. Cleansed injection port with an alcohol swab 8. Closed clamp on IV tubing or pinched off tubing 9. Aspirated to observe blood return

10. Injected medication slowly

11. Reopened clamp and adjusted infusion rate on pump 12. Observed patient and IV site for reaction

13. Documented appropriately

B. IVPB Voluset, Volutrol, Buretrol 1. Checked physician’s order & allergies

3. Washed hands

4. Gathered equipment

5. Explained procedure to patient and identified correct patient 6. Filled volume control set with solution

7. Cleansed ports of entry

8. Injected medication and agitated set to mix 9. Adjusted pump for desired administration 10. Medication labeled volume control set appropriately 11. Verbalized documentation

C. Partial-Fill or Secondary Bottle 1. Checked physician’s order & allergies

3. Washed hands

4. Prepared equipment and medication

5. Identified correct patient and explained medication

6. Medication labeled appropriately

7. Affixed tubing with appropriate device

8. Labeled tubing appropriately

9. Primed tubing

10. Cleansed port of entry

11. Inserted injection device and secured with tape

12. Hung primary bottle below partial-fill or secondary medication

13. Adjusted pump

14. Verbalized appropriate documentation

D. SALINE LOCK INFUSION

1. Checked physician’s order & allergies

2. Washed hands

3. Explained procedure to patient and identified correct patient 4. Gathered equipment

5. Gloved

6. Cleansed and unclamped injection port

7. Checked for patency of I.V. catheter with normal saline and flushed 8. Inserted medication syringe into port

9. Infused medication appropriately

10. Flushed with sterile saline after medication and clamped port 12. Secured injection port with tape needed

13. Maintained asepsis

14. Observed site and patient for reactions

15. Verbalized appropriate documentation

Imperial Valley College Division of Nursing Education and Health Skills Demonstration Discontinuing an IV Discontinuing an I.V. Skills Demonstrated Skill Not Demonstrated 1..Check Order

Equipment: 1 band aid 2-3 2x2s 2. Gather equipment. Open band aid and alcohol packages. 3. Identify patient 4. Wash hands and put on gloves. 5. Explain procedure to patient and identify correct patient. 6. Turn I.V. flow off with roller valve. 7. Stabilizing needle or catheter, remove tape/dressings. 8. Remove catheter quickly and smoothly. Check that catheter is intact. 9. Quickly press 2x2 over site. 10. Hold pressure over site until bleeding stops. 11. Apply band aid and observe for complications. 12. Cover catheter with glove and discard. 13. Check site again in 15-30 minutes 14. Document procedure.

Skill Demonstration Monitoring an IV Infusion Monitoring I.V. Infusions Skills Demonstrated Skills Not Demonstrated 1. Assess I.V. insertion site every 2 hours for signs of infection,tenderness, itching infiltration, fluid or blood leakage, intact dressing. Include gentle palpation through intact dressing. 2. Assess for correct I.V. solution, correct flow rate, amount of solution remaining. 3. Notify R.N. immediately if any complication. 4. Document IV site assessment.

Calculating and Regulating I.V. Flow Rate Skills Demonstrated Skill Not Demonstrated 1. Check physician’s order for amount and time factor 2. Check drop factor of I.V. tubing

3. Calculate flow rate using formula

4. Using a watch with second hand, count drops for one minute 5. Adjust clamp until desired number of drops

Imperial Valley College Division of Nursing Education and Health Technologies

Nasopharyngeal Suctioning with Catheter

Nasopharyngeal Suctioning w/ Catheter Demonstrated Not Demonstrated Identify patient 1. Washed hands and standard preparation steps 2. Assessed need for suctioning 3. Gathered equipment. . . a. Suction machine b. Suction catheter (1/2 diameter of nares) c. Suction catheter kit(sterile catheter, gloves and basin) 4. Explained procedure to patient 5. Turns on suction machine 6. Set amount of suction 120-150 mm Hg suction for adults 80-120 mm Hg suction for child 60-100 mm Hg suction for infant 7. Put on gloves and face/eye protection 8. Inserted catheter 6-8 inches into nares 9. Suctioned no longer than 5-10 seconds** 10. Allowed patient to recover between suctionings (RR and color return to normal)**

11. Suction oropharynx with catheter 12. Charted assessment findings, quantity, and description secretions, how patient tolerated the procedure, time, date, and other pertinent information.

* Highlighted areas are critical elements and must be done correctly to pass skill.

