Practical - Clinical skills PDF

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Clinical Skills Perineal Care: 1. Perform hand hygiene before patient contact. 2. Verify the correct patient using two identifiers. 3. Review orders for specific precautions concerning the patient’s movement or positioning. 4. In order to provide privacy, close room doors and draw the room divider curtain. 5. Prepare equipment and supplies (2 small towels, liquid soap, bucket) 6. If leaving the room is necessary, be sure the call light or button is within the patient’s reach. 7. Raise the bed to a comfortable height to perform perineal care. Female Perineal Care 1. Perform hand hygiene and don gloves. 2. Help the patient assume the dorsal recumbent or supine position. Assist the patient to flex the knees and slightly spread the legs. (Note any limitations on her positioning. If the patient cannot assume the dorsal recumbent or supine position, support her in the sidelying position with a leg raised while the perineum is bathed. If positioning causes the patient discomfort, reduce the degree of abduction in her hip.) 3. Position a waterproof pad or a towel under the patient’s buttocks. 4. Drape the patient with a bath blanket or towel placed over the torso and legs. Fold the the bath blanket or towel over the patient’s legs onto the abdomen to expose the perineum. 5. Wash one half of the mons down to the thigh on the same side with soap and water, use the other side of the washcloth to do the other half and other thigh and then dry them with a dry washcloth. 6. If the patient is able to maneuver and handle the washcloth, allow her to cleanse the perineum. If not, wash the labia majora. a. Use the nondominant hand to gently retract the labia from the thigh; with the dominant hand, carefully wash the skinfolds. b. Using a clean washcloth or perineal wipe, wipe from the perineum to the rectum (front to back). Repeat this process on the opposite side, using a new washcloth or perineal wipe. c. Rinse and dry the area thoroughly. 7. Gently separate the labia with the nondominant hand to expose the urethral meatus and vaginal orifice. 8. With the dominant hand, wash downward from the pubic area toward the rectum in one smooth stroke. Use a separate section of the cloth for each stroke. a. Thoroughly cleanse the labia minora, clitoris, and vaginal orifice.

b. For a woman who is menstruating, use a clean washcloth or perineal wipe instead of a separate section of the same cloth to cleanse the vaginal area. c. For a woman with an indwelling catheter, use a clean washcloth or perineal wipe to cleanse the catheter. Avoid placing tension on the catheter. Thoroughly cleanse the area around it. 9. Rinse the area thoroughly. If the patient uses a bedpan, pour warm water over the perineal area. 10. Dry the area thoroughly, using the front-to-back method. 11. Observe the perineal area for irritation, redness, or drainage that persists after perineal hygiene. 12. For the patient at risk of skin breakdown, apply skin protectant after perineal care. 13. Fold the lower corner of the bath blanket back between the patient’s legs and over the perineum. Ask the patient to lower her legs and assume a comfortable position. 14. Assess, treat, and reassess pain. 15. Discard supplies, remove gloves, and perform hand hygiene. 16. Document the procedure in the patient’s record. Male Perineal Care 1. Perform hand hygiene and don gloves. 2. Assist the patient to the supine position. Note any limitations on his positioning. If the patient is unable to lie supine, he may be positioned on his side. 3. Drape the patient with the bath blanket. 4. Fold the lower half of the bath blanket up to expose the upper thighs. Wash the thighs with soap and water and then dry and cover them with bath towels. 5. Fold back the bath blanket to expose the genitalia. 6. If the patient is able to maneuver and handle the washcloth, allow him to cleanse the perineum. If not, gently raise the penis and place a bath towel underneath. 7. Gently grasp the shaft of the penis. If the patient is uncircumcised, gently retract the foreskin. If the patient has an erection, defer the procedure until later. 8. Using a clean washcloth or perineal wipe, wash the tip of the penis at the urethral meatus first. a. Using a circular motion, cleanse the head of the penis from the meatus outward. b. Discard the washcloth or wipe and repeat with a clean washcloth or wipe until the head of penis is clean. c. Gently rinse and dry the head of the penis. d. If the patient has an indwelling catheter, use a clean washcloth or perineal wipe to cleanse it.

9. If the patient is uncircumcised, return the foreskin to its natural position. 10. Have the patient abduct his legs. Gently cleanse the shaft of the penis and the scrotum. a. Carefully clean the underlying surface of the penis. b. Lift the scrotum carefully and wash underlying skinfolds. c. Rinse and dry thoroughly. 11. Observe the perineal area for any irritation, redness, or drainage that persists after perineal hygiene. 12. For a patient at risk of skin breakdown, apply skin protectant after perineal care. 13. Fold the bath blanket down over the patient’s perineum and assist the patient to a comfortable position. 14. Assess, treat, and reassess pain. 15. Discard supplies, remove gloves, and perform hand hygiene. 16. Document the procedure in the patient’s record.

