Checklists for Clinical Nursing Skills

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Louise Sparkes, Jennifer Bassett and Elisabeth Jacob

Checklists for

Clinical Nursing Skills

Louise SparkEs RN, BN, MN (E d ), GC (E merg ) Lecturer, School of Nursing and Midwifery, Faculty of Medicine, Monash University JennIFER BASSETT RN, PGD ip NSG (P eriop ), D ip M gmt , CERT IVTAA Associate Lecturer Nursing, Simulation Educator/Clinical Learning Unit Manager, Department of Rural Nursing and Midwifery, LaTrobe Rural Health School Elisabeth Jacob RN, D ip A pp S ci (N sg ), G rad D ip C rit C are , ME d Lecturer, School of Nursing and Midwifery, Faculty of Medicine, Monash University

Adapted from Skill Checklists forTaylor’s Clinical Nursing Skills, third edition, by Pamela Lynn and Marilee LeBon

Checklists for Clinical Nursing Skills

Sample Contents

Complete Text Table of Contents

Chapter Two Health Assessment

Chapter Seven Hygiene

View further details of this title and more online at www.LWWBooks.com.au

Contents

Reviewers

vii

Preface

Introduction

Chapter 1 Skill 1-1 Skill 1-2 Skill 1-3 Skill 1-4 Skill 1-5 Skill 2-1 Skill 2-2 Skill 2-3 Skill 2-4 Skill 2-5 Skill 2-6 Skill 2-7 Skill 2-8 Skill 2-9 Skill 2-10 Chapter 2

Vital signs

Assessing body temperature

1 5 6 8 9

Assessing the peripheral pulse by palpation Assessing the apical pulse by auscultation

Assessing respiration

Assessing brachial artery blood pressure

Health assessment Taking a patient history Performing a general survey Assessing the skin, hair and nails Assessing the head and neck Assessing the thorax and lungs Assessing the cardiovascular system Undertaking a neurological examination Undertaking a musculoskeletal assessment Assessing the peripheral vascular system Assessing the abdomen

12 14 17 19 23 25 27 29 32 34 36 39 41 44 45 46 47 48 50 52

Chapter 3 Safety Skill 3-1

Falls prevention

Skill 3-2 Skill 3-3 Skill 3-4 Skill 3-5 Skill 4-1 Skill 4-2 Skill 4-3 Skill 4-4 Skill 4-5 Skill 4-6 Skill 4-7

Implementing alternatives to the use of restraints

Applying a restraint Clinical handover

Documentation

Chapter 4

Asepsis and infection control

Performing hand hygiene using soap and water (handwashing) Performing hand hygiene using an alcohol-based hand rub Preparing a sterile field using a packaged sterile drape Preparing a sterile field using a commercially prepared sterile kit or tray

Adding sterile items to a sterile field

Putting on sterile gloves prior to a procedure and removing soiled gloves post-procedure 54

Using personal protective equipment (PPE)

iii

Chapter 5 Medications Skill 5-1

Administering oral medications

59 62 65 68 71 74 77 80

Skill 5-2 Skill 5-3 Skill 5-4 Skill 5-5 Skill 5-6 Skill 5-7 Skill 5-8 Skill 5-9 Skill 5-10 Skill 5-11 Skill 5-13 Skill 5-14 Skill 5-15 Skill 5-16 Skill 5-17 Skill 5-18 Skill 5-19 Skill 5-20 Skill 5-21 Skill 5-22 Skill 5-23 Skill 5-12 Skill 6-2 Skill 6-3 Skill 6-4 Skill 6-5 Skill 6-6 Skill 7-2 Skill 7-3 Skill 7-4 Skill 7-5 Skill 7-6 Skill 7-7 Skill 7-8 Skill 7-9

Administering medications via a gastric tube Removing medication from an ampoule Removing medication from a vial Administering an intradermal injection Administering a subcutaneous injection Administering an intramuscular injection Administering continuous subcutaneous infusion

Administering medications by intravenous bolus or push through an intravenous infusion 82 Administering a piggyback intermittent intravenous infusion of medication 85

