Imperial Valley College
Division of Nursing Education and Health Technologies
Medical/Surgical Skills NS121
I.V. Procedure
Skill
1. Checks orders
2. Identifies patient
3. Assembles equipment and identifies correct
patient and order
4. Positions patient and adjusts lighting
5. Washes hands and applies gloves
4. Prepares equipment
6. Selects and prepares venipuncture
site
7. Applies tourniquet
8. Enters skin with cathelon needle either next to
or directly over vein
9. Observes for “pop” and flashback
10. Advances cathelon carefully
11. Releases tourniquet and applies pressure
above site
12. Opens clamp on I.V. tubing or instills saline
flush after checking for patency
13. Observes for swelling at I.V. site and patient
for reactions
14. Applies appropriate dressing
15. Tapes the needle and tubing
16. Sets flow rate on pump
17. Labels I.V. site
18. States the difference between
catheter and saline lock set-up
19. Uses universal precautions throughout
procedure
Demonstrated
Not Demonstrated
Imperial Valley College
Division of Nursing Education and Health Technologies
Skills Demonstration
I.V. Medications
Student’s Name
Skill
A. IV Push with continuous infusion
1. Checked physician’s order & allergies
2. Checked compatibility
3. Washed hands
4. Prepared medication
5. Identifies patient
6. Explained procedure to patient and correctly
identified patient
7. Cleansed injection port with an alcohol
swab
8. Closed clamp on IV tubing or pinched off
tubing
9. Aspirated to observe blood return
10. Injected medication slowly
11. Reopened clamp and adjusted infusion
rate on pump
12. Observed patient and IV site for reaction
13. Documented appropriately
B. IVPB
Voluset, Volutrol, Buretrol
1. Checked physician’s order & allergies
2. Checked compatibility
3. Washed hands
4. Gathered equipment
5. Explained procedure to patient and identified
correct patient
6. Filled volume control set with solution
7. Cleansed ports of entry
8. Injected medication and agitated set to
mix
9. Adjusted pump for desired
administration
10. Medication labeled volume control set
appropriately
Demonstrated
Not Demonstrated
11. Verbalized documentation
C. Partial-Fill or Secondary Bottle
1. Checked physician’s order & allergies
2. Checked compatibility
3. Washed hands
4. Prepared equipment and medication
5. Identified correct patient and explained medication
6. Medication labeled appropriately
7. Affixed tubing with appropriate device
8. Labeled tubing appropriately
9. Primed tubing
10. Cleansed port of entry
11. Inserted injection device and secured with tape
12. Hung primary bottle below partial-fill or secondary
medication
13. Adjusted pump
14. Verbalized appropriate documentation
D. SALINE LOCK INFUSION
1. Checked physician’s order & allergies
2. Washed hands
3. Explained procedure to patient and identified
correct patient
4. Gathered equipment
5. Gloved
6. Cleansed and unclamped injection port
7. Checked for patency of I.V. catheter with
normal saline and flushed
8. Inserted medication syringe into port
9. Infused medication appropriately
10. Flushed with sterile saline after
medication and clamped port
12. Secured injection port with tape needed
13. Maintained asepsis
14. Observed site and patient for reactions
15. Verbalized appropriate documentation
Imperial Valley College
Division of Nursing Education and Health
Skills Demonstration
Discontinuing an IV
Discontinuing an I.V.
1..Check Order
Skills Demonstrated
Skill Not Demonstrated
Equipment:
1 band aid
2-3 2x2s
2. Gather equipment. Open band aid and
alcohol packages.
3. Identify patient
4. Wash hands and put on gloves.
5. Explain procedure to patient and identify
correct patient.
6. Turn I.V. flow off with roller valve.
7. Stabilizing needle or catheter,
remove tape/dressings.
8. Remove catheter quickly and
smoothly. Check that catheter is
intact.
9. Quickly press 2x2 over site.
10. Hold pressure over site until bleeding stops.
11. Apply band aid and observe for
complications.
