The School Of Nursing And Midwifery. CLINICAL SKILLS PASSPORT

Transcription

1 The School Of Nursing And Midwifery. BMedSci Nursing (Adult) Student Details NAME: COHORT: I understand that this booklet may be reviewed by my mentor, the programme leader, my personal tutor, the UoS link tutor, the learning environment manager, the external examiner and all subsequent mentors. Signature of Student Date

2 Guidelines on the use of this document This document is designed to help you direct your learning in relation to your clinical skills development and assist you in keeping a record of your progress. It is a compulsory part of the summative assessment of practice documentation and should be used to provide additional evidence at your progress reviews at the intermediate and final interview of each practice learning experience. It should be completed by the end of the programme. It lists the core skills expected to be achieved by all students during the programme that may not be included in the assessment of practice record. The list of skills is not exhaustive; in recognition of this fact, a section is included for you to add any skills unique to your personal learning experiences. You can initial and date each skill at Level 1 when you have been instructed in or observed the skill. This can take place either in the School of Nursing or in practice.inital and date the other columns when: Level 1: You have been taught the skill in School or observed the procedure in the practice setting Level 2: You have participated in the skill under direct supervision Level 3: You have consistently performed the skill safely on a number of occasions and required minimal supervision Level 4: You can consistently perform the skill safely and competently, giving the rationale for your actions PLEASE BEAR IN MIND THAT APPROPRIATE LEVELS OF SUPPORT ARE REQUIRED FROM A FIRST LEVEL REGISTERED NURSE FOR EACH UNIT WHEN USING THIS DOCUMENT. It is expected that, when performing each skill, you exhibit not only the skill element but also demonstrate that you have a sound knowledge base and understand the underlying principles, making reference to national and local policies as appropriate. 2

3 First Level Registered Nurse Signature Register Print Name Clinical Area Job Role Signature Contact Telephone Number 3

4 Mandatory Training Record Fire Safety Year 1 Year 2 Year 3 Date Signature Date Signature Date Signature Patient Safety Personal Safety Basic Life Support Moving and Handling -Theory -Practical Infection Prevention and control -Handwashing Equality and Diversity Information Governance 4

5 Breathing Assess individuals ability to breath normally Monitor and record respiratory rate Monitor and record peak flow Maintain a persons airway Maintain safe administration of oxygen as prescribed via Monitor and record expectorant Mask Nasal cannula Humidifier Tracheostomy Obtain sputum specimen Correct disposal of sputum secretions Assist and monitor clients receiving nebuliser therapy Position and assist clients experiencing difficulty breathing Provide psychological support to the breathless client Assess, plan, implement and evaluate care for a range of clients with breathing problems Use airway adjuncts Assist clients in performing exercises to improve respiration Undertake A-E assessment and respond accordingly 5

6 MOBILITY Assess task, load and environment Safely assess and move inanimate objects Safely assess and assist patients in the following positions Upright Recumbent Semi recumbent Lateral Semi prone Prone Side to side Positioning/moving clients who have had a joint replacement Safely assess and move a range of clients from: Chair to chair Bed to chair Chair to bed Up the bed Up in the chair Cot Trolley to bed Safely assess requirement for and use moving and handling aids. Please list below

7 MOBILITY cont Assess risk of pressure sore development using acknowledged assessment tools Assess skin integrity Assess need for and use of appropriate pressure relieving devices.please list below Select appropriate dressing for clients with disordered skin integrity Apply appropriate dressing to pressure sore/leg ulcer Position to prevent deformity in clients with compromised mobility Provide continuity of care for clients receiving physiotherapy Perform risk assessment for mobility and falls Responds appropriately when a patient falls Assist the patient with mobility who requires walking aids.please list below Apply anti embolic stockings Apply pressure bandages Apply slings/triangular dressings Care for clients who have a splinter/cast Use of cot sides Accurately assess an individual s pain using appropriate tools Utilise a range of strategies to effectively relieve a client s pain Evaluate the effectiveness of pain relief strategies 7

8 Personal Cleansing and dressing Make a bed which is : Unoccupied Occupied Change a sheet underneath a patient : Top to bottom Side to side Dispose of linen which is: Uncontaminated Contaminated Assist individuals requiring a: Shower Bath Bed bath Wash Assist individuals to maintain their oral hygiene Administer eye care Perform or assist with facial shaving Care of hair: Washing in bed Dealing with infestation Assist individuals select appropriate clothing Assist a variety of individuals to dress Provide psychological support to the client requiring assistance with cleansing and dressing Develop a health education programme for clients experiencing difficulty maintaining their personal cleansing and dressing 8

9 Personal Cleansing and dressing cont Assess, plan, implement and evaluate care for a range of clients who are unable to cleanse or dress independently 9

