Revise Skills Enhancement

BULACAN STATE UNIVERSITY City of Malolos, Bulacan College of Nursing

Name:___________________________ Year and Section:___________________ Group:____

STATION 1AIRWAY MANAGEMENT

Description: This station deals Objectives: At the end of this station, the student nurse will be able to:

Differentiate oxygen delivery system Perform proper suctioning technique using oropharyngeal airway, nasal trumpet, endotracheal

tube and tracheostomy tube. Provide tracheostomy care Demonstrate correct pulse oxymetry technique Administering oxygen by nasal cannula and face mask

ARTIFICIAL AIRWAY SUCTIONING Rating: ________Steps: Weight Score Remarks

1. Check physicians order. 1

2. Gather materials needed. 1

3. Greet the patient & explain the procedure. 1

4. Wash your hands. 1

5. Provide privacy. 1

6. Assess the patient’s breath sounds. 1

7. Prepare patient for suctioning. Positioning to 30-45 degrees or in semi-fowler’s position.

1

8. Turn on suction device. 1

9. Open catheter package (French 10-16 for adults) and fill basin with sterile saline solution.

2

10. Don sterile gloves and pick-up sterile catheter with dominant hand and attach end to suction tubing.

3

11. Check equipment by suctioning small amount of saline from basin.

1

12. Hyperoxygenate the patient. 1

13. Insert catheter ( without applying suction) until resistance is met or patient coughs.

2

14. Slowly withdraw catheter in a rotating motion, applying suction intermittently.

4

15. Allow patient to recover; clear tubing with saline. 2

16. Reassess patient after at least 1 minute and repeat procedure if needed.

2

Total Perfect Score = 25

Using a Pulse Oximeter Rating: ________Steps: Weight Score Remarks




4. Select an appropriate finger making sure to avoid thumb or an edematous site. Note: Remove nail polish or artificial nails.

2

5. Assess the pulse and capillary refill. 2

6. Clean the area with alcohol swabs. 1

7. Attach the prove to patient’s finger and make sure that both sensor probes are aligned directly opposite each other ( oximeter sensor contain both red and infrared light emitting diodes “LEDS” and a photo detector. the photo detector registers light passing through the vascular bed, the basis for microprocessor determination of oxygen saturation.

2

8. Connect the sensor probe unit. 1

9. Check for alarms 1

10. Read pulse oximeter. 1

11. Refer for any abnormal reading. 1


Administering Oxygen by Nasal Cannula and by face mask Rating: ________

Steps: Weight Score Remarks1. Explain procedure to the patient and review

safety precautions necessary when oxygen is in use. Place a “No smoking” signs in appropriate areas.

3

2. Perform hand hygiene. 1

3. For nasal cannula: Connect nasal cannula to oxygen set up

humidification, if one is in use, adjust flow rate as ordered by physician. Check that oxygen is flowing out of prongs. Provide tracheostomy care

Place prongs on patient’s nostrils, adjust according to type of equipment.

Over and behind ear with adjuster comfortably under chin or around the Patient’s head.

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4. For face mask: Attach face mask to oxygen set up

humidification. Start flow of oxygen at specified rate. For a mask with a reservoir, allow oxygen to fill bag before placing a mask over patient’s nose and mouth.

Position face mask over patient’s nose and mouth. Adjust it with the elastic strap so mask fits snugly but comfortably of on face.

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Adjust the flow rate.

5. Use gauze pads at ear beneath tubing as necessary to reduce irritation on patient’s ear and scalp.

1

6. Encourage patient to breath through the nose with mouth closed for nasal cannula.

1

7. Wash hands 1

8. Remove mask and dry skin every 2 to 3 hours if oxygen is running continuously. do not powder around the mask.

1

9. Assess and chart patient’s response to therapy

2

10. Document the type of mask used, the amount of oxygen used, the oxygen saturation, the lung sounds and the rate/pattern of respirations.

