Control Lab Sheets Skills Video Demonstrations 22-25 Nursing Skills Peer Check Off Sheet 26-28 Environment/Isolation/medical asepsis Control Lab Sheet (Infection Control, Fall Risk Assessment, )
29-32
Vital Signs Skills Check Off Stations 33-34 Orhtostatic Vital Signs 35 Activity and Rest Skills Check Off Stations 36
Elimination practice check off sheet 37 PA Documentation Guide- general survey 38 PA Documentation Guide-skin,hair, nails 39 PA Documentation Guide-head and neck 40 PA Documentation Guide-chest and lungs 41 PA Documentation Guide-heart and peripheral vascular
42
PA Documentation Guide-abdomen 43 PA Documentation Guide- musculoskeletal 44 PA Documentation Guide-neurological 45-46 Physical Assessment Practicum grading sheet
Catheter Removal 52 Wound care practice check off sheet 53-54
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Student Preparation for Scenario Days in Skills Lab
Review all previously taught skills Bring Taylor’s Fundamentals of Nursing textbook Wear complete uniform and name tag References for documentation (class notes, abbreviation list, pen, etc.)
Scenario Day #1 Bring :
o Shorts and tank top or sports brao Soap o Lotiono Toothbrusho Toothpasteo Stethoscopeo Washcloth
Scenario Day #2
Bring: o Shorts and tank top or sports brao Stethoscopeo Isolation gown and mask
2
Clinical Folder Contents
The clinical folder is a record of your accomplishments throughout N210 and will continue to be used in N212. You are creating a quick reference resource for use at the clinical site. Insert any documents you think may be useful.
It should consist of the following elements:
1. Facility information and handouts2. Skills checklists (optional) or notes to assist in skill performance in clinical3. Clinical Evaluations4. Nursing Process Worksheet (NPW): guidelines, blank copies, examples,
Resident’s bill of rights. 7. N210 Clinical Schedule – Long Term Care
Please place in a 1” 3 ring binder.
3
Clinical Absence Make-Up Guidelines
Make-up for any clinical absence in N210:
1. The student will be assigned by the instructor to write a paper on one of the diagnoses of the patient(s) that the student would have cared for on the missed day.
2. The student is to research the diagnosis using the library or internet to find a recent nursing journal (within last 5 years) about the diagnosis.
3. The article should include the following information related to:
An explanation of the diagnosis Signs and Symptoms Risk factors/causes Diagnostic tests/measures Medical and Nursing treatment Evaluation of Outcomes
4. The student is to summarize the article, including in the summary all of the data stated in #3 (if possible).
5. The paper is to be typed. The paper and a copy of the article are to be turned in to the clinical instructor.
If the absence is due to illness, the paper is to be turned in on the Monday after the illness.
If the absence is due to being sent home for not being prepared, the paper is to be turned in the next day (ie: for a Tuesday absence, the paper is due on Wednesday)
6. The student may be asked to present the paper in post conference.
4
Weekly Journal Assignment
Definition: A reflective paper used to assist the student in identifying strengths and weaknesses.
Purpose: 1. Assist the student to identify and analyze his/her behaviors that may advance
or interfere with student learning. 2. Assist the student with evaluating problem solving skills. 3. Provide a one to one communication between student and instructor. 4. Allow the student the opportunity to have questions answered or concerns
addressed. 5. Find meaning in the activities experienced in lab and clinical.
Procedure: 1. Structure
Each entry must be dated. You may handwrite or use computer. If handwritten, it must be legible
and you must use a pen and a full sheet of lined paper. Minimum length is one page. Staple all pages together
2. Content Journal questions are provided on the next page. Your journal entry should address only the question asked. Your response
should show reflection and insight into the clinical experience.
3. Grading Turn in your journal on Tuesday. Your instructor will return it to you
during the week. Journals will not be graded based on content, but are an indicator of
your growth. Journals are a requirement of this course and a component of your grade. All
five journals must be turned in and must follow guidelines and is a part of the clinical component of this course. Failure to submit a journal will result in a verbal counseling from your clinical instructor. A repeat of this behavior will result in an advisement note (See professional behaviors in N210 Clinical Course Evaluation Tool).
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Journal Questions
The student should respond to all aspects of the question and turn in his/her journal entry on the following Tuesday to his/her clinical instructor.
Question
Journal 1 You have learned several nursing skills (vital signs, PHM, activity and rest) and were able to practice these skills. Discuss how it felt to practice these skills with your peers as well as your challenges in applying critical thinking skills with learned nursing skills. Discuss how you overcame these challenges?
Journal 2 Communication is a crucial aspect of the nurse-client relationship. Discuss your communication style. What are your strengths and what could you improve regarding communication. Describe what challenges you may face when communicating with a person who is ill, angry due to a terminal illness, or depressed due to a chronic disease.
Journal 3 You have now completed several weeks of nursing school. Based on your experience thus far, what do you think is the most challenging part of being a nurse and/or nursing as a profession?
Journal 4 Part of the role of a nurse is to provide end of life care. Discuss how you feel about this aspect of nursing, the challenges you might encounter and how you will overcome those challenges
Journal 5 What was your first impression of long term care? Discuss both the positive and negative impressions of the facility, environment, staff and patients. Now that you have spent some more time in LTC, how has your first impressions changed? Discuss how your impression of nursing may have changed.
