This Booklet Belongs to: If found, please return to Radford University School of Nursing P. O. Box 6964 Radford, Virginia 24142

Transcription

1 This Booklet Belongs to: If found, please return to Radford University School of Nursing P. O. Box 6964 Radford, Virginia 24142

2 RADFORD UNIVERSITY SCHOOL OF NURSING Nursing Skills Checklist Booklet Directions: 1. Practiced means anytime you practice/review a skill without using an actual client. This may be in the skills learning laboratory, clinical setting and/or classroom. 2. means you have used the skill with a client in the clinical setting. 3. Always take this booklet with you to labs and clinical rotations. Fill in the circle after you practice or apply the nursing skills. Keep the booklet up-to-date and ready for instructor review whenever a clinical/lab instructor asks to see it. 4. Each clinical/lab instructor must review this booklet at least once each semester. Your preceptor will also review this booklet during your clinical nursing practicum. 5. Your goal is to become proficient in as many skills as possible. Work cooperatively with your clinical/lab instructors to achieve this goal by the time you graduate from the upper division nursing program. Your completed Skills Checklist Booklet will be included in your portfolio. Revised: March 2009

3 Preventing the Spread of Microorganisms: Hand Washing Standard Precautions Universal Precautions Maintain medical asepsis Donning non-sterile glove Removing non-sterile gloves Donning protective gown Removing protective gown Donning protective face mask Donning protective eye wear Types of Isolation Isolation Procedures Disposal of sharps in sharps container Vital Signs: Use of oral thermometer Use of electronic thermometers Oral electronic temperature Tympanic temperature Rectal temperature Axillary Temperature Radial pulse Other peripheral pulses Apical pulse Respiration Manual blood pressure Blood pressure with machine

4 Hygiene Care: Exercise: Bathe an adult Bathe a child Bathe a newborn Provide perineal care Provide foley catheter care Shave a male Provide a back rub Provide mouth care Hair care Clean dentures Change an unoccupied bed Change an occupied bed Active ROM exercises Passive ROM exercises Dangle Assist client to ambulate Ambulate with cane Ambulate with walker Ambulate with crutches Position client in bed: Fowler s position Semi-Fowler s position Supine position Prone position Sim s Position Lateral Position Trendelenburg position Reverse Trendelenburg position

5 Moving Client: Up in bed Orthopneic position To side of bed Dangling position Log rolling Onto and off of stretcher Into wheelchair With a mechanical lifter Applying and Removing Restraints Wrist Vest Elbow Mitt Sterile Technique: Maintain sterile asepsis Opening a sterile package Preparing a sterile field Adding to a sterile field Handling sterile forceps Pouring sterile liquid Donning sterile gloves Performing surgical hand scrub Donning sterile gown

6 Medication Administration Dosage calculations Administering medications via these routes: Oral route Intramuscular Subcutaneous Intradermal Z-Track Topical Transdermal Ophthalmic Otic Nasal Inhalers Inhalers with spacers Sublingual Rectal Vaginal Administering meds via N/G tube Administering meds via PEG tube Identify injection sites Prepare meds from ampules Prepare meds from vials Mix insulins in one syringe Mix meds in one syringe Used Sliding Scale Insulin One Hand Recapping Technique Documentation of Medication Administration via written record Documentation of medication Administration via EMAR

7 Intravenous Therapy: Identify venipuncture sites Perform a venipuncture Documentation of IV insertion Start an IV infusion Change an IV solution container Monitor and maintain an IV infusion Change IV tubing Discontinue an IV site Convert an IV site to a PRN adapter Change a gown for a client with IV infusion Drew blood for lab tests Calculate IV infusion rate ml/hr Calculate gtts/min drip rate Administering IV Medications: IV push or IV direct Piggy back solution Using Infusion Devices: IV Site Care: Volume infusion pump PCA Pump Observation PRN adapters Peripheral dsg. Change Central line dsg. Change Documentation of IV site care Flushing peripheral lines Flushing central lines

8 Nutrition Prepare a client for meal Feed an adult Feed a child Feed an infant Add oral thickening to food Insert N/G Tube Check N/G tube placement Check ph Check residual Irrigate N/G tube Provide feeding via feeding pump Provide feeding via bolus Remove N/G tube Manage a gastric tube Provide site care for gastric tube Manage gastrointestinal suction Manage parenteral feeding Monitor caloric count Monitor intake Monitor output Measure abdominal girth Calculate Intake and Output Documentation of Nutrition Via written record Documentation of Nutrition Via electronic record

9 Bladder Elimination: Insert straight catheter Insert indwelling catheter Indwelling catheter care Empty catheter bag a leg bag Obtain specimen from catheter Provide bladder irrigation Remove indwelling catheter Serial urine specimens Provide skin care with incontinent client Teach patient about hygiene Teach Kegel exercises Bowel Elimination: Give a high volume enema Give a low volume enema Irrigate ostomy Empty an ostomy appliance Apply new ostomy appliance Manage a colostomy Manage an ileostomy Manage a jejunostomy Teach ostomy care Manage a urostomy Manage an ileal conduit Insert a rectal tube

10 Oxygenation: Administer oxygen via Cannula Mask Venti/mask Nasal catheter Ambu bag Applying CPAP device Humidify oxygen Manage nebulizers Provide oral/nasal care Assess client s ABG s Use a pulse oximeter Assist client turn, cough, deep breathe Incentive Spirometer Provide oropharyngeal suctioning Teach pursed-lip breathing Insert oral airway Provide tracheostomy care Percussion, postural drainage Vibration, rub shaking Change a tracheostomy dsg. Change a tracheostomy tape Provide tracheostomy suctioning Open method Closed method Provide endotracheal suctioning open method Profide endotracheal suctioning closed method Use ambu bag Manage client on a ventilator Suction client on a ventilator

