N210 Control Lab/Clinical Folder
Table of Contents (page 1-2)
_____________________________________________________________________________
Student preparation for Scenario Days
2
SCP on VCE pt.
3
Oral Medication Modules
4
Patient Teaching Paper &
5-6
Patient Teaching Paper Grading Rubric
Time Management Schedule
7-8
9-13
Instructions for Medication Administration Scenario Day, MD
orders, and Medication Administration Record
Laboratory Learning Outcomes (Use these outcomes to guide your
reading for lab content)
Medical Asepsis/Infection Control
Control
Vital Signs
Mobility Techniques
Hygiene Measures
Documentation and Reporting
Safety: Restraints/Environment
Elimination
NGT intubation
Nutrition lab
Foley catheterization
Wound Management (Wound Care)
Nursing Skills Practice
Skills Videos List/Access
Nursing Skills Peer Check Off Sheet
Control Lab Sheets (to be used during control lab. Bring to control
lab)
Medical asepsis/Infection Control Lab Sheet
Vital Signs Skills Check Off Stations
Safety : Restraints/Environment Critical Thinking Questions
Elimination practice check off sheet
PA Documentation Guide- general survey
PA Documentation Guide-skin,hair, nails
PA Documentation Guide-head and neck
PA Documentation Guide-chest and lungs
PA Documentation Guide-heart and
peripheral vascular
PA Documentation Guide-abdomen
PA Documentation Guide- musculoskeletal
PA Documentation Guide-neurological
Physical Assessment Practicum grading
Sheet
Nasogastric Tube Critical Thinking
Questions
Nasogastric Tube Removal
Urinary Catheterization Critical Thinking
Questions
Catheter Removal
Wound care practice check off sheet
N210 Clinical References
Medication Administration Procedure
N210 Assessment Guide Guidelines
Roy Adaptation Model Reference Sheet for completing
Assessment Guide
N212 NPWAG Blank Form
9-14
15
16
17
18
19
20
21
22
23
24
25-27
28-31
32-33
34-35
36-37
38
39
40
41
42
43
44
45
46-47
48-49
50
51
52
53
54-55
56-57
58-59
60-61
62-66
1
Nursing Caremap Instructions
Sample Caremap Template
N212 Medication Sheet (for Non-Med Days)
N212 Medication Sheet (for Scheduled Med Days)
Sample Med Sheet for Non-Med Days
N210 Clinical Course Evaluation
Guidelines for Clinical Performance
Evaluation Tool
Approved abbreviations
Unapproved abbreviations
N210 Clinical Schedule Long TermCare
Clinical Absence Make-up guidelines
CPE Sheet
___________________________________________________________




67
68
69
70
71
72-78
79-83
84-86
87
88-90
91
92-99
Student Preparation for Control Lab/Scenario Days in Skills Lab
Review all previously taught skills
Bring Taylor’s Fundamentals of Nursing textbook
Wear complete uniform and name tag
References for documentation (class notes, abbreviation list, pen, etc.)
Personal Hygiene Measures Control Lab Day (Week 2 Wednesday)
 Bring:
 2 towels, 2 washcloth
 sports bra and shorts (for
females)
 1 soap (bar or liquid)
 shorts for males (boxer or briefs
 1 lotion
to wear underneath patient
 plastic bag to hold your wet
gowns are unacceptable)
towels after lab
Scenario Day #1
 Bring:
 Shorts and tank top or sports bra
 Soap
 Lotion
 Toothbrush