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STATION 2TUBE MANAGEMENT

Description: This station introduces procedures in providing respiratory care to prevent respiratory complications and to promote effective gas exchange. Objectives: At the end of this station, the student nurse will be able to:

Assist in Nasogastric tube insertion Determine proper placement of NGT Administer tube feeding Discontinue NGT Perform catheterization for both male and female patients (indwelling or straight catheter)

Assisting in Nasogastric Tube Insertion Rating: ________ Steps: Weight Score Remarks

1. Check physicians order. 12. Gather materials needed. 13. Greet the patient & explain the procedure. 24. Place the patient to semi to high fowler’s

position with pillows behind head and shoulders.

1

5. Examine nostrils and select the most patent nostrils by having the patient breath through each one.(the student nurse will mention steps 6, 7, 8, & 9 instead of performing the steps ).

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6. Determine length of tube to be inserted and mark with tape. For placement in stomach, measure distance from tip of the nose, to ear lobe, to xiphoid process of the sternum.

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7. Wearing clean gloves, lubricate the tube using KY jelly and begin insertion gently through the nostrils to back of throat (posterior nasopharynx) with the patient position with head up. When the tube reaches back of throat, allow the patient to relax a moment.

5

8. Encourage the patient to swallow the tube. (if possible, give water with straw to facilitate swallowing ). Advance tube as patient swallows until desired length has been passes.

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9. Check position of tube in the back of throat with tongue blade.

Check placement of tube; proper placement is

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essential With catheter tip syringe, inject 10-15 ml of air

through the NG tube and listen with the stethoscope over for a rush of air or “whoosh” sound or gently aspirate for gastric fluid; measure pH. Gastric pH ranges 1 to 4.

If tube is not in the stomach, advance another 2.5-5 cm(1-2 inches) and again check position.

10. Secure tube to nose with tape. 1

11. Document the procedure. 1


Checking for NGT Placement Rating:________Steps: Weight Score Remarks

1. Gather materials needed 1

2. Identify the type of feeding tube used by the patient. Note: the top of the Salem sump (for irrigation) lies in the stomach while the tip of the Duofeed (for feeding) lies in the duodenum.

2

3. Wash hands. 1

4. Ask the patient to speak. if the patient is unable to talk, the tube is in the trachea.

2

5. Inspect the posterior pharynx for presence of coiled tube.

1

6. Draw up to 10-20 ml of air into catheter tipped syringe and attached at the end of the tube. Auscultate the left upper quadrant of the patient’s abdomen while quickly ejecting air into the tube.

3

7. Aspirate gently back on syringe to obtain gastric contents, Observe the color

2

8. Measure and return aspirated gastric content to prevent metabolic alkalosis.

2

9. Document the findings 1


Administering Tube Feeding Rating: ________Steps: Weight Score Remarks




4. Assess the type of tube used for enteral feeding (nasoenteric tube, gastrostomy tube, or jejunostomy tube)

1

5. Elevate patient’s head of bed 1

6. Verify tube placement and measure residual. 2

7. Aspirate the gastric secretions with syringe noting volume and pH. Return aspirated contents and flush with 30cc of water.

3

8. If aspirate volume is >100 ml, do not return the contents; hold feeding and notify the physician (or as per institutional policy.)

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9. If pH suggest improper placement of tube, hold feeding and notify the physician.

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10. Initiate feeding. Intermittent Feeding: Obtain desired amount of formula (room temperature) If using a feeding bag, place formula in the bag

and prime tubing. Attached distal end of tubing to proximal end of feeding; adjust rate flow with the roller clamp or feeding clamp. Infusion time varies depending on volume.

If using a syringe, remove barrel of syringe and insert syringe tip into the feeding tube. Pour desired amount of formula in upright syringe held 12-18 in above the insertion site. Allow formula to flow in by gravity.

upon completion of feeding, follow with 30 ml flush of water (or as specified), and clamp tubing.