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Time Management Schedule
Time management will be a key issue for you if you are to successfully transition to nursing school. Complete the two assignments listed below as tools to assist you in planning for this new adventure. Think about the connection between time management and prioritizing tasks.
1. Time Management Schedule Fill in the prototype weekly calendar. This is what you “plan” to do every week. (Not what you did last week). Hints:
Begin by filling in all inflexible times (classes, work) Guide for study time: 2 hours of study per 1 hour of lecture and 1 hour of study
per 1 hour of laboratory/clinic) Write in your place of study (home, library, skills lab) Use color or design if this helps you organize Remember to add:
Sleep (particularly the night before clinical)Travel time (to and from school, work, childcare) Personal hygiene timeGrocery shopping, cooking, eatingFamily responsibilitiesFamily togetherness timeExercise “Don’t forget your spouse/significant other” timeRelaxing timeTelephone/internet
2. Mantra
Mantra have been used throughout time, beginning in India many centuries ago, as a method of focusing the mind. Mantras are considered to have powerful effects on those who use them. Literally the word mantra means “the thought that liberates or protects”. Repeating a mantra can help you overcome fear, increase your creativity, give you energy when you are tired, and inspire you to keep going when you want to quit.
Many of us are familiar with mantras but may not realize it. Our lives are filled with such mantras as “No pain, no gain”, or “The teacher is out to get me”, or “This is too hard, I might as well quit now” or “Practice, makes perfect”.
In some spiritual traditions, mantras are given to students by their teachers. However, it is possible to make up your own mantra and use it as an antidote to other negative mantras you may already be using.
Design a mantra for your personal use in nursing school. This mantra will be a simple phrase that you will recite over and over. Be creative and have some fun. Be inspired.
Laboratory Learning Outcomes: Environment/Safety/ Asepsis/Infection Control
After studying this content, you should be able to:
1. Outline strategies to provide a safe patient environment
2. Identify clients who are at high risk of falls
3. Identify nursing actions in the event of a fire
4. Describe and draw the six steps in the chain of infection
5. List and describe conditions that predispose clients to infection
6. Describe what is meant by the term nosocomial infection (now known as hospital acquired infection) and discuss one intervention that will help prevent it
7. List the major organisms responsible for nosocomial infections
8. Define the term surgical asepsis and medical asepsis
9. Describe how and when personal protective equipment should be used.
10. Demonstrate and outline the steps in donning and removing personal protective equipment according to the Centers for Disease Control
11. Describe the practice of standard precautions and transmission based precautions.
12. Discuss the purpose of neutropenic precautions/ isolation and the measures that should be followed with this type of isolation.
13. Discuss multidrug resistant organisms and nursing implications
14. List interventions that might be used to meet psychological needs of a patient in isolation.
15. Describe the contents and care of an isolation room.
Skill: Application and Removal of personal protective equipment
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Laboratory Learning Outcomes: Vital Signs
After studying this content, you should be able to:
1. Define the terminology relating to vital signs
2. Explain physiologic processes involved in homeostatic regulation of temperature, pulse, respirations, and blood pressure.
3. Compare and contrast factors that increase or decrease body temperature, pulse, respirations, and blood pressure.
4. Identify sites for assessing temperature, pulse, and blood pressure.
5. Discuss the steps to accurately obtaining temperature, pulse, respirations, and blood pressure.
6. Discuss the normal ranges for body temperature, pulse, respirations, and blood pressure.
7. Demonstrate documentation of vital signs.
8. Discuss the steps to obtaining an orthostatic blood pressure and pulse as well as their indications.
After studying this content, you should be able to: 1. State nursing guidelines and rationale for use of proper body mechanics.
2. Identify variables that influence body alignment.
3. Describe common patient positions.
4. Demonstrate supine, lateral and Fowler’s positions.
5. Discuss positioning and protective devices and indications for use.
6. List nursing guidelines and rationales for patient transfer and ambulation.
7. Demonstrate patient transfer using a gait belt: bed to wheelchair and wheelchair to bed.
8. Describe the effects of exercise and immobility on major body systems
9. Assess body alignment, mobility, and activity tolerance, using appropriate interview questions and physical assessment skills.
10. Relate nursing guidelines and rationales for performing range of motion exercises.
11. Demonstrate appropriate range of motion exercises to all body joints.
12. Document range of motion procedure.
13. Compare comfort, rest and sleep.
14. Relate spiritual needs to comfort.
15. Differentiate between NREM and REM sleep.
16. State the relationship of age to sleep requirements.
17. Examine sleep promoting and sleep suppressing factors.
18. Review drugs that affect sleep.
Skills: transfer patient from bed to wheelchair and from wheelchair to bed with and without a gait belt, perform passive range of motion on all joints, positioning of a patient in bed, moving a patient up in bed, ambulating a patient with and without a gait belt
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Laboratory Learning Outcomes: Personal Hygiene Measures
After studying this content, you should be able to:
1. Describe and demonstrate correct hand washing techniques.
2. List all possible situations when hand washing should be performed.
3. Discuss the use of alcohol based antibacterial hand gels.
4. State the personal hygiene guidelines related to hair, fingernails and jewelry.
5. Discuss the characteristics of healthy skin, mucous membranes, nails, hair and teeth.
6. List nursing guidelines for bathing patients.
7. State the types of therapeutic baths and the purpose for each.
8. Describe interventions for care of patient’s teeth and mouth (including dentures and bridges), eyes, ears, nose, fingernails, feet, toenails and hair.