Toothpaste
Stethoscope
Washcloth and towel
Patient gown
Scenario Day #2
 Bring:
o Shorts and tank top or sports bra
o Stethoscope
o Isolation gown and mask
o Patient gown
2
Cerritos N210 Medical Surgical Nursing
Long Term/Acute Care Clinical Rotation
STANDARD CLINICAL PREPARATION: Nursing Process Worksheet Preparation
This activity will introduce you on how to navigate through the chart
to gather patient information while filling out your Nursing Process
Worksheet (NPW).
You will need the following materials:
 DVD on Standard Clinical Preparation (access online via N210
TalonNet site)
 Virtual Clinical Excursion (VCE) DVD-Rom. Complete the VCE patient
assigned to you by your instructor. TBA.
 A blank NPW form
Instructions:
1.
2.
Watch the v
ideo on Standard Clinical Preparation. (You may check out from the library or
watch online via TalonNet).
3.
Take notes for your reference.
4.
Using the VCE DVD-Rom, Go through the Virtual Clinical Excursion (VCE) and
practice looking through a patient’s chart. Choose the assigned patient from the
VCE e.g. Harry George, Piya Jordan and fill out a blank NPW form with the
patient information.
5.
Fill out the blank NPW as you go through the VCE chart (follow the steps as
shown in the Standard Clinical Preparation).
6.
Pay attention to “Course of Events in the hospital”. FILL OUT AND COMPLETE
THE PATIENT PREPARATION THINKING TOOL ON PAGES ______ ON THIS
CONTROL LAB FOLDER to assist you with the course of events in the hospital.
You will need to summarize this in your NPW as shown in the Standard Clinical
Preparation video.
7.
Turn in the completed NPW including lab data (significant normal lab results and
all abnormal lab results (NO NEED TO complete “Reason for Abnormal Values”
portion) of the NPW) of your VCE patient to your instructor by week 1
(THURSDAY) of N212.
8.
Practice with as many patients as you’d like. You may do this in pairs. Each
student is required to turn in 1 complete NPW for a VCE patient.
3
Name_________________
Lab___________________
Cerritos College
Nursing Department
N212: Medical Surgical Nursing
Oral Medication Module
Instructions: Complete 2 “patient” medication preparation scenarios by the medication
scenario day. You may work individually or in groups of two. You may complete as many
scenarios as you wish, but only two are required.
PLEASE DO NOT OPEN THE MEDICATION PACKAGES!!!!!!!!!!
1. Choose one patient.
2. Gather the MAR, physician’s order sheet and pull the medication drawer from the
medication cart for the patient you have chosen.
3. Review the physician’s order sheet and the MAR and check for accuracy. Note any errors
found.
4. Using your Mosby drug book, look up all of the medications ordered in preparation for
administration (despite times ordered).
5. Note any errors found.
6. Note any information you would need to gather before administering the medication: why
is this medication given (look at diagnosis and history), dosage and range, nursing
considerations (ex: antihypertensive medication, check BP before administration) and
common side effects (try to group side effects if possible (Ex: nausea/vomiting/diarrhea
should be GI distress). Complete dosage calculation if needed.
7. Remove the medications from the medication drawer in preparation for administration (5
“rights”). Note any errors or concerns.
8. Review the steps for administration that you would complete at the patient’s bedside (5
“rights”)
9. Complete the documentation below
10. Review the errors/concerns found with the N47 faculty member or N47 student worker and
have him/her sign below verifying completion.
11. Repeat the above steps for a second patient.
Date
Patient Name
Faculty/Staff Signature
*Submit this form (completed with faculty/staff signatures) on assigned DUE DATE to
your clinical instructor. Failure to do so will result in an advisement note.
4
Patient Teaching Paper (Taylor Chapter 22)
Each student will complete a Patient Teaching on an actual client that the student has cared for in this
clinical rotation.
Patient Teaching Paper will be a written essay of your patient teaching experience. It should be
submitted with a minimum of 1 page and a maximum of 2 pages (typed and double spaced).
You may include and submit brochures or handouts to enhance your teaching. Use different teaching
strategies or tool to deliver effective patient teaching. Be creative!
Patient Teaching Paper Guidelines
Requirements: The Patient Teaching Paper should include the following:
 Read the chapter readings on Patient Teaching (Taylor, Ch 22 Teacher and Counselor)
 Patient Teaching Paper should be Nursing focused (i.e. teaching provided should be in the
role of the Nurse, not physician, radiologist, dietician, pharmacist, etc.)
1. A complete NPW on the client including med sheets and assessment guide (do
not include concept maps).
2. Please read Chapter 22 of Taylor and write a paragraph describing the client
you taught which includes the following:
a.
A brief history of present illness (HPI)
b.
A description of client characteristics including details about any client variables/factors that
may affect the teaching/learning experience.
b.
Identify the patient’s “learning need” (see Taylor Ch 22- the content that the patient needs
to learn; patient’s learning style; developmental level, literacy level, language barrier if
applicable
c.
Identify the client’s readiness to learn (discuss the patient’s physiologic and psychological
readiness, willingness to make changes and participate, etc.)
d.
Identify any unique socioeconomic, cultural, and ethnic aspects (look at your client’s ethnic
background and consider any cultural factors that may affect the client’s learning and/or
health care practices. If identified, identify how you will tailor your patient teaching.)
3.What specific content taught based on the patient’s learning need?
4.Identify a specific “Patient Learning Outcome” for your patient (see page 480 Taylor).
5.What specific teaching strategies (e.g. demonstration, video, verbal, written or a combination) did
you use in patient teaching appropriate for your patient and situation and state the rationale for
choosing the specific strategy/ies.
6.Include an evaluation of your patient teaching. How did you evaluate the effectiveness of your
teaching? State specific client behaviors that demonstrates the effectiveness or ineffectiveness of your
patient teaching. If the teaching was ineffective, state the rationale and how you would approach the
client for a more effective teaching.
7.Attach your client’s completed NPW and Assessment Guide to your paper (Required). Attach
the Grading rubric when you submit this paper.
8.Include at least 2 references in the back of your paper. – must have at least 2 sources (e.g., Taylor,
Iggy, credible internet sites, etc.)
5
Patient Teaching Paper Grading Criteria
(Pass or Fail: 3/5 pts or greater= Pass)
Grading Rubric : Patient Teaching Paper
Student Name:
________________________________________
Clinical Instructor Name:
1
0.75
0.5
0.25
Content Accuracy
All content throughout
the paper is accurate.
There are no factual
errors. Information is
shortened to simple
phrases.
Most of the content is
accurate but there is
one piece of
information that might
be inaccurate.
Information is
presented in long
paragraphs.
The content is
generally accurate, but
one piece of
information is clearly
flawed or inaccurate.
Content is typically
confusing or contains
more than one factual
error. There is little or
no information.
Creativity
Student used several
teaching strategies
and showed
considerable
work/creativity and
which made the patient
teaching very effective
Student used 1
teaching strategy that
showed considerable
work/creativity and
which made the patient
teaching effective.
Student used 1
teaching strategy
which made the patient
teaching somewhat
effective.
Student used
ineffective or
inappropriate teaching
strategy/ies that made
the patient teaching
ineffective.
Relevance
Student assessed the
patient’s learning
needs. The content
taught to patient was
relevant to patient’s
learning needs and
condition/situation.
Student assessed
patient’s learning
needs. The content/s
taught to patient was
somewhat relevant to
the patient’s learning
needs. Some content/s
included where
unnecessary.
Student did not assess
the patient’s learning
needs and taught on
content that was
lacking relevance to
patient’s learning
needs and situation.
Student did not
assess the patient’s
learning needs. The
content taught was not
at all relevant to
patient’s learning
needs or situation.
Clarity
Content of patient
teaching presented
clearly in relation to
patient’s ability to
understand information
Content of patient
teaching presented
somewhat clearly in
relation to patient’s
ability to understand
information. Needs few
clarifications.
Content of patient
Content presented
teaching not presented confusing and needs
clearly in relation to
major clarifications.
patient’s ability to
understand
information. Needs
several clarifications.
Thoroughness
And
Completeness
Content is presented
and explained
completely. All areas
of teaching paper
#1,2,3, 4 &5
addressed thoroughly
Content is presented
and explained
somewhat completely
(Missing some areas
(subcontent i.e., #1 a,
b, c, d) of the teaching
paper).
Content presentation
and explanation
incomplete (Missing 1
major area (#1,2,3,4
&5) of the teaching
paper).
CATEGORY
Lacking in Content
presentation and
explanation (Missing
more than 1 major
area (#1,2,3,4 &5) of
the teaching project).
This grading rubric serves only as a guide to evaluate if the paper earned a Pass or Fail. There are no
points assigned to this assignment that will be included in the final course grades. Final grade will be
rounded to the nearest whole number.**
6
Time Management Schedule
Time management will be a key issue for you if you are to successfully transition to nursing
school. Complete the two assignments listed below as tools to assist you in planning for this
new adventure. Think about the connection between time management and prioritizing tasks.
1. Time Management Schedule
Fill in the prototype weekly calendar. This is what you “plan” to do every week. (Not what
you did last week).
Hints:
 Begin by filling in all inflexible times (classes, work)
 Guide for study time: 2 hours of study per 1 hour of lecture and 1 hour of study
per 1 hour of laboratory/clinic)
 Write in your place of study (home, library, skills lab)
 Use color or design if this helps you organize
 Remember to add:
Sleep (particularly the night before clinical)
Travel time (to and from school, work, childcare)
Personal hygiene time
Grocery shopping, cooking, eating
Family responsibilities
Family togetherness time
Exercise
“Don’t forget your spouse/significant other” time
Relaxing time
Telephone/internet
2. Mantra
Mantra have been used throughout time, beginning in India many centuries ago, as a method
of focusing the mind. Mantras are considered to have powerful effects on those who use
them. Literally the word mantra means “the thought that liberates or protects”. Repeating a
mantra can help you overcome fear, increase your creativity, give you energy when you are
tired, and inspire you to keep going when you want to quit.
Many of us are familiar with mantras but may not realize it. Our lives are filled with such
mantras as “No pain, no gain”, or “The teacher is out to get me”, or “This is too hard, I might
as well quit now” or “Practice, makes perfect”.
In some spiritual traditions, mantras are given to students by their teachers. However, it is
possible to make up your own mantra and use it as an antidote to other negative mantras you
may already be using.
Design a mantra for your personal use in nursing school. This mantra will be a simple phrase
that you will recite over and over. Be creative and have some fun. Be inspired.
7
Time Management Schedule and Mantra
Student Name__________________Lab Group_______________________
Time
04
05
06
07
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Study:
Work:
Sleep:
Study:
Work:
Sleep:
Study:
Work:
Sleep:
Study:
Work:
Sleep:
Study:
Work:
Sleep:
Study:
Work:
Sleep:
Study:
Work:
Sleep:
08
09
10
11
12
1
2
3
4
5
6
7
8
9
10
11
12
01
02
03
Add up
Hours
Mantra: __________________________________________________
8
Instructions for Medication Administration Scenario
1. Research all the necessary information to be prepared to administer
the medications during the Med Administration scenario day.
2. In preparation for Medication Administration Scenarios, you must
complete the following:
a. complete your N210 Medication Sheet (For Scheduled Med
Days) for all the medications listed in the MD orders and
Medication Administration Record following this instruction
page.
**You must have looked up all the medications listed in the MD
orders and MARs.
b. Watch the following Taylor Videos from
www.ThePoint.lww.com (log in as a new user or return user)
and complete Skills Video notes (will be checked by instructor)
 Ch. 29 : Medications, Watch and Learn: Medications: 3
Checks and Rights of Medication Administration
 Ch. 29 : Medications, Watch and Learn: Medications:
Preparing Unit-Dose Packaged Medications
3. Review Medication Administration chapter readings (Ch. 29) and
lecture.
4. Bring your skills video notes and completed N210 Medication Sheet
(For Scheduled Med Days), MAR, and MD orders, and the
“Medication Administration Procedure” from this packet to the
Medication Administration Scenario Day.
******Guidelines for Administration (See Taylor textbook)******
Oral meds:
• NEVER crush sustained release, controlled release or enteric-coated
pills.
• Capsules can not be split
• Scored tabs can be split in half
• Place into plastic/paper administration cup without touching the
med.
• May use pudding or applesauce for patient’s with difficulty
swallowing
• Stay with patient until all medications are taken. Never leave meds at
bedside.
Topical meds:
• Make sure previous dose is removed, before applying new dose.
• Apply patches to non-hairy areas of the body
• Take care not to touch topical medications with ungloved hands
9
Enteral tube administration:
• Use liquid form if possible
• Crush pills individually and mix with 20-30 mL of warm water.
• If medication should be given on empty stomach-stop feeding for 2030 minutes before and after med administration
• √ Placement, Flush with water, administer medication, flush with
water, administer medication, flush with water
10
Health Occupations Skills Lab
Physician’s Orders
Date
Time
Complete top portion with each Level of Care change. Indicate order with a Check Mark.
Outpatient Procedure
for
Place in Outpatient Observation Services for
yesterday
1400
Admit as Inpatient for
R/O gangrene
Physician Signature
Date
yesterday
Time
1400
Additional Orders: (Dates/Times required)
20. Accucheck ACHS
21. Humulin N 20 units SQ q am and 20 units SQ q pm
22. Sliding Scale with Regular insulin as follows:
If BS level:
Give:
150-200
2 units
201-250
4 units
251-300
6 units
301-350
8 units
351-400
10 units and
And call MD.
Allergies & Sensitivities
Patient Name:
Ibuprofen
Medical Record:
Grumpy
Weight
Height
Diagnosis
110 lbs
3’3”
R/O PNA vs. CHF, fracture left humerus
0000003
Bed Number:
SL123
11
Health Occupations Skills Lab
MAR
MAR
TODAY
Date
Site Codes:
1. Right Abdomen
3. Right Upper Arm
7. Right Anterior Thigh
2. Left Abdomen
4. Left Upper Arm
Drug Name, Strength, Dosage
Start
Stop
Time Period
(upper outer quadrant)
8. Left Anterior Thigh
Form
Time
Time
Dose
Rate
Route
Schedule
Demerol 75 mg IM q4 hours
prn pain
Vistaril 25 mg IM q4hours
prn pain. Give with Demerol.
Date
Date
today
discharge
today
discharge
Claforan IV 1 g Q 12 hours
today
discharge
Tylenol 650 mg PO q4 hours
prn temperature > 101.0
today
discharge
Albuterol nebulizer 1 unit
dose/0.5 mL NS q6h
today
Proventil nebulizer 1 unit
dose/0.5 mL NS q6h
Page 1
of 1
5. Right Buttock (upper outer quadrant)
0700To1459
Time/Init./Site
Time Period
1500 To 2259
Time/Init./Site
0800
2000
discharge
0600
1200
1800
today
discharge
0600
1200
Digoxin 0.125 mg PO QD
today
discharge
1000
Lasix 20 mg PO QD
today
discharge
1000
Colace 100 mg PO BID
today
discharge
1000
2200
Motrin 600 mg PO TID
today
discharge
1000
1400
2000
Ultram 100 mg PO BID
today
discharge
1000
2200
Neurontin 300 mg PO BID
today
discharge
1000
2200
D5 0.45% NS at 75 mL/hr
today
discharge
Zestril 10 mg PO QD. Hold if
SBP <100
today
discharge
1000
Xarelto 20 mg PO daily
today
discharge
1000
Humulin N 20 units SQ q am
and 20 units SQ q pm
today
discharge
0730
Signature
Initials
Signature
Patient Name
Patient No.
Grumpy
0000003
Room
Age
SL 123
56
Diagnosis
Pt.
Weight
6. Left Buttock
Time Period
2300 To 0659
Time/Init./Site
0000
1800
0000
1730
Initials
Signature
Initials
Allergies:
Ibuprofen
Pt. Height
3’3”
110 lbs
R/O PNA vs CHF exac., fracture L humerus
Physician’s Name
Dr.Suess
24 Hour MAR
12
Health Occupations Skills Lab
MAR
MAR
TODAY
Date
Site Codes:
1. Right Abdomen
3. Right Upper Arm
7. Right Anterior Thigh
2. Left Abdomen
4. Left Upper Arm
Drug Name, Strength,
Start
Stop
(upper outer quadrant)
8. Left Anterior Thigh Time Period
Dosage Form
Time
Time
Dose
Rate
Route
Schedule
Date
Date
Accucheck ACHS
today
discharge
Sliding Scale with Regular
insulin as follows:
today
discharge
If BS level:
Give:
150-200
2 units
201-250
4 units
251-300
6 units
301-350
8 units
351-401
10 units
and
And call
MD.
Signature
Initials
Signature
Patient Name
Patient No.
Grumpy
0000003
Room
Age
SL 123
56
Diagnosis
Pt.
Weight
0700To1459
Time/Init./Site
0600
1200
Initials
1
Page 1
of
5. Right Buttock (upper outer quadrant)
Time Period
1500 To 2259
Time/Init./Site
6. Left Buttock
Time Period
2300 To 0659
Time/Init./Site
1800
2100
Signature
Initials
24 Hour MAR
Pt. Height
3’3”
110 lbs
R/O PNA vs CHF exac., fracture L humerus
Allergies
NKA
Physician’s Name
Dr. Suess
13
Laboratory Learning Outcomes: Medical Asepsis/Infection Control (Ch. 27)
After studying this content, you should be able to:
1. Describe and demonstrate correct hand washing techniques.
2.
List all possible situations when hand washing should be performed.
3. Discuss the use of alcohol based antibacterial hand gels.
4. State the personal hygiene guidelines related to hair, fingernails and jewelry.
5. Describe and draw the six steps in the chain of infection
6. List and describe conditions that predispose clients to infection
7. Describe what is meant by the term nosocomial infection (now known as hospital
acquired infection) and discuss one intervention that will help prevent it
8. List the major organisms responsible for nosocomial infections
9. Define the term surgical asepsis and medical asepsis
10. Implement recommended techniques for medical and surgical asepsis.
11. Describe how and when personal protective equipment should be used.
12. Demonstrate and outline the steps in donning and removing personal protective
equipment according to the Centers for Disease Control
13. Describe the strategies for implementing the CDC guidelines for standard and
transmission based precautions.
14. Discuss the purpose of neutropenic precautions/ isolation and the measures that
should be followed with this type of isolation.
15. Discuss multidrug resistant organisms and nursing implications
16. List interventions that might be used to meet psychological needs of a patient in
isolation.
17. Describe the contents and care of an isolation room.
Skills:
Application and Removal of personal protective equipment
Demonstrate proper hand hygiene techniques
Demonstrate proper application and removal of sterile gloves and
nonsterile gloves
14
Laboratory Learning Outcomes: Vital Signs (Ch. 24)
After studying this content, you should be able to:
1. Define the terminology relating to vital signs
2. Explain physiologic processes involved in homeostatic regulation of
temperature, pulse, respirations, and blood pressure.
3. Compare and contrast factors that increase or decrease body
temperature, pulse, respirations, and blood pressure.
4. Identify sites for assessing temperature, pulse, and blood pressure.
5. Discuss the steps to accurately obtaining temperature, pulse, respirations,
and blood pressure.
6. Discuss the factors that contribute to false readings for blood, pressure.
7. Discuss the normal ranges for body temperature, pulse, respirations, and
blood pressure.
8. Demonstrate documentation of vital signs.
9. Discuss the steps to obtaining an orthostatic blood pressure and pulse as
well as their indications.
Skills: blood pressure, orthostatic blood pressure, radial pulse, apical
pulse, respirations and oral temperature, pulse oximetry
15
Laboratory Learning Outcomes: Mobility Techniques (Ch. 33,34)
After studying this content, you should be able to:
1. State nursing guidelines and rationale for use of proper body mechanics.
2. Identify variables that influence body alignment.
3. Describe common patient positions.
4. Demonstrate supine, lateral and Fowler’s positions.
5. Discuss positioning and protective devices and indications for use.
6. List nursing guidelines and rationales for patient transfer and ambulation.
7. Demonstrate patient transfer using a gait belt: bed to wheelchair and wheelchair
to bed.
8. Describe the effects of exercise and immobility on major body systems
9. Assess body alignment, mobility, and activity tolerance, using appropriate
interview questions and physical assessment skills.
10. Relate nursing guidelines and rationales for performing range of motion
exercises.
11. Demonstrate appropriate range of motion exercises to all body joints.
12. Document range of motion procedure.
13. Compare comfort, rest and sleep.
14. Relate spiritual needs to comfort.
15. Differentiate between NREM and REM sleep.
16. State the relationship of age to sleep requirements.
17. Examine sleep promoting and sleep suppressing factors.
18. Review drugs that affect sleep.
Skills: transfer patient from bed to wheelchair and from wheelchair to bed with
and without a gait belt, perform passive range of motion on all joints, positioning
of a patient in bed, moving a patient up in bed, ambulating a patient with and
without a gait belt
16
Laboratory Learning Outcomes: Hygiene Measures (Ch. 31)
After studying this content, you should be able to:
1. Discuss the characteristics of healthy skin, mucous membranes, nails, hair
and teeth.
2. List nursing guidelines for bathing patients.
3. Demonstrate techniques for assisting patients with hygiene measures,
including those used when administering different types of baths and
those used when cleaning each part of the body.
4. State the types of therapeutic baths and the purpose for each.
5. Describe interventions for care of patient’s teeth and mouth (including
dentures and bridges), eyes, ears, nose, fingernails, feet, toenails and
hair.
6. Describe how to shave male patients and list any nursing precautions.
7.
8. List medical asepsis guidelines related to handling of linen and the
disposition of contaminated articles.
Skills: hand hygiene, non-sterile gloving, bed bath, making occupied bed
17
Laboratory Learning Outcomes: Documentation and Reporting (Ch. 17)
After studying this content, you should be able to:
1. State at least 4 uses of documentation in a medical record and recognize
when documentation is used inappropriately.
2. Define and apply the following types of nurse’s notes documentation
(narrative, SOAPIE, Focus [DAR], PIE, and charting by exception)
3. Discuss the pros and cons of using flowsheets for documentation.
4. Name the components and use of a nursing care plan.
5. Discuss the pros/cons of computerized charting
6. Apply the “Golden Rules” of documentation
7. Recognize and utilize medical abbreviations, both approved and from the
“Do Not Use” list.
8. Convert traditional time to military time
18
Laboratory Learning Outcomes:
Safety/ Restraints/ Environment (Ch. 26)
After studying this content, you should be able to:
Restraints
1.
2.
3.
4.
5.
6.
7.
8.
Outline strategies to provide a safe patient environment
Identify clients who are at high risk of falls
Discuss the benefits and risks of using physical restraints
Explain the basis for enacting restraint legislation and National Patient Safety
Goals (NPSG) standards.
Demonstrate proper application of restraints
Discuss nursing responsibilities related to use of restraints
Differentiate between a restraint and a restraint alternative
List 5 restraint alternatives
Skills: Apply vest and wrist restraint to patient in bed, and application
of vest to patient in wheelchair.
19
Laboratory Learning Outcomes: Elimination (Ch. 37,38)
After studying this content, you should be able to:
Urinary Elimination
1. Describe the physiology of the urinary system.
2. Identify variables that influence urination.
3. Describe how the nurse would assist the patient with toileting, use of a
bedpan, a urinal, bedside commode and a condom catheter.
4. Describe the care and management of an indwelling catheter and external
urinary catheter.
5. State the rationale for measuring and recording the patient’s urinary
output.
6. Discuss the use of a “hat” in a commode and graduated cylinder to
measure urine output.
7. Describe the process of emptying a foley catheter drainage bag.
8. Describe how the collection of the following urine specimens are obtained
and give the reasons for why they are collected:
A.
Midstream
B.
24 hour
D.
Indwelling catheter.
Bowel Elimination
1.
2.
3.
4.
Review normal anatomy and physiology related to elimination.
Describe the characteristics of normal bowel elimination and stool.
Identify nursing interventions for patients with diarrhea or constipation.
Discuss the steps for the following procedures: removing fecal impaction;
rectal suppository, administering a large volume enema; administering a
small volume enema.
5. Identify nursing interventions if signs and symptoms of vagal response
occurs
6. Describe how stool specimens are collected and give the various reasons
why they are collected.
Skills: Enema Administration, applying a condom catheter, emptying a
Foley drainage bag, placing a patient on a bedpan/fracture pan, assisting a
patient with use of a urinal, emptying a BSC, providing pericare and foley
catheter care, obtaining a specimen from an indwelling foley catheter,
changing a incontinence brief
20
Laboratory Learning Outcomes: Nasogastric Intubation (Ch. 36)
After studying this content, you should be able to:
1. Discuss reasons for nasogastric intubation
2. Describe the process of nasogastric tube insertion and removal including
equipment needed.
3. Describe various methods to check placement of a nasogastric tube.
4. Discuss nursing interventions related to promoting patient comfort and
maintaining a nasogastric tube.
5. Compare and contrast the Salem sump and Levin gastric tubes
6. Discuss nursing management of the NGT attached to suction
7. Identify the purpose of NGT to suction.
8. Discuss the steps to discontinuing an nasogastric tube
Skills: Insertion and removal of a nasogastric tube; attaching NGT to
suction; discontinuing an NGT
21
Laboratory Learning Objectives : Nutrition Lab (Nix Chapter readings)
After studying this content, you should be able to:
1. Discuss the assessment of a patient’s normal nutritional status.
2. Discuss cultural influences related to meeting nutritional needs.
3. Describe how to feed a patient with special needs.
4. Describe commonly ordered therapeutic diets.
5. Demonstrate meal percentage and oral fluid intake measurement and
record.
6. List interventions to assist the patient who is on restricted fluids.
7. Discuss reasons for nasogastric and gastric intubation
8. Describe the process of administering a continuous and intermittent
nasogastric and gastrostomy tube feeding.
9. Demonstrate the process of administering a water bolus via an NGT or
gastrostomy feeding tube.
10. Discuss how nasogastric and gastrostomy feedings are measured and
recorded.
11. Compare the risks and benefits of gastric feeding versus total parenteral
nutrition.
Skill: Administering intermittent and continuous tube feeding;
Administering a water flush of an NGT/G tube.; How to measure and
document percentages of food tray consumed, and measuring fluid intake.
22
Laboratory Learning Outcomes: Foley Catheterization (Ch. 37)
After studying this content, you should be able to:
1. Demonstrate the insertion of a Foley catheter using sterile technique
2. Explain the procedure for removal of an indwelling catheter
3. Discuss patient teaching related to maintaining a foley catheter.
4. Discuss the patient teaching related to post foley catheter removal.
5. Identify unexpected outcomes that may occur during foley catheter
insertion and recommended nursing interventions.
Skill: Insertion and removal of an indwelling urinary catheter
23
Laboratory Learning Outcomes: Wound Care (Ch. 32)
After studying this content, you should be able to:
1. Identify the three stages of wound healing
2. Discuss the difference between primary, secondary and tertiary intention
wound healing.
3. List the factors that can affect wound healing to include nutrition,
medications, and health status.
4. Identify the signs and symptoms of a wound infection.
5. Identify the solutions used for wound irrigation and rationale for use.
6. Describe various types of wound drainage.
7. Describe the different types of wound treatments: e.g. transparent,
hydrocolloid, wound vac, hydrogel, calcium alginate and foams.
8. Discuss the indication for use of transparent and hydrocolloid wound
dressings.
9. Discuss the wound closure devices: staples, sutures, retention sutures
steristrips, dermabond and Montgomery straps, wound-vac.
10. Identify and discuss the mechanism of action of the following wound
drainage devices: penrose, Jackson-Pratt and hemovac .
11. State the guidelines for maintaining a sterile field
12. Describe the steps (and rationale for each step) for performing a sterile
wet to moist dressing.
13. Demonstrate a wet to moist sterile dressing change.
Bandages and Binders
1. State the purposes of bandages and binders.
2. Discuss the general guidelines for application and removal of bandages and
binders.
3. Demonstrate application of the following:
A. An abdominal binder
B. An ace bandage using the spiral turn, recurrent, and figure of eight turn
Thermal Therapy
1. List the common uses for both heat and cold as therapeutic modalities.
2. Describe techniques and related nursing responsibilities for heat and cold
applications.
Skills: wet to moist sterile dressing change
24
Taylor & TalonNet SKILLS VIDEOS
You are required to view the following skills demonstrations online (from any internet
access computer or the skills lab computers in SL 121, 122, 123, 110) prior to assigned
control lab days at The Point (Taylor website access to stuent Wath & Learn Videos) and
http://talonnet.cerritos.edu/osp-portal (TalonNet)
TheTalonNet videos were developed as an instructional aide by your instructors for
beginning nursing students.