Continuous Feeding: Pour formula (no more than volume to be

delivered in 4 hours) in feeding bag and prime tubing. Connect tubing through the feeding pump and attached distal end of feeding tube. Set hourly rate and begin infusion rate. Flush tube with 30 ml of water every 4-6 hours.

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11. Monitor for complications Intolerance of feeding (nausea, fullness, gastric

residual >100 ml). Aspiration formula. Diarrhea for than 3 times in 24 hours. Hyperglycemia (monitor in glucose) Fluid imbalance (monitor I&O)

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12. Document the findings 1Total Perfect Score = 30

Discontinuing NGT Rating: ________Steps: Weight Score Remarks

1. Check physicians order for NGT removal and materials needed.

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3. Wash your hands and provide privacy 2

4. Provide tissue and place towel over the patient’s chest.

2

5. Flush NGT with 20 ml water to clear tube so that the GI contents do not inadvertently drain into

6. esophagus on tube removal.

1

7. Follow water flush with a bolus air to free tube from the stomach lining.

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8. Loosen the tapes that secure tube to the patient’s nose.

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9. Turn off suction and disconnect NGT. 2

10. Plug tube or clamp it by folding it over in your gloved hand.

2

11. Pinch tube close to the patient’s nares, have patient take a deep breath and hold it a while you withdraw the tube. Holding breath closes the glottis and helps prevent aspiration.

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12. Wrap tube in paper towel to remove the patient’s view.

1

13. Offer oral and nasal hygiene. 1

14. Empty and record the amount and character of drainage.

2

15. Discard disposable equipment and return reusable equipment to appropriate area.

2

16. Remove and dispose of gloves and wash hands. 2

17. Document the findings and patient’s response. 2


Insertion of a Urinary Catheter Rating: ________Steps: Weight Score Remarks




4. Wash hands and provide privacy. 2

5. Position the patient in supine for male and dorsal recumbent for female to provide good visualization of urinary meatus.

1

6. Drape to provide maximum modesty. 1

7. Set up equipment. Open catheterization kit. Do sterile gloves Organize supplies within the kit. Test balloon (if inserting indwelling catheter)

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8. Apply sterile drape, maintaining sterile technique.

Female: tuck under the buttocks. Male: place over thighs just below the penis.

2

9. Clean urethral meatus. Female: Spread labia with non dominant

hand (maintain this position until catheter is inserted); pick up povidone iodine soaked cotton ball with forceps; wipe from back (clitoris to anus) on each side of the labia, then directly over center of urethral meatus (using a new cotton ball for each wipe).

Male: Grasp the penis at the shaft just below the glans with non dominant hand; pick up povidone iodine soaked cotton ball with forceps; clean tip of the penis in circular motion from meatus down to the base of glans- repeat at least 3 times (using a new cotton ball each time)

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10. Insert the catheter. 5

Pick up lubricated catheter with dominant hand and insert distal end through urethral meatus. Advance catheter until urine flows (2-3 inches females, 7-9 males); upon flow, advance another 1-2 inches.

Straight catheterization: drain urine from bladder using basin; when bladder is empty, ask the patient to hold breath and gently remove the catheter.

Indwelling catheter: inflate balloon and place drainage bag below level of bladder; secure catheter to patient’s leg (female) or abdomen (male).

11. Complete procedure. Remove supplies, remove providone iodine

from skin.

2

12. Document the procedure noting the color and volume of urine and patient’s response to procedure.

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STATION 3INTRAVENOUS MANAGEMENT

Description: This station introduces procedures that would ensure that correct intravenous fluid and amount is administered to the patient using the appropriate equipment.. Objectives: At the end of this station, the student nurse will be able to:

Described and state principles and procedures in IV management Assist in inserting a peripheral IV for fluid and electrolyte, medication and blood access Monitor and evaluate an IV infusion and using of infusion pump Change IV solutions, IV tubings, IV dressings, and IV sites

Discontinuing IV lines Initiating, maintaining and terminating a blood transfusion Flushing a central venous catheter Changing the central venous dressing.