9. Describe how to shave male patients and list any nursing precautions.
10. Describe and give the rationale for making open and closed beds, beds with skeletal traction device and surgical beds.
11.List medical asepsis guidelines related to handling of linen and the disposition of contaminated articles.
Skills: hand hygiene, non-sterile gloving, bed bath, making occupied bed
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Laboratory Learning Outcomes: Documentation and Reporting
After studying this content, you should be able to:
1. State at least 4 uses of documentation in a medical record and recognize when documentation is used inappropriately.
2. Define and apply the following types of nurse’s notes documentation (narrative, SOAPIE, Focus [DAR], PIE, and charting by exception)
3. Discuss the pros and cons of using flowsheets for documentation.
4. Name the components and use of a nursing care plan.
5. Discuss the pros/cons of computerized charting
6. Apply the “Golden Rules” of documentation
7. Recognize and utilize medical abbreviations, both approved and from the “Do Not Use” list.
After studying this content, you should be able to:
Bandages and Binders
1. State the purposes of bandages and binders.2. Discuss the general guidelines for application and removal of bandages and
binders. 3. Demonstrate application of the following:
A. An abdominal binderB. An ace bandage using the spiral turn, recurrent, and figure of eight turn
Restraints
1. Discuss the benefits and risks of using physical restraints2. Explain the basis for enacting restraint legislation and JCAHO accreditation
standards. 3. Demonstrate proper application of restraints4. Discuss nursing responsibilities related to use of restraints5. Differentiate between a restraint and a restraint alternative6. List 5 restraint alternatives
Thermal Therapy
1. Discuss concept of heat transfer and biophysical response to thermal therapy. 2. List the common uses for both heat and cold as therapeutic modalities. 3. Describe techniques and related nursing responsibilities for heat and cold
applications. 4. Discuss the risks of applying cold therapy for fever management
TED (Antiembolism stockings)
1. Describe the purpose of TED hose (antiembolism stockings) and the patient populations for which they are prescribed.
2. Describe the proper measurement and application of TED (antiembolism stockings).
3. Describe the neurovascular assessment performed on patients with TED hose (antiembolism stockings).
4. Discuss the purpose of sequential compression devices (venodyne, foot pumps, sequentials, SCDs).
Skills: Apply abdominal binder, vest and wrist restraint to patient in bed, antiembolism stockings; ace bandage using 2 techniques and application of vest to patient in wheelchair.
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Laboratory Learning Outcomes: Urinary and Bowel Elimination
After studying this content, you should be able to:
Urinary Elimination
1. Describe the physiology of the urinary system.2. Identify variables that influence urination.3. Describe how the nurse would assist the patient with toileting, use of a
bedpan, a urinal, bedside commode and a condom catheter. 4. Describe the care and management of an indwelling catheter and external
urinary catheter. 5. State the rationale for measuring and recording the patient’s urinary
output.6. Discuss the use of a “hat” in a commode and graduated cylinder to
measure urine output. 7. Describe the process of emptying a foley catheter drainage bag.8. Describe how the collection of the following urine specimens are obtained
and give the reasons for why they are collected: A. MidstreamB. 24 hour D. Indwelling catheter.
Bowel Elimination
1. Review normal anatomy and physiology related to elimination.2. Describe the characteristics of normal bowel elimination and stool. 3. Identify nursing interventions for patients with diarrhea or constipation.4. Discuss the steps for the following procedures: removing fecal impaction;
rectal suppository, administering a large volume enema; administering a small volume enema.
5. Identify nursing interventions if signs and symptoms of vagal response occurs
6. Describe how stool specimens are collected and give the various reasons why they are collected.
Skills: Enema Administration, applying a condom catheter, emptying a Foley drainage bag, placing a patient on a bedpan/fracture pan, assisting a patient with use of a urinal, emptying a BSC, providing pericare and foley catheter care, obtaining a specimen from an indwelling foley catheter, changing a incontinence brief
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Laboratory Learning Outcomes: Critical Thinking
After studying this content, you should be able to:
1. Define critical thinking.
2. Discuss the importance of critical thinking in nursing.
3. Describe the characteristics and attitudes of critical thinkers
4. Contrast 3 approaches to problem –solving.
5. Describe the 5 components of the nursing process.
6. Discuss the relationship of critical thinking to the nursing process.
7. Identify examples of critical thinking.
8. Apply critical thinking to a clinical situation.
Definition of Critical Thinking adopted by Cerritos College Department of Nursing
• Entails purposeful, outcome directed (results-oriented) thinking• Is driven by patient, family and community needs• Is based on principles of the nursing process and scientific method• Requires specific knowledge, skills and experience• Is required by professional standards and ethics codes • Requires strategies that maximize human potential (e.g. using individual
strengths) and compensate for problems caused by human nature (e.g. the powerful influence of personal perspectives, values and beliefs)
• Is constantly reevaluating, self-correcting and striving to improve
Alfaro-LeFevre, R. (1999) Critical Thinking in Nursing, 2nd Ed. Philadelphia: Saunders
5. Review the structure and function of the neurological system6. Describe specific assessments performed during examination of the
neurological system7. Describe the specific assessments included in the Glasgow Coma Scale8. Identify the specific subjective data necessary to obtain a health history of
the Neurological System9. Identify and describe sensory function tests and motor examination
After studying this content, you should be able to:
1. Discuss reasons for nasogastric intubation
2. Describe the process of nasogastric tube insertion and removal including equipment needed.
3. Describe various methods to check placement of a nasogastric tube.
4. Discuss nursing interventions related to promoting patient comfort and maintaining a nasogastric tube.
5. Compare and contrast the Salem sump and Levin gastric tubes
6. Discuss nursing management of the NGT attached to suction
7. Identify the purpose of NGT to suction.
8. Discuss the steps to discontinuing an nasogastric tube
Skills: Insertion and removal of a nasogastric tube; attaching NGT to suction; discontinuing an NGT
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Laboratory Learning Objectives : Nutrition Lab
After studying this content, you should be able to:
1. Discuss the assessment of a patient’s normal nutritional status.
2. Discuss cultural influences related to meeting nutritional needs.
3. Describe how to feed a patient with special needs.
4. Describe commonly ordered therapeutic diets.
5. Demonstrate meal percentage and oral fluid intake measurement and record.
6. List interventions to assist the patient who is on restricted fluids.
7. Discuss reasons for nasogastric and gastric intubation
8. Describe the process of administering a continuous and intermittent nasogastric and gastrostomy tube feeding.
9. Demonstrate the process of administering a water bolus via an NGT or gastrostomy feeding tube.
10.Discuss how nasogastric and gastrostomy feedings are measured and recorded.
11. Compare the risks and benefits of gastric feeding versus total parenteral nutrition.
Skill: Administering intermittent and continuous tube feeding; Administering a water flush of an NGT/G tube.; How to measure and document percentages of food tray consumed, and measuring fluid intake.
After studying this content, you should be able to:
1. Demonstrate the insertion of a Foley catheter using sterile technique
2. Explain the procedure for removal of an indwelling catheter
3. Discuss patient teaching related to maintaining a foley catheter.
4. Discuss the patient teaching related to post foley catheter removal.
5. Identify unexpected outcomes that may occur during foley catheter insertion and recommended nursing interventions.
Skill: Insertion and removal of an indwelling urinary catheter
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Laboratory Learning Outcomes: Wound Management
After studying this content, you should be able to:
1. Describe the three stages of wound healing
2. Discuss the difference between primary, secondary and tertiary intention wound healing.
3. List the factors that can affect wound healing to include nutrition, medications, and health status.
4. Identify the signs and symptoms of a wound infection.
5. Identify the solutions used for wound irrigation and rationale for use.
6. Describe various types of wound drainage.
7. Describe the different types of wound treatments: e.g. transparent, hydrocolloid, wound vac, hydrogel, calcium alginate and foams.
8. Discuss the indication for use of transparent and hydrocolloid wound dressings.
9. Discuss the wound closure devices: staples, sutures, retention sutures steristrips, dermabond and Montgomery straps, wound-vac.
10. Identify and discuss the mechanism of action of the following wound drainage devices: penrose, Jackson-Pratt and hemovac .
11.State the guidelines for maintaining a sterile field
12.Describe the steps (and rationale for each step) for performing a sterile wet to moist dressing.
13.Demonstrate a wet to moist sterile dressing change.
Skills: wet to moist sterile dressing change
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SKILLS VIDEO DEMONSTRATIONS
You are required to view the following skills demonstrations online (from any internet access computer or the skills lab computers in SL 121, 122, 123, 110) prior to assigned control lab days at http://talonnet.cerritos.edu/osp-portal (TalonNet)
These videos were developed as an instructional aide by your instructors for beginning nursing students.
