Nursing Skills · Nursing Skills Nursing School Made Simple Guaranteed © 2014 SimpleNursing.com...

Nursing Skills

Nursing School Made Simple Guaranteed © 2014 SimpleNursing.com All Rights Reserved.

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Table of Contents

1 Universal Competencies ....................................................................................................................................... 3

1.1 Universal Elements ...................................................................................................................................... 3

2 Critical Thinking Question ..................................................................................................................................... 4

3 Documentation ...................................................................................................................................................... 4

4 Handwashing ........................................................................................................................................................ 4

5 Moving a patient up in bed .................................................................................................................................... 4

6 Applying restraints ................................................................................................................................................ 4

7 Applying and removing personal protective equipment ........................................................................................ 5

8 Administering an Enema ....................................................................................................................................... 5

9 Performing Physical Assessment ......................................................................................................................... 5

10 Positioning a Patient ............................................................................................................................................. 5

11 Ambulating a patient ............................................................................................................................................. 5

12 Applying bandages/binders ................................................................................................................................... 5

13 Applying antiembolism stockings .......................................................................................................................... 6

14 Intermittent and continuous tube feeding administration ....................................................................................... 6

15 Nasogastric tube Insertion +/- suction ................................................................................................................... 6

16 Sterile Wet to Moist Dressing Change .................................................................................................................. 7

17 Foley Catheter Insertion ........................................................................................................................................ 7

18 Medication Administration ..................................................................................................................................... 7

19 Primary IV administration ...................................................................................................................................... 7

20 Secondary IV administration ................................................................................................................................. 8

21 IV flush with Saline ............................................................................................................................................... 8

22 Trach Suctioning ................................................................................................................................................... 8

23 Trach Care ............................................................................................................................................................ 8

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1 Universal Competencies

1.1 Universal Elements

Safety and Security

1. Physical safety and security: Any action or inaction on the part of the student that threatens the patient’s

well being or is in violation of the patient’s security.

2. Emotional Security: Any action or inaction which threatens the emotional well being of the patient or

significant others or is in violation of the patient’s emotional security.

Therefore, the student will AT ALL TIMES:

Identify the patient by reading the ID bracelet before initiating care and identifying allergies as needed

Protect the patient from physical harm at all times, such as raising side rails and returning bed to low

position when indicated, pt’s ability to ambulate is assessed prior to getting up, restraints are secured

safely without injuring the patient, and patient is positioned for therapeuticness and protection from harm

(aspiration, etc)

Protect the patient from psychological harm by referring to the patient by name, communicating verbally

and nonverbally in a therapeutic manner, providing accurate information about their care, preparing

patients appropriately for procedures, maintaining privacy at all times, maintain dignity and empathy

Utilize equipment safely t prevent human error

Demonstrate proper and consistent utilization of safety devices

Comfort

The student needs to assure comfort of the patient at all times and initiate interventions related to the tolerance

of the procedure


Assess the patient’s level of comfort before, during and after any procedure

Provide interventions to increase the patient’s comfort level

Position patients for comfort

Standard Precautions

The prevention of the introduction or transfer of organisms


Wash their hands before initiating direct contact with the patient and whenever hands are contaminated by

body secretions or substances

Wear gloves whenever in contact with body fluids

Protect the patient from contamination in all procedures

Confine any contaminated material to contaminated areas and dispose properly

Implement universal precautions at all times

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*** It is important to realize that all potential failures to protect the patient from harm cannot be described here.

2 Critical Thinking Question

Demonstrates application of knowledge obtained I current and previous courses related to the skill and patient

situation

3 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 changes and responses to care in designated records.

3. Use language, terms, and abbreviation that are consistent with professional standards, agency protocols,

and other specific guidelines

4. Records data so that entries are: clear accurate, precise, pertinent/relevant

4 Handwashing

Critical Elements

1. Regulate water temperature and flow

2. lather with soap covering all aspects of hands and wrists for appropriate length of time

3. Dry hands

4. Maintain medical asepsis and does not contaminate self

5 Moving a patient up in bed

Critical Elements

1. Assess the patient’s ability to assist

2. Position a draw sheet under the patient appropriately

3. Use proper body mechanics

4. Properly instruct the patient how to assist

6 Applying restraints

Critical Elements

1. Assess CSM or any contraindications to use of restraints

2. Explain rationale to patient and/or family

3. Apply restraint properly

4. Secure restraint to proper location on bed or wheelchair as appropriate

5. Assess at frequency dictated by agency policies

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7 Applying and removing personal protective equipment

Critical Elements

1. Identify needed equipment

2. Apply appropriate equipment in proper order

3. After use, remove protective equipment in proper order to prevent contamination

8 Administering an Enema

Critical Elements

1. Use warm water

2. Position patient to facilitate flow

3. Regulate flow of water to appropriate rate

4. Offer and place patient on bedpan after instillation

9 Performing Physical Assessment

Critical Elements

1. Position pt appropriately for system exam

2. Identify proper anatomical landmarks for inspection/auscultation

3. Identify normal /abnormal findings and be able to describe them with proper medical terminology

10 Positioning a Patient

Critical Elements

1. Maintain use of good body mechanics by the nurse

2. Use pillows appropriately for support

3. Support body during position changes as appropriate

11 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

12 Applying bandages/binders

Critical Elements:

1. Asses the CSM

2. Position body part in neutral, elevated position if possible

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3. Apply bandage using equal distance and equal pressure

4. Wrap the extremity distal to proximal

5. Secure appropriately

6. Choose proper sized binder for the patient

7. Position the binder appropriately

8. Asses for potential breathing or skin impairment

13 Applying antiembolism stockings

Critical Elements:

1. Measure patient for proper fit

2. Apply the stocking appropriately

3. Assess CSM and presence of wrinkled in stockings

14 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 > 100 mL

4. Using the correct port, administer (TF or water) correct type and amount at prescribed rate

5. Keep HPB at least 30° for at least 1 hour after feeding for intermittent feedings and maintain HOB always

at least 30° for continuous feedings

15 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 tube to appropriate place

6. Check placement

7. Secure the tube

8. Attach tube suction appropriately

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16 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

17 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

18 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, syringes and site selection

6. Correct administration

19 Primary IV administration

Critical Elements

1. Maintain asepsis

2. Minimal loss of fluid

3. Correct titration of drops rate if gravity or correct mL/hr if using correct infusion pump

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20 Secondary IV administration

Critical Elements

1. Maintain asepsis

2. Correct connection to primary line

3. Backflush method

4. Correct titration of drop rate if gravity or correct mL/hr if using infusion pump

21 IV flush with Saline

Critical Elements

1. Assess for complications

2. Cleanse injection port/maintain asepsis

3. Assess for blood return

4. Infuse saline while assessing for complications

22 Trach Suctioning

Critical Elements

1. Assess need for suctioning

2. Preoxygenate

3. Maintain asepsis

4. Correct methods for insertion and removal of secretions

5. Assess tolerance

23 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 tiles as needed

Nursing Skills · Nursing Skills Nursing School Made Simple Guaranteed © 2014 SimpleNursing.com...

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