Blacktown Clinical Competencies

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BLACKTOWN INTENSIVE CARE UNIT

Clinical Competencies

Name:_____________________________________ Commencement Date:___________________

Rationale- To provide safe and effective care for patients requiring management in the intensive care environment.

Clinical competencies are to be completed within set time frameClinical competencies are to be assessed by CNE, NUM or CNS working in ICU or your appointed Mentor

Compiled byLarissa McTegg ACNE

Danielle Callaghan ACNEKaye Williams CNS

Using ICU Competency & Professional Development Record


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COMPETENCY:- VENTILATION / O2 THERAPY

Aim of competency

Physical assessment of patients respiratory function Assessment of patients ventilation and oxygenation status Provide safe and effective care to patients receiving ventilatory and/or oxygenation support

Elements of competency

1. Respiratory assessment2. O2 therapy3. Care of ventilated patient4. BIPAP / CPAP5. Intubation6. Extubation7.

Oxylog Transport ventilator8. Tracheostomy Care

9. Under Water Seal Drains (UWSDs)


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Element 1- Respiratory physical assessment

Observable Criteria Questions to be asked by assessor Shown Safe Competent Actions

Inspects the patients chest, observing for equalrise & fall of chest, any structural abnormalities orabnormal chest wall movement

Why is it important to assess rise & fall of chest? What structural abnormalities may indicate a

problem? (Tracheal shift, flail chest)

Auscultates the patients chest. Checks for equalair entry and identifies abnormal breath sounds

What are the types of breath sounds & what dothey indicate?

Observes colour of mucous membranes Why is mucous membrane colour important?

Inspects patients CXR and identifies landmarks

Identifies any abnormalities on CXR and outlineswhat the abnormality represents

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Element 2- O2 therapy


NASAL CANNULA (PRONGS)

Outlines appropriate flow rateso 1-4lpm providing 23-35% O2

What are the advantages of nasal prongs? Is CO2 retention a problem for patients who are

using nasal prongs?

Outlines disadvantages of NPo Local irritation & drying of mucous

membranes

o low concentrations of O2

Can nasal prongs have a higher flow rate than4lpm?

When would you use NP when other forms of O2therapy are in use?

HUDSON MASK

Outlines flow rateso 5-10lpm providing 35-50% O2 How does expired gas leave a Hudson mask? What is a major disadvantage of the Hudson

mask, with regards to delivered and received fio2?

VENTURI MASK

Outlines flow rateso 50%o 40%o 35o 31%o 28%o 24%)

What is the advantage of the venturi mask overthe Hudson mask?

Does the patient re breathe their own Co2?

Outlines venturi principle Explain the venturi principle

NON REBREATHER

Outlines flow rateso 15lpm providing 90-100% O2o Flow great enough to prevent reservoir

bag collapsing on inspiration

What is the importance of the reservoir bag onthe mask?

How do you inflate the reservoir bag if it does notinflate spontaneously before you put it on the

patient?

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Element 3- Care of Ventilated patient


Set up of Evita 4 Ventilator

Gathers equipment for set up Can demonstrate set up and testing of circuit. Why is it important to do a self-test on the

ventilator?

When changing part of ventilator circuit what testmust be performed?

Demonstrates ability to measure & accurately document ventilation observations

Adheres to unit practice in documentation ofventilator observations

How often should you download and validateobservations?

Downloads & validates ventilator observationscorrectly in CIS adds appropriate information to

CIS

What extra information should be added to theCIS that is not automatically downloaded?

Correctly distinguishes between controlled,assisted & spontaneous breathes

How do you distinguish between controlled,assisted and spontaneous breaths?

Takes best of three breathes when documentingtidal volumes

Why is it important to take the best of threebreaths when recording the tidal volume?

Adds appropriate information to CISo type of tube (ETT / Tracheostomy)o Evita 4 / Evita 2

Discusses rationale for humidification & rationalefor set temperature

Why is it important to have humidification set atthe proper temperature, and what is that

temperature?

Demonstrates the appropriate settings and check of ventilator alarms

Apnea alarm limitso ensures alarm is ono apnea delayo apnea Vt & rate

What is this alarm? Why is it important that we check and set this

alarm for each individual patient?

High Vt What is this alarm? Why do we set a high Vt alarm?

High Pressure limit (PAW) What is this alarm? Why do we set a high pressure limit alarm?

Low minute volume What does minute volume indicate? Why do we set a low minute volume limit? What is the lowest limit acceptable?

Tube compensation on/off What is tube compensation? Why is it used?