Enter username (7 digit student ID number) and password (6 digit birthdate)
Click on My Video Links
Click on Nursing Skills Videos; click “I Agree” on the copyright;
Choose your video links according to assigned labs and view the videos (click on broadband if you have high speed internet; click on 56K if you have dial-up internet)
Physical Assessment No videos required prior to lab
2 Wed
B/B/Teds/Restraints/Thermal Therm
Elimination
Bandages and Binders/Teds/Restraints/Thermal Therapy
Enema
Collecting a Urine Specimen
Bandages
Enema
UrineSpecimen
3 Tues
Physical Assessment No videos required prior to lab
3 Wed
Scenarios Review previously learned skills videos
4 Tues
Physical Assessment No videos required prior to lab
4 Wed
NGT Insertion
VS Competency Testing
Nasogastric tube Insertion
Review Vital Signs videos
NGTube
5 Tues
Scenarios
Nutrition Lab
Review previously learned skills videos
5 Wed
Foley Catheterization
Wound Care
Foley Catheter
Wound Care
Catheter
WoundCare
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SKILLS VIDEO DEMONSTRATIONS- Continued
The Taylor’s Video Guide to Clinical Nursing Skills CD ROM is used as a supplement to the instructional videos provided on TalonNet. If there are no skills video on a particular skill on TalonNet, view the skills video from the Taylors CD
ROM prior to assigned control lab days. Insert CD ROM Click Chapter Select Watch the videos stated below r/t control lab activity
Week Title of CD ROM Skills Video1
TuesModule 2 Asepsis
Module 1Vital Signs
Performing Hand Hygiene Putting on Sterile Gloves Removing soiled gloves
Measuring oral temperature, radial pulse, resp rate, and blood pressure
Measuring blood pressure with an automatic electronic device
Measuring tympanic temperature Measuring rectal temperature Measuring axillary temperature Measuring an apical pulse Unexpected situations
1Wed
Module 9 Activity
Module 7 Hygiene
Turning a patient ROM exercises Assisting a patient up in bed one nurse working alone Assisting a patient up in bed two nurses working together Assisting a patient into a wheelchair Unexpected situations
Making an unoccupied bed Giving a bedbath and changing an occupied
bed Assisting a patient with oral care Unexpected situations
2Tues
CT ATI
PA 1
No videos to preview
2Wed
B/B/Restraints/Therm See Video from TalonNet
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Module 11Urinary Elimination
Module 13Bowel Elimination
Assisting with a urinal Assisting with a bedpan Applying a condom catheter
Administering a large volume cleansing enema
Administering a small volume cleansing enema
Unexpected situations3
TuesDoc and Reporting
PA 2
No videos to preview
3Wed
Scenarios Review previously learned skills
4Tues
PA 3 No videos to preview
4Wed
NGT insertion Administering a nasogastric tube Irrigating a nasogastric tube Removing a nasogastric tube Unexpected situations
5Tues
Scenarios
Nutrition Lab
Review previously learned skills
Administering a continuous tube feeding: Using a feeding pump and a prefilled closed tube feeding set-up
Administering an intermittent tube feeding: Using a gravity set-up and an open feeding bag system
Unexpected situations5
WedUrinary
Catheterization
Wound Care
Catheterizing the female urinary bladder: intermittent catheter
Catheterizing the female urinary bladder: indwelling catheter
Catheterizing the male urinary bladder: indwelling catheter
Catheterizing the male urinary bladder: intermittent catheter
Irrigating the urinary catheter using a closed system
Unexpected situations
See TalonNet video of wound care (wet-to moist dressing)
Obtaining a wound culture Irrigating a wound using sterile technique Unexpected situations
25
N210 Fundamentals of Nursing
Nursing Skills Peer Check Off
Following independent practice, demonstrate proper technique of the following nursing skills to your classmates three (3) separate times. Obtain peer signatures/dates indicating that you have demonstrated proper technique in performing the skills. If you need help, please refer to the videos online, your skills book, and/or see a skills lab instructor during open lab.
This sheet is to be completed prior to Skills CPE and submitted to clinical instructor on Skills CPE testing day (week 8). Any student who fails to turn in a completed sheet to the instructor will receive an advisement note and will not be allowed to test for CPE. Arrangements will be made with the instructor to test for CPE on a different day. If a student fails the CPE, a skills lab referral will be given for the failed skill and the student is to complete the Skills Lab referral within 1 week of the referral date.
Chain of Infection1. Discuss the chains of infection (reservoir, portal of entry, mode of
transmission, etc.) then give examples that apply to each chain (e.g. mode of transmission = direct contact, droplet). See Chain of Infection Illustration.
2. Scenarios
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A. Scenario 1: The spread of InfectionAn elderly patient, hospitalized with a gastrointestinal disorder, was on bedrest and required assistance for activities of daily living. The patient had frequent uncontrolled diarrhea stools and the nurse provided excellent care to maintain cleanliness and comfort. While cleaning the patient, the soiled linens touched the nurse’s uniform. The nurse placed the soiled linens on a chair and left the room. Following 1 episode of cleaning the patient and changing the bed linen, the nurse immediately went to a second patient to provide am care and assist with the morning meal. The nurse’s hands were not washed prior to assisting the second patient. 2 days later, the second patient developed diarrhea. His stool cultures showed positive for Vancomycin Resistant Enteroccocus (VRE).
Let’s examine the chain of infection as it applies to this situation
Question#1What is the:
Answer
Susceptible hostInfectious agentPortal of entryMode of transmissionReservoirPortal of exit
Question #2 AnswerBreak the Chain of Infection…What should the nurse do to prevent the spread of infection? Which PPE should be worn?
B. Scenario 2: The Nurse Breaks the Chain
A patient assigned for morning care has an open wound on her left lower leg. The wound is draining and when last cultured, the microorganism MRSA was identified.
In preparation for bed making, the hands of the nurses were washed. Clean linen and a bag for soiled linen were gathered from the linen room and placed on the patient’s clean bedside stand.
29
To remove the soiled linen from the bed, the following procedure was followed:
Hands washedGloves wornEach side of the soiled linen ends folded towards the middle of bedSoiled linen held away from the nurses’ uniformSoiled linen placed in the linen bag for later discardProtective gloves removedHands washed
Let’s examine the chain of infection as it applies to this situation
Directions: Place an “x” in front of elements that apply to your patient. Based on the assessment, check whatever applies to the patient. A patient for whom you place four or more “x” marks is at risk for falling.