Enter username (7 digit student ID number) and password (6 digit birthdate)
Click on My Projects (top menu bar)
Click on My Video Links
Click on Nursing Skills Videos; click “I Agree” on the copyright;
Choose your video links according to assigned labs and view the videos (click
on broadband if you have high speed internet; click on 56K if you have dialup internet)
Content
Name of Skills
Medical Asepsis
Nonsterile Gloving
GlovingNSterile
Sterile Gloving
GlovingSterile
Vital Signs
Taylor Watch and Learn
Video (Use access code on
inside cover of Taylor
textbook to access videos)
Hand hygiene
Ch. 27 Asepsis & Infection
Control, Watch & Learn:
Asepsis, Performing Hand
Hygiene
Vital signs
Ch 24: Vital Signs, Watch
and Learn: Measuring oral
Temp, Radial pulse, resp
rate and blood pressure
Ch 24: Vital Signs, Watch
and Learn: Measuring an
apical pulse
TalonNet
Video Link
VitalSigns
ApicalPulse
PulseOximetry
RectalTemp
TymAxTemp
25
Content
Name of Skills
Taylor Watch and Learn
Video (Use access code on
inside cover of Taylor
textbook to access videos)
TalonNet
Video Link
Activity and Rest
Ambulating a patient
AmbPatient
Bed Mechanics
BedMech
Moving a Patient up in
bed
MovingPatient
PassiveRange
ROM exercises
PositionPatient
Positioning a Patient
TransPatient
Transferring a Patient
Personal Hygiene Measures
See TalonNet Video
OR
See Taylor Videos
Ch: 31: Hygiene, Watch
and Learn: Giving a
Bedbath
No video required prior
to lab
Assessment Lab2
No video required prior
to lab
Assessment Lab3
No video required prior
to lab
B/B/Teds/Restraints/Thermal Bandages and
Therm
Binders/Teds/Restraints
/Thermal Therapy
Bed_Bath
(includes
occupied bed
change)
Assessment Lab1
Elimination
Enema
Collecting a Urine
Specimen
Bandages (view
only applying
bandages and
restraints;
NOT binders
and NOT
Teds)
Ch. 37: Bowel Elimination: Enema
Watch & Learn:
Administering a Cleansing
UrineSpecimen
Enema
Ch. 37: Bowel Elimination:
Watch & Learn: Urinary
26
Elimination: Applying a
Condom catheter
Scenarios
Review previously
learned skills videos
NGT Insertion
VS Competency Testing
Review Vital Signs
videos
Scenarios
Review all previously
learned skills videos
Nutrition Lab
Foley Catheterization
Wound Care
Foley Catheter
Wound Care
See Taylor Video-Ch. 36:
Nutrition, Watch and
Learn: Inserting a
Nasogastric tube
NGTube
Ch. 36: Nutrition: Watch
& Learn: Nutrition:
Administering a
continuous tube feeding:
Using a feeding pump and
a prefilled closed tube
feeding set-up
Ch. 37 Urinary
Elimination: Watch &
Learn: Urinary
Elimination: Catheterizing
a male urinary bladder
ONLY: Indwelling and
Intermittent catheters.
Live demo in
control lab
Catheter
draping
Catheter (watch
the female
urinary
catheterization
ONLY)
WoundCare
27
N210 Fundamentals of Nursing
Nursing Skills Peer Check Off
Following independent practice, demonstrate proper technique of the following nursing
skills to your classmates three (3) separate times. Obtain peer signatures/dates indicating
that you have demonstrated proper technique in performing the skills. If you need help,
please refer to the videos online, your skills book, and/or see a skills lab instructor during
open lab.
This sheet is to be completed prior to Skills CPE and submitted to clinical instructor on
Skills CPE testing day (week 8). Any student who fails to turn in a completed sheet to the
instructor will receive an advisement note and will not be allowed to test for CPE.
Arrangements will be made with the instructor to test for CPE on a different day. If a
student fails the CPE, a skills lab referral will be given for the failed skill and the student
is to complete the Skills Lab referral within 1 week of the referral date.
28
Nursing Skills Peer Check Off
Student___________________________ Clinical Instructor_____________________
Skill
Bed Bath And Occupied
Bed Making
Peer Name (PRINT)
1. _______________
2. _______________
3. _______________
Signature
1. _____________
2. _____________
3. _____________
Handwashing
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Sterile And Nonsterile
Gloving
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Denture Care
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Applying And Removing
PPE
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Taking Full Set Of Vital
Signs Temp (Oral, Ax,
Tymp, Rectal); Pulse
(Radial and AP), Resp, BP
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Patient Transfer From Bed
To Chair
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Positioning A Patient In Bed 1. _______________
1. _____________
Date
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
29
2. _______________
3. _______________
2. _____________
3. _____________
Ambulating A Patient
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Applying Bandages,
Binders, Restraints,
Anti-Embolism Stockings,
Thermal Therapy
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Enema Administration
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Collecting Urine Specimen
From A
Urinary Catheter
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Sterile Wet-Moist Dressing
Change
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Urinary Catheterization
(Male & Female)
Requires 2 peer and 1
Skills Lab Personnel
(instructor or student
worker) signature
Nasogastric Tube Insertion
1. _______________
2. _______________
1. _____________
2. _____________
3. _______________
3. _____________
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Water Bolus Via
1. _______________
1. _____________
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
30
Nasogastric Tube
2. _______________
3. _______________
2. _____________
3. _____________
Moving A Patient Up In
Bed
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
Range of Motion Exercises
1. _______________
2. _______________
3. _______________
1. _____________
2. _____________
3. _____________
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
1.
_______
2.
_______
3.
_______
REMINDER:
This sheet is to be completed prior to Skills CPE and submitted to clinical instructor on
Skills CPE testing day (week 8). Any student who fails to turn in a completed sheet to the
instructor will receive an advisement note and will not be allowed to test for CPE.
Arrangements will be made with the instructor to test for CPE on a different day. If a
student fails the CPE, a skills lab referral will be given for the failed skill and the student
is to complete the Skills Lab referral within 1 week of the referral date.
31
Infection Control
Control Lab Sheet
Chain of Infection
1. Discuss the chains of infection (reservoir, portal of entry, mode of
transmission, etc.) then give examples that apply to each chain (e.g. mode
of transmission = direct contact, droplet). See Chain of Infection
Illustration.
2. Scenarios
A. Scenario 1: The spread of Infection
An elderly patient, hospitalized with a gastrointestinal disorder, was
on bedrest and required assistance for activities of daily living. The
patient had frequent uncontrolled diarrhea stools and the nurse
provided excellent care to maintain cleanliness and comfort. While
cleaning the patient, the soiled linens touched the nurse’s uniform.
The nurse placed the soiled linens on a chair and left the room.
Following 1 episode of cleaning the patient and changing the bed
linen, the nurse immediately went to a second patient to provide am
care and assist with the morning meal. The nurse’s hands were not
washed prior to assisting the second patient. 2 days later, the
second patient developed diarrhea. His stool cultures showed
positive for Vancomycin Resistant Enteroccocus (VRE).
Let’s examine the chain of infection as it applies to this situation
Question#1
What is the:
Susceptible host
Infectious agent
Portal of entry
Mode of transmission
Reservoir
Portal of exit
Answer
Question #2
Answer
Break the Chain of Infection…
What should the nurse do to prevent the
spread of infection? Which PPE should
be worn?
32
B. Scenario 2: The Nurse Breaks the Chain
A patient assigned for morning care has an open wound on her left
lower leg. The wound is draining and when last cultured, the
microorganism MRSA was identified.
In preparation for bed making, the hands of the nurses were
washed. Clean linen and a bag for soiled linen were gathered from
the linen room and placed on the patient’s clean bedside stand.
To remove the soiled linen from the bed, the following procedure
was followed:
Hands washed
Gloves worn
Each side of the soiled linen ends folded towards the middle of bed
Soiled linen held away from the nurses’ uniform
Soiled linen placed in the linen bag for later discard
Protective gloves removed
Hands washed
Let’s examine the chain of infection as it applies to this situation
Question#1
What is the:
Infectious agent
Reservoir
Portal of exit
Question #2
a. How did the nurse break
the chain of infection?
b. Which chains where
broken?
c. Which PPE should be
worn?
Answer
Answer
33
N210 Fundamentals of Nursing
Vital Signs
Skills Check Off Stations
Lab Groups
Lab A & B
Lab C & D
Lab E & F
Room Assignment
SL 105
SL 122
SL 123
ACTIVITY
Check when
completed
Temperature
Practice taking temperature on another student:
 Oral
 axillary
 tympanic
Practice taking temperature on a manikin:
 rectal (using manikin)
__________
Set of Vital Signs
Take a full set of vital signs (temp., pulse & respirations, apical
pulse, blood pressure) on 3 clients & document on the graphic
sheet
Vital Signs Manikin
Apical Pulse
Listen to apical pulse on manikin. Identify the rhythm and
write on the back of this sheet.
Orthostatic Vital Signs
Practice taking orthostatic vital signs on another student
Answer orthostatic vital signs questions on the poster. Use the
back of this sheet.
VS Special Considerations (SL 121)
Assess the client and answer Measuring Blood Pressure
questions on the poster. Use the back of this sheet.
Complete this sheet by the end of week 2.
34
Vital Signs Questions
Apical Pulse
Identify the rhythm on the VS manikin. ______________
Orthostatic Vital Signs
1. How would you take orthostatic VS on a patient?
2. How would you take orthostatic VS on a patient who is dehydrated and is
experiencing some dizziness upon rising from a lying position?
Measuring Blood Pressure (VS Special Considerations)
1. You are caring for a post left-mastectomy patient. Where would you take
the patient’s blood pressure?
2. You received report from the previous shift’s nurse that your patient has
an atrio-venous graft (AV dialysis graft) on her right arm. Where would you
take the patient’s blood pressure?
35
N210: Fundamentals of Nursing
Safety: Restraints/ Environment
Critical Thinking Questions
1. Discuss the components of an environmental assessment.
2. Perform and verbalize an environmental assessment on your assigned
patient.
3. How often does the physician’s order need to be renewed for a client on
restraints?
4. When initiating restraints without a physician’s order, what is the time
frame in which the physician’s order needs to be signed?
5. How often do you release restraints on a client?
6. What are your nursing responsibilities when releasing a client from
restraints?
7. What would you need to monitor on a client who is on restraints and how
often would you do this?
8. How often should the need for continuation or termination of restraint use
be determined?
9. What would you need to assess after applying an abdominal binder on a
client?
10. What would you need to assess after applying anti-embolism stockings?
11. What are restraint alternatives? Give examples of these.
12. How would you prevent thermal injury on a client using a heating pad or
hot compress?
36
N210: Fundamentals of Nursing
Safety: Restraints/ Environment
Scenario:
As you enter your female client’s room, you find her with one leg over the side
rail, making attempts to get out of bed unassisted. Your client is an 82-yearold female with a history of congestive heart failure (CHF). When you
question what she is doing, she tells you, “I need to go to the bathroom.” She
also tells you she is sure her dog needs to be let out because she hasn’t been
able to get out of bed all morning. This is your second day caring for your
client. Your initial assessment on admission 2 days ago included her being
oriented to person, place, time, and purpose. The night shift did report off
saying she was disoriented all night.
1. What is your first nursing action? Provide rationale for your response.
2. What additional priority nursing actions are justified for your client?
3. What additional information do you need to gather to determine the
next step in her plan of care?
4. If it is determined that your client needs to be closely monitored for
possible falls, what interventions, by priority, will you implement?
5. Identify the legal requirements that must be implemented when a client
is placed on restraints. (Read the procedure, Managing a client of
restraints)
6. What documentation must be provided when a client is placed on
restraints?
37
N210: Fundamentals of Nursing
Elimination Practice Station Check-off
Station 1
Emptying Foley catheter bag______________________________
Specimen from foley catheter______________________________
Station 2
Assisting with urinal _____________________________________
Place a fellow student on a bedpan_________________________
Changing a brief________________________________________
Station 3
Enema Administration___________________________________
Station 4
Pericare on female manikin_________________________________
Emptying a BSC__________________________________________
Foley catheter care________________________________________
Station 5 (self station)
Condom catheter________________________________________
38
Physical Assessment Documentation Guide
Student____________________________
Date ________________
Client/Patient Initials________Age ________Sex__________
General State of Health
Subjective Data: (Obtain all info under “General State of Health” from
Review of Systems page 5 of Jarvis)
Objective Data:
Appearance
Posture (relaxed, erect, tripod position, slumped, leaning to one side)
Overall hygiene and grooming (clean, well groomed, unkempt)
Any apparent signs of distress
Dress (appropriately for situation)
Behavior
Level of consciousness (awake, asleep, lethargic, comatose)
Mood and affect/ Facial expressions (appropriate for situation)
Cognition
Orientation (person, place, time, and purpose-X4)
Speech (clear, garbled, slurred, incomprehensible)
Responsiveness (follows directions and responds appropriately)
Documentations: (Include both Subjective and Objective Data in Narrative
Form)
39
Physical Assessment Documentation Guide
Student____________________________
Date ________________
Client/Patient Initials________Age ________Sex__________
Assessment of the Skin, Hair, and Nails
Subjective Data: (Obtain all info under “Skin”, “Hair”, & “Nails” from
Review of Systems page 5 Jarvis)
Objective Data:
Inspection and palpation of the skin
Color(pink, cyanotic, jaundiced, erythematous),
Pigmentation (even, hyper/hypopigmentation)
Lesions (Describe 3)
Description – size & color
Structure - type of lesion (macule, papule, nodule etc.)
Anatomical Distribution
Hydration – skin turgor (immediate recoil, tenting)
Temperature & Moisture (warm/dry, cool/clammy)
Inspection and palpation of the hair
Color & condition
Quantity, distribution, & texture (abundant; balding/receding vs. bald
patches, smooth or course)
Inspection and palpation of the fingernails
Color of nail bed
Firmness, texture, ridging, or irregularities
Clubbing:
Palpate for firm nail matrix
Estimate nail angle (160 degrees or less; >160 degrees)
Documentation: (Include both Subjective and Objective Data in Narrative
Form)
40
Physical Assessment Documentation Guide
Student____________________________
Date ________________
Client/Patient Initials________Age ________Sex__________
Assessment of the Head and Neck
Subjective Data: (Obtain all info under “Head, Eyes, Ears, Nose, Mouth and
Neck” from Review of Systems page 5-6 Jarvis)
Objective Data:
Inspection and palpation of the head and face
Skull for symmetry & tenderness
Face (includes eyes, ears, nose, mouth, and neck)
Symmetry
Discoloration
Lesions
Drainage
Distention of neck
Oral mucous membranes –color, hydration(dry/moist), lesions
Documentation: (Include both Subjective and Objective Data in Narrative
Form)
41
Physical Assessment Documentation Guide
Student____________________________
Date ________________
Client/Patient Initials________Age ________Sex__________
Assessment of the Chest and Lungs
Subjective Data: (Obtain all info under Respiratory from Review of Systems
in Jarvis page 6)
Objective Data
Inspect chest wall
Color, Configuration (symmetry) and Lesions
Movement
Respiratory rate, depth, and effort
Auscultate systematically for quality of lung sounds
Assessment of lung sounds and location
(Clear, diminished, absent)
Identify adventitious sounds if present:
Wheezes (sibilant or sonorous rhonchi)
Crackles (fine or course)
Documentation: (Include both Subjective and Objective Data in Narrative
Form)
42
Physical Assessment Documentation Guide
Student____________________________
Date ________________
Client/Patient Initials________Age ________Sex__________
Assessment of the Heart and Peripheral Vascular System
Subjective Data: (Obtain all info under Cardiovascular, Peripheral Vascular
from Review of Systems page 6 Jarvis)
Objective Data
HEART
Inspection
Pulsations, lifts, heave
JVD with chest at 35-45 degree angle
Auscultation
Rhythm assessment of S1 and S2 (Regular/Irregular)
Assess all auscultatory sites: APETM
Count Apical Heart Rate
PERIPHERAL VASCULAR SYSTEM
Palpation of Peripheral Pulses
Radial
Femoral