11 Manage a Chest Tube: Assist to set-up chest tube Assess client with chest tube Provide emergency care of chest tube Provide care to client after chest tube removal Manage a Heimlich valve Musculoskeletal System: Provide care for a client with: Buck s traction Skeletal traction A cast An external fixator device Provide pin care Manage the following: Braces Immobilizers Slings Splints CPM machine Set up Trapeze or ortho frame Conduct a neurovascular check Measured for crutches Measured for walker Provided instructions for crutch walking Provided instructions for use of walker

12 Wound Care: Care for a simple decubitus Care for a complex decubitus Provide heat applications Provide cold applications Cleanse a wound Irrigate a wound Provide a wet-dry dressing Provide a wet-wet dressing Provide a wet-damp dressing Apply Montgomery straps Reinforce a dressing Apply a pressure dressing Apply a dry sterile dressing Apply a dry sterile dressing Apply a transparent dressing Apply an Ace bandage Apply steri strips Remove sutures Remove staples Manage JP drains Manage Hemovac drains Manage T-tubes Providing Pre-op Care: Prepare pre-op check-list Provide pre-op teaching Administer pre-op medications Providing Post-op Care: Monitor: Vital signs Circulation Neuro status Neurovascular status Oxygen Voiding Conduct post-op assessment Turn, cough, deep breath Encourage incentive spirometer Use pain scale

13 Observe management of PCA pump Sequential compression device thigh high Foot pump compression device Observe management of spinal analgesia Provide non-invasive comfort measures Encourage post-op exercise Encourage ambulation Measure for anti-embolism stockings Apply anti-embolism stockings Provide post-op teaching Documentation of Patient Care: Documentation of Assessment using handwritten charting system Documentation of Assessment using electronic charting system Documentation of nurses notes using handwritten charting system Documentation of nurses notes using electronic charting system Specimen Collection: Urine Collection : Routine voided Clean-catch From indwelling catheter Via straight catheter 24 hours specimen Stool: Guiac/Hemoccult Culture/sensitivity Ova, parasites Sputum:

14 Throat culture Nose Wound or lesion Emesis: Gastrocult Assisting with Specimen Collection: Paracentesis Thoracentesis Lumbar puncture Pap smear Bone marrow aspiration Miscellaneous Procedures: Give tepid sponge bath Give sitz bath Aqua-Pad or K-pad Manage AV shunt/fistula Identify thrill and bruit Use hypothermia blanket Use hyperthermia blanket Observe Administration of Blood or Blood Products: Blood (whole or red blood cells) Use of blood warmer Platelets Plasma Auto-transfusion Blood administration observation Blood administration documentation Other skills: Provide post-mortem care Screen for pediculosis

15 Manage the following: Apnea monitor A/B monitor Doppler AK pad Therapeutic bed 02 Sat monitor Monitor blood glucose Accucheck blood glucose Apply telemetry monitor Conduct an EKG test Manage Denver Shunt Manage Heparin via protocol Self Breast exam teaching Fall Risk Assessment Heimlich Maneuver Administer CPR Perform Glasgow Coma Scale assessment OB and Newborn Care: Measure fetal heart rate Measure fundal height Measure newborn s weight Measure newborn s length Measure newborn s: Head circumference Chest circumference Suction infant bulb syringe Provide circumcision care Provide cord care Perform Dubowitz exam Bathe infant Diaper infant Assist with breast feeding Conduct a postpartum check Manage hyperbilirubinemia Mental Health: Psychiatric Assessment

16 Mental Status Exam Suicide Assessment and Precautions Violence Prevention Active Listening Empathy Therapeutic Communication Assertive communication Cognitive-behavioral strategies Limit Setting Patient teaching/counseling Problem Solving Crisis Intervention Coping Enhancement Anger Management Relaxation Techniques Stress Management Reality Orientation Delusion Management Hullucination Management Leading Supportive/Educational Group Provide for Continuity of Care: Develop content mapping plan of care Develop plan of care in clinical agency setting Receive end of shift report Give end of shift report Admit a client Provide admission teaching Discharge a client Provide discharge teaching to client Provide discharge teaching to family

17 Transfer a client Use Physical Assessment Skills with an Adult: Mental status Skin Hair Nails Head Face Mouth Neck Vision Fundus of eye External ear Tympanic membrane Hearing Nose and sinuses Chest Lungs Breasts Lymph Nodes Heart sounds Assess Peripheral Pulses: Dorasalis pedis Posterior tibia Popliteal Femoral Radial Ulnar Brachial Carotid Thyroid gland Arms Legs Abdomen Bowel sounds Use Physical Assessment Skills with a Child: Skin Hair

18 Nails Head Face Mouth Neck Vision Fundus of eye External ear Tympanic membrane Hearing Nose and sinuses Chest Lungs Breasts Lymph nodes Carotid artery Heart sounds Arms Legs Abdomen Bowel sounds Mental status Use Physical Assessment Skills with a Newborn: Skin Hair

19 Nails Head, Fontanelles, Sutures Face Mouth Neck Clavicles Eye, Red Reflex External ear Hearing Nose Chest Lungs Breasts Lymph nodes Carotid artery Heart sounds Arms Legs Abdomen Bowel sounds Back/Spine Umbilicus Reflexes