Clinical Skills Development Pocket Book CFP and Adult Branch

Transcription

1 Clinical s Development Pocket Book CFP and Adult Branch Name... Intake Base Personal Tutor Contacts and Sources of Support Telephone Number School Reception Student Services Personal Tutor Clinical Placements Undertaken Placement Speciality Duration Date dtp 2462 Clinical s Log Book ADULT V1 1

2 Introduction and Guidelines This document is a formative self assessment tool, to aid your development of clinical skills. Using this Document Keep this document safe and accessible when in clinical practice. It is a tool to ensure your mentor is aware of your experience within clinical placements and to guide you towards the comprehensive range skills you should achieve during the course and in your future practice. This list is by no means exhaustive and other skills may be available according to opportunities which arise. The availability of experience varies between placements and hence skills may not be acquired in a particular order. However we have indicated those skills which should be considered as a priority with a * sign. This document should be considered as part of your portfolio and will support and aid your achievement of practice outcomes/competency. Additionally it also enables you to monitor your own progress and development. It is the students responsibility to liaise with the mentor to identify equipment for which local training is required, before use without supervision. Please note this will vary between trusts. (see also devices.gov.uk) Some practice placements may consider that individual skills are only to be undertaken by qualified nurses with extended skills. Local guidelines for practice should be followed. We strongly advice you to back up this document on a regular basis (electronic may be easiest, template available). This document is primarily for you to sign and date, however you may negotiate with your mentor to countersign, but this is not a requirement. Clinical s Log Book ADULT V1 2

3 SECTION HEADINGS Section skills relating to Page Health and Safety 4 Handling and Mobility 5 Management of Violence and Aggression 7 Infection Control 8 Communication s 10 Patient Assessment 12 Record Keeping and Documentation 13 Breathing 15 Circulation 17 Hydration and Nutritional 19 Elimination 21 Temperature 23 Neurological Status 24 Hygiene, Comfort and Dignity 25 Palliative Care and Care of the Dying 27 Pain 29 Sleep and Rest 30 Individuality (including Spiritual Care) 31 Cultural Needs 32 Administration of Medications 33 Peri operative Care 35 Wound Care 37 Public Health and Health Promotion 39 Working in an Inter disciplinary Team 42 Management 44 Leadership 45 Teaching 46 Additional s Acquired 47 Clinical s Log Book ADULT V1 3

4 Health and Safety * Fire procedure awareness *Basic Life Support First Aid skills, including a) ABC assessment b) The unconscious patient c) Airway obstruction d) Acute bleeding Aware of COSHH regulations Aware of RIDDOR regulations Reporting untoward incidents (inc. patient issues) Observe/contribute to, a Health and Safety risk assessment of a clinical area. Safe use of transport system for specimens. Able to access local policies, procedures and protocols Notes: Health and Safety Clinical s Log Book ADULT V1 4

5 Handling and Mobility Moving and Handling risk assessment Able to formulate a plan of care to enhance a patients mobility. a) Assessment b) Planning c) Implementation d) Evaluation Bed a) b) c) Sliding Systems a) b) Hoists a) b) c) Standing Aids a) Rotunda b) c) Walking Aids a) Zimmer frame b) Walking stick c) d) Wheelchairs a) Manual b) Electric c) Clinical s Log Book ADULT V1 5

6 Bathing aids a) b) Notes: Patient Handling and Mobility Clinical s Log Book ADULT V1 6

7 Violence and Aggression * Appropriate use of body language in conflict situations * Recognising triggers and cues of challenging behaviour Common strategies aimed at defusing aggression Verbal preventative strategies Assertiveness Stimulus change Mood matching Distraction Low arousal techniques Verbal response techniques * Maintenance of safe distance Techniques: a) Passive wrist release b) Wrist releases c) Hair releases d) Airway protection e) Fending off f) Taking balance g) Biting protection Notes: Violence and Aggression Clinical s Log Book ADULT V1 7

8 Infection Control * Demonstrates consistent and effective hand hygiene a) Social handwashing b) Hygienic handwashing c) Use Alcohol gels d) Scrubbing for surgical procedures * Demonstrates safe practice with regards to Waste and Linen Disposal a) Household waste b) Clinical Waste c) Sharps Disposal Demonstrates the importance of a clean and tidy environment for patients and visitors Able to undertake an MRSA screening Able to apply principles of infection control Principles of asepsis Care of the patient in isolation a) Protective b) Source Safe management of hazardous specimens Appropriate use of gloves Able to access expert infection control advice Contributes to an infection control risk assessment Observed supervised practice Clinical s Log Book ADULT V1 8

9 Using an infection control risk assessment is able to take/ suggest appropriate action Notes: Infection Control Clinical s Log Book ADULT V1 9

10 Communication s Customer Services reception and telephone skills Behaves and presents oneself in a professional manner * Able to initiate appropriate communication with patients, relatives and visitors * Able to terminate a conversation with patients and relatives in an appropriate manner Demonstrates appropriate and accurate reporting of information a) Patient handover b) Reporting to other team members Able to interpret non verbal cues from patients and relatives Able to greet patients, relatives and visitors in a courteous manner Able to call for appropriate assistance when dealing with complex situations Utilises appropriate skills when communicating with a) Visually impaired b) Hearing impaired c) Speech impairment Clinical s Log Book ADULT V1 10

11 Shows sensitivity to Cross cultural aspects of communication Demonstrates a basic ability to use Makaton Notes: Communication skills Clinical s Log Book ADULT V1 11

12 Patient Assessment * Demonstrates a structured approach to assessment a) Emergency b) Planned Able to undertake an initial patient admission Early recognition of the importance of observations made on patients Able to use and interpret an early warning score tool * Able to orientate a patient to the new environment Is able to use specific assessment tools; a) b) c) d) e) f) Takes appropriate action in response to abnormal findings Notes: Generic Patient Assessment Clinical s Log Book ADULT V1 12

13 Record Keeping and Documentation (Note: this links to all other sections) Demonstrates the ability to implement the NMC guidelines Ref NMC (2004) Records are: factual, consistent and accurate Written as soon as possible after an event has occurred, providing current information on the care and condition of the patient or client Written clearly and in such a manner that the text cannot be erased Written in such a manner that any alterations or additions are dated, timed and signed in such a way that the original entry can still be read clearly Accurately dated, timed and signed, with the signature printed alongside the first entry Must not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements Readable on any photocopies Clinical s Log Book ADULT V1 13

14 Records should be written, wherever possible, with the involvement of the patient, client or their carer Written in terms that the patient or client can understand Written consecutively Identify problems that have arisen and the action taken Notes: Record Keeping Clinical s Log Book ADULT V1 14

15 Breathing * Able to observe and record, rate, depth and rhythm Able to use and interpret pulse oximetry Record and interpret Peak Expiratory Flow Rate Obtain a sputum specimen (including documentation and preparation for collection) Set up oxygen equipment safely. a) Nasal cannula b) Venturi mask c) Humidification d) Non/partial rebreathing e) Use of a nebuliser a) Air compressor b) Oxygen driven Demonstrate and assess a patients use of an inhaler device Tracheostomy care a) b) Suction a) Equipment preparation and checking b) Oropharyngeal c) Tracheal d) Tracheostomy Open an airway using the triple airway manoeuvre Clinical s Log Book ADULT V1 15

16 Assess and insert a oropharyngeal airway Able to osculate the chest using a stethoscope Care for a patient with a chest drain Notes: Breathing Clinical s Log Book ADULT V1 16

17 Circulation * Able to obtain and record, rate and rhythm of the pulse Able to undertake a systematic assessment of a patients circulatory status Locating and recording peripheral pulses Measuring, recording and interpreting Blood pressure a) * Manual b) Electronic Assess limb perfusion Able to perform and interpret capillary refill test Assess a patients need for and apply anti embolic stockings Central Venous pressure measurement Arterial Pressure measurement Cardiac monitoring a) 3 lead b) 4 lead c) 5 lead Interpreting common arrhythmia on a 3 lead monitor Recording a 12 lead E.C.G. Clinical s Log Book ADULT V1 17

18 Measuring, documenting and interpreting central venous pressure. Care of a central line Using a vascular doppler machine See hydration for urine output Introduc ed in School Notes: Circulation Clinical s Log Book ADULT V1 18

19 Hydration and Nutritional Needs Perform a comprehensive assessment of hydration status and needs * Perform a comprehensive assessment of nutritional status and needs Principles of food hygiene Able to monitor a patients ability to swallow effectively Able to feed a client safely and with dignity Weighing and measuring a patient s height Accurately records urine output Recording and collating fluid balance * Assessment and care of a patients mouth Inserting a nasogastric tube Care of and feeding a patient with a nasogastric tube Care of and feeding a patient with a Percutanious Endoscopic Gastrostomy tube Clinical s Log Book ADULT V1 19

20 Care of a patient with an intravenous infusion; a) Cannula site and the need for recannulation. b) Selecting and Priming IV sets c) Management of an IV infusion (inc changing the administration set) d) Assisting with cannulation e) Managing an IV fluid regime (inc recording and calculations f) Removing an IV cannula Specific medical devices training (pumps and controllers) a) b) c) Undertake patient safety checks prior to administering a blood transfusion Monitoring a patient during a blood transfusion Perform, record and interpret capillary blood glucose measurement Notes: Hydration and Nutritional Needs Clinical s Log Book ADULT V1 20

21 Elimination Needs *Assessment of continence a) Urinary b) Faecal *Collect and measure urine output Perform and interpret routine urinalysis Collect and manage a MSSU Approaches a patients toileting needs whilst maintaining dignity Plan, implement and evaluate a patients management plan for elimination needs a) Urinary problems b) Faecal problems Apply after full assessment of patient needs; a) Pads b) Sheaths Care of a patient with a urinary catheter a) Routine care b) Bag emptying c) Specimen collection d) Safely performs a rectal examination considering patient dignity Demonstrates effective and safe use of a bladder scanner Clinical s Log Book ADULT V1 21

22 Urinary catheterisation a) male b) female Care of a colostomy Notes: Elimination Clinical s Log Book ADULT V1 22

23 Temperature * Able to obtain, record and interpret a patients temperature a) Orally b) Rectal b) Tympanic c) Care for a hypothermic patient Utilises methods of cooling a hyperthermic patient when appropriate Care for a hyperthermic patient Dispenses and monitors the effectiveness of pharmaceutical interventions Notes: Temperature Clinical s Log Book ADULT V1 23

24 Altered Neurological Status Is able to assess a patient using the AVPU system (alert, voice, pain, unresponsive) Undertake, record and interpret Glasgow Coma Score Care for an unconscious patient in relation to; a) Positioning b) Simple Airway control Demonstrates appropriate positioning of the unconscious stroke patient Able to care for a patient who has a seizure. a) During a seizure b) Following a seizure c) Recording the sequence of events that occur Notes: Neurological Status Clinical s Log Book ADULT V1 24

25 Hygiene, Comfort and Dignity Assess and document a patients ability to undertake self care Assess a patients skin condition Implement care for specific skin conditions a) dry skin b) c) * Oral Hygiene a) Assessment b) Care c) Assisting a patient * Providing hygiene care for a dependant patient in bed * Able to prepare a comfortable bed Plan and promote a patients independence. Able to select and use an appropriate pressure risk assessment tool a) b) c) * Following an episode of care, ensures that a patient is comfortable, dignified, is able to reach belongings and has access to further assistance if required Clinical s Log Book ADULT V1 25

26 Notes: Hygiene, Comfort and Dignity Clinical s Log Book ADULT V1 26

27 Palliative Care and Care of the Dying Undertake an assessment of the patients and carers needs a) Physical b) Psychological c) Social d) Spiritual Plan, implement and evaluate care to: a) Manage distressing symptoms e.g. dry mouth, pain, agitation b) Promote optimal comfort c) Provide psychological, social and spiritual support d) Refer to appropriate palliative care services communicate sensitively and compassionately Implement appropriate care of the patient after an expected death (last offices) Provide support and information for the bereaved Using an appropriate communication strategy when delivering potentially challenging/distressing information Assist with a complex discharge from hospital for a palliative/dying patient Clinical s Log Book ADULT V1 27

28 UNEXPECTED/SUDDEN DEATH a) Assess for safe environment b) Instigate appropriate First Aid/Resuscitation/Emergency care c) Facilitate contacting appropriate professionals and carers d) Participate in breaking bad news e) Make appropriate referrals to support services f) Work co operatively with the police/coroners office g) Provide detailed documentation of incident Notes: Palliative Care and Care of the Dying Clinical s Log Book ADULT V1 28

29 Pain Perform and document pain assessment using different tools * a) b) c) Identify appropriate pharmacological interventions and their side effects a) b) c) Undertake non pharmacological interventions a) b) c) d) Evaluate the effectiveness of pain control Notes: Pain Clinical s Log Book ADULT V1 29

30 Sleep and Rest Assess a patient s sleep and rest pattern and needs Able to plan a patient s day taking into account of the individual need for sleep and rest. Able to identify measures to promote sleep Notes: Sleep and Rest Clinical s Log Book ADULT V1 30

31 Patient Individuality (including Spiritual Care) Considers a patient spirituality and beliefs when planning care Shows sensitivity to patients spiritual needs Participates in collaboration with others (eg chaplain) to meet patients spiritual needs Participates in evaluating care plans related to spiritual care Care delivery is based on an understanding of individual need rather than assumptions derived from patient characteristics (eg age and gender) Notes: Individuality Clinical s Log Book ADULT V1 31

32 Cultural Needs Shows sensitivity to patients cultural needs Participates in collaboration with others to consider cultural needs when planning care a) Multi faith centre/advisors b) Cultural advisors Participates in evaluating care plans related to cultural care/needs Notes: Cultural Care Clinical s Log Book ADULT V1 32

33 Administration of Medications We suggest you also keep a separate document with respect to knowledge of individual medications * Is able to interpret an individual patient prescription * Accurately calculate does required a) Tablets b) Solutions c) IV rate d) * Safely check a patients identity (under supervision) Administer prescribed medication safely; a) Oral b) Rectal c) Vaginal (pessaries) d) Sub cutanous e) Intra muscular f) Inhaler g) Topical h) Ophthalmic i) Aural j) Nasal Demonstrates an understanding of the process of ordering and receiving; a) IV fluids b) Stock Drugs c) Individual patient drugs d) Medications to take home e) Controlled drugs Clinical s Log Book ADULT V1 33

34 Notes: Medications Clinical s Log Book ADULT V1 34

35 Peri operative Care Prepare a patient for a anaesthetic a) General i fasting ii hygiene iii specific preparation b) Regional i fasting ii hygiene iii specific preparation c) Local i fasting ii hygiene iii specific preparation Receive a patient into the theatre area Applying surgical gloves and surgical gown Care for a post anaesthetised patient a) Observation b) Laryangeal mask airway c) LMA removal Hand over a post operative patient to ward staff Receive a post operative patient and safely escort back to a ward Clinical s Log Book ADULT V1 35

36 Notes: Peri operative Care Clinical s Log Book ADULT V1 36

37 Wound Care Assess for pressure sore risk using the following assessment systems; a) b) c) d) Plan and implement care to prevent pressure sores Perform a pressure sore grading score a) b) c) Plan, implement and evaluate care to promote pressure sore healing Record a wounds healing progress by tracing Record a wounds healing progress by photography Assess a chronic wound Obtain and manage a wound swab Cleanse a chronic wound by a) b) Managing specific wound Drainage systems a) b) c) Clinical s Log Book ADULT V1 37

38 Assess an acute wound Cleanse an acute wound by a) b) Close an acute wound with closure tapes Assist with the suturing of a wound Select and apply an appropriate dressing Effectively apply a simple supporting bandage a) b) Provide health education to a patient with a wound Evaluate the healing of a wound a) Acute b) Chronic Removal of sutures Removal of clips Notes: Wound Care Clinical s Log Book ADULT V1 38

39 Public Health and Health Promotion Assess factors/risks which will determine client/carer health a) Within the care environment b) Within their own environment c) Assess factors/risks which will determine your own health status In the care environment a) home b) hospital c) other Demonstrate an ability to maintain a safe working/ care environment Assess client/carer need using appropriate communication a) Individual b) Family c) Group d) Other Interpret current health promotion messages for a) Clients/carers b) Staff Clinical s Log Book ADULT V1 39

40 Initiate appropriate plans/programmes of care and: a) give health information using appropriate tools /media b) provide health education appropriate to client/carer need staff need c) demonstrate appropriate choice and utilisation of approaches to promoting health and wellbeing of clients, and their significant others d) Demonstrate effective physical, psychological and or social interventions with clients/staff e) Signpost and refer clients to relevant support agencies f) Evaluate the appropriateness and effectiveness of the approach(es) taken with clients and their significant others to promote health and wellbeing Clinical s Log Book ADULT V1 40

41 Demonstrate effective collaborative working with others to promote health and wellbeing of clients and staff Notes: Public Health and Health Promotion Reference: Public Health and Health Promotion: linking Theory to Nursing Practice 2005 Curriculum Advisory document (internal). Clinical s Log Book ADULT V1 41

42 Working in an Inter disciplinary Team Able to identify the roles of IDT members a) b) c) d) Initiates and makes direct referrals to; a) Junior and senior medical staff b) Specialist nurses i) Respiratory ii) Cardiac iii) Stroke iv) Stoma care v) Pain team c) Physiotherapist d) Occupational Therapist e) Speech and Language Therapist f) Clinical Nutritionist g) h) i) Actively participates in a clinical hand over Actively participates in clinical case conferences Actively participates in ward round Clinical s Log Book ADULT V1 42

43 Notes: Inter disciplinary Team Clinical s Log Book ADULT V1 43

44 Management Demonstrates the ability to manage the overall care of an individual patient Demonstrates the ability to manage the overall care of 2 3 patients Manages the care of a group of patients (e.g. 6) over a period of time Aware of the process of ordering and receiving, a) Routine Supplies b) Emergency Supplies Able to delegate appropriately Notes: Management Clinical s Log Book ADULT V1 44

45 Leadership Acts as role model/buddy to junior students Leading a team to care for a group of patients Able to provide constructive feedback to peers and junior students Organisational awareness and management of policy initiatives a) b) c) Notes: Leadership Clinical s Log Book ADULT V1 45

46 Teaching Assessing learning needs Formulating a teaching plan Teaching a a) b) Subject area Assessing learning Evaluating effectiveness of teaching approach Notes: Teaching Clinical s Log Book ADULT V1 46

47 Additional s Acquired Clinical s Log Book ADULT V1 47