Assisting in Peripheral IV Insertion Rating: ______Steps: Weight Score Remarks

1. Check Physician’s order 1

2. Gather Materials needed and choose appropriate needs/catheter

1

3. Greet the patient and explain the procedure. 1

4. Wash hands before and after procedure. 2

5. Hang solution bag and primed administration set within easy reach. (Since only IV Therapists are allowed to do IV insertion, students nurse is required to mention the following steps in number 6,7,8,9,10,11,12 & 13).

2

6. Choose site for IV. If possible, select a vein on the patient’s non dominant arm. Distal end of the vein should be selected first while reserving the proximal areas for future IV therapy.

2

7. Apply tourniquet 5-12 cm. (2-6 inch) above injection site depending on condition of patient. Tourniquet traps blood and Engorges vein for better visibility.

2

8. Check radial pulse below tourniquet. 1

9. Prepare site with antiseptic solution according to hospital policy or cotton wipes with alcohol in a circular motion and below 30 seconds to dry. Do not touch the disinfected site.

2

10. Using the appropriate IV cannula, pierce skin with needle positioned in 15-30 degree angle. Insert the IV cannula in the direction of venous return or towards the heart to avoid damaging the venous valve

4

11. Upon flashback Visualization, decrease the angle and advance the catheter and stylet (1/4 inch) into the vein

2

12. Position the IV catheter parallel to the skin. Hold stylet stationary and slowly advance the catheter. Until the hub nearly meets the puncture site. Use the one hand technique or 2 hand technique. Never insert the catheter cannula until the hub for patient safely

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13. Slip sterile gauze under the hub. Release the tourniquet; remove the stylet while applying digital pressure over the catheter with one finger about ½ inches from the tip of the inserted catheter

4

14. Open the clamp, regulate the flow rate 2

15. Anchor needle firmly in place with the use of:

Transparent tape/dressing directly on the puncture site

Tape using any appropriate anchoring stylet Note: Never place unsterile tape directly on IV insertion site, instead place a small piece of sterile gauze & then secure it with adhesive tape

1

16. Tape a small loop of IV tubing for additional anchoring; apply splint. 2

17. Calibrate the IVF bottle and regulate flow of infusion according to prescribed duration.

118. Label on IV tape near the IV site to indicate

the date of insertion, type and gauge of IV catheter and countersign

1

19. Label with tape or appropriate label on the IV tubing to indicate the date when to change the IV tubing

1

20. Observe and report any untoward effect 1

21. Discard sharps and waste according to hospital policy.

1

22. Document in the patient’s chart and endorse to the incoming shift. 2

Total Perfect Score = 40Using an Electronic Flow-Control Device

(Infusion Pump) Rating: ______Steps: Weight Score Remarks

1. Explain every step of the procedure to the patient

1

2. Wash hands 1

3. Spike IV solution bag 1

4. Fill drip chamber to maximum ½ full. This amount allows sufficient air space in drip chamber

1

5. Prime tubing by opening and regulating the clamp slowly and allowing tubing to fill with IV solution. If using cassette tape tubing, follow package instructions to connect the cassette portion of the tubing that edges into the control device

If alarm sounds, check the following:

Infusion complete – when the exact volume to be delivered is set and volume limit has been reached, alarm sounds and machines goes to KVO or “Keep Vein Open” mode. Establish if the total volume of the container is delivered; change the solution container if needed, and reset the volume to be infused.Occlusion – all devices sounds an alarm when they cannot maintain delivery in the face of increasing resistance. In this instance, check the insertion site for infiltration, and look for position problems, pinched tubing, and closed clamp. Turned stopcock or clogged filterOther problems – other messages may indicate “air in the line”, “Low battery”, “cassette”,(Improper loaded), or ‘free flowNursing action: check trouble spot carefully, readjust and restart the infusion