GENERAL DATA
_____ Age over 60_____ History of falls before admission_____ Postoperative/admitted for operation_____ Smoker
_____ Diuretics or diuretic effects_____ Hypotensive or CNS suppressants drugs_____ Postoperative/admitted for operation (e.g., narcotic, sedative, psychotropic, hypnotic, tranquilizer, antihypertensive, antidepressant)_____ Medication that increases GI motility
PHYSICAL CONDITION
_____ Dizziness/imbalance_____ Unsteady gait_____ Diseases/other problems affecting weight bearing joints_____ Weakness_____ Paresis_____ Seizure disorder_____ Impairment of vision_____ Impairment of hearing_____ Diarrhea_____ Urinary frequency
Fall Risk Assessment Mr. Jackson is a 73-year-old stroke patient with recent
mental status changes, admitted for prostate surgery. He has right-sided weakness and has fallen once at home while trying to go to the bathroom. He has difficulty initiating a urinary stream, dribbling of urine, and nocturia. He has a history of hypertension, for which he takes hydrochlorothiazide (diuretic).
List specific interventions to ensure Mr. Jackson’s safety in the hospital.
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N210 Fundamentals of Nursing
Vital SignsSkills Check Off Stations
Lab Groups Lab A & B Lab C & D Lab E & F
Room Assignment SL 105 SL 122 SL 123
ACTIVITY Faculty Initials
TemperaturePractice taking temperature on another student:
Oral axillary tympanic
Practice taking temperature on a manikin: rectal (using manikin)
Set of Vital SignsTake a full set of vital signs (temp., pulse & respirations, apical pulse, blood pressure) on 3 clients & document on the graphic sheet
Vital Signs ManikinApical PulseListen to apical pulse on manikin. Identify the rhythm and write on the back of this sheet.
Orthostatic Vital SignsPractice taking orthostatic vital signs on another student
Answer orthostatic vital signs questions on the poster. Use the back of this sheet.
VS Special Considerations (SL 121)Assess the client and answer Measuring Blood Pressure questions on the poster. Use the back of this sheet.
Complete this sheet by the end of week 2.
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Vital Signs Questions
Apical PulseIdentify the rhythm on the VS manikin. ______________
Orthostatic Vital Signs1. How would you take orthostatic VS on a patient?
2. How would you take orthostatic VS on a patient who is dehydrated and is experiencing some dizziness upon rising from a lying position?
Measuring Blood Pressure (VS Special Considerations)1. You are caring for a post left-mastectomy patient. Where would you take
the patient’s blood pressure?
2. You received report from the previous shift’s nurse that your patient has an atriovenous graft (AV dialysis graft) on her right arm. Where would you take the patient’s blood pressure?
34
N210 Fundamentals of Nursing
Measuring Orthostatic Vital Signs
Definition: Orthostatic vital signs (VS) are serial measurements of blood pressure (B/P) and pulse that are taken with the patient in the supine, sitting, and standing positions. Results are used to assess possible volume depletion. The results can help the practitioner decide if the patient needs fluid replacement, more extensive testing or treatment.
STEPS1. Wait 1 minute between position changes before measuring the pulse and blood
pressure. For consistency, do not remove the BP cuff in between position changes and measurements.
2. Have the patient lie supine, without pillows, for 3-5 minutes then measure pulse and blood pressure. For accuracy, take 2 sets of pulse and blood pressures in this position and use the 2nd reading as the baseline measurement.
3. Assist the patient to a standing position. Once the patient is standing, ask the patient how he/she is feeling. Do not ask leading questions as “Are you dizzy?” Positive symptoms include dizziness, lightheadedness, fainting, pallor, or nausea.
4. Wait 1 minute after the patient stands then take the pulse and blood pressure and note any orthostatic changes.
**Note: Taking the pulse and blood pressure in the sitting position is recommended only if the patient is unable to stand (i.e. patient gets dizzy with standing or is showing signs of syncope. When measuring in this position, the patient should be sitting upright, with their legs dangling at the side of the bed.
INTERPRETATIONPositive Orthostatic Change: The “30-10” rule may be used as a guide. The rule refers to a decrease in systolic BP (up to 30 mm Hg); a decrease in diastolic BP of 10 mm Hg;
as well as a subsequent rise in pulse of up to 40 BPM (Taylor).