12. Cover catheter with glove and discard.
13. Check site again in 15-30 minutes
14. Document procedure.
Monitoring I.V. Infusions
Skill Demonstration
Monitoring an IV Infusion
Skills Demonstrated
Skills Not
Demonstrated
1. Assess I.V. insertion site every 2 hours for signs
of infection,tenderness, itching infiltration, fluid or
blood leakage, intact dressing. Include gentle
palpation through intact dressing.
2. Assess for correct I.V. solution, correct flow rate,
amount of solution remaining.
3. Notify R.N. immediately if any
complication.
4. Document IV site assessment.
Calculating and Regulating I.V. Flow Rate
1. Check physician’s order for amount and time
factor
2. Check drop factor of I.V. tubing
3. Calculate flow rate using formula
4. Using a watch with second hand, count drops for
one minute
5. Adjust clamp until desired number of drops
Skills Demonstrated
Skill Not
Demonstrated
Imperial Valley College
Division of Nursing Education and Health Technologies
Nasopharyngeal Suctioning with Catheter
Nasopharyngeal Suctioning w/ Catheter
Demonstrated
Not
Demonstrated
Identify patient
1. Washed hands and standard preparation
steps
2. Assessed need for suctioning
3. Gathered equipment. . .
a. Suction machine
b. Suction catheter (1/2 diameter of
nares)
c. Suction catheter kit(sterile catheter,
gloves and basin)
4. Explained procedure to patient
5. Turns on suction machine
6. Set amount of suction
120-150 mm Hg suction for adults
80-120 mm Hg suction for child
60-100 mm Hg suction for infant
7. Put on gloves and face/eye protection
8. Inserted catheter 6-8 inches into nares
9. Suctioned no longer than 5-10 seconds**
10. Allowed patient to recover between
suctionings (RR and color return to
normal)**
11. Suction oropharynx with catheter
12. Charted assessment findings, quantity,
and description secretions, how patient
tolerated the procedure, time, date, and
other pertinent information.
* Highlighted areas are critical elements and must be done correctly to pass skill.
Imperial Valley College
Division of Nursing Education and Health Technologies
Skills Demonstration
Deflation/Inflation of Tracheal Cuff
Skills
Demonstrated
1. Identifies patient
2. Gathered equipment
a. 10-12 ml. syringe
b. suction equipment
3. Explained procedure to patient.
4. Washed hands
5. Suctioned nose and/or mouth and
tracheostomy using separate suction set
before deflating cuff.
6. Withdrew air from cuff
7. Assessed respirations
8. Re-inflated cuff with determination of correct
amount of air.
9. Monitored correct cuff pressure and
assessed respirations and breath sounds. **
10. Documentation
** Areas are critical elements and must be done to pass skill.
Skills Not
Demonstrated
Imperial Valley College
Division of Nursing Education and Health Technologies
Skills Demonstration
Plugging a Tracheostomy
Skills
Demonstrated
1. Gathered equipment
a. Trach plug
b. Suction
c. Sterile suction kit
d. 10-12 ml. syringe
2. Checked physicians orders re: time to
remain plugged
3. Explained procedure to patient and
identified correct patient
4. Washed hands and applied gloves,
personal protection equipment
5. Suctioned nasopharynx
6. Suctioned tracheostomy using new suction
kit
7. Deflated cuff**
8. Removed and set aside inner cannula
9. Placed tracheal plug
10. Observed patient for respiratory distress
11. Provided safety measures to protect
patient
12. Removed plug and replaced inner
cannula when time elapsed.
13. Documentation
** Areas are critical elements and must be done correctly to pass skill.
Skills not
Demonstrated
Imperial Valley College
Division of Nursing Education and Health Technologies
Suctioning Endotracheal/Tracheostomy Tube
using In-Sleeve Catheter
Skills
Demonstrated
1. Gathered Equipment
a. In-Sleeve Catheter attached to endotracheal or
tracheostomy tube.
Catheter size appropriate
Adult: 12-18
Child: 8-10
Infant: 5-8
b. Suction source and container.