Posterior Tibial
Dorsalis Pedis
Skin color – extremities (upper and lower)
Capillary refill after blanching (secs)
Fingers/toes
Presence of Edema- depress for 5 seconds (grade if pitting)
**Practice the following skills: Use of Doppler; applying antiembolism
stockings; applying Sequential compression Device**
Documentation: (Include both Subjective and Objective Data in Narrative
Form)
43
Physical Assessment Documentation Guide
Student____________________________
Date ________________
Client/Patient Initials________Age ________Sex__________
Assessment of the Abdomen
Subjective Data: (Obtain all info under Gastronintestinal, Genitourinary
from Review of Systems page 6-7 Jarvis)
Objective Data
Inspection
Contour
Lesions
Scars
Distention
Pulsations
Hernia (while patient lifts head)
Auscultation (all quadrants)
Bowel sounds
Palpation
Light palpation
Tension of abdominal wall (soft, firm, hard)
Tenderness
Masses
Deep palpation
Tenderness
Masses
Enlarged organs
Percussion
CVA tenderness
Documentation: (Include both Subjective and Objective Data in Narrative
Form)
44
Physical Assessment Documentation Guide
Student____________________________
Date ________________
Client/Patient Initials________Age ________Sex__________
Assessment of the Musculoskeletal System
Subjective Data: (Obtain info from Review of Systems under
Musculoskeletal in Jarvis)
Objective Data
Muscle strength
Check each muscle group against resistance
Compare right with left:
Upper extremities
Triceps
Biceps
Adduction arms
Abduction arms
Wrists – flexion, extension
Lower extremities
Quadriceps
Hamstrings
Abduction knees
Adduction knees
Plantar flexion feet
Dorsiflexion feet
Documentation: (Include both Subjective and Objective Data in Narrative
Form)
45
Physical Assessment Documentation Guide
Student____________________________
Date ________________
Client/Patient Initials________Age ________Sex__________
Neurological Assessment
Subjective Data: (Obtain info from Review of Systems under Neurological
in Jarvis)
Objective Data
Mental Status Examination
Appearance (posture, body movement, dress appropriate
for setting, grooming/hygiene)
Behavior (level of consciousness, facial expression,
mood and affect)
Cognition (orientation x4, responsiveness, speech)
Thought Processes (thought content for consistency and logic, perceptions
consistency with reality, any suicidal thought)
Pupillary Reaction
(equality, size, shape, reaction to direct and consensual light)
Sensory system (assess for intactness of the following sensory functions)
Light touch
Pain and temperature (only unable to feel light touch)
Vibration
Kinesthesia/Proprioception (position sense)
Stereognosis
Graphesthesia
Two-point discrimination
Motor function (assess for strength)
Hand grips (ask client which is dominant hand)
Foot pushes( plantar flexion)
46
Deep tendon reflexes (Grade)
Biceps (optional)
Triceps (optional)
Brachioradialis (optional)
Quadriceps or Patellar
Achilles (optional)
Cerebellar Functions
Balance
Gait
Gross motor coordination – heel to toe walking
Romberg
Coordination
Finger to Nose (eyes closed)
Rapid Alternating Movements (RAM)
Documentation: (Include both Subjective and Objective Data in Narrative
Form)
47
PHYSICAL ASSESSMENT PRACTICUM
Student____________________________
Date ________________
**Starred ** items are critical elements and must be passed by the student.
Technique
(5)
Organization
(5)
Clear
Instructions(2)
Description
Accurate (4)
General Survey:
Appearance (posture, grooming, hygiene,
apparent signs of distress, dress)
Behavior (attitude, mood and affect, facial expressions)
Cognition (mental status, speech, level of orientation)
Skin
Color (pink, cyanotic, jaundice, dusky, pale/appropriate for race)
Hydration – skin turgor
Temp. and Moisture (warm/cool, dry/clammy)
Lesions (describes morphology, size, color, pattern of
arrangement, and distribution) (Describe two lesions)
Neurological
Pupils - equal, round, reactive to direct and consensual light
Head and Neck
Visual Inspection of skull, face (eyes, ears, nose, mouth, and neck)
Include oral mucous membranes (color, moist/dry, lesions)
Assess for drainage, lesions, distention, discoloration, and symmetry
Lungs
Performs inspection before auscultation
Assess respiratory effort and rate
Assess for symmetry of chest wall movement
Auscultate for breath sounds (anterior or posterior chest)
in a systematic order
Heart
Identify auscultatory sites:
Aortic – 2nd right ICS
Pulmonic – 2nd left ICS
Tricuspic – Left 5th ICS sternal border or midsternal line
Mitral – left 5th ICS midclavicular line
**Auscultate S1 and S2 - assess rhythm (S1 S2 Reg./irreg.)
assess for extra heart sounds & murmurs
Identify PMI (left 5th ICS midclavicular line)
Count Apical heart rate (BPM) for 1 full minute
48
Technique
(5)
Organization
(5)
Clear
Instruction (2)
Description
Accurate (4)
Peripheral Vascular
Palpates for pulses together:
Radial, Pedal
Capillary refill (secs) (hands)
**Assess for edema (depresses medial malleolus
& pretibial area for 5 seconds)
Abdomen ** Auscultation before Palpation
Inspect for contour,lesions,distention
Ausculate all 4 quadrants for bowel sounds
Count in each quadrant for 1 full minute
Light palpation all quadrants (bend knees before palpation)
(begins at RLQ and proceeds clockwise)
Motor - Assess hand grips and foot pushes bilaterally
_______________________________________________________________________________________________________________
Musculoskeletal
ROM and Motor strength against resistance:
If unable to assess patient’s ability to move in the bed during the
assessment, then test specific muscle sets:
Upper extremities (arms only – biceps, triceps)
Lower extremities (legs only – quadriceps, hamstrings)
Performance
HIPIE
X
Worked from head to toe
Professional behavior (verbal and nonverbal communication,
draping of patient)
TOTAL SCORE:
COMMENTS:
_____/149
/50
/45
X
/18
X
/36
__________SATISFACTORY (95% or better= 141/149 points)
__________NEEDS INPROVEMENT (90-94% = 133-140/149- Skills Lab Referral for head to toe physical assessment)
__________UNSATISFACTORY (<90% or 132/149: Advisement note and retest with instructor).*** Failure to pass retest will result
in requirement to complete N251 course prior to Fall semester N220 course or concurrent with Spring semester N220 course.
49
Nasogastric Tube Insertion
Critical Thinking Questions
Act out the most appropriate nursing actions for the following patient situations while you
practice with the manikins.
1. Name nursing interventions/actions appropriate for a nasogastric tube that is difficult to advance
2. What nursing action is appropriate if the client coughs, is unable to speak, and becomes cyanotic
during NGT insertion?
3. During advancement of the NGT, passed the nasopharynx, the client gags and coughs, but remains
pink and is able to speak. What is the nurse’s next appropriate action?
4. Your client has a history of dysphagia from a previous stroke. The physician has ordered the client
to remain NPO (nothing by mouth) and to insert a nasogastric tube. How would you proceed to
instruct the patient to assist in advancing the NG tube once you have passed the nasopharynx.
5. If a Salem Sump pigtail leaks gastric contents, what should the nurse do?
6. Your client who has an NG tube connected to suction suddenly vomits around the tube. What is the
appropriate action the nurse should take next?
7. Your client who is receiving a bolus NG-tube feeding is due for his morning medications. As you
proceed to assess placement (by flushing with air and aspirating for gastric contents), you feel
resistance and are unable to push the plunger. What may be the cause of the resistance and what
is your most next appropriate action?
8. Your 72 year old male client has had a left sided stroke and is receiving a continuous G-tube
feeding at 60 mL/hr.
a. In considering the client’s diagnosis and treatment, what is he most at risk for?
b. What is the most appropriate nursing intervention to prevent this risk?
c. You are checking the client’s residual and you obtain no residual. What does this mean and
what actions will you take?
d. You are checking the client’s residual and you obtain 12 mL of residual volume. What does
this mean and what action will you take?
9. Practice connecting the tubing for the Kangaroo pump and priming the tubing prior to connecting to
the end of the NG tube or G-tube.
50
Nasogastric Tube Removal (AIR-WATER-AIR)
1. Check physician’s order for NG tube removal
2. Gather equipment: Towel, paper towel, stethoscope, container of sterile normal saline (or
tap water), 60 mL syringe with catheter tip, tissues, clean gloves, tube plug
3. Assess client to determine presence of bowel sounds. Signs more indicative of GI function
include passage of flatus, bowel movement, absence of nausea and vomiting, and
presence of hunger.
4. Perform IPIE. Explain to client that removal may cause some nasal discomfort, coughing,
sneezing, or gagging.
5. Place towel over client’s chest
6. Disconnect NG tube from suction tubing of feeding machine if indicated
7. AIR: Flush tube with a 15-20 mL bolus of air (to displace the tube from the gastric mucosa)
then aspirate gastric contents to check for placement
8. WATER: Flush NG tube with 20 mL of NS or tap water (To clear tube so that GI contents
do not inadvertently drain into the esophagus during tube removal)
9. AIR: Follow saline or water flush with a 20 mL bolus of air (to clear saline or water from
tube and to free tube from stomach or intestinal lining)
10. Unpin tube from client’s gown and loosen tape that secures tube to client’s nose.
11. Plug tube or clamp it by folding it over in your gloved hand
12. Pinch tube to client’s nares, have client take a deep breath and hold it while you withdraw
the tube (Holding breath closes glottis and helps prevent aspiration)
13. Wrap tube in paper towel and remove from client’s view
14. Offer oral and nasal hygiene
15. Empty and record amount and character or drainage if applicable
16. Discard equipment and clean up
17. Remove gloves and perform hand hygiene
51
Urinary Catheterization
Critical Thinking Questions
1. Catheter is inserted into the female client’s vagina. What is the next most appropriate action by the
nurse? (Role play this during practice and discuss your options with your fellow classmates).
2. Difficulty inserting catheter into a male client.
a. Name two or three reasons a catheter would be difficult to insert in a male client.
b. Identify appropriate nursing actions if experiencing this difficulty.
3. As you are inserting an indwelling catheter into your male client, he begins to have an erection.
What is the most appropriate nursing action at this time?
4. As you insert an indwelling catheter into your male patient, there is no urine return. What are
possible causes and what are appropriate actions by the nurse in this case?
5. Demonstrate and practice the steps to removing a catheter. See back page (Catheter Removal).
6. What appropriate nursing assessments and client teachings would you perform for a client who has
had his/her catheter remove/discontinued?
7. Continuous Bladder Irrigation (CBI) – see CBI station and do the following as a group.
a. Discuss the purpose of a CBI
b. Discuss the procedure of initiating a CBI on your patient
c. What color and consistency of urine output would you expect to see on the urine drainage
bag immediately after a TURP-Transurethral Resection of the Prostate; and just before
discontinuing the continuous bladder irrigation?
ACCEPTABLE Alternative method during catheter insertion: Once the unine flows, you may choose to
keep the sterile dominant hand holding the catheter and use your nonsterile /nondominant hand to inflate
the balloon.
NOTE: Preferred methods
1. You may also place the waste receptacle (cath kit bag) on the side of the patient
instead of at the foot of the bed.
2. There is no need to pretest the catheter balloon if already pretested by the
manufacturer. E.g. BARD catheter Kits have pretested balloons therefore do not
need to test the catheter balloon.
52
N210 Fundamentals of Nursing
CATHETER REMOVAL
SKILLS CHECKLIST
Recommended Technique
N.I.
S
Comments
U
CHECK physician’s orders (and when last changed
if requiring changing)
WASH hands
ASSEMBLE equipment: syringe, unsterile gloves
Identify (armband)
Explain
Privacy
POSITION:
-Male: none required
-Female: legs slightly apart
REMOVAL:
-empty FC drainage bag and discard urine.
-empty catheter baloon by withdrawing fluid
with syringe until resistance felt
(balloon empty); note location of
meatus in female if F/C being changed
-Gently pull on F/C near meatus while
pinching tube; inspect F/C for
intactness (tip sent for C&S in some
agencies)
CLEAN perineum; provide patient comfort
MEASURE urine; record I&O
DISCARD equipment
DOCUMENT procedure
-Time
-Patient’s response
TEACHING:
-2500 cc fluid/day, possibly acidifying
liquids (cranberry juice)
-Dribbling can occur for several hours
-Need to void within 6-8 hrs; report if unable
urge/fullness
ASSESSMENT:
-First void after d/c (If no void,
include in shift report)
-Frequency
-Burning
-Hesitation
-Dribbling
-Cloudiness or any other color or change
in characteristics
Rev. Fall’07
53
Wound Care Practice Station Check Off
N210: Fundamentals of Nursing
Station 1
Identify the wound pictures. Identify the wound as red/yellow/black. Stage the pressure ulcer.
Picture 1_____________________________
Picture 2_____________________________
Picture 3_____________________________
Picture 4_____________________________
Station 2
Identify the name of each treatment and what type of wounds each treatment is used for.
pg 924 and 925 as a reference)
(use
Transparent dressing_______________________________________________
Hydrocolloid dressing_______________________________________________
Wound vac_______________________________________________________
Hydrogel_________________________________________________________
Alginate__________________________________________________________
Foams___________________________________________________________
Station 3
Identify which wound is healing by primary intention and which wound is healing by secondary
intention. Pay special attention to statement on tertiary healing in page 1189 -1190 of Taylor’s
textbook.
Primary _________________________
Secondary_______________________
Tertiary _________________________
Station 4
Identify each drainage device. The JP and Hemovac work by negative pressure- when
compressed the drainage is PULLED into the collection area.
Penrose__________________________________________________
Jackson-Pratt______________________________________________
Hemovac__________________________________________________
Station 5
Identify each of wound closure device
54
Staples_____________________________________________________
Retention sutures_____________________________________________
Sutures_____________________________________________________
Dermabond__________________________________________________
Steristrips____________________________________________________
Montgomery straps____________________________________________
Station 6
Identify each of the following types of wound drainage
Serous__________________________________________________________
Sanguineous_____________________________________________________
Serosanguineous__________________________________________________
Purulent_________________________________________________________
Station 7
Check your answers on the study guide
Station 8 (optional)
Remove sutures
Station 9
Practice a sterile wet to moist dressing change.
55
Cerritos College
N212 Medication Administration Procedure
1. You will be assigned by your clinical instructor to administer scheduled medications to 1 patient
on 2 consecutive days (2 days of care).
2. You MUST choose a patient that you will administer meds to the night before clinical and
throughly complete the Schedule Med Day Medication Sheet for all the patient’s meds.
3. Choose a patient that has scheduled meds. Do not choose to give meds to a patient who has none
or only 1 scheduled med (PO, SQ, IM, Inh., PR, Top.)
4. On the day of your scheduled Med Administration, you will administer all scheduled meds (PO,
SQ, IM, Inh., PR, Top., etc.) to your patient with instructor supervision.
5. You and any other student (not scheduled to give meds) may give PRN IM/SQ meds with
instructor supervision upon instructor availability.
6. You will not administer any scheduled IV fluids or IVPB medications.
7. If your patient has any scheduled IV/IVPB, be sure to remind your RN that you are not
administering these.
8. Inform your RN that you will be administering all scheduled meds for your patient (except IV/IVPB)
and obtain the patient’s Medication Administration Record (MAR).
9. Inform your clinical instructor regarding the scheduled times that you are to administer the
medications.
10. Check the MAR against MD orders for all scheduled meds you will be administering to your patient.
11. Check the patient’s medication cassette for all scheduled meds as early as possible when you
begin your shift. Practice doing the five rights at this time.
12. If a medication is missing from the patient’s cassette, send a “missing medication” form to the
pharmacy before the scheduled time to give the medication (Ask your instructor for assistance in
filling out the facility’s form).
NOTE: It takes pharmacy time to get the medications up on the floor, so do it early….The earlier,
the better.
56
Cerritos College
N212 Medication Administration Procedure
12. Students should be prepared with appropriate data (VS, labs, and patient assessment) necessary
prior to administering scheduled medications

