BSN RD Vital Signs 3 - Return Demo Guidelines PDF

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Return Demo Guidelines...

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BSN Skills Return Demonstration Vital Signs

Page 1 of 8

SKILLS MODULE VIDEO: TEMPERATURE; RESPIRATION; BLOOD PRESSURE TWO-STEP METHOD; RADIAL PULSE; PULSE OXIMETRY Student Name:

D#:

Course Number and Name:

If Other:

Session:

Year:

Course Coordinator:

Campus Location:

If Other:

Program: Number of Self-Identifiable Breaks Utilized:

Skill Completed in 30 minutes: Yes, how long _____________ Essential Elements Met:

Yes

No, how long _____________ No

Student Verbalized All Steps of Return Demonstration:

Yes

No

Faculty Name Evaluating Attempt #1:

Attempt #1 Date _____________ and Outcome: Satisfactory Unsatisfactory

Faculty Name Evaluating Attempt #2:

Attempt #2 Date _____________ and Outcome: Satisfactory Unsatisfactory

Requirements:

Essential Elements:

• Student must complete all essential elements of the skills return demonstration in a one-on-one, non-cueing environment with faculty evaluating.

During nursing skills return demonstration, students must complete all essential elements, which are bolded throughout the skills checklist. Unsafe nursing behaviors, unsafe actions, not completing skill within designated time-frame or omitting any bolded essential element(s) without self-identifying, will result in an unsatisfactory for the return demonstration. Only the bolded areas count towards unsatisfactory rating.

• Students are not allowed to use notes or any resources, with the exception of the supplies and/or equipment for the skill (tape, pulse oximeter, etc.). • Students must verbalize their steps as they are performing them throughout the return demonstration. • Students must complete Vital Signs Return Demonstration within 30 minutes. • Students must complete and submit the Direct Patient Care Documentation: Laboratory Courses the same day the return demonstration is completed (or as directed by course coordinator). Documentation is not included in this time-frame. Students will earn a Satisfactory/Unsatisfactory grade on the return demonstration. A satisfactory return demonstration does not imply proficiency or tan ability to proceed into a clinical learning setting to perform any nursing skills independently. Additional return demonstrations may be required by your faculty. Failure to demonstrate successful return demonstrations of any required skill could limit and/or impact future learning opportunities. • A student may be unsatisfactory one time on a single skill with an opportunity to remediate. If the student fails to complete the remediation session and satisfactorily complete the same skill on a second attempt, it will result in course failure. • A student may only be unsatisfactory on two different skills. If unsatisfactory on a third skill, it will result in a course failure.

Self-Identifiable Breaks: Self-identifiable breaks are defined as the acknowledgment made by a student during a return demonstration of either a missed action or the incorrect performance of an action that is required for the successful skill completion. Students have a designated number of self-identifiable breaks for each return demonstration. • One self-identifiable break for Temperature permitted. • One self-identifiable break for Radial Pulse permitted. • One self-identifiable break for Respirations permitted. • One self-identifiable break for Blood Pressure permitted. • One self-identifiable break for Pulse Oximeter permitted. Return Demonstration Parameters for Vital Signs: a. Each skill consists of pain, temperature, pulse, respirations, blood pressure and pulse oximeter. b. Blood pressure must be within 4 mmHg total between the systolic and diastolic readings. c. Pulse must be within 4 bpm. d. Respirations must be within 2 breaths per minute.

The steps to perform have been modified from ATI® skills module videos. Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 28 | Chicago, IL 60661 12-180415.2

©2020 Chamberlain University LLC. All rights reserved.

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BSN Skills Return Demonstration Vital Signs

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NR-224 Course Outcomes Met with Vital Signs Return Demonstration:

NR-299 Course Outcomes Met with Vital Signs Return Demonstration:

• CO1 Differentiate between the components and apply the principles of the nursing process in the learning laboratory setting using simulated patient care scenarios (PO1).

• CO3 Participate in health promotion, illness prevention and rehabilitative activities as a member of the healthcare team (PO2).

• CO2 Apply the concepts of health promotion and illness prevention in the laboratory setting (PO2).

• CO4 Demonstrate communication skills necessary for interaction with other health team members and for providing basic nursing care to individuals and families (PO3).

• CO3 Demonstrate communication skills necessary for interaction with other health team members and for providing basic nursing care in a simulated environment (PO3). • CO7 Demonstrate beginning roles and responsibilities associated with professional nursing while planning for cost-effective basic nursing care to individuals and families (PO7). • CO8 Explain the rationale for selected nursing interventions based upon current nursing literature (PO8).

