NUR216 Skills Lab
Fall 2007
Page 1 of 13
Georgia Baptist College of Nursing
Of Mercer University
NUR 216 Skills Lab
MODULE FOUR – IMMOBILITY/ASSISTIVE DEVICES/RANGE-OF-MOTION
(Part 1 of 3)
Focus: Assistive Devices
Outcomes: Upon completion of this laboratory activity, the learner will:
1. Demonstrate correct use of cane, crutches, and walker.
2. Perform the following movements made with crutches:
a. Stand from sitting position
b. Four-point gait
c. Three-point gait
d. Two-point gait
e. Swing-to gait
f. Swing-through gait
g. Sitting in chair
3. Perform passive range-of-motion exercises correctly.
Required Readings:
Elkin, M., Perry, A., & Potter, P. (2007). Nursing Interventions & Clinical Skills.
(4th Ed.). (pp. 115-131). St. Louis: Mosby.
Learning Activities:
1. Perform walking with assistive devices and performance of rang-of-motion
exercises.
2. Participate in activities and discussion.
3. Define related module vocabulary
Validation:
1.
2.
3.
4.
Demonstrate proficiency in related lab activities.
Use correct body mechanics for nurse and client.
State scientific rationale/principles for each action.
Complete module checklist.
Clinical Application:
1. Provide safe, thorough, and effective care for the pre and postoperative client
with mobility needs.
2. Initiate interventions designed to prevent complications related to the surgical
experience or immobility.
Rev. 9/07 MH
NUR216 Skills Lab
Fall 2007
Page 2 of 13
Georgia Baptist College of Nursing
Of Mercer University
NUR 216 Skills Lab
(Part 2 of 3)
MODULE FOUR:
 BANDAGES AND BINDERS
 WOUND DRESSINGS
 STAPLE REMOVAL
 OPENING STERILE PACKAGES AND POURING STERILE SOLUTIONS
 APPLICATION OF STERILE GLOVES
(Part 2 of 3)
Focus: Application of binders/ Wound dressing identification/
Surgical Asepsis/SterileTechnique
Outcomes: Upon completions of the laboratory activity, the learner will:
1. Correctly identify assorted types of bandages.
2. Demonstrate application of ace bandage utilizing assorted turns.
3. Discuss removal of staples/sutures.
4. Identify situations in which sterile technique is needed.
5. Assemble a sterile field and pour sterile solution.
6. Demonstrate donning sterile gloves.
Required readings:
Elkin, M., Perry, A., & Potter, P. (2007). Nursing Interventions & Clinical Skills.
(4th Ed.). (pp. 83-89, 500-504, 521-523, 531-535). St. Louis: Mosby.
Learning Activities:
1. Identify indications for various wound dressings.
2. Demonstrate ability to apply ace bandaging utilizing different turns.
3. Construct use of staple and suture removal kits.
4. Perform opening of sterile package and pouring of sterile solution maintaining
sterility.
Validation:
1. Demonstration of competence in required learning activities.
2. Completion of module check-off list.
Clinical Application:
1. Identify situations in which sterile technique is needed.
2. Implement principles of sterile technique when appropriate.
3. Recognize different types of dressings seen in clinical setting.
Rev. 9/07 MH
NUR216 Skills Lab
Fall 2007
Page 3 of 13
Georgia Baptist College of Nursing
Of Mercer University
NUR 216 Skills Lab
MODULE FOUR – HEALTH ASSESSMENT: MUSCULOSKELETAL AND
INTEGUMENTARY ASSESSMENT
(Part 3 of 3)
Focus: Assessment of musculoskeletal and integumentary systems
Outcomes: Upon completion of the laboratory activity the learner will:
1. Demonstrate accurate assessment of an individual’s skin, nails, and hair,
utilizing inspection and palpation.