Administering an intermittent intravenous infusion of medication via a mini-infusion pump Administering an intermittent intravenous infusion of medication via a volume-control (burette) administration set

91 94 96 98

Applying a transdermal patch

Instilling eye drops

Administering an eye irrigation

Instilling ear drops

100 102 104 106 108 110 112 114 116 120 122 124 127 131 133 136 138 140 142 144 146 148 151

Administering an ear irrigation

Instilling nose drops

Administering a vaginal cream or pessary Administering a rectal suppository

Administering medication via a metered-dose inhaler (MDI) Administering medication via a small-volume nebuliser (nebuliser mask)

Administering medication via a dry powder inhaler (DPI)

Chapter 6 Perioperative nursing Skill 6-1

Providing preoperative preparation and patient care: hospitalised patient

Deep-breathing exercises, coughing and splinting

Leg exercises

Providing preoperative preparation and patient care: hospitalised patient (day of surgery) Providing postoperative care when the patient returns to their room

Applying a forced-air warming device

Chapter 7 Hygiene Skill 7-1

Giving a bed bath

Assisting the patient with oral care

Providing denture care

Providing oral care for the dependent patient

Removing contact lenses

Shampooing a patient’s hair in bed Assisting the patient to shave

Making an unoccupied bed Making an occupied bed

Chapter 8

Skin integrity and wound care

Skill 8-1 Skill 8-2 Skill 8-3 Skill 8-4 Skill 8-5 Skill 8-6 Skill 8-7 Skill 8-8 Skill 8-9 Skill 8-10 Skill 8-11 Skill 8-12 Skill 8-13 Skill 8-14 Skill 8-15 Skill 9-2 Skill 9-3 Skill 9-4 Skill 9-5 Skill 9-6 Skill 9-7 Skill 9-8 Skill 9-9 Skill 9-10 Skill 9-11 Skill 9-12 Skill 9-13 Skill 9-14 Skill 9-15 Skill 9-16 Skill 9-17 Skill 9-18 Skill 9-19 Skill 9-20

Cleaning a wound and applying a dry, sterile dressing

154 156 158 160 162 165 168 171 173 175 178 180 181 183 185 187 190 192 194 196 199 202 204 206 208 210 212 214 216 218 220 222 224 227 229

Assessing a wound

Applying a hydrocolloid dressing Performing irrigation of a wound Collecting a wound culture Caring for a Penrose drain Caring for a T-tube drain Caring for a Jackson-Pratt drain Caring for a Haemovac drain

Applying negative pressure wound therapy (NPWT)

Removing sutures

Removing surgical staples Applying a warm compress Assisting with a Sitz bath

Applying cold therapy

Chapter 9 Activity Skill 9-1

Assisting a patient with turning in bed

Moving a patient up in bed with the assistance of another nurse

Transferring a patient from the bed to a trolley Transferring a patient from the bed to a chair Transferring a patient using an electric sling hoist

Providing range-of-motion exercises Assisting a patient with ambulation

Assisting a patient with ambulation using a walking frame Assisting a patient with ambulation using crutches Assisting a patient with ambulation using a walking stick Applying and removing anti-embolism stockings Applying a pneumatic compression device (PCD) Applying a continuous passive motion (CPM) device

Applying a triangular sling Applying a figure-eight bandage Assisting with plaster cast application

Caring for a plaster cast

Applying skin traction and caring for a patient in skin traction

Caring for a patient in skeletal traction

Caring for a patient with an external fixation device

Chapter 10 Comfort Skill 10-1

Promoting patient comfort

231 235 238

Skill 10-2 Skill 10-3

Caring for a patient receiving patient-controlled analgesia (PCA) Caring for a patient receiving continuous wound perfusion pain management

Chapter 11 Nutrition Skill 11-1

Assisting a patient with eating and drinking

241 243 246 249 251 253 256 258 260 262 264 267 270 272 274 276 279 286 288 290 292 294 298 300 303 306 309 311 313 316 319 322 324 281 283

Skill 11-2 Skill 11-3 Skill 11-4 Skill 11-5

Inserting a nasogastric (NG) tube Administering a tube feeding Removing a nasogastric (NG) tube Caring for a gastrostomy tube