Adult: 80-120 mmHg. Maximum
Infant/Children: 60-80 mmHg. Maximum
c. Oxygen source: 15 mmHg or as needed
d. Normal saline for irrigation 5 cc
2. Washed hands and standard preparation and
identification steps
3. Turn on suction
4. Turn on oxygen or increase liter flow rate on
ventilator if indicated
5. Advance catheter without suction applied until
resistance is met
6. Begin suctioning by using a rotating (pill rolling)
motion as catheter is removed
7. Limit suction to no more than 5-10 seconds at one
time **
8. Allow patient to take a few breaths between
suctioning
9. Report procedures as necessary. When
procedure is completed, turn off suction and
return oxygen to pre-suction and return oxygen to
pre-suction level, if changed. Position 3-way stop
cock in off position
11. Assess lung sounds for changes
12. Wash hands
* Highlighted areas are critical elements and must be done correctly to pass skill.
Not Demonstrated
Imperial Valley College
Division of Nursing Education and Health Technologies
Skills Demonstration
Tracheostomy Suctioning
1. Gathered equipment
a. Sterile disposable saline ampule
b. Sterile suction kit with
appropriate size of catheter
c. Sterile saline
d. Suction machine or wall suction is 80-120
mmHg/adults (maximum safe suction is 80120 mmHg for adults; 60-100 mmHg for
infants and children; 40-60 mmHg for
premature infants)
e. Goggles, gown, mask as appropriate for
patient's condition
f. Manual resuscitation bag with touch adaptor
g. Oxygen source
2. Explained procedure to patient
3. Washed hands
4. If planning to deflate trac cuff,
oro/nasal/pharyngeal suctioning should be done
first, using a separate suction kit. Discard
suction kit.
5. Preparation of resuscitator bag, oxygen supply
(O2 flow meter @ 15L/min), and suction.
6. Sterile preparation of trach suction kit.
7. Remove oxygen source from trach tube.
8. Sterile techniques maintained in suctioning.
Hyperinflation of lungs done using resuscitator
bag and oxygen before, during, and after
suctioning. Suction no more than 10
seconds infants and children
9. Auscultate lungs and assess patient response
10. Wash hands
11. Documentation
Skills
demonstrated
Skills not
demonstrated
Imperial Valley College
Division of Nursing Education and Health Technologies
Skills Demonstration
Cleaning Tracheostomy Inner Cannula and Tracheostomy Care
Skills Demonstrated
1. Gathered equipment
a. Tracheostomy cleaning set
b. Sterile gloves
c. Disposible inner cannula
2. Explained procedure to patient
3. Washed hands
4. Don sterile gloves and personal protection
equipment as appropriate.
5. Remove oxygen humidification
source to trach tube.
6. Removed, inner cannula, and replaced
with disposable inner cannula using
sterile technique
7. Cleaned incision site with N.S.
Applied medication if ordered.
8. Changed tracheal ties or velcro fastener.
9. Placement of sterile trach dressing using
sterile technique.
10. Replaced oxygen-humidification source
to trach. tube and assess response.
11. Documentation
Skills Not
Demonstrated
Imperial Valley College
Division of Nursing Education and Health Technologies
Skills Demonstration
Teaching Testicular Self-Examination
Skill
1. Verbalize purpose
2. Gather teaching material i.e. pamphlets,
model etc.
3. Explain risk factors
a. Male age 15 to 35 years
b. Undescended testicles
c. Early puberty
d. Family history
e. Race
4. Teach warning signs of cancer of the testicle
a. Check testicles monthly for:
1. Lumps
2. Feeling of heaviness in the testicle
3. Enlargement of the testicle
4. Change in texture
5. Sudden accumulation of fluid or blood
in scrotum
6. Dull ache in groin
7. Swelling/tenderness in other parts of
body
5. Assess client understanding
6. Documentation
Demonstrated
Not
Demonstrated
Imperial Valley College
Division of Nursing Education and Health Technologies
Skills Demonstration
Post-Mastectomy Arm Exercises
Skills
Demonstrated
Not Demonstrated
1. Verbalized purpose
2. Verbalize time post-op exercises instituted
3. Demonstrated exercises,
a. Ball squeezing
b. Wall climbing
c. Pendulum swing
d. Deep breathing
e. Lifting, clasped hands
f. Rope full
4. Verbalized home instruction
a. Related ADL
Skills Demonstration
Teaching Patient to Perform Breast Self Exam
Skill
Demonstrate Breast Assessment
Inspect Breast
Note: size, symmetry, & contour of breast.