Imperial Valley College Division of Nursing Education and Health Technologies Skills Demonstration Deflation/Inflation of Tracheal Cuff

Skills Skills Not Demonstrated Demonstrated 1. Identifies patient

2. Gathered equipment a. 10-12 ml. syringe b. suction equipment 3. Explained procedure to patient.

4. Washed hands 5. Suctioned nose and/or mouth and tracheostomy using separate suction set before deflating cuff.

6. Withdrew air from cuff 7. Assessed respirations 8. Re-inflated cuff with determination of correct amount of air.

9. Monitored correct cuff pressure and assessed respirations and breath sounds. **

10. Documentation

** Areas are critical elements and must be done to pass skill.

Skills Demonstration Plugging a Tracheostomy

Skills Skills not Demonstrated Demonstrated 1. Gathered equipment a. Trach plug b. Suction c. Sterile suction kit d. 10-12 ml. syringe 2. Checked physicians orders re: time to remain plugged 3. Explained procedure to patient and identified correct patient 4. Washed hands and applied gloves, personal protection equipment 5. Suctioned nasopharynx 6. Suctioned tracheostomy using new suction kit 7. Deflated cuff** 8. Removed and set aside inner cannula

9. Placed tracheal plug 10. Observed patient for respiratory distress

11. Provided safety measures to protect patient 12. Removed plug and replaced inner cannula when time elapsed.

13. Documentation

** Areas are critical elements and must be done correctly to pass skill.

Suctioning Endotracheal/Tracheostomy Tube using In-Sleeve Catheter

Skills Demonstrated Not Demonstrated 1. Gathered Equipment a. In-Sleeve Catheter attached to endotracheal or tracheostomy tube. Catheter size appropriate Adult: 12-18 Child: 8-10 Infant: 5-8 b. Suction source and container. Adult: 80-120 mmHg. Maximum Infant/Children: 60-80 mmHg. Maximum c. Oxygen source: 15 mmHg or as needed d. Normal saline for irrigation 5 cc 2. Washed hands and standard preparation and identification steps 3. Turn on suction 4. Turn on oxygen or increase liter flow rate on ventilator if indicated 5. Advance catheter without suction applied until resistance is met 6. Begin suctioning by using a rotating (pill rolling) motion as catheter is removed 7. Limit suction to no more than 5-10 seconds at one time ** 8. Allow patient to take a few breaths between suctioning 9. Report procedures as necessary. When procedure is completed, turn off suction and return oxygen to pre-suction and return oxygen to pre-suction level, if changed. Position 3-way stop cock in off position 11. Assess lung sounds for changes 12. Wash hands * Highlighted areas are critical elements and must be done correctly to pass skill.

Skills Demonstration

Tracheostomy Suctioning Skills Skills not demonstrated demonstrated 1. Gathered equipment a. Sterile disposable saline ampule b. Sterile suction kit with appropriate size of catheter c. Sterile saline d. Suction machine or wall suction is 80-120 mmHg/adults (maximum safe suction is 80- 120 mmHg for adults; 60-100 mmHg for infants and children; 40-60 mmHg for premature infants) e. Goggles, gown, mask as appropriate for patient's condition f. Manual resuscitation bag with touch adaptor g. Oxygen source 2. Explained procedure to patient 3. Washed hands 4. If planning to deflate trac cuff, oro/nasal/pharyngeal suctioning should be done first, using a separate suction kit. Discard suction kit.

5. Preparation of resuscitator bag, oxygen supply (O2 flow meter @ 15L/min), and suction. 6. Sterile preparation of trach suction kit.

7. Remove oxygen source from trach tube. 8. Sterile techniques maintained in suctioning. Hyperinflation of lungs done using resuscitator bag and oxygen before, during, and after suctioning. Suction no more than 10 seconds infants and children 9. Auscultate lungs and assess patient response 10. Wash hands 11. Documentation

Skills Demonstration Cleaning Tracheostomy Inner Cannula and Tracheostomy Care

Skills Demonstrated Skills Not Demonstrated 1. Gathered equipment a. Tracheostomy cleaning set b. Sterile gloves c. Disposible inner cannula

2. Explained procedure to patient

3. Washed hands 4. Don sterile gloves and personal protection equipment as appropriate.

5. Remove oxygen humidification source to trach tube. 6. Removed, inner cannula, and replaced with disposable inner cannula using sterile technique

7. Cleaned incision site with N.S. Applied medication if ordered.

8. Changed tracheal ties or velcro fastener.

9. Placement of sterile trach dressing using sterile technique.

10. Replaced oxygen-humidification source to trach. tube and assess response.

11. Documentation

Skills Demonstration Teaching Testicular Self-Examination

Not Skill Demonstrated Demonstrated 1. Verbalize purpose 2. Gather teaching material i.e. pamphlets, model etc. 3. Explain risk factors a. Male age 15 to 35 years b. Undescended testicles c. Early puberty d. Family history e. Race 4. Teach warning signs of cancer of the testicle a. Check testicles monthly for: 1. Lumps 2. Feeling of heaviness in the testicle 3. Enlargement of the testicle 4. Change in texture 5. Sudden accumulation of fluid or blood in scrotum 6. Dull ache in groin 7. Swelling/tenderness in other parts of body 5. Assess client understanding 6. Documentation

Skills Demonstration

Post-Mastectomy Arm Exercises

Skills Demonstrated Not Demonstrated

1. Verbalized purpose

2. Verbalize time post-op exercises instituted

3. Demonstrated exercises, a. Ball squeezing b. Wall climbing c. Pendulum swing d. Deep breathing e. Lifting, clasped hands f. Rope full 4. Verbalized home instruction a. Related ADL

Skills Demonstration Teaching Patient to Perform Breast Self Exam

Skill Demonstrated Not Demonstrated

Demonstrate Breast Assessment

Inspect Breast Note: size, symmetry, & contour of breast. Compare one side of breast with the other

Teach client the four positions for inspecting the breast while in front of mirror. (1) hands at sides (2) hands raised over head (3) hands pressed on hips or pressed together (4) leaning forward at the waist

Teach client to inspect areolae, nipples and axillae

Teach client to palpate breast utilizing the three methods of palpation; (1) circular (2) vertical strip (3) wedge

Demonstrate charting of abnormal findings using clock method or quadrants. Discuss Risk Factors: Client age, history of breast cancer in self or close family relatives, late age of menopause, onset of menstruation before age 12, older than 30 years at birth of first child, never giving birth Discuss normal and abnormal finding with client Instruct client on monthly BSE schedule and mammogram recommendations.

Imperial Valley College Division of Nursing Education and Health Technologies Respiratory Assessment Skills Demonstration Outline

Inspection

1. Characteristics of Respirations

2. General appearance

3. Thoracic configuration

4. Cough, sputum

Palpation

1. Status of skin and chest wall

2. Demonstrate and give rationale for; `

a. Tactile fremitus

b. Chest excursion

Percussion

1. Demonstrate Technique

2. Lung fields

a. Quality of sounds/tissue density

1) normal

2) abnormal

Auscultation

1. Demonstrate Technique

2. Verbalize/Describe:

a. Normal breath sounds/locations

1. Vesicular

2. Bronchovesicular

3. Bronchial

b. Adventitious breath sounds/locations

1. Crackles (rales)

2. Wheezing

3. Rhonchi

4. Pleural friction rub Imperial Valley College Division of Nursing Education and Health Technologies Skills Demonstration

Skin Assessment

1. Obtains history of problem, including symptoms, time frame, prior treatments. 2. Inspects the skin for, general color, localized areas of color, lesions. 3. If lesions present, inspects and palpates area. 4. Palpates skin for temperature, turgor, moisture, texture. 5. Documents findings, including measurements of suspicious lesions. 6. Verbalizes signs of cancerous lesions.

Imperial Valley College Division of Nursing Education and Health Technologies Skills Demonstration - Physical Assessment-adult and child Skill Demonstrated Not Demonstrated Obtains patient history, biographical data, present health status, chief complaint and hx of present illness Obtains family history, social history Completes review of systems Obtains vital signs, ht/wt. General inspection of appearance, LOC, mood, body movement, stature, and nutrition. Inspects head including skin, scalp, hair, eyes, ears, nasal cavities, mouth. Inspects neck, including carotid pulses (one at a time), ROM, lymph nodes, thyroid gland Inspects upper extremities for symmetry, skin, nails. Palpates for temperature, moisture, capillary refill, pulses. Tests ROM, muscle strength, DTRs, sensory function, fine motor function. If IV in place, assesses site. Inspect chest shape and skin, respiratory movement. Palpates skin and chest wall. Auscultates anterior and posterior lung fields and identifies adventitious breath sounds. Auscultates heart sounds for rate, rhythm, pitch, splitting, murmurs.

Inspects abdomen for contour, movement, scars, lesions. Auscultates for bowel sounds in 4 quadrants. Percusses and palpates abdomen. Observes gait. Inspects lower extremities for symmetry, skin, nails. Palpates for temperature, capillary refill, moisture, distal pulses. Tests ROM and strength of feet and legs. Tests DTRs. Tests for sensory function. Inspects and assesses any tubes or drains from patient for patency, cleanliness, physician order being appropriately carried out.