e.g. check BP before administering a BP med

e.g. K+ level before administering Lasix
•
•
Prepare the medications:
• Calculate drug dosage
• Prepare one medication at a time
• Leave medications in packages if possible.
• Use appropriate measuring devices to prepare medications.
Be prepared to do the five rights in the presence of your instructor.
13. Be prepared to answer questions about the medication you are to administer

Know why the patient is receiving the particular medication (you may need to look at the
admission diagnosis or chronic illnesses from the H&P, or MD progress notes – Ask your instructor
for guidance if you are having trouble with this).

You should know the medications’ use/effect, adverse effects, nursing considerations, patient
teaching, & pertinent drug-drug interactions.
14. Go into your patient’s room with your clinical instructor, patient’s scheduled meds, and MAR.
15. Wash hands and perform IPIE.
16. Identify your patient by comparing the armband against MAR using 2 identifiers: Medical record or
patient number and patient’s name. Ask for allergies.
17. Open all meds at the patient’s bedside and proceed to administer the medications as ordered.
18. Perform basic patient teaching (medication, dose, and indication).
•
Always tell patient: (Name of medication, Dosage, & Indication for use)
Ex: “Here is your atenolol 25mg, it is t o help control your blood pressure.”
19. Document on MAR
a. As soon as possible AFTER administration
b. Document time administered
c. Initials
d. Make sure signature/initials are in signature section of MAR
20. Document client response
a. Narrative note
b. Flowsheet
c. Especially document for PRN medications and first time a new medication is administered
21. Document if refused or held
a. Circle time
b. Initial
c. Reason not administered
22. Monitor patient for therapeutic effects.
57
NPW and Assessment Guide Guidelines
General Instructions:
 All work must be neat and legible
 NPW to be completed on EVERY patient cared for in the clinical setting BEFORE you
provide nursing care to the patient
 Complete an assessment guide for ONE patient and submit each week
 Staple any additional papers
 Highlight any abnormal findings on the Assessment Guide
 Make extra blank copies and keep them in your clinical folder
 If no order can be found, write “no order”.
NPW Page 1
Student: write your full name
Date: date(s) caring for patient
Co-Assigned Nurse/NA: Nurse and nursing assistant assigned to the patient
Patient Initials: Remember HIPPA regulations and only put the patient’s initials
Room #: The room number of the patient
Age: Age of the patient
Admit date: The date the patient was admitted to the facility
Surgery date: If applicable, state the date the patient had surgery relevant for the current
admission
Code Status: The resuscitation status for the patient. Ex: DNR, No Code, Full Code, No CPR
Allergies: State all allergies to medications, food, environment
Admitting diagnosis: State the diagnosis given as reason for admission. Ex: Pneumonia. May
not have admitting diagnosis in long term care. May only have chronic diagnoses. Ask
your instructor for assistance as necessary.
History of present illness: Describe the events that occurred from time of onset of illness to
time of admission. May not have in long term care.
Course of events in hospital: What major events occurred from the time of admission to the
time you assume care. Ex: Admitted with R/O Myocardial Infarction. That diagnosis was ruled
out. Patient was found to have a hiatal hernia causing him chest pain and is schedule for surgery
(fundoplication) to repair the hiatal hernia. Will not complete in long term care.
Hx: State the patient’s significant past medical and surgical history. Ex: History of COPD,
osteoarthritis, cataracts in the right eye
MD Orders
*ONLY MD ORDERS FROM THE ORDER SECTION OF THE CHART ARE ENTERED IN THIS
SECTION
Vital Signs: Frequency ordered Ex: every 4 hours.
Diet/Feedings: Diet ordered and/or tube feedings (name of solution, volume to be administered,
continuous vs. intermittent)
Activity: The activity level ordered
IVF: Intravenous fluids ordered for continuous infusion only. Ex: D5.45NS @ 100 ml/hr. Any
piggyback solutions are written under medications
Blood glucose monitoring: Frequency ordered Ex: QAC and HS (before meals and before
bedtime).
Treatments/Nursing Orders: This section should include any additional orders for the patient.
Ex: strict I/O, wet to dry dressing change every 8 hours, Foley catheter, O2 at 2L NC.
Diagnostic Results
 Should be the most recent lab results
Record the normal range for each lab result
-Urine: specify which urine test you are referring to. Ex: culture normal (-), patient
result is + for E.Coli
58
-X-ray: specify which X-ray is done. Ex: CXR normal is (-) and patient result is right
lower lobe infiltrate
Record the reason for patient values.
-If normal: state WNL. If this normal is unexpected, also state this and why
Ex: WBC is normal for a patient admitted with pneumonia is an abnormal finding, but
could be explained in a patient that is immunocompromised
-If abnormal: state the reason the value is abnormal. Ex: Elevated WBC in a patient
with pneumonia occurs because of response to inflammation and infection.
NPW Page 2
Create two concept maps to represent the following information: pathophysiology, signs and
symptoms, medical treatment and nursing interventions.
 In long term care, you may create concept maps for chronic medical problems. Ideally
ones that have signs and symptoms you can observe and that have nursing interventions
you can implement.
 In N212, you will need a concept map for every admitting medical/surgical diagnosis and
additional concept maps if the patient has diabetes, hypertension, COPD and/or chronic
renal failure (ESRD, CRD, is on dialysis).
Medications Page 3
Drug Names: State the trade (one) and the generic name of the medication
Class: State both the functional and chemical class for each drug.
Dosage and range: State the normal dosage range for this person (ex: elderly) and the dosage
ordered for the patient
Route: State the route ordered for the patient. Ex: oral, intramuscular, subcutaneous, etc.
Indication for use for this patient and nursing implications: Why is this medication ordered
for this patient? State any nursing implications for the administration of this medication. Ex:
Check BP before administering an antihypertensive.
Time and frequency: State when the drug is ordered to be administered and the frequency of
administration. Ex: Ordered twice a day and the administration times are 0900 and 2100
 Attach additional paper if needed
Assessment Guide (AG) Page 4
The Assessment Guide is based on the diagnostic divisions based on the Roy Adaptation Model.
The RAM diagnostic divisions page should be used as a guide to assist you in figuring out what
information should be included in each section. This page is arranged in a stepwise approach,
addressing each piece of information as you complete the Assessment Guide chart. Eventually
this will become second nature and you will not have to refer to the diagnostic divisions page for
reference.
Once the data collection is completed, you will be directed from your clinical instructor on how
many complete diagnostic divisions should be thoroughly completed, starting with one, adding
more sections as you become more proficient.
AG Psychosocial & Documentation Page 5
Use this area for documentation as directed by your clinical instructor. You may be instructed to
document a narrative, DAR, SOAPIE note or any variation that may be used by your facility.
59
Roy Adaptation Model Reference Sheet for Completing the Assessment Guide
Neurological
Neurological Function
-Subjective Data
Obj: LOC, GCS (eye opening, verbal
response, motor response), seizures (describe,
timing), altered mental status, aphasia,
intellectual functioning
-Lab results: radiology (EEG, MRI, etc)
-Interventions: seizure precautions, etc.
Include Sensation
-Subjective Data
-Pain (location, intensity, character, onset and
duration), vision, hearing, response to sensory
overload
-Interventions: PCA pump, special devices
(glasses, hearing aid)
Protection
Protection
-Subjective Data, immunization status
-Obj: Temperature, Shivering, Diaphoresis,
Skin/Hair/Nails (describe), Lesions (describe,
location), Incisions (describe, location), IV site
(describe, location),
AV shunt (describe)
-Lab results: WBC, C&S (specify source: wound,
sputum)
-Interventions: Wound dressing (location, describe),
drainage tubes (type, site, describe), Isolation,
Siderails, Bed position, Restraints (Type, reason)
Oxygenation-gas exchange
Oxygenation-gas transport
Focused Assessment Plan
Oxygenation : Gas Exchange
-Subjective Data
-Obj: Respiratory Rate, Depth, Effort,
Breath Sounds (describe, location),
Cough (describe), Sputum production
(describe)
-Lab results: Sputum C&S, radiology
results, ABG
-Interventions: positioning, turning,
DB&C, oxygen (flow rate and method),
pulse oximetery (% on how much
oxygen), incentive spirometer (volume,
frequency of use), suctioning (type,
frequency, response)
Nutrition
Nutrition
-Subjective Data
-Obj: Height, Weight, Ideal body weight,
Nutrition intake, NPO status and reason,
food intolerances , nausea, emesis
(describe), swallowing ability, gag reflex,
oral cavity (inspect and describe),
cultural preferences
-Lab results: Cholesterol (HDL, LDL),
blood sugar, Ca, K, Na, Albumin
-Interventions: Diet; Enteral feedings
(tube type, formula and flow rate),
TPN/Lipids
F&E
Fluid and Electrolytes
-Subjective Data
-Obj: Changes in weight, LOC, thirst,
24 hour intake/output, abnormal loss
(edema, drainage, diuresis,
diaphoresis, tachypnea, diarrhea,
emesis), tissue turgor,
mucous
membranes)
-Lab results: Na; Cl; K; ABG:
HCO3, pH; Urine specific gravity
-Interventions: IVF (solution, tonicity
of solution, flow rate), NG drainage
(amount, describe)
Oxygenation: Gas
Transportation
-Subjective Data
-Obj: Blood pressure, apical
pulse, peripheral pulses
(location, rhythm and
strength), edema (degree,
location), capillary refill
(location), skin/mucous
membranes,
Homan’s sign
(if appropriate)
-Lab results: Hgb, Hct, RBC,
platelets, PT/PTT, INR
Bowel/Urinary Elim
Bowel/Urinary Elimination
-Subjective Data
-Obj: Abdomen (inspection,
auscultation, palpation), urine
(describe), Flatus, Stool (describe),
last bowel movement
-Lab results: Urinalysis/Culture,
Serum: BUN, creatinine, RBCs,
WBCs, stool specimen results,
radiological studies
-Interventions: catheter,
colostomy/ileostomy, bladder
irrigation
Act & Rest
Endocrine
Activity and Rest
-Subjective Data
-Obj: Activity level and tolerance
-Muscle and joints (description,
movement, strength, coordination),
posture/gait (describe),
circulation/sensation/movement
(describe), rest and sleep patterns
(describe)
-Lab results: Ca, Phos, Mg, radiological
results
-Interventions (assistive equipment-cast,
trapeze, traction, CPM, etc), special beds
(type)
Endocrine Function
-Subjective Data
-Diabetes Mellitus, Thyroid,
Parathyroid, Reproductive
function (last menstrual period,
menopause, infertility, changes in
sexual function)
-Lab results: Thyroid (TSH, T3,
T4), blood sugar, estrogen, other
60
Assessment Guide-Psychosocial
Interdependence:
-Interdependence: Significant others and support systems: Does patient have families/significant others/friends who
can assist them? Assess for safety concerns regarding their behaviors and ability to care for self both in the hospital
and when they go home. Assess the patient’s ability to accept assistance and care from their healthcare team. Assess
and document if the patient is exhibiting inappropriate dependent or independent behaviors affecting patient safety.
Role Function
-Role Function: Focus on assessment
of patient chronic diseases and their
acceptance,
knowledge and home
management. Focus on how the patient
is adapting to their acute illness and
hospitalization. Are they participating
in their care, or refusing care? Assess
for body image concerns in patients
who have removal of organs, incisions
or tubes, disfiguring procedures and
surgeries such as amputations or
removal of a breast or prostrate?
Date/Time
Focus
Cultural Considerations
Cultural: Health
care beliefs
(pain, nutrition, disease,
health, family and gender
roles). Language (barriers) and
Communication considerations;
cultural considerations re: eye
contact, touch, & space.
Self Concept
-Self Concept: Focus on how the patient
views themselves. Do they have positive
or negative self-esteem? Do they feel
good about themselves? Are they out
going or withdrawn? Are they
experiencing any fear, anxiety, anger or
grief regarding their life situation? How
are they coping? What spiritual concerns
might they have and are spiritual needs
being met? Any problems with
sexuality?
Documentation
61
Assessment Guide
Patient Initial: _______ Room#: ______ Date: __________
Neurological
Subj: “My hands ache, it must be
raining outside”
Obj: AAOX4, GCS 15
Pain 5/10 Bil. hands, aching, onsetupon waking, Motrin ↓’d pain to 1/10
Protection
Subj: Flu shot in the fall, Pneumovax 1 year ago
Obj: Temp 100.5 F, No chills
Fluid and Electrolytes
Subj:
Obj: 2 lb wt loss since admission
Skin: intact, ,pink, warm and dry
Lesion: R heel stage III. 1cmX 1cm, red, serous discharge.
IV site: R AC. No s/s infection or infiltration.
2/5/05 I: 1500 ml/ O: 2200ml
Tissue turgor: good
MM: dry
Labs: Na: 144, K: 4.0; Cl: 102
Labs: WBC: 18
Labs: NA
Oxygenation: Gas Exchange
Subj: “I can’t breathe”
Obj: RR 24, even and labored.
Focused Assessment Plan
Oxygenation: Gas
Transport
Obj: BP 142/85 lying; Apical:
O2@ 2L NC with O2 Sat. of 95%.
Breath sounds: crackles BLL. Cough
productive of mod. amt of thick
green/yellow sputum.
Labs: CXR: BLL infiltrate
105
S1S2 irregular;Radial/pedal 2+
Bil., irregular
Edema: none; Cap refill
BUE/BLE 2 sec
Skin color: pink; Skin temp:
warm ; MM: pink/dry
Labs: H/H: 16/48; RBC: 5.2;
platelet: 200,000; PT: 12; PTT:
62; INR: 2.3
Nutrition
Subj: “I’m not hungry”
Obj: Ht: 5’11” Wt. 176 lbs
Bowel/Urinary
Subj:
Obj: Abdomen non-distended, soft,
IBW: 166 lbs
Intake: Breakfast 30%, Lunch 40%
Oral cavity: full dentition, Tongue:
pink/dry, no lesions; Gums: pink/dry
Labs: 205; Ca: 8.5; K: 4.0; Na 144:
Albumin: 3.8
nontender, BS X4-hypoactive. LBM
2/1/05. States “I usually have a bowel
movement every day after I eat my bran
cereal. I feel constipated”
Urine: clear, yellow
Activity/Rest
Subj: “I feel weak”
Obj: BRP,
Endocrine
Subj: “I’ve been a type II
Muscle/Joints: no contractures, morning
stiffness in B hands. Movement limited in
hands. Strength: strong BUE, BLE
Coordination: smooth
Posture/gait: kyphotic/ steady
CSM: Feet cool, sensation intact, movement
intact
Sleeps 6 hours a night with one wakening for
bathroom
Obj:
Labs: Ca:
Labs: UA:
negative 2/4/05
BUN: 11, Creat: 0.6
diabetic for 5 years”
Labs: Serum glucose: 205
Fingerstick BS (0730) 198, (1130)
213
8.5
62
Assessment Guide-Psychosocial
Interdependence
Significant Others
Subj: Wife and children
Obj:
Rec: Accepts calls and visits from family.
Giving: Returns affection of wife, calls wife
Psychosocial: Role Function
Cultural Considerations
Self Concept
Primary Role:
Psychosocial Self Concept
Sex M Age 68
Ego integrity vs. Despair
Secondary Role:
Role: Diabetic
Instr: Check BS 4X/day at home. Asks about glucose
reading. Tries to follow diet
Expr: “I know I have to keep my BS under control, I
don’t want to loose a limb.”
Role: Husband
Instr: Calls wife every day
Exp: “I have to get home and be with my wife, she
misses me”
Tertiary Role:
Role: Pneumonia patient
Instr: Takes breathing treatments and oral meds,
Performs TCDS exercises
Exp: “I want to get my breathing back to normal”
Role: Masonic member
Instr: Attends monthly meetings. Chairperson of
fundraising
Exp: “It feels good to be a member of a group.”
Date/Time
02/02/12
1400
Focus
Resp
Physical Self:
Body sensation
Subj: “My hands ache”
“I don’t like to wear this oxygen, it makes me feel old”
“Am I going to have to wear this oxygen forever?” “I just
want to go back to my normal self” “I believe that God
will help me through this. “
Obj: wearing O2 al 2L per NC
Rubbing hands together.Tears in eyes
Performs TCDB exercises, verbalizes desire to learn
about medications and treatments to improve.
Prays in room. Asks for chaplain to visit
Documentation
S: “I can’t breathe”---------------------------------------------------------------------------O: Resp shallow, labored, 30/min. Intercostal retractions present. BS c coarse
crackles BLL and sibilant wheezes BUL. O2 @ 2L NC c pulse ox 90%.A: Impaired gas exchange-------------------------------------------------------------------P: Administer prn bronchodilator---------------------------------------------------------I: Administered Albuterol unit dose via face mask @ 1340 ---------------------E: States “My breathing is better now” Resp regular, unlabored, 22/min. No
intercostals retractions. Remains on
O2@2L NC c pulse ox
95%. BS c coarse crackles BLL. No wheezing noted. . No apparent distress
noted. ________________________________________________N.Nurse SNCC
63
Lab Group _____
N212 Nursing Process Worksheet-NPW
Student:____________________________ Date(s):____________
Co-Assigned Nurse/Nursing assistant:_____________________
Patient Initials:_________ Room #_________Age/Sex_______
Admit Date:___________ Surgery Date:__________________
Code Status:___________ Allergies:_______________________________________________________________________________
Admitting Dx:
History of present illness:
PMH:
Course of events in hospital:
MD Orders from Physician Order Section of Chart
Vital Signs (Frequency)
Treatments/ Nursing Orders: (Restraints, Fluid Restriction, PT etc)
Diet/Feedings:
Activity:
O2
Foley
Glucose Testing Times:
Tests & Procedures:
IV & Rate:
Wound Care & Dressing Change
Result
and
(↓ ↑)
Admit
Na+
K+
ClCa+
Albumin
Creatinine
BUN
Glucose
WBC
RBC
Hgb
Hct
Platelets
PT
PTT
aPTT
INR
Urine
X-ray
Normal
Range
Result (↓↑)
Tuesday
Result (↓↑)
Wednesday
I&O
NGT
JP
Lab Result Summary: Discuss abnormal lab
values and diagnostics and relate them to the
admitting diagnosis or chronic/concurrent
diseases
Comments
(Monitoring ,
Actions, Notified
MD)
136-145
3.5-5.0
98-106
9.0-10.5
3.5-5.0
(M) 0.6-1.2
(F)0.5-1.1
10-20
70-150
5000-10000
(M)4.7-6.1
(F)4.2-5.4
(M)14-18
(F)12-16
(M)42-52
(F)37-47
150000-400000
11-12.5
60-70
30-40
0.9-1.2
NEG
NEG
64
Assessment Guide
Patient Initial: _______ Room#: ______ Date: __________
Neurological
Subj:
Subj:
Protection
F&E
Subj:
Obj:
Obj:
Obj:
Labs:
Labs:
Labs:
NIC:
NIC:
NIC:
Oxygenation-gas exchange
Subj:
Focused Assessment Plan
Oxygenation-gas transport
Subj:
Obj:
Obj:
Labs:
Labs:
NIC:
NIC:
Nutrition
Bowel/Urinary Elim
Subj:
Subj:
Obj:
Obj:
Labs:
Labs:
NIC:
NIC:
Act & Rest
Endocrine
Subj:
Subj:
Obj:
Obj:
Labs:
Labs:
NIC:
NIC:
65
Assessment Guide-Psychosocial
Interdependence:
Subj:
Obj:
Role Function
Cultural Considerations
Self Concept
Subj:
Subj:
Obj:
Obj:
Date/Time
Focus
Documentation
66
Nursing CareMaps
Identify the MAIN medical/ surgical diagnosis and all chronic medical diagnosis. Construct a Caremap (See CareMap Guidelines) that includes the following:
1.
2.
3.
4.
5.
6.
Define and explain the pathophysiology of the Medical diagnosis.
Identify all signs and symptoms pertinent for the medical diagnosis.
List nursing interventions appropriate for the medical diagnosis.
List all treatments including pharmacological and non-pharmacological modalities for the medical diagnosis
List all the diagnostic tests and laboratory tests pertinent to this medical diagnosis.
List all possible nursing diagnoses appropriate for this medical diagnosis.
67
Nursing Diagnoses:
SAMPLE CAREMAP
TEMPLATE
Nursing Interventions
Signs and Symptoms
Medical Diagnosis
Pathophysiology
Pharmacological Treatment
Diagnostic tests:
68
MEDICATION SHEET (for Non-Med Days)
MEDICATION:
Generic / Trade
Classification
(Functional/Chemical)
DOSE /ROUTE/
FREQUENCY:
Reason why THIS Patient is receiving
69
Medication Sheet for Med Days
MEDICATION:
ROUTE/DOSE /
Generic / Trade
FREQUENCY:
Classification
(Functional/Chemical) Safe Dose Range
ACTION &
SIDE EFFECTS:
Most common and
life threatening
NURSING
CONSIDERATIONS:
ASSESSMENTS / LABS
PT TEACHING
NEEDED:
Reason why my pt
is receiving this
70
SAMPLE MEDICATION SHEET FOR NON-MED DAYS
Drug Names (trade/generic)
Class (functional/chemical)
Apo-Pen VK/ penicillin V
potassium
F: Broad spectrum antiinfective
C: natural penicillin
Cleocin/ clindamycin HCL
F: antiinfective-misc
C: Lincomycin derivative
Percocet
Proventil/albuterol
F: Bronchodilator
C: Adrenergic B2-agonist,
sympathomimetic, bronchodilator
Oxycodone
F: Opiate analgesic
C: Semisynthetic derivative
Tylenol/ acetaminophen
F: Nonopiod analgesic
C: nonsalicylate, paraminophenol
derivative
Cardura/ doxazosin
F: Alpha Blocker,
antihypertensive
C: Quinazoline
Dose Route Time
Frequency
Why is my patient receiving this
400mg
IV
QID
1200,0600,
1800,2400
600 mg
IV
BID
0900, 2100
2.5mg/ml unit dose
Inhaled
QID
PRN
-
Bacterial pneumonia (gram + cocci)
-
Bacterial pneumonia
-
Bronchodilation to assist breathing difficulty from pneumonia
5mg
PO
Q 4 hours
PRN
325mg PO
Q 4 hours
PRN
-
Reduce pain caused by osteoarthritis and pleuritic chest pain
-
Fever and could be used for pain management for the
osteoarthritis and pleurtic chest pain
2mg PO
Once a
Day
-
To lower blood pressure (hx of HTN)
2.5mg PO
Once a Day
1600
-
Prevent embolus formation from atrial fibrillation
RISS/SC
QAC, HS
0730,1130,1700,2100
-
Lower blood sugar (Hx of diabetes )
0900
Coumadin/ warfarin
F: Anticoagulant
Humulin R/ regular insulin
F: pancreatic hormone
C: exogenous unmodified insulin
71
Student ____________________________
___Fall____Spring _____Year
Cerritos College
Health Occupations Division
Associate Degree Nursing Program
Clinical Performance Evaluation
Nursing 210
This evaluation tool will be used for measurement of the clinical course objectives.
Evaluation of the clinical performance will be based on behaviors identified in the
evaluation key and the accompanying guidelines. Professional nursing requires
competency in both theoretical knowledge and application to clinical practice. Clinical
Competency must be demonstrated by meeting all Critical Clinical Competencies, as
well as a “satisfactory” or “needs improvement” marking at the end of the clinical tool to
pass the clinical component of this nursing course.
CRITICAL CLINICAL COMPETENCIES:
MASTERY MUST BE DEMONSTRATED IN ALL OF THE FOLLOWING CRITICAL
CLINICAL COMPETENCIES AT ALL TIMES. A CRITICAL BEHAVIOR IN ONE OF
THE FOLLOWING AREAS WILL CONSTITUTE AN IMMEDIATE CLINICAL FAILURE.