35
N210 Fundamentals of Nursing
Activity and RestSkills Check Off Stations
8:30-11 (Groups switch at 9:45)12:00-2:30 (Groups switch at 1:15)
Station Activity FacultyInitials
SL 105 Ambulation Students to:
1. Practice ambulating a client with and without a gait belt
2. Practice assisting a client who is falling to minimize injuries to the client/nurse
ROMPractice the correct sequence of ROM exercises
Hoyer LiftSee poster for instructions
_________
_________
_________
SL 121 PositioningPractice positioning of a patient (student) in bed: Supine, Left Lateral, Low Fowlers, Semi-Fowlers; High-Fowlers
Transfer from Bed to ChairPractice transferring a patient (student) from bed to chair with and without gait belt
_________
_________
N210: Fundamentals of Nursing
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Elimination Practice Station Check-off
Station 1
Emptying Foley catheter bag______________________________Specimen from foley catheter______________________________
Station 2
Assisting with urinal _____________________________________Place a fellow student on a bedpan_________________________Changing a brief________________________________________
Pericare on female manikin_________________________________Emptying a BSC__________________________________________Foley catheter care________________________________________
Subjective Data: (Obtain all info under “General State of Health” from Review of Systems page 5 of Jarvis)
Objective Data:Appearance
Posture (relaxed, erect, tripod position, slumped, leaning to one side)Overall hygiene and grooming (clean, well groomed, unkempt)Any apparent signs of distress Dress (appropriately for situation)
BehaviorLevel of consciousness (awake, asleep, lethargic, comatose)Mood and affect/ Facial expressions (appropriate for situation)
CognitionOrientation (person, place, time, and purpose-X4)Speech (clear, garbled, slurred, incomprehensible)Responsiveness (follows directions and responds appropriately)
Documentations: (Include both Subjective and Objective Data in Narrative Form)
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Physical Assessment Documentation Guide
Student____________________________ Date ________________
Subjective Data: (Obtain info from Review of Systems under Neurological in Jarvis)
Objective DataMental Status ExaminationAppearance (posture, body movement, dress appropriate
for setting, grooming/hygiene)Behavior (level of consciousness, facial expression,
mood and affect)Cognition (orientation x4, responsiveness, speech)Thought Processes (thought content for consistency and logic, perceptions
consistency with reality, any suicidal thought)
Pupillary Reaction (equality, size, shape, reaction to direct and consensual light)
Sensory system (assess for intactness of the following sensory functions)Light touchPain and temperature (only unable to feel light touch)VibrationKinesthesia/Proprioception (position sense)StereognosisGraphesthesiaTwo-point discrimination
Motor function (assess for strength)Hand grips (ask client which is dominant hand)Foot pushes( plantar flexion)
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Deep tendon reflexes (Grade)Biceps Triceps Brachioradialis Quadriceps Achilles
Cerebellar FunctionsBalance
GaitGross motor coordination – heel to toe walkingRombergRapid Alternating Movements (RAM)
Documentation: (Include both Subjective and Objective Data in Narrative Form)
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PHYSICAL ASSESSMENT PRACTICUM
Student____________________________ Date ________________
**Starred ** items are critical elements and must be passed by the student.
Technique Organization Clear Description (5) (5) Instructions(2) Accurate (4)
General Survey:Appearance (posture, grooming, hygiene,
apparent signs of distress, dress)Behavior (attitude, mood and affect, facial expressions)Cognition (mental status, speech, level of orientation)
SkinColor (pink, cyanotic, jaundice, dusky, pale/appropriate for race)Hydration – skin turgorTemp. and Moisture (warm/cool, dry/clammy)Lesions (describes morphology, size, color, pattern of
arrangement, and distribution) (Describe two lesions)
Head and NeckVisual Inspection of skull, face (eyes, ears, nose, mouth, and neck)Include oral mucous membranes (color, moist/dry, lesions)Assess for drainage, lesions, distention, discoloration, and symmetry
LungsPerforms inspection before auscultationAssess respiratory effort and rateAssess for symmetry of chest wall movement Auscultate for breath sounds (anterior or posterior chest)
in a systematic orderHeart
Identify auscultatory sites:Aortic – 2nd right ICSPulmonic – 2nd left ICSTricuspic – Left 5th ICS sternal border or midsternal lineMitral – left 5th ICS midclavicular line
**Auscultate S1 and S2 - assess rhythm (S1 S2 Reg./irreg.)assess for extra heart sounds & murmurs
Identify PMI (left 5th ICS midclavicular line)Count Apical heart rate (BPM) for 1 full minute
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Technique Organization Clear Description(5) (5) Instruction (2) Accurate (4)
Peripheral VascularPalpates for pulses together:Radial, Pedal
Capillary refill (secs) (hands) **Assess for edema (depresses medial malleolus & pretibial area for 5 seconds)
Abdomen ** Auscultation before PalpationInspect for contour,lesions,distentionAusculate all 4 quadrants for bowel sounds Count in each quadrant for 1 full minuteLight palpation all quadrants (bend knees before palpation) (begins at RLQ and proceeds clockwise)
MusculoskeletalROM and Motor strength against resistance:If unable to assess patient’s ability to move in the bed during the assessment, then test specific muscle sets:
Upper extremities (arms only – biceps, triceps)Lower extremities (legs only – quadriceps, hamstrings)
Neurological
Pupils - equal, round, reactive to direct and consensual lightMotor - Assess hand grips and foot pushes bilaterally
Worked from head to toe X X X Professional behavior (verbal and nonverbal communication,
draping of patient)
TOTAL SCORE: _____/149 /50 /45 /18 /36COMMENTS:__________SATISFACTORY (95% or better= 141/149 points)__________NEEDS INPROVEMENT (90-94% = 133-140/149- Skills Lab Referral for head to toe physical assessment)__________UNSATISFACTORY (<90% or 132/149: Advisement note and retest with instructor).*** Failure to pass retest will result in requirement to complete N251 course prior to Fall semester N220 course or concurrent with Spring semester N220 course.
Act out the most appropriate nursing actions for the following patient situations while you practice with the manikins.
1. Name nursing interventions/actions appropriate for a nasogastric tube that is difficult to advance
2. What nursing action is appropriate if the client coughs, is unable to speak, and becomes cyanotic during NGT insertion?
3. During advancement of the NGT, passed the nasopharynx, the client gags and coughs, but remains pink and is able to speak. What is the nurse’s next appropriate action?
4. Your client has a history of dysphagia from a previous stroke. The physician has ordered the client to remain NPO (nothing by mouth) and to insert a nasogastric tube. How would you proceed to instruct the patient to assist in advancing the NG tube once you have passed the nasopharynx.
