CLINICAL SKILLS PASSPORT

Transcription

1 The School Of Nursing And Midwifery. Pre-registration Postgraduate Diploma in Nursing (Adult) CLINICAL S PASSPORT NAME: COHORT: Student Details I understand that this booklet may be reviewed by my mentor, the programme leader, my personal tutor, the link lecturer, the learning environment manager, the external examiner and all subsequent mentors. Signature of Student Date

2 CLINICAL S PASSPORT REVIEW This booklet should be reviewed and signed by the mentor along with the assessment of practice record. UNIT NAME OF MENTOR SIGNATURE AND DATE part part

3 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 should initial and date the first column when you have been instructed in or studied the theoretical underpinnings of the skill. Initial and date the other columns when: You have observed the procedure in the practice setting - Level You have participated in the skill under direct supervision - Level You have performed the skill on a number of occasions and required minimal supervision - Level You can perform the skill safely and competently, giving the rationale for your actions - Level You have taught the skill to others - Level 5 PLEASE BEAR IN MIND THAT APPROPRIATE LEVELS OF SUPPORT ARE REQUIRED FROM A FIRST LEVEL REGISTERED NURSE FOR EACH UNIT WHEN USING THIS DOCUMENT. UNIT : DIRECT OBSERVATION UNIT : GUIDANCE UNIT : SUPERVISION UNIT : MINIMAL SUPERVISION 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 e.g. Essence of Care, NSF s.

4 BREATHING Assess individuals ability to breath normally Monitor and record respiratory rate Monitor and record peak flow Maintain airway of airway Position and assist clients experiencing difficulty breathing Monitor and record expectorant Disposal of sputum secretions Obtain sputum specimen Maintain safe administration of oxygen as prescribed via: Mask Nasal cannulae Humidifier Tracheostomy Assess, plan, implement and evaluate care for a range of clients who are breathless Provide psychological support to the breathless client Use of airway adjuncts: A: B: C: D: Assist clients receiving nebuliser therapy Assist clients in performing exercises to improve respiration

5 MOBILITY Assess task, load and environment Safely assess and move inanimate objects Safely assess and assist patients into 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 & handling aids: Please list:

6 MOBILITY (continued) Assess risk of pressure sore development Assess need for and use of appropriate pressure relieving devices: Please list: 5 Prevent deformity in clients with compromised mobility Provide continuity of care for clients receiving physiotherapy Perform risk assessment for mobility and falls Respond appropriately when a patient falls Assist the patient with mobility who requires walking aids Please list: Assess the skin integrity of a range of clients using acknowledged assessment tools Select appropriate dressings for clients with disordered skin integrity Apply appropriate dressings to pressure sores/leg ulcers Apply anti-embolic stockings Apply pressure bandages/tubigrip Apply slings/triangular bandages Care for clients who have a splint/plaster cast Accurately assess an individual s pain using appropriate tools Utilise a range of strategies to effectively relieve clients pain Evaluate the effectiveness of pain relief strategies 6

7 PERSONAL CLEANSING & DRESSING Make a bed/ which is: Unoccupied Occupied Changing a sheet underneath a patient: Top to bottom Side to side Dispose of linen which is: Uncontaminated Contaminated Assist individuals requiring a: Shower General bath Bed bath/towel bath Wash Assist individuals to maintain their oral hygiene: Administer eye care Perform/assist with facial shaving: Care of hair: Washing in bed Dealing with infestation Assist individuals to 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 Assess, plan, implement and evaluate care for a range of clients who are unable to cleanse or dress independently 7

8 MAINTAINING A SAFE ENVIRONMENT Prevent cross infection by effective: Hand washing Use of gloves Use of plastic aprons Safe disposal of equipment Adheres to Health and Safety at Work Act in relation to: CoSHH Disinfection policies Disposal of infected materials Isolation/barrier nursing procedures Dealing with mercury spillage Dealing with blood and body fluids Assessing and swabbing clients for identification of infective organisms Radiation Monitor pulse: Radial Carotid Apex Femoral Use of cot sides Monitor and record Blood Pressure using: A sphygmomanometer An electronic device Perform a simple dressing using aseptic technique Obtain a wound swab Removal of sutures/clips Care for and change (if appropriate) wound drains Removal of drains: Wound Other Recognise the significance of laboratory results and respond accordingly Care of individuals clothing and personal belongings 8