Demonstrates safe practice of designated nursing skills.
Provides for physical safety of patient.
Protects patients from emotional harm.
Communicates clearly both verbally and in writing
Seeks assistance from instructor or other healthcare members for care which
is beyond the student’s level of knowledge or experience.
 Calls attentions to own errors and reports situations accurately.
 Maintains confidentiality.
 Complies with college and agency policies and procedures.
 Submits required graded papers.
 Passes Medication Calculation Exam
Other behaviors that will result in clinical failure include:
 Dishonesty including but not limited to cheating, plagiarism, fabrication, and
misrepresentation.
 Violent or aggressive behavior
 Disrespectful and/or abusive language or behavior
 Use of drugs or alcohol (legal or otherwise) in clinical setting
 Stealing
 Conviction of felony
72
0
OUTSTANDING: Consistently above-average performance and self-directed.
Requires minimum guidance.
S SATISFACTORY: Overall satisfactory, occasionally requires some guidance
NI NEEDS IMPROVEMENT: Inconsistent performance requires repeated
guidance and supervision.
Nursing 210 Clinical Evaluation Tool
Overall Clinical Performance Evaluation:
There are (8) Major Areas of clinical performance for evaluation: Professional
Behaviors, Communication, Critical Thinking and Clinical Decision Making, Nursing
Process, Caring, Teaching and Learning, Clinical Skills, and Managing Care.
I. Three or more needs improvement “NI” in one major area will result in an “overall
needs improvement” for that major area. (ex: 3 “NI”s out of the 8 criteria in the area of
Professional Behaviors will result in an overall NI for Professional Behaviors). A student
may progress to the next clinical with an overall “NI” in only one major area. In this
case, the student will receive an overall “Needs Improvement” in clinical and an
Advisement Notice for the major area of Needs Improvement.
II. A student who receives an “overall needs improvement” in more than one major area
will fail clinically. (ex: overall “NI” in Communication and overall “NI” in Nursing
Process).
III. A student who has a “needs improvement” marking in eight or more single, isolated
boxes throughout the entire tool will fail clinically.
IV. For less than eight single “needs improvements” throughout the entire tool, the
student can progress to the next clinical with an overall “Satisfactory” or “Needs
Improvement” (with an Advisement Notice attached) based upon instructor evaluation
and anecdotal.
73
Core Clinical Competencies
PROFESSIONAL BEHAVIORS: Practices safe professional
behaviors consistent with ethical, legal and regulatory standards of
professional nursing practice when providing client care.
O
S
NI
O
S
NI
1. Complies with college, nursing department, and facility
regulations and policies.
2. Arrives at clinical prepared for patient care. Submits all
assignments within designated time frame, including
referrals and make-up assignments.
3. Notifies instructor when unable to attend clinical or will
be late.
4. Demonstrates responsibility and accountability for one’s
actions.
a. Calls attention to errors and reports situations to
clinical instructor.
b. Reports unsafe practices.
c. Maintains professional boundaries in the nurse-client
relationship.
5. Practices within guidelines of N210; individual
knowledge and expertise; and seeks assistance for
care beyond level of knowledge.
6. Abides by HIPPA standards
7. Follows universal precautions.
8. Demonstrates professional behavior such as a positive attitude,
punctuality, self-direction, and an appropriate appearance (follows
dress code – ref. student handbook).
OVERALL EVALUATION ON PROFESSIONAL BEHAVIORS:
COMMUNICATION: Communicates effectively with nursing staff,
various members of the healthcare team, patients and family
members.
1. Communicates verbally in a clear and concise manner
in English.
2. Writes in a clear and concise manner in English.
3. Begins to utilize therapeutic communication when interacting with
patients, family and significant others.
4. Verbalizes assessment, interventions and evaluations using
appropriate medical terminology at a beginning level.
5. Begins to communicate with the healthcare team:
providing patient updates in a timely manner to staff
nurse and instructor.
OVERALL EVALUATION ON COMMUNICATION:
74
CRITICAL THINKING AND CLINICAL DECISION MAKING: Uses
critical thinking when performing all steps of the nursing process with
patients in the clinical setting.
O
S
NI
O
S
NI
O
S
NI
1. Begins to make clinical judgment decisions to ensure
safe and effective care when providing patient care with
instructor support.
2. Begins to organize plan of care and prioritize total patient care for
one patient.
3. Demonstrates, at a beginning level, the ability to apply
theory to clinical situations, stating scientific rationale,
incorporating best practices.
OVERALL EVALUATION ON CRITICAL THINKING / DECISION
MAKING:
NURSING PROCESS: Applies the Nursing Process in implementing
care.
1. Begins to utilize appropriate sources to elicit data about
the patient.
2. Performs and documents a physical assessment, demonstrating
appropriate use of medical terminology and approved
abbreviations, at a beginning level.
3. Initiates an environmental assessment.
4. Begins to identify appropriate nursing problems / nursing
diagnosis.
5. Begins to develop patient-specific interventions.
6. Begins to evaluate patient response to care and revises patient
care as needed.
OVERALL EVALUATION ON NURSING PROCESS:
CARING INTERVENTIONS: Demonstrates caring behaviors
towards the patient and significant others.
1. Assists the patient to obtain optimum comfort and functioning.
2. Provides a safe physical and psychological environment
protecting the patient from undue harm, maintaining
dignity and respect.
3. Identifies and adapts care to honor the patient’s values and
customs, and the emotional, cultural, and spiritual needs.
4. Advocates for the patient.
75
5. Demonstrates empathy when providing nursing care.
OVERALL EVALUATION ON CARING BEHAVIORS:
TEACHING AND LEARNING: Demonstrates application of teachinglearning principles.
O
S
NI
O
S
NI
O
S
NI
1. Provides simple explanations and instruction to patients prior to
interventions and / or procedures.
OVERALL EVALUATION ON TEACHING AND LEARNING:
CLINICAL SKILLS: Competently performs technical skills with
patients in the health care setting.
1. Demonstrates safe practice of designated nursing skills for N210
in clinical and/or skills lab.
2. Seeks out patients that provide varied learning and skills
opportunities.
OVERALL EVALUATION ON CLINICAL SKILLS:
MANAGING CARE AND COLLABORATION: Effectively manages
patient care in collaboration with other members of the healthcare
team, patient and significant others.
1. Begins to work cooperatively with health care team members,
peers, faculty, patients and their significant others toward
common
patient-centered outcomes.
2. Manages the patient assignment in an organized and efficient
manner completing care within allotted time frame.
OVERALL EVALUATION ON MANAGING CARE:
76
N210 Nursing Skills Competency
Check box for each skill: S= Satisfactory, NI= Needs Improvement, LP= lab
Performance only, LO= Lack of opportunity to evaluate
S
NI
LP
LO
Performs skills necessary to meet activity and rest needs
including:
Utilizing body mechanics, positioning, ambulation, and transfer
activities
Utilizing active and passive range of motion and isometric
exercises
Making unoccupied and occupied beds
Performs skills necessary to meet nutritional
needs including:
Feeding patients orally
Feeding patients via nasogastric and/or gastrostomy tubes (H20
flush/placement check)
Inserting nasogastric tube
Assessing nutritional status (% of meal consumed and recording
oral intake)
Performs skills necessary to meet elimination needs including:
Assisting with toileting
Inserting and maintaining catheters
Assessing and recording fluid output
Administering an enema or Harris flush
Inserting rectal tube and/or suppository
Collecting specimens
Performs skills necessary to meet oxygenation needs including:
Performing, assessing and recording vital signs (temperature,
pulse [apical and radial], respirations, pulse oximetry and blood
pressure)
Performs skills necessary to meet protection needs including:
Hand hygiene
Provide personal hygiene measures (bath, oral care)
Gowning and gloving
Applying isolation techniques
Applying bandages, binders, restraints and anti-embolism
stockings
Maintaining a sterile field
Providing wound care
Assessing level of pain
Performs physical assessment practicum (Pass/Fail)
Pass random skill testing within 2 tries. Failure to pass within 2
attempts will be reflected in your overall clinical evaluation.
List all skills the student performed in this clinical rotation:
77
N 210 Overall Clinical Competency
0
S
NI
OUTSTANDING: Meets all Critical Clinical Competencies. Consistently aboveaverage performance and self-directed. Requires minimum guidance.
SATISFACTORY: Meets all Critical Clinical Competencies. Overall satisfactory,
occasionally requires some guidance
NEEDS IMPROVEMENT: Meets all Critical Clinical Competencies. Inconsistent
performance requires repeated guidance and supervision.
1) Overall “NI” in only one major area OR
2) Fewer than eight single needs improvement throughout the clinical tool
U
*Advisement Notice Required for students with an overall “Needs Improvement”
UNSATISFACTORY: Unsatisfactory performance.
1) Fails to meet one or more critical clinical competency OR
2) Receives more than one “overall needs improvement” in a major area OR
3) Receives a single “needs improvement” in eight or more single boxes throughout
the entire tool.
*Results in clinical failure.
Midterm Evaluation (as needed):
_________ Needs Improvement ___________ Unsatisfactory
Comments:
Instructor Signature:___________________________ Date:_____________
Student Signature:_____________________________ Date:_____________
Final Overall Evaluation:
____Outstanding _____Satisfactory _____Needs Improvement
_____Unsatisfactory
Comments:
Instructor Signature:___________________________
Date:_____________
Student Signature:_____________________________ Date:_____________
78
Cerritos College
Health Occupations
Department of Nursing
Guidelines for Clinical Performance Evaluation Tool
Professional Behavior
Students will practice safe professional behaviors consistent with ethical, legal
and regulatory standards of professional nursing practice when providing client
care.
 Students are held accountable to standards of practice for nursing care.
Policies and procedures should be used to guide practice and be upheld.
 Students must notify instructor of any clinical absence or tardiness.
Failure to do so will result in a clinical failure.
 Tardiness is not an accepted clinical behavior. The first tardy will
result in a verbal warning, the second will result in an advisement
note and the third tardy will result in a clinical failure.
 Two or more absences may result in a clinical failure.
 All clinical hours will be made up according to individual course policy.
 Students are to arrive at the clinical site in a timely manner with written
assignments completed and equipped with the knowledge necessary to
give safe competent care. Failure to do so will result in adjustment of the
patient care assignment, up to and including being sent home.
 Students are expected to demonstrate consistency in growth in both
written assignments and clinical performance.
 The ability to follow directions and guidelines is imperative in the practice
of professional nursing. Students are expected to adhere to all directions
and guidelines, both in the care of the patient and in preparation of written
assignments. It is the responsibility of the student to seek clarification, if
unclear about expectations. Assessment of the ability to follow guidelines
and directives extends to the policies and procedures of the clinical facility
to which the student is assigned.
 Practices within guidelines of N210 and individual knowledge and
expertise and seeks assistance for care beyond level of knowledge.
Clinical instructors recognize that students are learning. Students are to
acknowledge the limitations of their knowledge and seek to correct areas
of knowledge deficit. Assistance should be sought as needed; failure to
do so may jeopardize the patient, the student or others.
 Students are expected to verify dependent nursing interventions in the
physician’s orders prior to implementation. This includes all treatments
and medications. In addition the student is responsible to check the
physicians’ orders regularly to determine if existing orders have been
altered or new orders have been written.
 Students represent not only themselves and their families, but Cerritos
College, the clinical facility to which they are assigned and the profession
of nursing as a whole. Physicians, patients, families and other health care
79