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Managing Alarms

Outline the reasons behind and management ofthese alarms

o tidal Volume Higho Low Minute Volumeo High Pressure Alarmo Apnea

Why do you need to press the alarm-reset buttonafter the apnea alarm has sounded?

How do you tell if the apnea alarm is turned on? What is the immediate action for management of

these alarms?

Modes of Ventilation

Is able to differentiate between various modes ofventilation

What is CPAP & PEEP What is PS What is SIMV PCV APRV

Outlines the advantages / disadvantages of eachmode

CPAP & PEEP PS SIMV PCV APRV

Notes size & position of ETT / Tracheostomy

Is able to explain importance of correctpositioning & size of tube

When do you chart the size and position of theETT?

Why is it important to chart the position of theETT?

Repositions tube as ordered by medical staffo Confirms ETT position on CXR before

repositioning

o Repositions ETT to correct placement andsecures ETT appropriately

o Checks cuff pressure followingrepositioningo Listens for equal air entry

o Observes for respiratory distress postrepositioning

o Informs MO ETT is repositioned andorganizes CXR

Why is it important to confirm position on CXRprior to repositioning?

What equipment is needed to reposition tube? Who should assist with this procedure?

Why is it necessary to recheck cuff pressure? Why do we listen to air entry?

Why is it necessary to observe the patientfollowing repositioning?

Why is a CXR necessary following repositioning ofETT

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Demonstrates methods of securing ETT and Tracheostomy

Adheres to unit practice in securing ETT Tracheostomy

How many nurses are required to secure an ETTor a trachy?

Ensures tube is secure Observes skin integrity What are some preventive measures to ensure good

skin integrity?

Maintains adequate ETT / tracheostomy cuff seal & correct measurement of cuff pressure

Maintains cuff pressure within acceptable range What is the acceptable range for both the ETT andtrachy cuff pressure?

Correctly records cuff pressure in CIS Why is it important to chart the cuff pressure inthe CIS?

Checks cuff pressure 4/24 Why do we need to check cuff pressure regularly? Discusses management of cuff leaks How do you tell if you have a cuff leak and what

action should you take?

Suctioning ETT / Tracheostomy

Outlines reasons for suctioning Why do patients with an artificial airway requiresuctioning?

Explains procedure to patient where necessary Gathers equipment Uses correct PPE for procedure Pre-oxygenates patient prior to procedure What is the importance of pre-oxygenating a

patient prior to suctioning?

Attempts two passes according to unit protocol How long should you have the suction catheterdown the patients airway for?

Flushes trache care and suction tubing afterprocedure

Nebulisers

Can demonstrate the connection / disconnectionof Nebuliser to circuit

Adheres to units policy with PPE How do you safely disconnect the ventilator circuit toavoid a splash injury when adding a Nebuliser to the

circuit? Demonstrates the use of MDI Why is timing important when administering an

MDI?



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Ventilator Emergency

Explain what a ventilator emergency is Outlines the signs of a ventilator emergency Outlines the protocol for dealing with a ventilator

emergency

What is your first priority during a ventilator

emergency?

Laerdel Bag

Demonstrate laerdel bag set up in < 1 minute What is one of the main mistakes when setting upa Leardel bag?

Demonstrates the appropriate testing of a Leardel

bag

Why is it important to test a Leardel bag if theprevious shift has done it?

Why should you still have a facemask at thebedside, even when you have a ventilated

patient?

Explain the principle of a PEEP valve Demonstrates manual ventilation using laerdel

bag

Humidification

Justify the use of humidification in the circuit Why do we humidify our ventilator circuit? Set correct temperature on humidifier for

ventilator circuit and explain the reasons behind

the temperatures



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Element 4- BIPAP


Set up of BiPAP Vision machine

Gathers equipment for set up Can demonstrate set up Tests exhalation port appropriately Why do you need to test the exhalation port?Demonstrates ability to measure & accurately document BIPAP observations

Correctly distinguishes between ST and CPAPmodes

What is IPAP and EPAP? Should the BiPAP be turned on or off before

connecting the patient?

Adheres to unit practice in documentation ofBIPAP observations

Why is it important to press Learn Base Flowwhen connecting / disconnecting Nebuliser?

What would you check if your patient was notreceiving the required pressures?

Takes best of three breathes when documentingtidal volumes

Why is it important to take the best of threebreaths?

Enters BIPAP observations correctly in CIS addsappropriate information to CIS

What values should be charted on the CIS andwhy?

Adds appropriate information to CIS:- Type of mode-

Discusses rationale for humidification &identifies correct set temperature

Choice of mask

Explain the positive and negative effects of using:- Regular mask- Full face mask

How do you get a claustrophobic patient used tothe BiPAP mask?