• CO6 Discuss health promotion, illness prevention, health maintenance, health restoration and rehabilitation in relation to the nurse’s role in working with various populations, including the older adult (POs 1, 2). • CO7 Explain and apply principles of legal, ethical and professional standards in relation to clinical nursing practice (PO6). • CO8 Demonstrate the beginning roles and responsibilities associated with health promotion and nursing care (PO7).

Supplies: Blood pressure cuff, watch with second hand, pulse oximeter, thermometer, stethoscope, alcohol prep pads, black pen, disinfectant wipe (one moist and one dry).

VITAL SIGNS Step No.

Complete

Incomplete

Self-Identified Break

Step to Perform

1

Introduces self to patient

2

Identifies patient with two identifiers

3

Verifies provider’s orders

4

Assesses for allergies

5

Provides privacy

6

Places supplies on a clean surface

7

Performs hand hygiene Informs patient of procedure to be performed:

8

Rationale for performing vital signs

Not to speak and breathe normally

Answers questions Assesses patient for: 9

Cold or hot to drink recently

Smoking

AV fistula

Fingernail polish and removes

Mastectomy 10

Assists patient to sitting or lying position Cleanses equipment with dry disinfectant wipe:

11

Blood pressure cuff

Pulse oximeter probe

Temporal thermometer (if applicable)

Stethoscope

Evaluator Comments:

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 28 | Chicago, IL 60661 12-180415.2

©2020 Chamberlain University LLC. All rights reserved.

1120pflcpeADA

BSN Skills Return Demonstration Vital Signs

Page 3 of 8

PAIN Step No.

Complete

Incomplete

Self-Identified Break

Step to Perform Assesses pain:

1

What makes pain better/worse

Intensity

Description

Intermittent

Travel/spread, if so where Evaluator Comments:

TEMPERATURE: STUDENT DEMONSTRATES ONE (1) OF THE FOLLOWING ROUTES: ORAL, TYMPANIC, AXILLARY OR TEMPORAL TEMPERATURE: ORAL Step No.

Complete

Incomplete

Self-Identified Break

Step to Perform

1

Slides thermometer probe into the disposable plastic probe cover and pushes gently until the cover locks into place

2

Places covered thermometer probe under patient’s tongue in the posterior sublingual pocket

3

Instructs patient to close lips gently around the thermometer probe and to keep mouth closed until temperature has been measured

4

Removes thermometer probe upon audible signal, disposes cover into trash receptacle and returns probe back into thermometer unit

Evaluator Comments:

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 28 | Chicago, IL 60661 12-180415.2

©2020 Chamberlain University LLC. All rights reserved.

1120pflcpeADA

BSN Skills Return Demonstration Vital Signs

Page 4 of 8

TEMPERATURE: TYMPANIC Step No.

Complete

Incomplete

Self-Identified Break

Step to Perform

1

Removes thermometer from holder

2

Pushes the disposable plastic cover over the tip of the electronic thermometer until the cover locks in place

3

Pulls the pinna (auricle) back, up and out gently and inserts the tip of the covered thermometer probe into the ear canal

4

Presses the scan button

5

Leaves thermometer probe in place until audible signal, removes, disposes cover into trash receptacle and returns thermometer back into holder

Evaluator Comments:

TEMPERATURE: AXILLARY Step No.

Complete

Incomplete

Self-Identified Break

Step to Perform

1

Exposes axilla and ensures axilla is dry

2

Removes thermometer from charging unit

3

Slides probe into disposable cover and places into center of axilla

4

Lowers patient’s arm over covered probe and holds patient’s arm across the abdomen

5

Removes thermometer probe upon audible signal, removes and discards probe cover into trash receptacle and places probe back into thermometer unit

Evaluator Comments:

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 28 | Chicago, IL 60661 12-180415.2

©2020 Chamberlain University LLC. All rights reserved.

1120pflcpeADA

BSN Skills Return Demonstration Vital Signs

Page 5 of 8

TEMPERATURE: TEMPORAL Step No.

Complete

Incomplete

Self-Identified Break

Step to Perform

1

Places clean thermometer in center of forehead and presses scan button while keeping it depressed

2

Slides probe gently across the temple into hairline

3

Lifts the probe and places it on the patient’s neck behind earlobe while keeping the button depressed

4

Removes thermometer from the skin and releases button

Evaluator Comments:

RADIAL PULSE Step No.