Insulin pen/syringe: Mixing Insulin from Two Vials 1. Wipe off tops of both vials with alcohol swab. 2. Agitate the NPH vial 3. Using a syringe aspirate volume of air equivalent to first medication dose (NPH). 4. Inject air into NPH vial, making sure that the needle or needleless access device does not touch the solution. 5. Holding on to plunger, withdraw needle or needleless access device and syringe from vial A. Aspirate air equivalent to second medication dose (vial B) into syringe. 6. Insert needle or needleless access device into vial B. Inject volume of air into vial B and then withdraw medication from vial B into the syringe. 7. Withdraw needle or needleless access device and syringe from vial B. Ensure that proper volume has been obtained. 8. Determine what the combined volume of the medications should measure on the syringe scale. 9. Insert needle or needleless access device into vial A, being careful not to push plunger and expel medication within syringe into vial. Invert vial and carefully withdraw the desired amount of medication from vial A into syringe. If too much medication is withdrawn from second vial, discard syringe and start over. Do not push medication back into vial.

10. Withdraw needle or needleless access device and expel any excess air from syringe. 11. Check fluid level in syringe for proper dose. Medications are now mixed. 12. Replace filter needle with needleless system or with appropriatesize needle according to route of medication. 13. Compare MAR, computer screen, or computer printout with prepared medication and labels from vials. 14. Label the prepared medication syringe. 15. Keep needle of prepared syringe sheathed or capped until ready to administer medication (Table 1). 16. Discard used supplies. 17. Check syringe again carefully for total combined dose of medications before administering. 18. Clean work area. 19. Perform hand hygiene. 20. Document the procedure in the patient's record.

Sterile wound care: Wet-to-Dry Wound: 1. 2. 3. 4. 5.

Perform hand hygiene before patient contact. Verify the correct patient using two identifiers. Verify practitioner’s orders for dressing change. Assess the size, location, and condition of the wound. Determine the patient’s level of comfort using an organizationapproved pain scale. 6. Assess need, readiness, and willingness for caregivers to participate in dressing the wound. 7. Assess risk factors for delayed wound healing. 8. Assess the patient for allergies, including sensitivity to tapes and other adhesives. 9. Place a disposable waterproof bag within reach of the work area. Fold the top of the bag to make a cuff. 10. Administer prescribed analgesic as needed before dressing change. 11. Reassess the patient's pain status, allowing for sufficient onset of action per medication, route, and the patient's condition. 12. Perform hand hygiene and don gloves. Don gown, mask, and eye protection, if risk of splashing from wound exists. 13. Position the patient comfortably. Drape the patient to expose only the wound site.

14. Remove tape, gauze wrap bandages, or ties securing the existing secondary dressing. 15. Using the nondominant hand, gently press down on the intact skin just outside the dressing edges to provide counter pressure, and then pull tape parallel to the skin toward the dressing. a. If the dressing is over hairy areas, remove in the direction of hair growth. b. If needed, obtain patient permission to clip hair from area. c. Remove any excess adhesive from the skin using an adhesive remover wipe. 16. Use fingers or forceps to remove the secondary dressing. Then remove the primary dressing that is in contact with the wound bed. If drains are present, slowly and carefully remove dressings and avoid tension on any drainage device. a. If a dry dressing adheres to the wound and mechanical debridement is not indicated, moisten with saline and remove. b. If a moist-to-dry dressing, which is ordered for the purpose of mechanical debridement, adheres to the wound, alert the patient to the possibility of discomfort, and then gently remove the dressing. Use moist-to-dry dressing only when mechanical debridement is appropriate (i.e., when nonviable, necrotic tissue is present and no other debridement options are available). c. If mechanical debridement is not the goal, consult with ordering practitioner to consider modifying the dressing order to specify use of saline-moistened gauze for wet-to-moist therapy. 17. Inspect the wound and periwound, noting color, size (length, width, and depth), drainage, edema, presence and condition of drains, any odor, and signs of healing. a. Gently palpate wound edges, noting any bogginess, induration, or patient report of increased pain. b. If the wound is healing by secondary intention, gently probe wound bed and inner edges with a moistened cotton-tipped applicator for presence of undermining, tunneling, or sinus tract(s). 18. Fold dressing with drainage contained inside, discard in a waterproof bag, and remove gloves inside out. With small dressing, remove gloves inside out over the dressing, and discard gloves with soiled dressing in a waterproof bag. 19. Perform hand hygiene and don clean gloves. 20. Reassure the patient as needed. Describe or explain the appearance of the wound and any indicators of wound healing or delayed wound healing. 21. Cleanse the wound. a. Use a separate saline-moistened gauze for each cleansing stroke, or spray the wound surface with an appropriate wound cleanser.