5. If a Salem Sump pigtail leaks gastric contents, what should the nurse do?
6. Your client who has an NG tube connected to suction suddenly vomits around the tube. What is the appropriate action the nurse should take next?
7. Your client who is receiving a bolus NG-tube feeding is due for his morning medications. As you proceed to assess placement (by flushing with air and aspirating for gastric contents), you feel resistance and are unable to push the plunger. What may be the cause of the resistance and what is your most next appropriate action?
8. Your 72 year old male client has had a left sided stroke and is receiving a continuous G-tube feeding at 60 mL/hr.
a. In considering the client’s diagnosis and treatment, what is he most at risk for?
b. What is the most appropriate nursing intervention to prevent this risk?c. You are checking the client’s residual and you obtain no residual. What
does this mean and what actions will you take?d. You are checking the client’s residual and you obtain 12 mL of residual
volume. What does this mean and what action will you take?
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Nasogastric Tube Removal (AIR-WATER-AIR)
1. Check physician’s order for NG tube removal
2. Gather equipment: Towel, paper towel, stethoscope, container of sterile
normal saline (or tap water), 60 mL syringe with catheter tip, tissues, clean
gloves, tube plug
3. Assess client to determine presence of bowel sounds. Signs more
indicative of GI function include passage of flatus, bowel movement,
absence of nausea and vomiting, and presence of hunger.
4. Perform IPIE. Explain to client that removal may cause some nasal
discomfort, coughing, sneezing, or gagging.
5. Place towel over client’s chest
6. Disconnect NG tube from suction tubing of feeding machine if indicated
7. AIR : Flush tube with a 15-20 mL bolus of air (to displace the tube from the
gastric mucosa) then aspirate gastric contents to check for placement8. WATER : Flush NG tube with 20 mL of NS or tap water (To clear tube so
that GI contents do not inadvertently drain into the esophagus during tube
removal)
9. AIR : Follow saline or water flush with a 20 mL bolus of air (to clear saline or water from tube and to free tube from stomach or intestinal lining)
10.Unpin tube from client’s gown and loosen tape that secures tube to client’s
nose.
11.Plug tube or clamp it by folding it over in your gloved hand
12.Pinch tube to client’s nares, have client take a deep breath and hold it
while you withdraw the tube (Holding breath closes glottis and helps
prevent aspiration)
13.Wrap tube in paper towel and remove from client’s view
14.Offer oral and nasal hygiene
15.Empty and record amount and character or drainage if applicable
1. Catheter is inserted into the female client’s vagina. What is the next most appropriate action by the nurse? (Role play this during practice and discuss your options with your fellow classmates).
2. Difficulty inserting catheter into a male client.a. Name two or three reasons a catheter would be difficult to insert in a male
client.
b. Identify appropriate nursing actions if experiencing this difficulty.
3. As you are inserting an indwelling catheter into your male client, he begins to have an erection. What is the most appropriate nursing action at this time?
4. As you insert an indwelling catheter into your male patient, there is no urine return. What are possible causes and what are appropriate actions by the nurse in this case?
5. Demonstrate and practice the steps to removing a catheter. See back page (Catheter Removal).
6. What appropriate nursing assessments and client teachings would you perform for a client who has had his/her catheter remove/discontinued?
7. Continuous Bladder Irrigation (CBI) – see CBI station and do the following as a group.
a. Discuss the purpose of a CBIb. Discuss the procedure of initiating a CBI on your patientc. What color and consistency of urine output would you expect to see on
the urine drainage bag immediately after a TURP-Transurethral Resection of the Prostate; and just before discontinuing the continuous bladder irrigation?
ACCEPTABLE Alternative method during catheter insertion : Once the unine flows, you may choose to keep the sterile dominant hand holding the catheter and use your
nonsterile /nondominant hand to inflate the balloon.
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N210 Fundamentals of Nursing
CATHETER REMOVALSKILLS CHECKLIST
Recommended TechniqueS
N.I.U
Comments
CHECK physician’s orders (and when last changed if requiring changing)WASH handsASSEMBLE equipment: syringe, unsterile glovesIdentify (armband)ExplainPrivacyPOSITION: -Male: none required -Female: legs slightly apartREMOVAL: -empty FC drainage bag and discard urine. -empty catheter baloon by withdrawing fluid with syringe until resistance felt (balloon empty); note location of meatus in female if F/C being changed -Gently pull on F/C near meatus while pinching tube; inspect F/C for intactness (tip sent for C&S in some agencies)CLEAN perineum; provide patient comfortMEASURE urine; record I&ODISCARD equipmentDOCUMENT procedure -Time -Patient’s responseTEACHING: -2500 cc fluid/day, possibly acidifying liquids (cranberry juice) -Dribbling can occur for several hours -Need to void within 6-8 hrs; report if unable urge/fullnessASSESSMENT: -First void after d/c (If no void, include in shift report) -Frequency -Burning -Hesitation -Dribbling -Cloudiness or any other color or change in characteristicsRev. Fall’07
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Wound Care Practice Station Check OffN210: Fundamentals of Nursing
Station 1
Identify the wound pictures. Identify the wound as red/yellow/black. Stage the pressure ulcer.
Identify which wound is healing by primary intention and which wound is healing by secondary intention. Pay special attention to statement on tertiary healing in page 1189 -1190 of Taylor’s textbook.