Complete

Incomplete

Self-Identified Break

Step to Perform

1

Ensures patient has been at rest for five to ten minutes prior

2

Locates the radial pulse while supporting the patient’s arm

3

4

5

Applies light pressure until pulse is felt: Thumb is not included while applying light pressure Measures: Rate

Quality or strength

Regularity

If pulse is irregular, counts pulse for one full minute

Evaluator Reading: Pulse within 4bpm

Rhythm

Counts pulse for 30 seconds and multiplies by two if the pulse is normal: Student Reading: Pulse not within 4bpm

Evaluator Comments:

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 28 | Chicago, IL 60661 12-180415.2

©2020 Chamberlain University LLC. All rights reserved.

1120pflcpeADA

BSN Skills Return Demonstration Vital Signs

Page 6 of 8

RESPIRATIONS Step No.

Complete

Incomplete

Self-Identified Break

Step to Perform

1

Places patient’s arm in a relaxed position across abdomen and appears to be taking radial pulse while observing respirations

2

Observes one full respiration cycle, then begins to count breaths

3

Assesses the respirations for depth by observing the degree of chest-wall movement during inspiration and expiration Counts respirations for 30 seconds and multiples by two if the respiration cycle is normal:

4

If respirations are irregular, counts respirations for one full minute

Evaluator Reading:

Student Reading:

Respirations within 2 breaths per minute

Respirations not within 2 breaths per minute

Evaluator Comments:

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 28 | Chicago, IL 60661 12-180415.2

©2020 Chamberlain University LLC. All rights reserved.

1120pflcpeADA

BSN Skills Return Demonstration Vital Signs

Page 7 of 8

BLOOD PRESSURE: TWO-STEP METHOD Step No.

Complete

Incomplete

Self-Identified Break

Step to Perform

1

Places arm at heart level with palm turned up and exposes patient’s upper arm completely

2

Palpates for the brachial pulse

3

Centers appropriate size blood pressure cuff one inch above where brachial pulse was palpated

4

Wraps blood pressure cuff evenly and snugly around skin of upper arm

5

Positions manometer at eye level and brachial pulse palpated again

6

Inflates blood pressure cuff with dominant hand while using fingertips on non-dominant hand to palpate brachial pulse

7

Continues inflating the cuff another 30mm Hg when pulse is no longer felt and notes number (estimated systolic blood pressure)

8

Slowly deflates blood pressure cuff by turning the valve on the bulb counter-clockwise and waits 30 seconds

9

Places bell or diaphragm of a clean stethoscope over brachial pulse and inflates cuff

10

Inflates blood pressure cuff quickly to 30mm Hg above the estimated systolic pressure

11

Deflates blood pressure cuff slowly, allowing manometer needle to drop at a rate of two to three mm Hg per second Notes the number on manometer:

12

When first clear sound heard (systolic blood pressure)

When sound disappears (diastolic blood pressure)

13

Listens for a few more seconds after sound disappears, then quickly deflates blood pressure cuff

14

Removes blood pressure cuff from patient’s arm

Evaluator Reading:

Student Reading:

Blood Pressure within 4 mmHg total between systolic and diastolic reading

Blood Pressure not within 4 mmHg total between systolic and diastolic reading

Evaluator Comments:

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 28 | Chicago, IL 60661 12-180415.2

©2020 Chamberlain University LLC. All rights reserved.

1120pflcpeADA

BSN Skills Return Demonstration Vital Signs

Page 8 of 8

OXYGEN SATURATION Step No.

Complete

Incomplete

Self-Identified Break

Step to Perform

1

Turns on pulse oximeter or vital sign machine

2

Assesses skin temperature and capillary refill

3

Places probe on appropriate vascular access (finger, toe or earlobe)

4

Leaves pulse oximeter on appropriate vascular access until consistent reading and/or waveform appears

5

Removes pulse oximeter from vascular access Cleanses equipment with moist disinfectant wipe:

6

Blood pressure cuff

Pulse oximeter probe

Temporal thermometer (if applicable)

Stethoscope

Informs patient of all vital sign findings: 7

Temperature

Pulse

Respirations

Pulse oximeter

BP 8

Bed is in lowest position

9

Bed is locked

10

Side rails up (if applicable)

11

Call light within reach

12

Performs hand hygiene

Evaluator Reading:

Student Reading:

Evaluator Comments:

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 28 | Chicago, IL 60661 12-180415.2

©2020 Chamberlain University LLC. All rights reserved.

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