team members judge nursing care by the behavior and appearance of the
nurse. The expectation is that students will role model the highest
standards of professionalism, including adherence to the Student Dress
Code policy. A professional demeanor is to be maintained at all times.
A component of action and behavior on the part of the professional is the
ability to be self-directed, and example of which is to use clinical time
wisely by seeking learning experiences. Students are expected to
participate in shared learning experiences, including group conferences.
Development of awareness and understanding of how
personal/professional behavior influences patient care is expected of each
student.
Students are to demonstrate knowledge of and competency in infection
control measures appropriate to the clinical site and the needs of each
patient. These include but are not limited to: hand hygiene, wiping down
equipment, and proper use of personal protective equipment.
Students are expected to maintain the confidentiality of all personal health
information in accordance with HIPPA. Identifying data must be removed
from all documents leaving the clinical site.
Communication
Students will communicates effectively with nursing staff, various members of the
healthcare team, patients and family members.
 Students are expected to communicate clearly in English at all times and
use appropriate medical terminology. Bilingual students may
communicate with their patients in the patient’s preferred language.
 The student should be able to communicate a clear and concise verbal
report of their patients. Students are expected to communicate with their
patients while providing care.
 Written assignments should be legible and grammatically correct.
 Students are expected to show improvement in their documentation and
verbal skills as they progress in clinical.
 Ability to communicate following proper lines of authority will be included
in the evaluation. Students are expected to clarify their role
responsibilities with the RN and CNA prior to assuming care.
 Verbal Report
First Semester Students
Students should begin to formulate a verbal report that includes patient
condition, pertinent assessment findings and priority care needs.
Second semester students
Students are expected to provide an organized verbal and written report.
Second Year Level Students
Students are expected to provide an organized verbal report reflecting
patient condition, pertinent assessment findings and priority care needs.
Critical Thinking and Clinical Decision Making
Student will use critical thinking when performing all steps of the nursing process
with patients in the clinical setting.
80








Nursing Process Worksheets (NPWs) are to be completed on all patients
prior to clinical. Arriving to clinical unprepared will result in adjustment of
the patient care assignment, up to and including being sent home. Being
sent home warrants an advisement note and the student is required to
complete a clinical make-up assignment. .
Students are expected to show progression in critical thinking and problem
solving skills.
Students are expected to function within the scope of practice within their
respective course.
Unsafe clinical behaviors/judgment will result in a clinical failure.
Students are expected to transfer and apply knowledge from previous and
current courses.
Students must show progression in the application of scientific rationale.
Students are expected to show a progression in the ability to synthesis
data and develop an understanding of the patient’s clinical situation.
Students should show a progression in being able to recognize the
relationship between assessment data (physical assessment findings,
diagnostic tests, and medications).
Problem Solving
First Year Level
Students will begin to apply problem solving with support from the clinical
instructor. Students should present problem issues to the clinical
instructor armed with possible solutions to the problem at hand that
demonstrate critical thinking.
Second Year Level
Students will apply problem solving while providing care for more complex
and increased number of patients with increased confidence. Students
should begin to anticipate possible outcomes prior to deciding nursing
actions. They will validate decisions with the instructor and require less
direction and dependency throughout the clinical rotation. Their level of
independence remains within the student role but allows for a safe and
smooth transition to the next course.
NURSING PROCESS
Student will apply the Nursing Process in implementing patient care.
 Students will utilize the nursing process when assessing, implementing
and evaluating care.
 The Roy Adaptation Model will be used to collect and organize
assessment data.
 Assessment data should include subjective and objective data. Objective
data may include but not limited to diagnostic tests, lab values, past
medical history, physical assessment, medications, physician orders and
interdisciplinary treatments.
 Students are expected to use NANDA approved nursing diagnoses
provided in the course packet. (N/A at N210)
81


The ability to formulate a nursing care plan that reflects the priority
nursing problems for a patient is critical to the function of a nurse. Failure
to achieve 75% on the Nursing Care Plan/Concept Map will result in an
advisement note. Failure of a Nursing Care Plan/Concept Map in a
subsequent course will result in a clinical failure in that course. (N/A at
N210)
Students are encouraged to seek instructor assistance and/or guidance
prior to submission of the Nursing Care Plan/Concept Map. (N/A at N210)
Caring Interventions
Student will demonstrate caring behaviors towards the patient, significant others,
peers and members of the healthcare team. Students are expected to:
 Protect and promote the patient dignity.
 Identify psychosocial needs.
 Provide for the privacy of patients at all times.
 Protect the patient from physical harm by identifying potential or actual
threats and act to correct them. Examples of unacceptable behaviors
include: leaving side-rails down when patient is at risk for falling, leaving
syringes with needles in the room, not recognizing breaks in sterile
technique, picking up items off the floor and using in patient care, not
discriminating clean versus unclean, not using gloves when needed when
protecting self or others, not utilizing hand hygiene, not recognizing when
contamination occurs and taking appropriate corrective actions or not
adhering to isolation policies.
 Protect the patient from emotional harm by identifying potential or actual
threats and act to correct them. Examples of unacceptable behaviors
include: ignoring patient concerns; failure to psychologically prepare
patients before procedures; making statements that instill fear or anxiety;
using inappropriate “slang” language or inappropriate terms of
endearment such as “honey” or “sweetie”; sexual innuendos; not
promoting an environment that allows the patient to express their feelings;
not demonstrating empathy while caring for patients and performing
procedures; not seeking guidance if unsure of course of action; failure to
report abnormal findings or change in condition.
Teaching and Learning
Students will demonstrate application of teaching-learning principles. Students
are expected to:
 Document patient teaching on NPW and patient record as indicated.
 Include teaching in the care of their patients and families from the first
clinical course and throughout the program.
 Demonstrate the ability to prepare and present educational needs of the
patient as well as evaluate the effectiveness of the teaching.
82

Utilize patient teaching opportunities with medication administration. (N/A
at N210)
 Assess the patient’s understanding of clinical situation or disease process.
 Assess patient’s management of chronic conditions.
 Respond to patient questions appropriate to their level.
Managing Care/Collaboration
Students will effectively manage patient care in collaboration with other members
of the healthcare team.
 Students are expected to interact in a professional and collegial manner
with all members of the healthcare team.
 The student team coordinator obtains pertinent data from team members
on all patients assigned to the team. (N/A at N210)
 The team coordinator gives a complete report to the clinical instructor on
the status of patients assigned to the team. (N/A at N210)
 All students are to utilize appropriate channels of communication
(assigned staff nurse, student team coordinator, and instructor) when
providing patient care.
 Students are expected to report to appropriate staff and instructor
pertinent abnormal patient information or when patient situations change.
Examples: abnormal VS, respiratory distress, unrelieved pain, low urine
output, abnormal labs, signs of bleeding, changes in level of
consciousness and inappropriate behavior.
 Students are to assist fellow students and staff as needed. Students are
expected to answer all patient call lights and requests for assistance even
if the student is not assigned to the patient. Students should relay
requests to appropriate staff nurse.
 Students will delegate aspects of nursing care to the appropriate members
of the student team according to Team Role Guidelines. (N/A in N210)
 Students are expected to begin developing leadership and assertiveness
skills and show initiative in solving problems and meeting patient needs.
Examples: Following up on missing food trays, medications, checking
orders, providing education, asking MD questions, volunteering to assist
MDs, seeking out learning opportunities, and developing communication
skills.
83
Approved Abbreviations
i
ii
∆
°
ā
AAOx4
abd
ABG
AC
a.c.
ADA
ADL
ad lib
AFA
aka
AKA
alb
ALOC
AMA
amb
amt
ant
as tol
ASA
ASHD
Ax
bid
BKA
BLE
BM
BMP
B/P or BP
BPH
BR
BRBPR
BRP
BS
one
two
change
degrees or hours
before
awake, alert, and
oriented X4
abdomen
arterial blood gas
antecubital
before meals
American Diabetes
Association
activities of daily living
as desired
appropriate for age
also known as
above knee amputation
albumin
altered level of
consciousness
against medical advice
ambulate
amount
anterior
as tolerated
aspirin
arteriosclerotic heart
disease
axillary
twice a day
below knee amputation
bilateral lower
extremities
bowel movement
basic metabolic panel
blood pressure
benign prostatic
hypertrophy
bedrest
bright red blood per
rectum
bathroom privileges
bedside
BS
BSC
BUN
BX
℅
c
Ca
CA
CABG
CAD
cap
cath
CBC
CDB
C/D/ I
CHF
cm
CMP
CMS
CNS
COPD
CP
CPM
C&S
CT
CTA
CVA
CVD
CXR
DAT
DJD
DKA
DM
DOB
DOE
bowel sounds
bedside commode
blood urea nitrogen
biopsy
complains of,
complaints of
with
calcium
cancer
coronary artery bypass
graft
coronary artery disease
capsule
catheter
complete blood count
cough and deep breath
clean, dry, intact
congestive heart failure
centimeters
complete metabolic
panel
circulation, movement,
sensation
central nervous system
chronic obstructive
pulmonary disease
chest pain
continuous passive
motion
culture and sensitivity
computerized
tomography
clear to auscultation
cerebrovascular
accident
cardiovascular disease
chest X-ray
diet as tolerated
degenerative joint
disease
diabetic ketoacidosis
diabetes mellitus
date of birth
dyspnea on exertion
84
DP
dorsalis pedis
drsg
dressing
DSD
dry sterile dressing
DVT
deep vein thrombosis
DX
diagnosis
ECF
extended care facility
ECG/EKG electrocardiogram
ED
emergency department
EGDesophagogastroduodenoscopy
ESRD
end stage renal
disease
FA
forearm
FBS
fasting blood sugar
FC
foley catheter
FFP
fresh frozen plasma
F/U
follow up
FUO
fever of undetermined
origin
FWB
full weight bearing
fx
fracture
GCS
Glasgow coma scale
GI
gastrointestinal
G-tube
gastrostomy tube
GU
genitourinary
HA
headache
Hct
hematocrit
HD
hemodialysis
Hgb
hemoglobin
H&H
hemoglobin and
hematocrit
HOB
head of bed
HOH
hard of hearing
H&P
history and physical
HR
heart rate
hs
at bedtime
HTN
hypertension
I&D
incision and drainage
IDDM
insulin dependent
diabetes mellitus
inc
incontinent
IM
intramuscular
I&O
intake and output
IS
incentive spirometer
IV
intravenous
J-tube
jejunostomy tube
JVD
jugular vein distention
K
KCL
KVO
KUB
L
LE
lg
LLL
LLQ
LMP
LUL
LVN
MAE
mg
MOM
MRI
MRSA
MAR
ml
MM
MVA
Na
NAD
NCP
NGT
NIDDM
NKA
NS
Nsg
NPO
N/V/D
NWB
O2
OA
OBS
OOB
ORIF
p
potassium
potassium chloride
keep vein open
kidneys, ureters, and
bladder x-ray
left
lower extremity
large
left lower lobe (lung)
left lower quadrant
last menstrual period
left upper lobe (lung)
licensed vocational
nurse
moves all extremities
milligrams
milk of magnesia
magnetic resonance
imaging
methicillin-resistant
Staphylococcus aureus
medication
administration records
milliliter
mucous membranes
motor vehicle accident
sodium
no apparent distress
nursing care plan
nasogastric tube
non-insulin dependent
diabetes mellitus
no known allergies
normal saline
nursing
nothing by mouth
nausea, vomiting,
diarrhea
non-weight bearing
oxygen
osteoarthritis
organic brain syndrome
out of bed
open reduction and
internal fixation
after
85
pc
per
PCN
PCXR
PEG
PERL
PERLA
PERRLA
PICC
PMH
po
POD
post
pre
PR
PRN
Pt
PT
PVD
PWB
q2h
R
R/O
RR
RUL
RUQ
Rx
s
sat
SL
SNF
SOB
S/P
spec
S/S
SSE
after meals
by, or through
Penicillin
portable chest X-ray
percutaneous
endoscopic
gastrostomy
pupils equal and
reactive to light
pupils equal and
reactive to light and
accommodation
pupils equal, round,
reactive to light and
accommodation
peripherally inserted
central catheter
past medical history
by mouth
postoperative day
after
before
per rectum
as needed
patient
physical therapy
peripheral vascular
disease
partial weight bearing
every 2 hours
right
rule out
regular rhythm
right upper lobe (lung)
right upper quadrant
prescription
without
saturation
sublingual
skilled nursing facility
shortness of breath
status post
specimen
signs and symptoms
soap suds enema
SSRI
STAT
SW
sx
TCDB
TDWB
THA
THR
TIA
T.O
tol
TWE
TPN
TSH
TURP
Tx
UA
UE
UGI
UO
URI
US
UTI
VO
VRE
WBAT
WBC
W/C
W&D
WNL
VS
selective serotonin
reuptake inhibitor
at once
social worker
symptom
turn, cough, deep
breathe
touch down weight
bearing
total hip arthroplasty
total hip replacement
transient ischemic
attack
telephone order
tolerated
tap water enema
total parentral nutrition
thyroid stimulating
hormone
transurethral resection
of the prostate
treatment
urinalysis
upper extremity
upper gastrointestinal
urine output
upper respiratory
infection
ultrasound
urinary tract infection
verbal order
vancomycin-resistant
enterococcus
weight bearing as
tolerated
white blood cell
wheelchair
warm and dry
within normal limits
vital signs
86
Unapproved Abbreviations
DO NOT USE
AU
cc
D/C, DC
IU
MgSO4
MS
MR
HCTZ
q
qhs, qd, qod
SQ or SC
U or u
µg
OD
OS
OU
per os
ss
each ear
cubic centimeter
discharge, discontinue
international units
Magnesium Sulfate
Morphine Sulfate, Multiple Sclerosis, Mitral Stenosis
Mitral Regurgitation, may repeat, medial record
Hydrochlorothiazide
every
every hour sleep, every day, every other day
subcutaneous
unit
microgram
right eye
left eye
both eyes
orally
sliding scale
Do not use slash marks to separate doses (/) (ex: 25 units/100ml). Use “per”
Do not use “greater than” (>) or “less than” (<) marks. Spell out greater than or less than.
When writing dosages, do not use zeros after the decimal point for doses in whole numbers (ex. 1mg). Always use a zero
before the decimal point when the dose is less than a whole number (0.5mg)
**For a complete list of Error –Prone abbreviations, visit the Institute of Safe Medication Practices website
http://www.ismp.org/Tools/errorproneabbreviations.pdf
87
CERRITOS COLLEGE NURSING PROGRAM
N210 CLINICAL SCHEDULE
LONG TERM CARE
WK
DATE
ASSIGNMENT
EXPERIENCES
0800-1100
LTC Orientation
Tour, Scavenger Hunt
Facility information, Fire/disaster
codes, clinical expectations,
Clinical evaluation tool
NPW/ Assessment Guide; Clinical
Schedule and Student
Assignments
POSTCONFERENCE
What is due?
6
1200-1500
PA Practicum
Nothing
6
0650-1150
Caremaps and Meds for COPD Due

Buddy with C.N.A.