3

6. Follow manufacturer’s instruction to load administration set into device, taking care to fit tubing and cassette into appropriate receptor sites. (the multiple-channel pump can infuse 3 different IV solutions at one time)

2

7. Close device door to latch1

8. Don gloves 1

9. Check that the patient’s venipuncture site if free from signs of vein irritation or infiltration

1

10. Connect administration set tubing to established infusion site protective cap using a needleless cannula 1

11. Open regulating clamp on administration set 1

12. Turn device on

13. Measure device parameters for operation, again following manufacturer’s instructions or machines set ups prompts

Parameters may include: Infusion (e.g primary) Volume to be infused Rate (ml/hr) Vary; mmHg, cmH2O or psi

4

14. Start device when parameters are set 1

15. Observe that infusion is running properly1

16. Remove Gloves and wash hands2

17. Check the patient’s infusion site frequently

118. Document procedure

1Total Perfect Score = 25

Changing IV Solutions and Tubing Rating: ___________Steps: Weight Rating RemarksNote: IV solutions are change every 24 hours while IV tubing is change every 48-72 hours

1. Check Doctor’s order for the new solution to infused

2

2. Gather Materials needed 1

3. Greet t5he patient and explain the procedure.

2

4. Wash hands 1

5. Clamp the tubing on the administration set

1

6. Invert the solution bag and remove the spike

2

7. Remove protective cap from the new tubing

1

8. Spike the new tubing to the solution bag 1

9. Reopen the clamp and adjust the flow rate

2

10. Release the clamp to allow IV flow through tubing

111. Remove old administration set and insert

new IV tubing into extension tubing 2

12. Open clamp of new tubing, with short extension tubing taped in place. Label 4

the tape on the IV tubing to indicate the date when to change the IV tubing


Discontinuing IV Lines Rating:_____________Steps: Weight Score REMARKS

1. Check physician’s order. 1

2. Gather equipment. 13. Wash hands and don clean gloves. 24. Explain every step of the procedure to

the patient.1

5. Turn off IV infusion. 16. Loosen dressing and tape, peeled

dressing edges back toward puncture site. Minimize trauma to puncture site.

2

7. Stabilize needle or catheter while removing dressing and tape. Stabilizing the site prevents unnecessary movement that could injure the vein.

2

8. Remove needle/catheter carefully and smoothly, keeping it almost flush with the skin. Do not press down on top of the needlepoint while it is in the vein.

3

9. Quickly press the sterile pad over the venipuncture site and hold firmly. Pressure on the puncture site prevents bleeding.

3

10. Apply clean pad and tape in place. 211. Elevate but do not bend arm at elbow.

Bending elbow causes hematoma formation while elevating arm reduces pressure and helps to collapse vein.

2

12. Observe venipuncture site for redness, swelling or hematoma.

3

13. Dispose of equipment and gloves according to hospital policy.

2

14. Wash hands. 115. Check the site again in 15 minutes. 116. Record volume infused on Input &

Output sheet.1


Adding Medication to an Intravenous Solution Rating: ______________Steps: Weight Score REMARKS

1. Gather all equipment and bring to patient’s bedside. Check medication order against physician’s order.

2


3. Identify patient by checking the band on the patient’s wrist and asking patient his or her name. Check for any allergies the patient may have.

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4. Explain the procedure to the patient. 1

5. Add medications to IV solution that is infusing.

Check that the volume in bag or bottle is adequate.

8

Close IV clamp. Clean medication port with alcohol swab. Steady container. Uncap needle or

needleless device and insert into the port. Inject medication.

Remove container from IV pole and gently rotate solution.

Rehang container, open clamp and readjust flow rate.

Attach label to container so that dose of added medication is apparent.

6. Add medication to IV solution before infusion.

Carefully remove any protective cover and locate injection port. Clean with alcohol swab.

Uncap needle or needleless device and insert into port. Inject medication.

Withdraw needle and insert spike into proper entry site on bag or bottle.