b. Clean from the least to most contaminated area. c. Cleanse around the drain (if present), using circular strokes starting near the drain and moving outward and away from the insertion site. d. Use a separate dry gauze to blot the wound dry from the least to most contaminated area. If a drain is present, use circular strokes starting near the drain and moving outward and away from the insertion site. 22. Apply antiseptic ointment, if ordered, with cotton-tipped applicator or gauze over the incision. 23. Remove gloves and perform hand hygiene. Don clean gloves if necessary. 24. Apply dressing. a. Dry dressing i. Apply a layer of gauze over the wound as the contact layer, or primary dressing. ii. If drain is present, apply precut, split 4 × 4-inch (10.1 × 10.1-cm) gauze around the drain. iii. Apply additional layers of gauze, as needed. iv. Apply a thicker absorbent pad (e.g., abdominal [ABD] pad). b. Moist-to-dry dressing i. Pour prescribed sterile solution (i.e., saline) on gauze or gauze wrap, or cut packing strip to be used to fill the wound bed. Wring out excess solution. If a packing strip is used to fill the wound, use sterile scissors to cut the amount of dressing needed to fill the wound. Do not let the strip touch the side of the bottle in order to avoid contaminating the packing strip. ii. Apply moistened gauze or packing material as a single layer directly onto the wound surface. A. If wound is deep, loosely fill wound with additional gauze or packing material using sterile forceps until all wound surfaces are in contact with moist gauze, including any sinus tracts, tunnels, or undermining. B. Make sure moist gauze does not overlap onto the periwound skin. Do not pack the wound too tightly as it may cause wound trauma when the dressing is removed. iii. Apply dry sterile 4 × 4-inch (10.1 × 10.1-cm) gauze over the moist gauze. iv. Cover with an ABD pad (or similar product) or additional layers of gauze. 25. Secure dressing. a. Apply tape to dressing edges in a window-pane fashion, ensuring sufficient contact with both intact skin and dressing. Use nonallergenic tape as needed.

b. Use Montgomery ties or straps. i. Ensure that the surrounding skin is clean and intact. ii. Apply a skin barrier, such as a hydrocolloid, if needed. iii. Expose adhesive surface of the ties. iv. Place the ties on opposite sides of the secondary dressing directly onto the surrounding skin or skin barrier. v. Lace ties securely, avoiding excessive pressure. c. Use roll gauze or elastic netting. i. Apply roll gauze circumferentially to secure secondary dressing. ii. Cut elastic netting and apply over secondary dressing to secure without using tape or other adhesives. 26. Label the dressing per the organization's practice with the date and time of application and the nurse's initials. 27. Assist the patient to a comfortable position. 28. Assess, treat, and reassess pain. 29. Discard supplies, remove personal protective equipment (PPE), and perform hand hygiene. 30. Document the procedure in the patient’s record.

Bed making: Occupied: 1. Perform hand hygiene before patient contact. 2. Verify the correct patient using two identifiers. 3. Determine if the patient has been incontinent or if excess drainage is visible on the linen. 4. Assess restrictions in the patient's mobility or positioning. Explain the procedure to the patient, noting that he or she will be asked to turn over layers of linen. 5. Assess the patient for pain and premedicate him or her as warranted. 6. Draw the privacy curtain around the bed. 7. Assemble clean linen and a linen bag on the bedside table. 8. Lower the head of the bed, keeping the patient comfortable. Raise the bed to a comfortable working position and lower the side rail from the side where the work will be completed. 9. Perform hand hygiene and don gloves. 10. Loosen the top linen at the foot of the bed. 11. Remove the blanket separately. If it is to be reused, fold it into a square and place it over the back of the chair. If it is soiled, fold it into a bundle or square, holding it away from the body, and place it in the linen bag. Avoid shaking or fanning the blanket.

