SAMPLE Certificate IV in Nursing (Enrolled/Division 2 Nursing) Version 1. Clinical Record Book TAFE NSW Component. HLT07 Health Training Package

Transcription

1 HLT07 Health Training Package 3262 Certificate IV in Nursing (Enrolled/Division 2 Nursing) Student name: College: Group : Version 1 Clinical Record Book TAFE NSW Component Training and Education Support Industry Skills Unit Meadowbank Product Code: 5392

2 The State of New South Wales, Department of Education and Training, TAFE NSW, Training and Education Support Industry Skills Unit, Meadowbank, Copyright of this material is reserved to TAFE NSW Training and Education Support Industry Skills Unit, Meadowbank. Reproduction or transmittal in whole or in part, other than for the purposes of private study or research, and subject to the provisions of the Copyright Act, is prohibited without the written authority of, TAFE NSW. Training and Education Support Industry Skills Unit, Meadowbank.

3 CONTENTS SUMMARY OF SKILLS DEMONSTRATED AND PRACTISED IN TAFE... 5 SKILLS ASSESSED IN SIMULATED TAFE ENVIRONMENT... 9 Clinical Skills Assessment No 1: HAND HYGIENE...13 Clinical Skills Assessment No 2: CARDIOPULMONARY RESUSCITATION...14 Clinical Skills Assessment No 3: MANUAL HANDLING/RISK ASSESSMENT...16 Clinical Skills Assessment No 4: ASSESSING AND RECORDING TEMPERATURE, PULSE AND RESPIRATION...18 Clinical Skills Assessment No 5: ASSESSING AND RECORDING BLOOD PRESSURE...20 Clinical Skills Assessment No 6: PERFORMING URINALYSIS...22 Clinical Skills Assessment No 7: BLOOD GLUCOSE MONITORING (BGL)...24 Clinical Skills Assessment No 8: COMPLEX WOUND MANAGEMENT...26 Clinical Skills Assessment No 9: NEUROLOGICAL OBSERVATIONS...29 Clinical Skills Assessment No 10: CHECKING OF SCHEDULE 8 MEDICATION WITH A REGISTERED NURSE (RN)...31 Clinical Skills Assessment No 11: ORAL or ENTERAL ADMINISTRATION OF MEDICATION...34 Clinical Skills Assessment No 12: IMI or SCI ADMINISTRATION OF MEDICATION...37 Clinical Skills Assessment No 13: INTRAVENOUS (IV) ADMINISTRATION MEDICATION...41 Developed by Training & Education Support Industry Skills Unit, Meadowbank TAFE NSW 2010

4 SUMMARY OF SKILLS DEMONSTRATED AND PRACTISED IN TAFE Page 5 of 48

5 Certificate IV in Nursing (Enrolled/Division 2 Nursing) Summary of skills demonstrated and practised in TAFE Clinical Skill Hand hygiene Basic hygiene Assessing and recording temperature, pulse and respiration Assessing and recording blood pressure Pulse oximetry monitoring General body observations Vascular observations Admission, discharge, transfer Mobility aids Active and passive exercises Positioning Report writing Feeding clients Bedmaking Fluid balance charts Deep breathing and coughing Manual handling/ risk assessment Performing Urinalysis Application of embolic stockings Oxygen therapy, incentive breathing devices/nebulisers Care plans/ critical pathways Catheter care Catheterisation and removal of a catheter Insertion and removal of NG Tube Neurological observations Tracheostomy care Fluid infusion devices Cardiopulmonary resuscitation Wound drain - removal Removal of peripheral IV cannula demonstrated practised Teacher s signature Page 7 of 48

6 Clinical Skill Suctioning- * naso/oro phayngeal * tracheostomy Recording 12 lead ECG/cardiac monitoring demonstrated practised Teacher s signature Blood glucose monitoring (BGL) Complex wound management Wound drain shortening Checking of a Schedule 8 medication with a registered nurse Oral or enteral administration of medication IMI or SCI administration of medication Intravenous (IV) administration of medication Page 8 of 48

7 SKILLS ASSESSED IN SIMULATED TAFE ENVIRONMENT All clinical skills have been mapped to the Australian Nursing & Midwifery Council national competency standards for the enrolled nurse (2002) and this is evidenced in the related unit guide for each unit of competency. Page 9 of 48

8 Summary of compulsory clinical skills assessments assessed in simulation in TAFE Clinical skill Achieved Competency Teacher name Teacher signature 1. Hand Hygiene 2. Cardiopulmonary resuscitation 3. Manual handling/risk assessment 4. Assessing and recording temperature, pulse, respiration 5. Assessing and recording blood pressure 6. Performing Urinalysis 7. Blood glucose monitoring (BGL) 8. Complex wound management 9. Neurological observations 10. Checking of a Schedule 8 medication with a registered nurse 11. Oral or enteral administration of medication 12. IMI or SCI administration of medication 13. Intravenous (IV) administration of medication Page 11 of 48

9 Clinical Skills Assessment No 1: HAND HYGIENE Student s name: TAFE College: Group: Expected performance Demonstrates satisfactory knowledge base for safe practice Prepares for and performs hand hygiene appropriate ly and safely Critical Aspects Attempt 1 Adheres to relevant legislation and policies Prepares appropriate equipment and hand washing solution. Attempt 2 Attempt 3 Removes jewellery Checks water temperature Applies water to wrists and hands Applies soap and applies friction Washes hands, covers all surfaces, and finishes at the wrist Applies friction for seconds Keep hands lower than elbows throughout procedure Rinse thoroughly Turns taps off without contaminating hands Dries hands without contamination Identifies contamination and takes appropriate action/s Student s comment Student s signature Assessor s name Assessors comment Assessor s signature competency achieved Page 13 of 48

10 Clinical Skills Assessment No 2: CARDIOPULMONARY RESUSCITATION Student s name: Expected performance DANGER (Safety, Hazards and Risks) RESPONSE AIRWAY BREATHING COMPRESSIONS TAFE College: Group: Critical Aspects Attempt 1 Attempt 2 Attempt 3 Review hazards and risks. Ensure area is safe. Assess client for a response using touch and talk techniques. Not responding: Press emergency call button/bell. Shout for help. Open airway: Tilt head back and lift chin. If airway is clear, leave client on their back. If the airway is obstructed, turn on to their side to allow foreign material to drain. Look, listen and feel for normal breathing. If breathing normally, turn client into recovery position and assess for other injuries and monitor signs of life. Not breathing normally: Place client on their back, open airway, give 2 rescue breaths, at one breath per second, check for signs of life. If no signs of life, commence CPR: Hands are positioned over the centre of the chest, depress to 1/3 depth of chest, maintain smooth Page 14 of 48

11 Expected performance COMPRESSIONS (cont d) COMMUNICATION Document findings and informs the RN of data Student s comment Student s signature Assessor s name Assessor comment Assessor s signature competency achieved Critical Aspects Attempt 1 uninterrupted compressions breathing ratio of 30:2 for 1 operator (approximate rate at 100 compressions per minute), observe for any return of breathing or signs of life. Debrief to emergency response team/senior staff. Further participation will be directed by senior staff member. Attempt 2 Attempt 3 Accurately records findings. Page 15 of 48