10 Maintaining a safe Environment Prevent cross infection by effective: Hand washing Use of gloves Use of disposable aprons Safe disposal of equipment Adheres to Health and safety at Work Act in relation to : CoSHH Radiation Disinfection policies Dispoasal of infected materials Isolation /barrier nursing Dealing with mercury spillages Dealing with blood and body fluids Assessing and swabbing clients for identification of infected organisms Monitor Pulse: Radial Carotid Apex Femoral Monitor and record blood pressure using : A sphygmomanometer An electronic device Contribute to the monitoring and recognition of Patients at Risk ( EWS) 10

11 Maintaining a Safe Environment cont Monitor, record and recognise the significance of neurological observation TPR and B/P General orientation Pupil reaction Motor activity Glasgow coma scale (Level of consciousness ) Cardiac Monitoring Respond in the event of an actual or suspected emergency :Please list below: Management of anaphylaxis Care of clients requiring infusion of blood/blood products Obtaining and storing blood and blood products As per Trust Policy and with the appropriate supervision assist in the maintenance of therapy for individuals with Driver syringe Intravenous Pump Central venous line Preparation and care of clients requiring : General anaesthesia Local anaesthesia Regional anaesthesia Safely care for a variety of clients in the post operative period Safely care for a variety of clients undergoing investigation/procedures.please list below: Care of an individuals clothing and belongings Recognise the significance of laboratory results and respond accordingly 11

12 Maintaining a Safe Environment cont Provide psychological support to the clients requiring assistance with maintaining a safe environment Assess, plan, implement and evaluate care for a range of clients who are unable to safely maintain their environment 12

13 Maintaining Body Temperature Assist individuals to select suitable attire to maintain normal body temperature Monitor and record the temperature of : Infant Child Adult Oral Axilla Tympanic Care for patient with Pyrexia Care for patient with hypothermia Recognise environmental influences on maintaining body temperature Adapt environment accordingly list strategies used below : Utilise a range of strategies designed to reduce a client s body temperature : List below Utilise a range of strategies designed to increase a client s body temperature 13

14 Eating and Drinking Assess individuals nutritional status monitors and records nutritional intake Monitors and records fluid balance Assists patients into a position that is suitable for eating and drinking, taking into account any health conditions/needs they may have. Assists clients with feeding Assist clients with drinking Feed dependant clients Ordering of special dietary needs for clients including supplements Understands the risks associated with dysphagia and can deliver appropriate care to minimise the risks. Assist clients in selecting appropriate meals and fluid Cares safely for clients who require Intravenous infusion subcutaneous infusion Nasogastric feed PEG feed Enteral feed Parental feed Monitor and record blood glucose level in accordance with local policies 14

15 Eliminating Assess individuals ability to eliminate effectively Assist Clients to use Bed Pan Urinal Commode Toilet Assess need for appropriate continence aids Cares for clients with indwelling catheters Empty s catheter bag as required Monitors urine output Can perform catheterisation ( as Trust policies permit): Male Female Monitors and records bowel action, Monitors and records vomit/gastric aspirate Can perform urinalysis Can obtain specimens of urine/faeces/vomit for laboratory testing Refers clients to Continence Nurse Specialist Administer an enema Administer a suppository Administer Bowel preparation for surgery or investigation Care for a client with a stoma Change a bag Care for skin 15

16 Communicating Communicate by telephone appropriately and effectively Assess the communication needs of Clients Relatives and Carers Interview : Clients Relatives Significant others Communicate sensitively and effectively with clients who have a : Hearing difficulty Speaking Difficulty Language difficulty Comprehension difficulty Give and receive reports of clients conditions : Orally Through Documentation Communicate effectively with members of multidisciplinary and multiagency teams Respond appropriately to requests for information from : Clients Relatives Significant other Other members of the multidisciplinary and multi agency team External agencies Engage interpreters/and other modes of communication appropriately 16

17 Sleep and Rest Assess individuals needs related to sleep and rest Monitor and record individuals sleep and rest patterns Assist individuals to achieve a balance between activity and rest Use a variety of interventions designed to promote clients comfort and sleep Provide psychological support to the client who has difficulty sleeping and/or resting Assess, plan, implement and evaluate care for a range of clients who have difficulty resting/sleeping Minimise environmental factors which might influence an individuals ability to rest and sleep 17

18 Dying ( EoL care) When and where appropriate : Communicate sensitively with patients at End of Life Communicate sensitively with relatives of dying patients Communicate sensitively with the bereaved Contributes to the assessment, planning, implementation and evaluation of care for clients who are at EoL, recognising and respecting their individual beliefs and values. Provide psychological support for clients who are at EoL and their significant others Liaise with other member of the MDT McMillan Nurse Hospice team Voluntary Services Clinical Nurse Specialist Refer patients and their relatives to appropriate support agencies Follows local policies and legal requirements in relation to care of the deceased person( including last offices) Can provide appropriate support to bereaved relatives/significant others 18

19 ADDITIONAL Skills 19

20 ADDITIONAL Skills 20