With tubing clamped, gently rotate IV solution in the bag or bottle. Hang the IV bag.

Attach the label to the container so that dose of added medication is apparent.

6

7. Dispose of equipment according to agency policy.

1


9. Chart addition of medication to IV solution. 1

10. Evaluate the patient’s response to medication within appropriate time frame.

1


Adding a Bolus Intravenous Medication to an Existing Intravenous Line Rating: __________

Steps: Weight Score Remarks1. Gather equipment and bring to patient’s

bedside. Check medication order against physician’s order. Check a drug resource to clarify if medication needs to be diluted before administration.

3

2. Explain procedure to the patient. 1

3. Perform hand hygiene. Don gloves. 2

4. Identify patient by checking the hand on the patient’s wrist and asking his or her name.

1

5. Assess IV site for presence of inflammation or infiltration.

1

6. Select the injection port on the tubing closest to the venipuncture site. Clean port with alcohol swab.

2

7. Uncap syringe. Steady port with your non dominant hand while inserting needleless device or needle into the center of port.

2

8. Move your non dominant hand to the section of IV tubing just beyond the injection port. Fold the tubing between your fingers to temporarily stop the flow of IV solution.

2

9. Pull back slightly on plunger just until blood appears in tubing between your fingers to temporarily stop the flow of IV solution.

2

10. Inject medication at the recommended rate.

1

11. Remove needle. Do not cap it. Release tubing and allow IV fluid to flow at the proper rate.

3

12. Dispose of syringe in proper receptacle. 1

13. Remove gloves and perform hand hygiene.

2

14. Chart administration of medication. 1

15. Evaluate patient’s response to medication within appropriate time frame.

1


Administering a Blood Transfusion Rating: _______________Steps: Weight Score Remarks

1. Determine whether the patient knows reason for transfusion. Ask if patient has had a transfusion or transfusion reaction in the past.

2

2. Explain procedure to the patient. Make sure there is a signed consent for transfusion, if required by the agency. Advice the patient to report any chills, itching, rash or unusual symptoms.

3

3. Perform hand hygiene and put on gloves. 2

4. Hang container of 0.9% normal saline with blood administration set to initiate blood infusion and follow procedure for administration of blood.

2

5. Start IV with a gauge 18 or 19 catheter, if not already present, start an IV infusion. Keep IV line open by starting flow of normal saline.

3

6. Obtain blood product from blood bag according to agency policy.

1

7. Complete identification and checks as required by agency:

Identification number Blood group and type Expiration date Patient’s name Unit and hospital number Type of blood product compared with

doctor’s order Inspect blood for clots

8

8. Wash hands and put on gloves. 2

9. Take baseline set of vital signs before beginning transfusion.

1

10. Open blood administration kit and move roller clamps to “off” position,

1

11. For Y-tubing set: Spike the 0.9% sodium chloride bag and

open roller clamp on Y-tubing connected to bag and roller clamp on unused inlet tube until tubing from 0.9% sodium chloride bag is filled. Close clamp on unused tubing.

Squeeze sides of drip chamber and allow filter to partially fit.

Open roller clamp and allow tubing to fill with 0.9% sodium chloride.

Close tower clamp. Invert blood bag once or twice. Spike

blood 5bag and open clamps on inlet tube to allow blood to cover filter completely.

Close lower clamp.

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12. For single tubing set: Spike blood unit. Squeeze sides of drip chamber and allow

filter to partially fill. Open roller clamp and allow tubing to fill

with 0.9% sodium chloride. Open roller clamp and allow tubing to fill

with blood to hub. Prime another IV tubing with 0.9% sodium

chloride and piggyback it to blood administration set with a needle, secure all connections with tape.

5

13. Attach tubing to venous catheter using sterile precautions and open lower clamps.

2

14. Start infusion of blood product. 1

15. Prime in-line filter with blood. Start administration slowly (no more than

25-50 ml for first 15 minutes). Stay with patient for first 5 to 15 minutes of transfusion.

Check vital signs at least every 15 minutes for the first half hour after start of

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transfusion. Follow the institution’s recommendations for vital signs during the remainder of the transfusion.

Observe patient for flushing, dyspnea, itching, hives, or rash.

Use a blood-warming device if indicated, especially with rapid transfusions through a central venous catheter.

16. Maintain prescribed flow rate as ordered

or as deemed appropriate by the patient’s overall condition, keeping in mind the outer limits for safe administration. Assess frequently for transfusion reaction. Stop blood transfusion and allow saline to flow if you suspect a reaction. Notify physician and blood bank.

4

17. When transfusion is complete, infuse 0.9% normal saline.

1

18. Record administration of blood and patient’s reaction as ordered by agency. Return blood transfusion bag to blood bank according to agency policy.

2


Blood Glucose Monitoring Rating: _____________Steps: Weight Score Remarks1. Determine the specific condition needed to met before sample collection. Check physician’s order.

1

2. Prepare needed equipment and supplies:a. Blood Glucose chartb. blood glucose reagent stripc. disposable glovesd. sterile lancete. alcohol wipesf. cotton balls

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3. Wash your hands and instruct the client to wash hands with soap, warm water, if able.

2

4. Remove reagent strip from the container and tightly seal the cap.

1

5. Apply disposable gloves. 1

6. Choose the puncture site: side of the finger (adult) or outer aspect of the heel (infant).

2

7. Hold the finger to be punctured. 2

8. Smear the strip after 1 minute. 2

9. Apply pressure to puncture site. 3

10. Wait 60 seconds and compare test strip with the color scale

3

11. Wait for additional 60 seconds and match the color chart for result.

1

12. If color chart indicates reading darker than 240 mg/dl, wait for another 60 seconds and compare the test strip with the color scale.

1

13. Check physician’s order and glucose level, 2

describe response including appearance of puncture site. Report abnormal blood glucose levels to physician.14. Document the procedure and glucose level; describe response including appearance of the puncture site. Report abnormal glucose level to the physician.

1


STATION 4CRITICAL CARE AND MANAGEMENT

Description: This station deals with carrying out emergency resuscitation procedures, whether in the street, at home, or in any healthcare facility.

Objectives: At the end of this station, the student nurse will be able to:1. Apply ECG leads properly. 2. Obtain cardiac tracing via ECG machine.3. Apply Cardiac Monitor appropriately.4. Obtain a clear waveform that is free from artifact displayed on the cardiac monitor.5. Perform Cardiopulmonary Resuscitation without complications.6. Perform Emergency Defibrillation. (Asynchronous) properly.7. Elaborate the mechanism of action of drugs commonly used in medical emergency situations.

Obtaining an Electrocardiogram Rating: _____________Steps: Weight Score Remarks

1. Place the electrocardiogram ( ECG ) machine close to the patient’s bed and plug the power cord into the wall outlet.

1

2. Perform hand hygiene. Check the patient’s identification.

2

3. As you set up the machine to record a 12-lead ECG, explain the procedure to the patient. Tell him that the test records the heart’s electrical activity and it may be repeated at certain intervals. Emphasize that no electric current will enter his body. Also tell the patient that the test basically takes at least 5 minutes.

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4. Have the patient lie supine in the center of the bed with his arms at his sides. Raise the head of the bed if necessary to promote comfort. Expose the patient’s arms and legs and drape appropriately. Encourage the patient to relax the arms and legs. If the bed is too narrow, place the patient’s hands under his buttocks to prevent muscle tension. Also, use this technique if the patient is shivering or trembling. Make sure the feet are not touching the bed board.

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5. Select flat fleshy areas to place the electrodes. Avoid muscular and bony areas. If the patient has an amputated limb, choose a site on the stump.