Compare one side of breast with the other
Teach client the four positions for inspecting the
breast while in front of mirror.
(1) hands at sides
(2) hands raised over head
(3) hands pressed on hips or pressed together
(4) leaning forward at the waist
Teach client to inspect areolae, nipples and axillae
Teach client to palpate breast utilizing the three
methods of palpation;
(1) circular
(2) vertical strip
(3) wedge
Demonstrate charting of abnormal findings using clock
method or quadrants.
Discuss Risk Factors: Client
age, history of breast cancer in self or close family
relatives, late age of menopause, onset of
menstruation before age 12, older than 30 years at
birth of first child, never giving birth
Discuss normal and abnormal finding with client
Instruct client on monthly BSE schedule and
mammogram recommendations.
Demonstrated
Not Demonstrated
Imperial Valley College
Division of Nursing Education and Health Technologies
Respiratory Assessment
Skills Demonstration Outline
Skill
Inspection
1. Characteristics of Respirations
2. General appearance
3. Thoracic configuration
4. Cough, sputum
Palpation
1. Status of skin and chest wall
2. Demonstrate and give rationale for; `
a. Tactile fremitus
b. Chest excursion
Percussion
1. Demonstrate Technique
2. Lung fields
a. Quality of sounds/tissue density
1) normal
2) abnormal
Auscultation
1. Demonstrate Technique
2. Verbalize/Describe:
a. Normal breath sounds/locations
1. Vesicular
2. Bronchovesicular
3. Bronchial
b. Adventitious breath sounds/locations
1. Crackles (rales)
2. Wheezing
3. Rhonchi
4. Pleural friction rub
Demonstrated
Not Demonstrated
Imperial Valley College
Division of Nursing Education and Health Technologies
Skills Demonstration
Skin Assessment
Skill
1. Obtains history of
problem, including
symptoms, time frame,
prior treatments.
2. Inspects the skin for,
general color, localized
areas of color, lesions.
3. If lesions present,
inspects and palpates area.
4. Palpates skin for
temperature, turgor,
moisture, texture.
5. Documents findings,
including measurements of
suspicious lesions.
6. Verbalizes signs of
cancerous lesions.
Demonstrated
Not Demonstrated
Imperial Valley College
Division of Nursing Education and Health Technologies
Skills Demonstration - Physical Assessment-adult and child
Skill
Demonstrated
Not Demonstrated
Obtains patient history,
biographical data, present
health status, chief complaint
and hx of present illness
Obtains family history, social
history
Completes review of systems
Obtains vital signs, ht/wt.
General inspection of
appearance, LOC, mood, body
movement, stature, and
nutrition.
Inspects head including skin,
scalp, hair, eyes, ears, nasal
cavities, mouth.
Inspects neck, including
carotid pulses (one at a time),
ROM, lymph nodes, thyroid
gland
Inspects upper extremities for
symmetry, skin, nails. Palpates
for temperature, moisture,
capillary refill, pulses. Tests
ROM, muscle strength, DTRs,
sensory function, fine motor
function. If IV in place,
assesses site.
Inspect chest shape and skin,
respiratory movement.
Palpates skin and chest wall.
Auscultates anterior and
posterior lung fields and
identifies adventitious breath
sounds.
Auscultates heart sounds for
rate, rhythm, pitch, splitting,
murmurs.
Inspects abdomen for contour,
movement, scars, lesions.
Auscultates for bowel sounds
in 4 quadrants. Percusses and
palpates abdomen.
Observes gait. Inspects lower
extremities for symmetry, skin,
nails.
Palpates for temperature,
capillary refill, moisture, distal
pulses. Tests ROM and
strength of feet and legs. Tests
DTRs. Tests for sensory
function.
Inspects and assesses any
tubes or drains from patient for
patency, cleanliness, physician
order being appropriately
carried out.