2. Document findings from skin, nails, and hair assessment.
3. Demonstrate accurate assessment of an individual’s musculoskeletal system.
4. Document findings from assessment of the musculoskeletal system.
Required Readings:
Jarvis, C. (2004). Physical examination & health assessment. (4th ed).
(pp. 230-247, 614-645). St. Louis: Saunders.
Learning Activities:
1. Practice required assessment skills, using assessment sheets, with partner in
lab.
2. Complete module vocabulary lists and knowledge assessments.
Validation:
1. Successful performance of end of semester assessment checks off.
Clinical Application:
1. Weekly performance of assigned assessments on clinical patients.
Rev. 9/07 MH
NUR216 Skills Lab
Fall 2007
Page 4 of 13
Georgia Baptist College of Nursing
Of Mercer University
NUR 216 Skills Lab
MODULE FOUR – VOCABULARY
Directions: Define each word in the space provided.
1. Articulation
2. Synovial
3. Ligament
4. Fasciculi
5. Supination
6. Abduction
7. Circumduction
8. Eversion
NUR216 Skills Lab
Fall 2007
Page 5 of 13
9. Partial Weight Bearing
10. Surgical Aseptic Technique
11. Package integrity
12. Montgomery straps
13. Vaseline gauze
14. Pallor
15. Profile sign
16. Turgor
17. Primary lesion
18. Secondary lesion
Georgia Baptist College of Nursing
NUR216 Skills Lab
Fall 2007
Page 6 of 13
Of Mercer University
NUR 216 Skills Lab
MODULE FOUR – KNOWLEDGE ASSESSMENT
Directions: Select the BEST answer for the following questions:
1. When a patient is standing, the crutch pads should be three inches below the
axilla.
A. True
B. False
2. The type of gait a client uses in crutch walking depends on the
A.
B.
C.
D.
type of crutch being used.
height and weight of the patient.
client’s ability to be independent with movement.
amount of weight client is able to support with legs.
3. An audible and palpable crunching that accompanies movement is known as
A.
B.
C.
D.
crackles.
articulation.
crepitus.
bursa.
4. On assessment a patient with scoliosis will have
A.
B.
C.
D.
limited ROM.
a difference in shoulder elevation.
tenderness.
unequal leg lengths.
5. When assessing for which assistive device to use, it is important for the nurse to
know the client’s
A.
B.
C.
D.
level of compliance.
weight-bearing status.
favorite assistive device.
expected outcome.
6. List 3 things to check for to confirm the sterility of a package.
NUR216 Skills Lab
Fall 2007
Page 7 of 13
A.
B.
C.
7. Put the following steps in order for opening a sterile package correctly.
_____Right hand opens right side
_____Open the top layer away from you
_____Left hand opens left side
_____Place package in center of work area
_____Open bottom layer towards you
8. When working in sterile attire, you keep your hands above your waist and keep
sterile equipment on top of the tables because
A.
B.
C.
D.
everything below the waist or table is nonsterile.
sterility is a matter of certainty, not conjecture.
contamination often occurs accidentally.
your back is considered potentially contaminated.
9. Application of sterile technique includes all of the following EXCEPT
A. considering the border or edge of a sterile drape to be
contaminated.
B. avoiding talking over a sterile field.
C. keeping the sterile field within the range of vision.
D. considering the objects sterile if the outer wrap is wet, but not
the inner wrap.
10. Edema is most evident in
A. the face.
B. dependent parts of the body.
C. central areas of the body.
D. the feet.
11. When assessing pigmented lesions, the E in ABCDE, stands for
A. Easy to see.
B. Eccyhmotic.
C. Enlargement.
D. Erythemic.
Georgia Baptist College of Nursing
Of Mercer University
NUR216 Skills Lab
Fall 2007
Page 8 of 13
NUR 216 Skills Lab
Directions: Participate in the following activities. Check or initial when complete. Have
faculty sign or initial in the space provided when you have completed all activities.