Demonstrates the appropriate settings of BIPAP alarms

Apnea alarm limits- Ensures alarm is on- Apnea delay- Apnea rate

How do you tell if the apnea alarm is on or off?

High Vt What is the importance of the high-pressurealarm?

High Pressure limit

Low minute volume



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Element 4- BIPAP


Contraindications

Explain why you would use caution when feedinga patient

What is a possible side effect of a patient who hasjust eaten and then swallows air at highpressure?

Humidification

Explain the importance of humidification Set correct temperature on humidifier for BiPAP

circuit and explain the reasons behind the set

temperature

Do you set the same temperature for BiPAP that you

would set for a patient with an ETT?

Element 5- Intubation


Discusses indications for intubation Assembles equipment Explain the importance of all the equipment

required for intubation.

Demonstrates application of cricoid pressure What is the importance of cricoid pressure? When do you release cricoid pressure?

Explains reasons for drugs that may be used Fentanyl Propofol Aramine Midazolam Rocuronium Explain the importance of a set ventilator mode as

opposed to a spontaneous mode when using someof these drugs.

Suxamethonium

Post Intubation

Secure ETT Explains importance of CXR to locate ETT and

NGT Where is the appropriate position for the ETT to sit

on the CXR?

Ensures adequate sedation ordered andadministered

Why is sedation needed post intubation?



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Element 6- Extubation


Informs ICU Reg and Nursing Team Leader of intention to extubate after medical order has been given and documented.

Assembles equipment Suctions patient via ETT Aspirates NG tubeand documents aspirate in CIS Why is it important to cease feeds prior to

extubation and how long should they be ceasedbefore extubation?

Why is it important to aspirate the NG prior toextubation?

Connects appropriate O2 mask and turns on O2 What oxygen concentration would you put thepatient on post extubation?

Suctions oropharynx Explains procedure to patient Suctions via ETT when extubating Suctions oral cavity after extubation Documents extubation and new O2 therapy in CIS What signs should you observe post extubation?

What would you do if your patient failedextubation?

Post Extubation

Ensures resp rate monitoring turned on The CIS automatically downloads the respiratoryrate as a part of the routine observations. Should

you rely on this post extubation?

Closely monitors O2 sats and patients respiratoryeffort

What are the signs and symptoms of respiratorydistress?

Checks ABGs results 1 hour post extrubation Why are ABGs attended one hour postextubation?



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Element 7- Oxylog transport ventilator


Set up of Oxylog Ventilator

Locates Oxylog machine and tubing What do you do with the tubing once you have

finished with it?

Gathers big O2 bottle and ensures enough O2 Demonstrates correct set up of Oxylog Performs pre use check of Oxylog Why is it important to do a pre use check on the

Oxylog?

Sets appropriate settings on Oxylog Documents parameters in the CIS

Element 8 Tracheostomy Care


Insertion of Tracheostomy

List the indications for the insertion of aTracheostomy

Demonstrate the set up of Tracheostomy What equipment is required for a Tracheostomyand why?

Nursing Responsibilities

Ensure appropriate equipment is kept at thebedside

What is the appropriate equipment and whyshould it be at the bedside?



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Element 8 Tracheostomy Care


Suctioning Tracheostomy

Outlines reasons for suctioning Explains procedure to patient where necessary Gathers equipment Uses correct PPE for procedure Uses sterile gloves Why are sterile gloves needed to suction, when

you do not use sterile gloves to suction an ETT?

Why is it important to check the Trach care sizebefore you suction a patient with a closed suction

system?

Attempts two passes according to unit protocol How often should suctioning of a Tracheostomy beattended?

What parameters should you observe whensuctioning?

Humidification

Explain the importance of humidification Why is humidification important for a patient witha tracheostomy?

Set correct temperature on humidifier forTracheostomy

Types of Tracheostomy

Discusses the different Tracheostomy:percutaneous or surgical

Explain why a patient may have a surgical asopposed to a percutaneous tracheostomy.

Tracheostomy dressing Outline the policy for a tracheostomy dressing How many staff required for a Tracheostomy

dressing?

When would you do a swab on a tracheostomy? Demonstrate a tracheostomy dressing



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Element 9 Under Water Seal Drains


INDICATIONS FOR INSERTION

List the indications for the insertion of an UWSD Why would you insert an UWSD?

Insertion Gathers equipment required for the insertion of an

UWSD

Demonstrates correct set up of equipment Why is it important to maintain a sterile fieldwhen setting up the equipment for an UWSD?

Observations

Demonstrates correct observations of UWSD How often should UWSD observations be done? When attending observations, should suction be

on or off?

Do you clamp the UWSD during routineobservations?

Explain the meaning of:- Oscillation- Bubbling- Draining

Suction

Demonstrate the set up of a Low Wall suctionoutlet

Do you use low or high suction for an UWSD? What is the suction to be set at when the UWSD is

on low wall suction?

Dressing

Demonstrates an occlusive and anchoringdressing to the chest drain.

Why does the dressing need to anchor the chestdrain?

Why does the dressing need to be occlusive?Removal

Gathers equipment required for removal of UWSD What equipment is required for removal of a chestdrain?

Demonstrates the removal of an UWSD What is the idea behind the purse string suture? Ensures CXR 4 hours post removal Why is it important to do post removal CXR?



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COMPETENCY:- HEMODYNAMIC MONITORING

Aim of Competency

Assessment of patients cardiac function Provide safe and affective care to patients receiving cardiac support

Elements of Competency

1. Cardiac monitoring2. Managing Arrythmias3. 12 Lead ECG4. CVP5. Arterial lines6. PICCO7. Inotropes8. Pulmonary Artery Catheters



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Element 1 Cardiac Monitoring


Marquette Monitor

Can identify correct lead placement for cardiacmonitoring

Displays cardiac rhythm in Lead II

Why is it important to monitor in Lead II?

Sets appropriate vital sign alarms according topatient and explains reasons for same

What limits would you set for alarms?

Downloads and validates vital signs observationsand cardiac rhythm in the CIS

What do you do if the downloaded observations arevastly different from what your patient has had allshift?

Ensures any change in vital signs are downloadedand validated

How frequently do you zero your arterial line? Why should you NOT leave the five minute silence

alarm on, when things have returned to normal? How do you trouble shoot artifact on your monitor?

Transport Monitor

Identifies correct lead placement for cardiacmonitoring

Displays cardiac rhythm in Lead II Sets appropriate alarm limits for the trip outside

the unit

Do you need to review the alarm limits if you are only

going to CT and back?



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Element 2 Managing Arrhythmias


Detects each rhythm below & discusses management

What actions would you take for each rhythm? What rhythms would you defibrillate? What is the difference between defibrillation and

cardio version?

What do you do if you are unsure of a rhythm?

Normal Sinus Rhythm Sinus Tachycardia Sinus Bradycardia Atrial Fibrillation Atrial Flutter Supraventricular Tachycardia Ventricular Tachycardia Ventricular Fibrillation Asystole



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Element 3 12 Lead ECG


Identifies indication for an ECG to be performed Identifies indications for 12 lead ECG

Performs 12 Lead ECG Gathers appropriate equipment Identifies correct patient Explains procedure to patient Maintains patients privacy Applies leads in correct

position How often do you change the ECG dots on your

patient?

Removes jewelry Why should jewelry be removed before an ECG isattended?

Clips hair if necessary does not shave Positions patient correctly Acquires EGC on monitor and prints How do you get the ECG to download to the CIS?

How do you trouble shoot artifact when trying to doan ECG?

Shows ICU team the ECG to review and sign Places printed ECG into patients folder Documents appropriately in CIS Returns monitor to display Lead II and turns off

V2-V6 fail Why do you change the monitor to monitoring

rather than diagnostic after the ECG?



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Element 4 Central Venous Pressure (CVP)


Discusses units policy for taking CVP measurement What is the CVP measuring? Ensures correct set up to take a CVP measurement

including correct lumen placement

Why is it important for the patient to be lying flat? What lumen must the CVP be attached to and why?

Takes CVP measurement as per units policy What effect does PEEP have on CVP? How frequently are CVPs attended?

Documents CVP correctly in CIS Competently removes CVC as per unit policy How is patient positioned for CVC removal

During what part of the respiratory cycle is CVCremoved

What maneuver do you ask the patient to undertakefor removal (if able to)

Element 5 Managing Arterial lines


Indications for Insertion of Arterial line

Lists indications for arterial line insertions Name the different insertion sites of an arterial line Demonstrates and explains reason for Allans test Outlines the potential risks of an Arterial line What actions would you take if the observationsaltered to both the insertion site and limb

observations?

Why is it important to observe the insertion siteregularly?

Demonstrates the set up of an arterial line insertion

Gathers equipment to set up

Attaches label with Date and Time Why is it important to maintain an appropriatepressure in your pressure bag?

What pressure should your pressure bag be kept at?