12. Cover the patient with a blanket, placing it over the top sheet. Have the patient hold the top edge of the blanket or tuck the blanket under his or her shoulders. Reach beneath the blanket and remove the top sheet. Discard the sheet in the linen bag. 13. Assess the location and tension of the patient's medical devices, tubes, and wires. Position them to minimize the effect on their function and prevent excessive tension on any external medical devices during bed making. 14. Assist the patient to a side-lying position, facing the opposite direction. Encourage the patient to use the side rail to aid in turning. Adjust the pillow under the patient's head. 15. Loosen the bottom linens, moving from head to foot. Fanfold the bottom sheet, drawsheet, and any cloth pads toward and under the patient. Tuck the edges of the soiled bottom linen alongside the patient's buttocks, back, and shoulders. 16. Clean, disinfect, and dry the exposed mattress surface, if needed. 17. Apply clean linens to the exposed half of the bed in separate layers. Start with the bottom sheet by placing it lengthwise with the center crease in the middle of the bed. Fanfold the bottom sheet to the center of the bed alongside the patient. Repeat this process with the drawsheet. a. For a fitted bottom sheet, pull it smoothly over the mattress edges. b. For a flat bottom sheet, perform the following steps: i. Spread the flat sheet smoothly over the mattress so it hangs a few inches over the mattress edges. ii. Move to the foot of the bed to ensure that the sheet is hanging over the mattress there. The sheet's lower hem should lie seam down and be even with the bottom edge of the mattress. iii. Move back to the head of the bed. Pull the remaining top portion of the sheet over the top edge of the mattress. iv. While standing at the head of the bed, miter the top corner of the sheet. v. Pick up the top portion of the sheet several inches from the top edge of the mattress. Lift the sheet and lay it on top of the mattress to form a triangular fold, with the lower base of the triangle even with the mattress side edges. vi. Tuck the lower edge of the sheet, which is hanging free, under the mattress. Hold the portion of the sheet covering the side of the mattress in place with one hand. With the other hand, pick up the triangular linen fold and bring it down over the side of the mattress. Tuck with palms down, without pulling the triangular fold. Tuck this portion under the mattress.

vii.

Tuck the remaining portion of the sheet under the mattress, moving toward the foot of the bed. Keep the linen smooth. 18. After placing the bottom sheet, place the open drawsheet along the middle of the bed lengthwise. Tuck the remainder under the patient's buttocks and torso. Place a waterproof pad under the drawsheet, if needed. 19. Raise the side rail and ask the patient to turn toward the nurse; assist as needed. Tell the patient that he or she will be rolling over layers of linen. Advise the patient to roll across them without lifting the body. Ensure that the patient turns slowly. 20. Move to the opposite side of the bed; lower the side rail. Assist the patient with positioning on the other side across the folds of linen. 21. Loosen the edges of soiled linen from under the mattress. 22. Remove the soiled linen by folding it into a bundle or square, holding it away from the body, and placing it in the linen bag. Avoid shaking or fanning the linen. 23. Clean, disinfect, and dry the other half of the mattress, as needed. 24. Pull the clean, fanfolded linen over the edge of the mattress from the head to the foot of the bed. 25. Assist the patient with rolling back into a supine position. If the bottom sheet is fitted, pull it over the mattress ends. 26. If the bottom sheet is flat, miter the top corner. 27. Facing the side of the bed, grasp the remaining edge of the bottom sheet. Lean back, keep the back straight, and pull the fitted sheet over the mattress ends or pull and tuck the excess linen of the flat sheet under the mattress from the head to the foot of the bed. 28. Smooth the fanfolded drawsheet over the bottom sheet. Tucking is optional. Also, smooth out the waterproof pad, if used. 29. Place the top sheet over the patient with the vertical centerfold lengthwise down the middle of the bed. Open the sheet out from head to foot and unfold it over the patient. Ensure that the top edge of the sheet is even with the top edge of the mattress. 30. Ask the patient to hold the clean top sheet. Remove the blanket and discard it in the linen bag. 31. Place a clean or reused blanket on the bed over the patient. Ensure that the top edge is parallel with the top edge of the sheet and a few inches below it. 32. Make a cuff by turning the edge of the top sheet down over the top edge of the blanket. 33. Stand at the foot of the bed and make a horizontal toe pleat by performing the following steps: a. Fanfold the sheet and blanket a few inches across the bed. b. Pull the sheet and blanket up from the bottom to make a fold several inches from the bottom edge of the mattress.

c. Tuck the remaining portion of the sheet and blanket together under the foot of the mattress. Be sure the toe pleats are not pulled out. 34. Make a modified mitered corner with the top sheet ...