Table of Contents 1 Universal Competencies... 3 1.1 Universal Elements... 3 2 Critical Thinking Question... 4 3 Documentation... 4 4 Handwashing... 4 5 Moving a patient up in bed... 4 6 Applying restraints... 4 7 Applying and removing personal protective equipment... 5 8 Administering an Enema... 5 9 Performing Physical Assessment... 5 10 Positioning a Patient... 5 11 Ambulating a patient... 5 12 Applying bandages/binders... 5 13 Applying antiembolism stockings... 6 14 Intermittent and continuous tube feeding administration... 6 15 Nasogastric tube Insertion +/- suction... 6 16 Sterile Wet to Moist Dressing Change... 7 17 Foley Catheter Insertion... 7 18 Medication Administration... 7 19 Primary IV administration... 7 20 Secondary IV administration... 8 21 IV flush with Saline... 8 22 Trach Suctioning... 8 23 Trach Care... 8 Page 2 of 8
1 Universal Competencies 1.1 Universal Elements Safety and Security 1. Physical safety and security: Any action or inaction on the part of the student that threatens the patient s well being or is in violation of the patient s security. 2. Emotional Security: Any action or inaction which threatens the emotional well being of the patient or significant others or is in violation of the patient s emotional security. Therefore, the student will AT ALL TIMES: Identify the patient by reading the ID bracelet before initiating care and identifying allergies as needed Protect the patient from physical harm at all times, such as raising side rails and returning bed to low position when indicated, pt s ability to ambulate is assessed prior to getting up, restraints are secured safely without injuring the patient, and patient is positioned for therapeuticness and protection from harm (aspiration, etc) Protect the patient from psychological harm by referring to the patient by name, communicating verbally and nonverbally in a therapeutic manner, providing accurate information about their care, preparing patients appropriately for procedures, maintaining privacy at all times, maintain dignity and empathy Utilize equipment safely t prevent human error Demonstrate proper and consistent utilization of safety devices Comfort The student needs to assure comfort of the patient at all times and initiate interventions related to the tolerance of the procedure Therefore, the student will AT ALL TIMES: Assess the patient s level of comfort before, during and after any procedure Provide interventions to increase the patient s comfort level Position patients for comfort Standard Precautions The prevention of the introduction or transfer of organisms Therefore, the student will AT ALL TIMES: Wash their hands before initiating direct contact with the patient and whenever hands are contaminated by body secretions or substances Wear gloves whenever in contact with body fluids Protect the patient from contamination in all procedures Confine any contaminated material to contaminated areas and dispose properly Implement universal precautions at all times Page 3 of 8
*** It is important to realize that all potential failures to protect the patient from harm cannot be described here. 2 Critical Thinking Question Demonstrates application of knowledge obtained I current and previous courses related to the skill and patient situation 3 Documentation 1. Document patient care using the following methods, as designated: assessment forms, flow graphs, or other standard clinical forms, narrative process recording 2. Document patient changes and responses to care in designated records. 3. Use language, terms, and abbreviation that are consistent with professional standards, agency protocols, and other specific guidelines 4. Records data so that entries are: clear accurate, precise, pertinent/relevant 4 Handwashing 1. Regulate water temperature and flow 2. lather with soap covering all aspects of hands and wrists for appropriate length of time 3. Dry hands 4. Maintain medical asepsis and does not contaminate self 5 Moving a patient up in bed 1. Assess the patient s ability to assist 2. Position a draw sheet under the patient appropriately 3. Use proper body mechanics 4. Properly instruct the patient how to assist 6 Applying restraints 1. Assess CSM or any contraindications to use of restraints 2. Explain rationale to patient and/or family 3. Apply restraint properly 4. Secure restraint to proper location on bed or wheelchair as appropriate 5. Assess at frequency dictated by agency policies Page 4 of 8
7 Applying and removing personal protective equipment 1. Identify needed equipment 2. Apply appropriate equipment in proper order 3. After use, remove protective equipment in proper order to prevent contamination 8 Administering an Enema 1. Use warm water 2. Position patient to facilitate flow 3. Regulate flow of water to appropriate rate 4. Offer and place patient on bedpan after instillation 9 Performing Physical Assessment 1. Position pt appropriately for system exam 2. Identify proper anatomical landmarks for inspection/auscultation 3. Identify normal /abnormal findings and be able to describe them with proper medical terminology 10 Positioning a Patient 1. Maintain use of good body mechanics by the nurse 2. Use pillows appropriately for support 3. Support body during position changes as appropriate 11 Ambulating a patient 1. Assess patient s ability to ambulate 2. Correctly position self and arms to provide for assistance and safety 3. Evaluate patient s gait, distance and tolerance of exercise 12 Applying bandages/binders : 1. Asses the CSM 2. Position body part in neutral, elevated position if possible Page 5 of 8
3. Apply bandage using equal distance and equal pressure 4. Wrap the extremity distal to proximal 5. Secure appropriately 6. Choose proper sized binder for the patient 7. Position the binder appropriately 8. Asses for potential breathing or skin impairment 13 Applying antiembolism stockings : 1. Measure patient for proper fit 2. Apply the stocking appropriately 3. Assess CSM and presence of wrinkled in stockings 14 Intermittent and continuous tube feeding administration : 1. Position HOB at least 30 unless contradicted 2. Check placement and patency of tube 3. Perform residual check; hold if residual > 100 ml 4. Using the correct port, administer (TF or water) correct type and amount at prescribed rate 5. Keep HPB at least 30 for at least 1 hour after feeding for intermittent feedings and maintain HOB always at least 30 for continuous feedings 15 Nasogastric tube Insertion +/- suction 1. Measure tube for appropriate positioning 2. Lubricate the tube 3. Instruct the patient regarding procedure and patient participation 4. Facilitate chin tuck when appropriate 5. Insert tube to appropriate place 6. Check placement 7. Secure the tube 8. Attach tube suction appropriately Page 6 of 8
16 Sterile Wet to Moist Dressing Change 1. Remove old dressing 2. Assess wound and drainage 3. Establish sterile field 4. Apply sterile gloves 5. Apply dressing using sterile technique 6. Secure dressing 17 Foley Catheter Insertion 1. Establish sterile field 2. Apply sterile gloves 3. Check foley balloon 4. Cleanse perineum correctly 5. Insert catheter maintaining sterile technique 6. Inflate foley bulb at appropriate location 18 Medication Administration 1. Correct calculation dose 2. Medication preparation using aseptic technique 3. Utilizes 5 Rights 4. Appropriate drug knowledge 5. Correct needle, syringes and site selection 6. Correct administration 19 Primary IV administration 1. Maintain asepsis 2. Minimal loss of fluid 3. Correct titration of drops rate if gravity or correct ml/hr if using correct infusion pump Page 7 of 8
20 Secondary IV administration 1. Maintain asepsis 2. Correct connection to primary line 3. Backflush method 4. Correct titration of drop rate if gravity or correct ml/hr if using infusion pump 21 IV flush with Saline 1. Assess for complications 2. Cleanse injection port/maintain asepsis 3. Assess for blood return 4. Infuse saline while assessing for complications 22 Trach Suctioning 1. Assess need for suctioning 2. Preoxygenate 3. Maintain asepsis 4. Correct methods for insertion and removal of secretions 5. Assess tolerance 23 Trach Care 1. Remove inner cannula 2. Maintain asepsis 3. Clean reusable cannula or replace with disposable cannula 4. Clean skin and trach plate 5. Replace tiles as needed Page 8 of 8