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Element 5 Managing Arterial lines


Management of an Arterial line

Performs and correctly documents arterial lineobservations on the CIS

How would you assess the accuracy of arterial lines? How can you tell if you have a dampened arterial

trace?

Checks alarm limits for arterial line at the beginningof shift and documents same correctly in CIS

How do you know what the alarm limits should beset at?

Demonstrates correct procedure for zeroing thetransducer

Why is it necessary to zero transducers and howoften should it be done?

Demonstrates an arterial line dressing as per unitprotocol

How frequently should your arterial line dressing beattended?

Demonstrates the method of securing an arterial lineas per unit protocol

Why is it important to make sure that your securingtape is not too close to the arterial insertion site?

Removal of Arterial line

Checks coag results before removal Why do coags need to be checked prior to removalof arterial line?

Checks with ICU team for any bloods to be takenbefore removal Demonstrates the removal of an arterial line as per

units policy How long do you need to apply pressure to the

insertion site for post removal of line?

Documents removal of line correctly on CIS Why is it important to document removal of thearterial line in the CIS?



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Element 6 PICCO


Insertion of PiCCO line:

Lists indications for PiCCO line insertions What are the possible insertion sites for PiCCO linesand what is the reason for this?

Why do we need a CVC and where would it need tobe? Gathers machine and equipment required Demonstrates the set up of an PiCCO line insertion Outlines the potential risks of an PiCCO line

Management of a PiCCO line

Performs and correctly documents PiCCO lineobservations hourly on the CIS

How would you assess the accuracy of PiCCO lines? What parameters do you document each hour? What do the following abbreviations stand for:

- CO / CI?- SVR / SVRI?- EVLW / EVLWI?

Checks alarm limits for PiCCO on Marquette monitor atthe beginning of shift and documents same correctly inCIS

Demonstrates correct procedure for gaining accuratewaveform on Marquette monitor

Why is it necessary to zero transducers and howoften should it be done?

Demonstrates PiCCO calibration procedure How often do we need to calibrate the PiCCO? What lumen on the CVC is needed for effective

calibration of the PiCCO?

Why do we need a CVP to calibrate the PiCCO? Documents extra parameters once machine calibrated Demonstrates an PiCCO line dressing as per unit

protocol

Demonstrates the method of securing an PiCCO line Why is it important to observe the insertion siteregularly?


Element 6 PICCO


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Element 6 PICCO


Removal of PiCCO line

Checks coagulation results before removal Why do coags need to be checked prior to removal Checks with ICU team for any bloods to be taken

before removal of line

Demonstrates the removal of an PiCCO line as perunits policy

How long should a PiCCO line remain in?

Documents removal of line correctly on CIS How long do you need to apply pressure for at theinsertion site post removal?

Element 7 Vasoactive / anti arrhythmic drug therapy


Outline the properties of these drugs & the management of the infusions Why is it important to keep vasoactive drugs on the

same lumen?

Which lumen do the vasoactive drugs run on? What are the nursing responsibilities when running

vasoactive drugs?

Adrenaline Noradrenaline Dobutamine Vasopressin Levosimendin GTN Amioderone Why does Amiodarone have to go in a glass bottle after

the initial loading dose?



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Element 8 Pulmonary Artery Catheters


Indications for PA Catheter

Outline the need for PAC insertion What are the indications for PA monitoring

Set up for PAC insertion

Gathers equipment needed for line insertion Assists Dr with insertion What are the risks of PAC insertion?

What is the importance of ECG monitoring duringline insertion?

Nursing Responsibilities with PACs

Outlines the need for measuring placement ofcatheter regularly

Why is placement important?

Outlines the need to ensure balloon syringe is notdepressed when not doing a measurement

What if balloon is inflated?

Outlines importance of continuous PA monitoring Why is it important to continuously visualize PAtrace on monitor?

What is the importance of recording themeasurement regularly?

Performing a PCWP measurement

Informs the patient about the procedure that is aboutto take place

Demonstrates appropriate positioning of patient foracquiring a wedge pressure

Demonstrates ability to correctly zero pulmonaryartery catheter and record pressures in the CIS

Demonstrates ability to perform a wedge safely forno longer than the maximum time limit.

Who routinely performs a PCWP measurement? Where does the balloon inflate when doing a

measurement?

What is the absolute time limit for balloon inflation?

Why is it important not to leave the balloon wedgedfor too long?

What is a major, serious side effect of over inflatingor prolonged wedging of balloon?

Demonstrates the locking off of the wedging syringeand safe securing of same

Why is this important?