_____1. Identify various assistive devices
_____2. Demonstrate ability to walk with crutches using all 5 gaits
_____3. Perform ROM exercises with partner (one side)
_____4. Practice musculoskeletal assessment on partner
_____5. Perform 5 types of bandage turns using ace bandages or kerlix gauze
_____6. Is familiar with various types of gauze/dressing material
_____7. Demonstrates ability to open a sterile package
_____8. Demonstrates ability to pour sterile solution
_____9. Demonstrates ability to don sterile gloves
____10. Practice assessment of skin, hair, and nails on partner
____11. I feel I have mastered the content of this module and am able to apply in
the clinical setting.
____12. I need more practice/instruction.
___________________________
(Faculty/Date)
_______________________
(Student)
NUR216 Skills Lab
Fall 2007
Page 9 of 13
NUR216 Skills Lab
Fall 2007
Page 10 of 13
Nursing Process, Skills, and Concepts (NUR216)
Assessment Guidelines: SKIN, HAIR, and NAILS
Procedure
Y N
NUR216 Skills Lab
Wash
Fallhands
2007
Pagesupplies
11 of 13needed for the exam and bring them to the bedside.
Gather
Greet patient using the patient’s proper name
COMMENTS
NUR216 Skills Lab
Fall 2007
Page 12 of 13
Identify patient by checking the armband.
Create and maintain an appropriate environment
 Provide privacy throughout the exam
 Introduce self and purpose of exam
 Wear appropriate attire (Use PPE if indicated)
 Indicate confidentiality
Utilize effective communication skills
 Use and respond to nonverbal behavior
 Use appropriate terminology/language
Position patient appropriately
Don gloves (when indicated)
Inspect skin for:
 Color
 Lesions
 Vascularity or bruising
Palpate skin for:
 Temperature
 Moisture
 Thickness
 Turgor
Inspect hair for:
 Color
 Lesions (including infestations)
 Texture
 Distribution
Palpate hair noting texture
Inspect and palpate nails for:
 Shape and contour
 Color
 Capillary refill
Clean work space, make bed.
Return supplies to the appropriate location.
Document findings
___________________________________
Student signature
date
07/06 KS/JR
_______________________________________
Instructor signature
date
NUR216 Skills Lab
Fall 2007
Page 13 of 13
Nursing Process, Skills, and Concepts (NUR216)
Assessment Guidelines: MUSCULOSKELETAL SYSTEM
Procedure
Y N
COMMENTS
Wash hands
Gather supplies needed for the exam and bring them to the bedside.
Greet pt using patient’s proper name; Identify patient by checking armband.
Create and maintain an appropriate environment
 Provide privacy throughout the exam
 Introduce self and purpose of exam
 Wear appropriate attire (Use PPE if indicated)
 Indicate confidentiality
Utilize effective communication skills
 Use and respond to nonverbal behavior
 Use appropriate terminology/language
Position patient appropriately
Don gloves (when indicated)
Observe for symmetry of the upper and lower extremities.
Inspect for size, contour, and range of motion (active movement of at least
two of each joint’s normal range of motion movements):
 temporomandibular joint
 wrists
 ankles
 neck
 fingers
 toes
 shoulders
 hips
 Spine
 elbows
 knees
Palpate, noting temperature, bony articulations, abnormalities during range
of motion:
 temporomandibular joint
 wrists
 ankles
 neck
 fingers
 toes
 shoulders
 hips
 Spine
 elbows
 knees
Palpate bilaterally:
 Pterygoid(jaw)
 deltoids
 Suppraspinatus
(shoulders)
 biceps
 quadriceps
(thigh)
 gastrocnemius(ca
lf)
Assess for muscle strength bilaterally:
 temporomandibular joint
 wrists
 ankles
 neck
 fingers
 toes
 shoulders
 hips
 Spine
 elbows
 knees
Clean work space, make bed.
Return supplies to the appropriate location; Document findings
Student signature:
date:
Instructor signature:
07/06 KS
date: