Family/Caregiver Education Checklist Return Demonstration of Knowledge FIRST 24 HOURS
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1 of Knowledge FIRST 24 HOURS The following checklists will be completed by a PDN RN or LPN to ensure family/caregiver s skill level is adequate to safely take care of their child independently Teaching Checklist Review for: Date Completed: First Name Last Name Example: 1/10/2010 Home Safety How to secure power cords and patient tubing to prevent tripping Location of working smoke detectors, fire extinguishers, and carbon monoxide detectors in the home Location of working flashlight in patient s room How to use safety belts, straps, restraints, railings, car seats, gates Explains Emergency Action Plan is and how to use it Infection Prevention Practices Proper hand cleansing technique Apnea Equipment/Procedures Explains what an apnea monitor is and what it is used for How to turn the monitor off How to properly place the electrodes How to respond to an alarm Oximetry Equipment/Procedures Explains what an oximeter is and what it is used for How long the internal battery will last in the oximeter How to properly place and secure the oximeter probe Explain when to replace the oximeter probe Explain how to tell if the oximeter readings are accurate Explain how to respond to an alarm IMPORTANT: The checklists are not intended to be a substitute for any doctor s instruction for any Page 1 of 6
2 of Knowledge FIRST 24 HOURS Ventilator / Tracheostomy Care Equipment Explains why equipment alarms must be heard from any place in the home How to properly use the equipment and to verify the equipment settings (vent settings, humidifier settings) How to test a ventilator BEFORE using it Explains why the tubing circuit should drain down and AWAY from the child Explain the purpose of humidity with ventilator or tracheostomy Explain what to do if of water has drained into a patient s tracheostomy How to plug in the battery-operated back-up equipment How to charge the external batteries for ventilators, Bilevels and CPAPs How to connect an external battery to the ventilator, Bilevel, or CPAP Suctioning Explain the correct size catheter to use How to set the correct suction pressure How to test for suction pressure Explains when deep (pre-measured) suctioning is necessary, demonstrates proper technique Explains how to use the manual suction catheter in the event of a suction pump failure Explains and locates the 14 fr suction catheters, and when one should be used Emergency Bag and Emergency Bedside Stock Explains what an emergency bag is for and where it should be kept Explains the contents of an emergency bag Explains why there is a current size trach and one-size smaller trach at the bedside AND the patient s emergency bag Resuscitation Bag How to use a resuscitation bag Explains why a resuscitation bag needs to be kept at the bedside AND in the emergency bag How to connect the oxygen to the resuscitator bag and check it to make sure it is working as it should How to set the proper oxygen liter flow to use with the resuscitator IMPORTANT: The checklists are not intended to be a substitute for any doctor s instruction for any Page 2 of 6
3 of Knowledge FIRST 24 HOURS Tracheostomy Care Explain trach tube type, size, and downsize backup Explain the signs of airway blockage Explain how to perform a trach change (routine frequency versus unplanned/emergency) Explain how to determine when 911 should be called Oxygen How to give oxygen (if needed) in line or via resuscitation bag Nebulizer/Inhaler How to assemble neb kit, connect in-line Explain which medications can be mixed versus others that require designated neb kits 2 Respiratory System Management Explain the signs of respiratory distress (increased WOB: nasal flaring, retractions, abd Breathing, increase/decrease in RR and/or HR, decrease in SpO2, skin color, secretion changes) Explain appropriate airway management, interventions for respiratory distress (ie suctioning, nebulizer therapy, humidity, trach change, venting GT) Gastrointestinal/Genitourinary System s Management Explain GER/Aspiration/Emesis precautions (body positioning, elevating HOB, Danny Sling) (if applicable) How to check residuals, when to hold feedings How to feed (use food pump, bolus, gravity, etc) The procedure to correctly mix and store formulas How to vent the GI tube, what the Farrell bag used for (if applicable) Explain the average hang time for formulas IMPORTANT: The checklists are not intended to be a substitute for any doctor s instruction for any Page 3 of 6
4 of Knowledge FIRST 24 HOURS Cardiac System Management Explain their child s cardiac disease and impact on other systems Explain normal skin color for their child How to obtain manual pulses apical and peripheral Explain relation of activity level for their child How to identify edema/intervention for their child How to check capillary refill normal, significance of increased time Explain diuretics and the impact on cardiovascular and gi systems Neurologic System Management Explain the normal mental status/level of consciousness, significance of increased/decreased level of consciousness Explain normal neuromuscular movement/mobility for their child Explain how to identify seizures/interventions Explain shunt type, signs of malfunction How to identify edema/intervention How to check capillary refill normal, significance of increased time Explain what diuretics are and the impact on cardiovascular and gi systems Vascular System (Infusion) Management Explain the type of IV line being used and why How to prepare a safe work area for IV line management/meds How to scrub the hub of the IV catheter Explain what to do if an uncapped tip, iivtubing, or hub is touched Explain how to inspect the IV catheter site and catheter what to look for Explain how to secure the IV catheter Explain the signs of a bloodstream infection Explain who/when to report signs of a blood stream infection IMPORTANT: The checklists are not intended to be a substitute for any doctor s instruction for any Page 4 of 6
5 of Knowledge FIRST 24 HOURS Integumentary Change Diaper Normal Skin Appearance Soaps/Ointments/ Lotions Medications Review Drug Information (names, doses, times, side effects, storage and desired effects) See Medication Profiles Route (PO, GT, Topical, SQ, IM, IV, PR, inhalers, puffs) Check Pharmacy Labels/Expiration Dates Prepare and Administer All Medications per CGN Protocol Scheduled Medications vs PRN medications Communication / Resources PDN agency DME, Equipment Manuals Pharmacy Home Medical Equipment Company Respiratory Therapist Home Infusion Company/Specialty Pharmacy Infusion Nurse HME/Infusion Dietician Transportation (Life Link, Medivan) Poison Control Personal Supp System IMPORTANT: The checklists are not intended to be a substitute for any doctor s instruction for any Page 5 of 6
6 of Knowledge FIRST 24 HOURS Final Completion Signatures NURSE First Name Last Name Credentials Signature Date FAMILY/CAREGIVER First Name Last Name Signature Date Nurse Reviewer Initials IMPORTANT: The checklists are not intended to be a substitute for any doctor s instruction for any Page 6 of 6
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