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COMPETENCY:- FLUIDS AND ELECTROLYTES

Aim of Competency

Assessment of patients fluids and electrolytes Provide safe and affective care to patients receiving renal support such as dialysis


1. Fluids / Electrolytes / Pathology Results2. Peritoneal Dialysis3. CVVHDF4. EDD-f5. IDC



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Element 1 Fluids


Fluids

Accurately documents fluid balance chart in CIS What are the signs and symptoms of fluid overload? What are the signs and symptoms for dehydration?

Outline the difference between a crystalloid andcolloid.

What is the difference between a crystalloid and acolloid?

Blood products

Demonstrate the correct procedure foradministering blood products

Why is it important to warm pack cells whenadministering through a CVC?

What other fluids can blood products run with on asingle lumen?

Electrolytes

Can locate pathology results on the CIS Can identify acceptable electrolyte levels What are the potential risks for a patient with an

abnormal potassium level?

How fast can potassium be given via a: Central line? Peripheral cannula?

Element 2 Peritoneal Dialysis


Outlines reasons for peritoneal dialysis Why would a patient need to receive peritonealdialysis?

PD set up

Verifies order in Fluid Balance Chart

Gathers equipment needed for procedure Warms PD fluid to appropriate temperature Why does PD fluid need to be warmed?


El t 2 P it l Di l i


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Element 2 Peritoneal Dialysis


Managing PD

Connects bag to patients catheter aseptically Why is asepsis important when the patient wouldnormally do this procedure at home?

Drains dwelling fluid and records weight in fluidbalance chart

Why is it important to accurately chart both theinput and the output of peritoneal dialysis?

How much fluid do you need to remove during PD?

Runs PD fluid into abdominal cavity Once completed, attaches new cap to patients

catheter aseptically

Element 3 CVVHDF


Indications for CVVHDF

Outlines the indications for CVVHDF What does CVVHDF stand for? What is the difference between dialysis and

filtration?

CVVHDF Set up

Gathers machine and equipment needed to set upCVVHDF

Checks electrolyte levels and fluid orders fromteam

Why is it important to check the patients electrolytelevels?

What is osmosis? Demonstrates set up and priming of

Prisma Prismaflex

What is the difference between pre and post filter?

Sets treatment parameters on machine Removes Heparin lock from Vas Cath If there are no labels on the lumen how do you

know if the lumen has been heparin locked or not?

Connects patient and observes hemodynamicstatus once treatment is commenced


Element 3 CVVHDF


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Running CVVHDF

Can appropriately troubleshoot alarms What actions would you take for the followingalarms

High access pressure? Access disconnection?

Monitors patients hemodynamic status duringtreatment

What parameters must be observed when startingtreatment and why?

Documents correct parameters in the CIS Why is it important to chart pressure levels on theCIS when they have no bearing of the fluid status

Ensures regular EUCs are taken during treatment Why is this important

Changes fluid removal appropriately to maintaindesired balance

When would you increase the amount of fluid to beremoved from the prisma/prisma flex?

Ceasing treatment

Returns blood back to patient once treatmentceased

Why is it necessary to return blood? When would it not be appropriate to return the

blood?

Disposes of circuit appropriately, cleans machineand returns machine to storage area

What parts of the circuit are disposable?

Vascath line care

Demonstrates a Heparin lock of a Vascath What is the concentration of Heparin used in aHeparin lock and how much do you inject to Heparin

lock a Vas Cath?

Outlines the dressing protocol for a Vascath Why is it important to be able to se the line insertionsite once the dressing is completed?

How frequently should a line dressing be attended?


Element 4 EDD-f


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Element 4 EDD f


EDD-f Set up

Outlines the indications for EDD-f What does EDD-f stand for? Gathers machine and equipment needed to set up

EDD-f Explain equipment needed to perform EDD-f.

Checks electrolyte levels and fluid orders fromteam

Why is it important to check the potassium andsodium bicarbonate orders before set up of themachine?

Demonstrates set up and priming of Freseniusmachine

What needs to be checked on the machine beforepriming can take place?

What is the difference between pre and post filter? Sets treatment parameters on machine:

- UF Menu- Dialysate menu

What are the correct parameters?

Removes Heparin lock from Vas Cath How do you remove a heparin lock from a vas cath Connects patient and observes hemodynamic

status once treatment is commenced

What parameter must be observed when startingtreatment and why?

Why is it important to monitor the patients Apptduring treatment?

Running EDD-f

Can appropriately troubleshoot alarms What actions would you take for the followingalarms:

High access pressure? Access disconnection?

Monitors patients hemodynamic status duringtreatment

Documents correct parameters in the CIS


Element 4 EDD-f


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Element 4 EDD f


Ceasing treatment

Returns blood back to patient once treatmentceased

Why is this necessary? When would it be inappropriate to return blood?

Ensures EUCs are taken after treatment Why should EUCs be attended post treatment?Heparin locks Vas Cath once treatment ends What is the concentration of Heparin used in a

Heparin lock and how much do you inject to Heparin

lock a Vas Cath?

Disposes of circuit appropriately, cleans machineand returns machine to storage area

Element 4 IDC Insertion


Insertion

Outline the indications for IDC insertion How much urine does the patient pass if they are: Anuric? Polyuric? Oliguric?

Gathers equipment needed How do you assess the catheter size for eachperson?

Inserts IDC as per policy for Male Female

Outlines the reasons and times for collecting aurine culture

Removal of IDC

Demonstrates removal of IDC If the patient has not passed urine after removal, howlong do we wait before re insertion of IDC?


COMPETENCY:- GASTROINTESTINAL CARE


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Aim of Competency

Assessment of patients Gastrointestinal system Provide safe and affective care to patients receiving entral feeding


1. Gastrointestinal Assessment2. Nasogastric Tube Insertion3. Entral Feeding4. Total Parental Nutrition (TPN)


Element 1 GIT Assessment


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Inspects & palpates the patients abdomen,observing for bruising or marks and any structural

abnormalities

What is the difference between guarding andrebound pain?

Auscultates the patients abdomen. Checks forbowel sounds in all four quadrants

How long should you listen for bowel sounds untilyou can say they are absent?

Checks condition of stomas or colostomies What should stomas look like? Inspects patients abdomen X Ray, identifies any

abnormalities.

Documents all findings in CIS

Element 2 Nasogastric Tube Insertion


Nursing Responsibilities

Aspirates regularly and records amount in FluidBalance Chart

How often do we aspirate NG tubes? Do fine bore tubes get aspirated? How do you troubleshoot a blocked fine bore tube? What type of medications can not be given via an

NG tube?

Do you aspirate an NG tube that is on low wallsuction?

Ensures patent airway opened if NG is on freedrainage

Records amount of drainage in Fluid Balance Chart

and changes bag every 12 hours When does gastric drainage get charted when a

patient is on low wall suction?

Ensures Low Wall outlet is set appropriately whenNG is on Low Wall suction

Should there be an airway or a spigot in place whenthe NG is on low wall suction?

Records drainage amount in Fluid Balance Chart


Element 2 Nasogastric Tube Insertion


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Indications for insertion

Outline the reasons for NG tube insertion What is the difference between a Salem sump andfine bore?

Insertion

Gathers equipment for insertion What equipment is required for NG insertion? Explains procedure to patient Measure correct insertion length for patient How do you measure correct length of the NG? Inserts NG tube How do you tell if the NG has gone in the right

place?

What are the complications of insertion? Organises CXR post insertion to confirm placement Why is a post insertion X-ray important?

Element 3 Enteral Feeding


Indications for enteral feeding

Outlines the indications of enteral feeding What is the importance of starting NG feeds early ina patients ICU stay?

Set up of Feeds

Gathers equipment Confirms correct feed formula with doctors Aspirates NG prior to NG Feeds commencing Why should you aspirate the NG prior tocommencing feeds? Begins feeds at a rate of 30ml/hr


Element 3 Enteral Feeding


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Running NG Feeds

Aspirates NG after 4 hours What is the amount of aspirate required to stop NGFeeds?

Turns rate up by 30ml/hr every 4 hours until goalrate is reached

Why is it important to slowly turn up NG feedsslowly rather than going straight to goal rate?

Aspirate every 4 hours and document amountaspirated in Fluid Balance Chart

Ceasing NG Feeds

Outlines the reasons for ceasing NG Feeds Why is it important to check BSL and actrapid levelson completion of NG feeds?

Checks with team when ceasing NG Feeds How long before extubation should NG Feeds beceased?

Element 4 Total Parental Nutrition (TPN)


Set up of TPN lines

Gathers equipment needed to commence TPN Follows unit protocol for TPN set up and connection

including aseptic technique Why is aseptic technique required during set up of

TPN?

Why is it important that NO drugs or fluids are to begiven via the TPN line?

What is the only infusion that can run with TPN? Documents appropriate rates in Fluid Balance Chart


COMPETENCY NEUROLOGICAL CARE


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COMPETENCY:- NEUROLOGICAL CARE

Aim of Competency

Assessment of patients Neurological system Provide safe and affective care to patients with altered Neuro status


1. Neurological Assessment2. Chemical / Physical Restraints


Element 1 Neurological Assessment


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Accurately performs assessment of conscious levelusing the GCS

What are the three aspects assessed when using theGCS?

What is the lowest score you can get on a GCS?

Documents appropriately in CIS Demonstrates best method of applying a central

painful stimulus

Why is assessing central painful stimuli preferable

over assessing peripheral painful stimuli?

Demonstrates accurate assessment of pupilaryfunction

Performs assessment of limb movements Why is it important to make commands achievablefor your patient, i.e. poking your tongue out rather

than raising your arms and legs?

When assessing a motor response, why is itimportant to request that your patient both squeeze

and release your fingers?

Element 2 Chemical / Physical restraints


Sedation

Can appropriately document sedation scale in CIS How often should a sedation scale be done onpatients with sedation running?

Restraints

Charts restraints appropriately in the CIS Why is it important to chart both the GCS andsedation scale when restraints are applied?

What physiological/environmental/ psychologicalfactors can contribute to the need for restraints?

Removes restraints when not necessary Adheres to hourly limb observations when patient

restrained Why do limb obs need to be charted when a patient

is restrained?

Why is it important not to tie restraints to the top ofthe bed rail?


Element 2 Chemical / Physical restraints


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AWS

Chart AWS accurately in CIS and notifies healthcare team accordingly

Why is it important to get the patient to stretch their

fingers wide apart when checking for a tremor as a part

of the AWS?



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COMPETENCY:- SKIN AND WOUND CARE

Aim of Competency

Assessment of patients dressings, lines, drains and pressure areas Provide safe and aseptic wound dressing changes


1. Dressings2. Drains


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Element 1 Pressure Area Care



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Turns

How often do we do pressure area care on a:- Ventilated patient- Bed bound patient- Ambulatory patient

Why is documentation of turns important?What should you do if your patient refuses a turn?

Dressings

Demonstrate the appropriate dressing of apressure area

Why is PAC documentation so important with regardto pressure sores?

Should water filled gloves be used to dispersepressure from the heel profligately?

Air Mattress

Set up of Air Mattress When would you consider the use of an air mattressfor a patient?

Proning

Explain the reasoning behind proning How can proning improve a patients lung function? Demonstrates the preparation of a patient prior to

proning. How many staff are required to safely turn a patient

to the prone position?

What preparations are needed to ensure a smoothturn to the prone position?

Explains to the patient if appropriate what is goingto happen

Demonstrates the safe turning of a patient to theprone position

Ensures appropriate sedation is ordered for thepatient post turning. Monitors Hemodynamics and ventilation

parameters post turning. How do you monitor a patient in the prone position?What Hemodynamic and ventilator changes may be seen

when turning a patient prone?

Documents turn and appropriate PAC in CIS. What are some of the PAC and general bodyconcerns when turning a patient prone?



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COMPETENCY:- WARD ROUTINES

Aim of Competency

Admit a patient into the CIS and provide base line admission information Discharge a patient to the ward/other hospital with appropriate documentationElements of Competency

1. Admission2. Discharge


Element 1 Admission


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Element 1 Admission


Ensure all necessary equipment needed to set upbed area

What equipment is essential at all bed areas prior topatient admission?

Enters patients name and MRN into CIS andmonitor

How many digits are required in the MRN to beadded to the CIS correctly?

Ensures patient label is put into red admissionbook and patients name is on the whiteboard

Attaches leads to patient for monitoring Ensure patient identification band and allergy band

are insitu

Even though ICU nursing is usually one to one, whyis it important to ensure patient ID band and allergyband is on patient?

Ensures admission tests are carried out: 12 Lead ECG CXR

What initial tests/ procedures are carried out on allpatients at admission?


Element 2 - Discharge



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Q y p

Checks with TL regarding the discharge ward andtime the bed is available

Ensures discharge checklist is completed What is the importance of a properly filled outdischarge checklist?

Removes arterial line as per protocol Why should the arterial line be removed beforedischarge?

Collects patients belongings and completes theinternal transfer checklist

Why is it important to have a patient ID band on thepatient prior to discharge?

Ensures patients notes are up to date and printsout computer notes

Why is it important to put an entry in the patientsnotes prior to discharge?

Organises patients notes for transfer includingwritten medication chart and fluid order chart

Make up infusions with ward giving set Ring receiving ward to inform of any required

equipment (pumps, suction set up) Why should the receiving ward be rung before

transfer?

Page wards man Remove patient from monitor and transfer to ward Ensure patient is discharged from CIS and

Marquette monitor

Why is it important to remove the patient from the CIS

on discharge