9 MAINTAINING A SAFE ENVIRONMENT (continued) Respond in the event of an actual or suspected emergency Please list: Management of anaphylaxis Provide psychological support to the client requiring assistance with maintaining a safe environment Care of clients requiring the infusion of blood/blood products: Obtaining and storing blood/blood products Administering blood/blood products Cardiac Monitoring Monitor, record and recognise the significance of neurological observations: TPR and B/P General orientation Pupil reaction Motor activity Level of consciousness Glasgow coma score Contribute to the monitoring and recognition of Patients at Risk (PAR Scoring) 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 investigations/procedures: Please list 5 6 9

10 MAINTAINING A SAFE ENVIRONMENT (continued) 7 Assess, plan, implement and evaluate care for a range of clients who are unable to safely maintain their environment 0

11 EATING and DRINKING Assess individuals nutritional status Maintain adequate hydration for a range of clients Assist clients in selecting appropriate meals/fluids Monitor and record nutritional intake Maintain adequate nutrition for a range of clients Monitor and record fluid balance Assist clients with feeding Assist clients with drinking Feed dependant clients Feed clients with difficulty swallowing Monitor and record blood glucose level in accordance with local policy Ordering of special dietary needs for clients including supplements Providing dietary/nutritional guidance including: Care of clients requiring insertion and maintenance of a naso-gastric tube Care and maintenance of clients requiring an intravenous infusion Care of maintenance of clients requiring a subcutaneous infusion Maintenance of therapy for individuals with a: Syringe driver Intravenous pump Central venous line Care of clients requiring parenteral feeding Feeding by and care of enteral tube: Jejunostomy Percutaneous Endoscopic Tube (PET)

12 COMMUNICATING Communicate by telephone appropriately and effectively Assess the communication needs of clients Relatives 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 condition: Orally Through documentation Respond appropriately to requests for information from: Clients Relatives Significant others Other members of the multidisciplinary and multi-agency team External agencies Communicate effectively with the client and other members of the multidisciplinary and multi-agency teams Engage interpreters/other modes of communication as appropriate

13 DYING When and where appropriate: Communicate sensitively with dying patients Communicate sensitively with relatives of dying patients Communicate sensitively with the bereaved Assess, plan, implement and evaluate care for a range of clients who are dying, recognising and respecting their individual beliefs and values Provide psychological support for clients whom you know to be dying and their significant others Provide psychological support to the recently bereaved Liaise effectively with other support agencies: MacMillan nurse Hospice team Voluntary sector Clinical nurse specialists Perform last offices Refer patients to support agencies Refer relatives to support agencies

14 ELIMINATING Assess individuals ability to eliminate effectively Assist clients to use: Bedpan Urinal Toilet Commode Assess need for and use appropriately continence aids Perform routine urinalysis Empty a catheter bag Care for an indwelling catheter Change a catheter bag Monitor and record urinary output Monitor and record bowel actions Monitor and record vomit/gastric aspirate Obtain specimen of urine/faeces/vomit for laboratory examination Refer clients to Continence Nurse Specialist Administer an enema Administer a suppository Bowel preparation for surgery or investigation Care for a client with a stoma: Changing bag Care of skin Care of a client with an indwelling catheter Catheterisation (as Trust policy permits): Male Female

15 MAINTAINING BODY TEMPERATURE Assist individuals to select suitable attire to maintain a normal body temperature Monitor and Record the temperature of: Infant Child Adult Orally Axilliary Aurally/tympanic Care for individuals with: Pyrexia Hypothermia Recognise environmental influences on maintaining body temperature Adapt environment accordingly Strategies utilised: Utilise a range of strategies designed to reduce a client s body temperature 5 Utilise a range of strategies designed to increase a client s body temperature 5 5

16 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 Accurately assess an individual s pain using appropriate tools Utilise a range of strategies to effectively relieve clients pain Evaluate the effectiveness of pain relief strategies Assess, plan, implement and evaluate care for a range of clients who have difficulty resting/sleeping Minimise environmental factors which might influence an individual s ability to sleep and rest 6

17 ADDITIONAL S 7