By the end of the day, choose 1
patient (1 diagnosis) for next
week’s assignment and complete
front and back page of NPW
(include concept map); No Lab
data
Skills: baths, beds, feeding, assist
with transfers, ROM, VS, NGT/GT
feedings, positioning, hot/cold
applications, bandages/binders,
TED hose, restraints, enemas,
isolation, Physical Assessment
Foley Cath, Wound Care, NGT
1100-1150
NPW / Assessment
Guide: sample/blank
Clinical Experiences
NPW: page 1 and
page 2 including
concept map due
next Tuesday in
pre-conference.
Charting: VS, I&O
1330-1530
PA Practicum
88
7
0650-1250


Care of 1 patient
NPW due in pre-conference
Skills: baths, beds, feeding, assist
with transfers, ROM, VS, NGT/GT
feedings, positioning, hot/cold
applications, bandages/binders,
TED hose, restraints, enemas,
isolation, Physical Assessment
Foley Cath, Wound Care, NGT
1100-1150
Nothing
NPW/ Assessment
Guide
Physical Assessment
techniques
Clinical Experiences
and observations
Charting: VS, I&O
7
0650-1250
SCP/NPW on VCE patient Due
By the end of the day, choose 1 patient (2
Diagnoses) for next week’s assignment
and complete front and back pages of
NPW (include concept map) +
medications; No Lab data
Skills: Same as above
1100-1150
NPW / Assessment
Guide: sample/blank
Clinical Experiences
NPW: page 1, & 2
including concept
map, and page 4
(documentation) for
the patient cared
for this week due
on Wed postconference
89
8
0650-1250



Skills: Same as above
1100-1150
NPW/ Assessment
Guide
Physical Assessment
techniques
Care of 1 patient
NPW due in pre-conference
By the end of the day, choose 1
patient (2 diagnoses) for next
week’s assignment and complete
front and back pages of NPW
(include concept map) +
medications and Lab data
NPW: page 1-5
for patient cared for
this week
AND
Assessment guide:
all sections for
physical mode for
patient cared for
this week due on
Tues postconference
SL 121 0700-1600
CPE: All skills
Full Uniform
8
Nothing
9
0650-1250

Show this week’s completed
NPW/AG to clinical instructor by
end of day for feedback
CPE Retesting
Arrange Hours with Instructor
9
Skills: Same as above
1100-1150
NPW/ Assessment
Guide
Physical Assessment
techniques
Clinical Experiences
and observations
No Clinical

All NPWs due in pre-conference to your clinical instructors which will be returned to you during clinical
90
Clinical Absence Make-Up Guidelines
Make-up for any clinical absence in N210:
1. The student will be assigned by the instructor to write a paper on one of the
diagnoses of the patient(s) that the student would have cared for on the missed
day.
2. The student is to research the diagnosis using the library or internet to find a
recent nursing journal (within last 5 years) about the diagnosis.
3. The article should include the following information related to:






An explanation of the diagnosis
Signs and Symptoms
Risk factors/causes
Diagnostic tests/measures
Medical and Nursing treatment
Evaluation of Outcomes
4. The student is to summarize the article, including in the summary all of the
data stated in #3 (if possible).
5. The paper is to be typed. The paper and a copy of the article are to be
turned in to the clinical instructor.
 If the absence is due to illness, the paper is to be turned in on the
Monday after the illness.
 If the absence is due to being sent home for not being prepared,
the paper is to be turned in the next day (ie: for a Tuesday
absence, the paper is due on Wednesday)
6. The student may be asked to present the paper in post conference.
91
Cerritos College
Department of Nursing
NURS 210: Competency Performance Examination (CPE)
Official Record of Student Performance
Name of Student______________________________________
Vital Signs Competency
Date________
Name of Clinical Examiner_______________________________
Pass___________ Fail_____________
Comments_____________________________________________
Retest Date___________Pass ___________Fail ______________
Comments _____________________________________________
Comprehensive Skill Competency
Date___________
Name of Clinical Examiner_________________________________
Pass__________
Fail_______________
Check ALL competencies examined in this CPE:
___Universal competencies
___Occupied bed making
___Positioning of Patient
___Ambulating a patient
___Applying Bandages
___Applying Binders
___Applying antiembolism stockings
___Administering an enema
___NGT insertion +/- suction
___Sterile wet to moist dressing change
___Bed bath
___Range of Motion
___Transfer of Patient from bed to chair
___Moving a Patient up in bed
___Applying restraints
___Applying and removing PPE
___Irrigation (flush) of NGT/Gtube
___Administering intermittent/continuous
tube feeding
___ Foley catheter insertion
Legal Validation of Failure to Meet Critical Elements:
In the case of failure of the comprehensive skill CPE, the examiner must cite the specific
critical element(s) that the student did not pass and write the objective description of the
reason for failure, using the space below (use additional lines as needed).
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Retest date_________________________
Pass_______ Fail________
Outcome of performance_________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
92
Cerritos College
Department of Nursing
The Universal Competencies and related clinical elements are supplied in all
aspects of client care. The Universal Competencies which will be evaluated in
N210 include: safety and security, standard precautions (asepsis), comfort and
documentation.
At the end of the clinical rotation, the student will be able to perform the following
competencies and related critical elements:
Universals:
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 physical security.
2. Emotional security: Any action or inaction which threatens the emotional
well being of the patient or significant others or is a violation of the
patient’s emotional security.
It is important to realize that all potential failures to protect the patient from harm
can not be described here.
Met
___
Not Met
_______
___
________
___
_____
Critical Elements
1. Identify assigned patient by reading ID bracelet before
initiating care
2. Protect the patient from physical harm at all times, such as
the following:
a. Side rails are raised when indicated
b. Bed is left in low position
c. Patient’s ability to ambulate safely is assessed before beginning
ambulation
d. Restraints are secure, when required, without injuring patient
3. Protect the patient and significant other from psychological
harm by the following actions:
a. Refer to the patient by designated or preferred name
b. Communicate verbally and non-verbally in professional manner
c. Communicate verbally and non-verbally in a manner that does
NOT express anger, distrust, abuse, familiarity or demeaning
behaviors to the patient and/or significant others.
d. Provide accurate information to patient and/or significant others
e. Keep all patient-related information professionally confidential
f. Maintain patient’s personal privacy at all times
g. Explain procedure to patient prior to initiating skill
93
Standard Precautions: The prevention of the introduction or transfer of
organisms
Met
___
Not Met
_______
___
________
___
___
___
___
________
________
_______
________
___
________
Critical Elements
1. Wash hands before initiating direct contact with patient and
whenever hands are contaminated by patient’s body
secretions or substances. (During an examination wash
hands in presence of examiner before beginning care.)
2. Wear gloves whenever coming in contact with human
secretions
3. Protect patient from contamination.
4. Protect self and others from contamination
5. Confine contaminated material to contaminated areas.
6. Dispose of contaminated materials in designated
containers,
7. Implement any designated special precautions as required
Comfort: The assessment of and interventions related to the patient’s tolerance
of the procedure.
Met
___
Not Met
_______
___
_______
Critical Elements
1. Assess the patient’s comfort level before, during and after a
potentially uncomfortable procedure.
2. Provide interventions to increase the patient’s comfort level
Documentation: The recording of data required by, or pertinent to, the
designated situation.
Met
___
Not Met
_______
___
________
___
________
___
_______
Critical Elements
1. Document patient care using the following methods, as
designated:
a. assessment forms, flow graphs, or other standard clinical forms
b. narrative process recording
2. Document patient changes and responses to care in
designated records.
3. Use language, terms, and abbreviations that are consistent
with professional standards, agency protocols, and other
specific guidelines
4. Record data so that entries are:
a. clear
b. accurate
c. precise
d. pertinent/relevant
94
Competencies Specific to N210: Fundamentals of Nursing
1. Vital Signs: to measure the blood pressure, pulse, respirations, temperature
and pulse oximetry of a patient
Met
Not Met
Critical Elements:
___
_______
___
___
___
___
___
______
______
______
______
______
1. Measure vital signs accurately
a. within +/- 4 mmHg of systolic and diastolic blood pressure
b. within +/- 4 bpm of pulse
c. within +/- 2 of respirations per minute
2. Prepare and place thermometer correctly
3. Count irregular and apical pulse for one minute
4. Count irregular respiration for one minute
5. Use correct size blood pressure cuff
6. Correctly identify location of apical pulse
2. Handwashing: reducing microbial load on hands with the use of water and
soap.
Met
Not Met
Critical Elements:
___
___
_______
_______
___
___
_______
_______
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 do not contaminate self
3. Occupied bedmaking: to change the soiled sheets on a bed occupied by a
patient
Met
Not Met
Critical Elements:
___
___
___
___
_______
_______
_______
_______
1.
2.
3.
4.
___
___
_______
_______
___
_______
Maintain medical asepsis of linen
Place bed at working level for height
Keep patient covered at all times
Maintain proper positioning of patient and body mechanics
of nurse.
5. Create mitered corner and foot tent
6. Center top sheet and bedspread to hang equally on both
sides
7. Place clean pillowcase on pillow
4. Range of Motion: to move patient’s joints actively or passively through set
movements
Met
Not Met
Critical Elements:
___
___
___
_______
_______
_______
1. Proceed systematically from head to toe
2. Support joint being exercised
3. Perform exercise 3-5 times
95
5. Transfer of patient from bed to chair: assisting a patient to change
locations
Met
Not Met
___
_______
___
___
_______
_______
___
___
___
_______
_______
_______
Critical Elements:
1. Assess patient’s ability to assist; presence of weaknesses or
paralysis; cognitive function
2. Maintain use of good body mechanics by the nurse
3. Maintain proper body alignment of the patient during
Changes in position by supporting weak limbs
4. Position bed at working level for height
5. Demonstrate appropriate use of gait belt
6. Position wheelchair at appropriate angle and locked
6. Moving a patient up in bed: assisting a patient to a higher position in a
hospital bed, so that the patient bends at the appropriate place
Met
Not Met
___
___
___
___
_______
_______
_______
_______
Critical Elements:
1.
2.
3.
4.
Assess the patient’s ability to assist
Position a draw sheet under the patient appropriately
Use proper body mechanics
Properly instruct the patient how to assist
7. Applying restraints : Apply a device that limits movements of an extremity
or body part
Met
Not Met
___
___
___
___
_______
________
________
________
___
________
Critical Elements:
1.
2.
3.
4.
Assess CSM or any contraindications to use
Explain rationale to patient and/or family
Apply restraint properly
Secure restraint to proper location on bed or wheelchair
as appropriate
5. Assess at frequency dictated by agency policies
8. Applying and removing personal protective equipment: use of materials
that are worn to decrease the transmission of microbes
Met
Not Met
___
___
___
_______
_______
_______
Critical Elements:
1. Identify needed equipment
2. Apply appropriate equipment in proper order
3. After use, remove protective equipment in proper order to
Prevent contamination
9. Administering an Enema: instilling a solution per rectum
Met
___
___
___
___
Not Met
_______
_______
_______
_______
Critical Elements:
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
96
10. Nasogastric tube insertion +/- suction to insert a catheter through the
nose into the stomach and attach to suction if ordered
Met
Not Met
___
___
___
_______
_______
_______
___
___
___
___
___
_______
_______
_______
_______
_______
Critical Elements:
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 the tube to the appropriate place
6. Check placement
7. Secure the tube
8. Attach tube to suction appropriately
11. Sterile Wet to moist dressing change:
Met
Not Met
___
___
___
___
___
___
_______
_______
_______
_______
_______
______
Critical Elements:
1.
2.
3.
4.
5.
6.
Remove and assess old dressing
Assess wound and drainage thoroughly and accurately
Establish sterile field & properly apply sterile gloves
Cleanse wound correctly using sterile technique
Pack wound and apply dressing using sterile technique
Secure dressing
12. Bed bath: to clean the body of a patient that remains in bed
Met
Not Met
Critical Elements:
___
___
_______
_______
___
_______
___
___
_______
_______
1. Prepare supplies using medical asepsis
2. Maintain proper body positioning of the patient and good
body mechanics of the nurse; minimizing movements of the
patient and nurse
3. Keep patient covered to maintain modesty and prevent
chilling
4. Clean from head to toe; perineal area last
5. Change water when appropriate
13. Positioning a Patient: assisting a patient into positions used
therapeutically in nursing practice
Met
Not Met
___
_______
___
___
_______
_______
Critical Elements:
1. Maintain use of good body mechanics for the nurse and
patient
2. Use pillows appropriately for support
3. Support body during position changes as appropriate
97
14. Ambulating a patient: providing a one person assistance to walk
Met
Not Met
___
___
_______
_______
___
_______
Critical Elements:
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
15. Applying bandages : Apply a device that provides support to a designated
area/joint
Met
Not Met
___
___
___
___
___
___
___
_______
_______
_______
______
_______
_______
______
Critical Elements:
1.
2.
3.
4.
5.
6.
7.
Assess CSM
Position body part in neutral, elevated position if possible
Apply bandage using equal distance and equal pressure
Use the proper wrapping technique for the body part
Wrap the extremity distal to proximal
Secure appropriately
Reassess CSM
16. Applying binders : Apply a device that provides support to the abdomen
and/or torso
Met
Not Met
___
___
___
_______
_______
_______
Critical Elements:
1. Choose proper sized binder for the patient
2. Position the binder appropriately
3. Assess for potential breathing or skin impairment
17. Applying antiembolism stockings : Apply a device that promotes the
return of blood to the heart
Met
Not Met
___
___
___
_______
_______
_______
Critical Elements:
1. Measure patient for proper fit
2. Apply the stocking appropriately
3. Assess CSM and presence of wrinkles in stockings
18. Intermittent and continuous tube feeding administration: administering
a set amount of tube feeding solution via a NGT, G-tube, or J-tube.
Met
Not Met
___
___
___
___
___
_______
_______
_______
_______
______
Critical Elements:
1.
2.
3.
4.
5.
Position HOB at least 30º unless contraindicated
Check placement and patency of tube
Perform residual check; hold if residual >100 mL
Administer correct type and amount at prescribed rate
Keep HOB at least 30° for at least 1 hour after feeding for
intermittent feedings and maintain HOB always at least
30°for continuous feedings
98
19. Foley catheter insertion: to insert a catheter into bladder utilizing sterile
technique
Met
Not Met
___
___
___
___
___
___
______
_______
_______
_______
_______
_______
Critical Elements:
1.
2.
2.
3.
4.
5.
Establish sterile field
Properly apply sterile gloves
Check foley balloon (optional if using BARD catheter kit)
Cleanse perineum correctly
Insert catheter maintaining sterile technique
Inflate foley bulb at appropriate location & holds on to catheter during
inflation
20. Irrigation (flush) of NGT/Gtube to instill water or saline into NGT/Gtube
Met
___
___
___
___
___
Not Met
______
_______
_______
_______
_______
1.
2.
3.
4.
5.
Critical Elements:
Stop current feeding or suction (as applicable)
Check tube placement
Aspirate for residual
Instill prescribed solution and amount using appropriate method
Resume feeding or suction (as applicable)
99