2

6. If an area is excessively hairy, clip it. Clean excess oil or other substances from the skin.

2

7. Apply the electrode paste or gel or the disposable electrodes to the patient’s wrist

3

and to the medical aspects of his ankles. If using paste or gel, rub it into the skin. If using disposable electrodes, peel off the contact paper and apply the electrodes directly to the prepared site, as recommended by the manufacturer’s instructions. Position disposable electrodes on the legs with the lead connection pointing superiorly.

8. If using paste or gel, secure electrodes promptly after you apply the conductive medium. Never use acetone pads in place of the electrode paste or gel.

2

9. Connect the limb lead wires to the electrodes. The tip of each lead wire is lettered and color-coded for easy identification. The white or RA 8lead wire goes to the right arm; the green or RL lead wire, to the right leg; the black or LA lead wire, to the left arm, and the brown or V1 to V6 lead wires to the chest. Make sure the metal parts of the electrodes are clean and bright.

6

10. Expose the patient’s chest. Put a small amount of electrode gel or paste on a disposable electrode at each electrode position. Position chest electrodes as follows:

V1: Fourth intecostal space at the right sterna borderV2: Fourth intercostals space at the left sterna borderV3: Halfway between V2 and V4V4: Fifth intercostals space at midclavicular lineV6 Fifth intercostals space at anterior axillary line (halfway between V4 and V6)V6 Fifth intercostals space at midaxillary line, level with V4

8

11. Check to see that the paper speed selector is set to the standard 25 mm and that the machine is set to full voltage.

1

12. If necessary, enter the Appropriate patient identification data.

1

13. Ask the patient to relax and breathe normally. Tell him to lie still and not to talk when you record his ECG.

2

14. Press the AUTO button. Observe the tracing quality. The machine will record all 12 leads automatically, recording three consecutive leads simultaneously.

1

15. Some machines have a display screen so you can preview waveforms before the machine records them on paper. Adjust waveform if necessary. If any part of the waveform extends beyond the paper when you record the ECG, adjust the normal standardization and repeat. Note this adjustment on the ECG strip because this will need to be considered in interpreting the results.

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16. When the machine finishes recording the 12-lead ECG, remove the electrodes and clean the patient’s skin.

2

17. After disconnecting the lead wires from the electrodes, dispose off or clean the electrodes, as indicated.

2

18. Label the ECG recording with the patient’s name, room number, and facility administration, if not done by the machine. Also record the date and time as well as any clinical information on the ECG. Document the test’s date and time as well as significant responses by the patient I the medical record.

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STATION 5INTEGRATION OF CRITICAL THINKING SKILLS AND NURSING PROCESS

Description: This station deals with the critical thinking abilities and decision making skills of the student nurse as she/he utilizes the nursing process in providing care to her/his patients.

Objectives: At the end of this station, the student nurse will be able to:- Quickly assess the case presented- Identity priorities of care- Formulate possible nursing diagnoses- Rationalize relevant nursing interventions- Evaluate plan care

HYPOTHETICAL CASES:

1. PNEUMONOCCAL PNEUMONIA2. CARDIAC ARREST3. STATUS ASTHMATICUS4. SUBARACHNOID HEMORRHAGE5. STROKE6. RECTAL PAIN and BLEEDING7. RHEUMATOID ARTHRITIS8. DECUBITUS ULCER9. MULTIPLE SCLEROSIS10. INFECTIOUS HEPATITIS11. ACUTE ABDOMINAL PAIN12. OSTEOARTHRITIS13. WOMAN in LABOR REQUIRING FETAL MONITORING14. A HYSTERECTOMY PATIENT15. A POST MASTECTOMY PATIENT

Instruction: Given a hypothetical situation, the student nurse will: Rating: _____________Steps: Weight Score Remarks1. Distinguish objective data and subjective data.

6

2. Identify one priority nursing diagnosis

2

3. Set objectives of care 24. Identify appropriate nursing interventions and rationalize.

5

5. Evaluate plan of care 5

Total Perfect Score= 20

Documents

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