Chapter 12 Urinary elimination Skill 12-1

Assisting with the use of a bedpan Assisting with the use of a urinal

Skill 12-2 Skill 12-3 Skill 12-4 Skill 12-5 Skill 12-6 Skill 12-7 Skill 12-8 Skill 12-9 Skill 12-10 Skill 12-11 Skill 12-12

Assisting with the use of a bedside commode

Assessing bladder volume using an ultrasound bladder scanner

Applying an external condom catheter Catheterising the female urinary bladder Catheterising the male urinary bladder

Removing an indwelling catheter

Performing intermittent closed catheter irrigation Care of continuous closed bladder irrigation

Emptying and changing a stoma appliance on an ileal conduit

Caring for a suprapubic urinary catheter

Chapter 13 Bowel elimination Skill 13-1 Administering an enema

Skill 13-2

Changing and emptying an ostomy appliance

Chapter 14 Oxygenation Skill 14-1

Using a pulse oximeter

Skill 14-2 Skill 14-3 Skill 14-4 Skill 14-5 Skill 14-6 Skill 14-7 Skill 14-8 Skill 14-9 Skill 14-10 Skill 14-11

Teaching a patient to use an incentive spirometer

Administering oxygen by nasal cannula

Administering oxygen by mask

Suctioning the nasopharyngeal and oropharyngeal airways

Inserting an oropharyngeal airway

Suctioning the tracheostomy: open system

Providing tracheostomy care

Providing care of a chest drainage system

Removal of a chest tube

Using a hand-held resuscitation bag and mask

Chapter 15 Fluid, electrolyte and acid–base balance Skill 15-1 Inserting a peripheral IV cannula

Skill 15-2 Skill 15-3 Skill 15-4 Skill 15-5

Commencing an IV infusion

Changing an IV fluid bag and giving set Monitoring an IV site and infusion Changing an IV cannula dressing

vii

Skill 15-6 Skill 15-7

Capping for intermittent use and flushing a peripheral IV cannula

326 328

Administering a blood product transfusion

Chapter 16 Cardiovascular care Skill 16-1

Obtaining an electrocardiogram (ECG)

331 334 337 340 342 344 346 348 350 352 354 356 358 360 362 364 366 369 372 381

Skill 16-2 Skill 16-3 Skill 16-4

Applying a cardiac monitor

Performing adult cardiopulmonary resuscitation (CPR) Performing emergency automated external defibrillation

Chapter 17 Neurological care Skill 17-1 Logrolling a patient

Skill 17-2 Skill 17-3 Skill 17-4

Applying a hard cervical collar

Employing seizure precautions and seizure management

Caring for a patient in halo traction

Chapter 18 Laboratory specimen collection Skill 18-1 Testing stool for occult blood

Skill 18-2 Skill 18-3 Skill 18-4 Skill 18-5 Skill 18-6 Skill 18-7 Skill 18-8 Skill 18-9 Skill 18-10

Collecting a stool specimen for culture

Obtaining a capillary blood sample for glucose testing

Obtaining a nasal swab

Obtaining a nasopharyngeal swab

Collecting a sputum specimen for culture

Collecting a urine specimen (clean-catch, midstream) for urinalysis and culture Obtaining a urine specimen from an indwelling urinary catheter Using venepuncture to collect a venous blood sample for routine testing Obtaining a venous blood specimen for culture and sensitivity

APPENDIX A National competency standards for the registered nurse

APPENDIX B Competencies for registered nurses

Chapter 2 Health assessment

Name __________________________________________________________ Date ____________________________________ Course _________________________________________________________ Year ____________________________________ Instructor/examiner _ ____________________________________________ Position _ _______________________________

skill 2-1 Taking a patient history

Comments

Goal: An accurate and concise patient history is obtained.

Excellent

Satisfactory

Needs practice

____ ____ ____ ____ ____ ____

1. Identify the patient and place an ID band on the patient. 2. Review any documentation that has accompanied the patient (e.g. doctor’s letter, preadmission clinic information). 3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent. 4. Gather the necessary equipment. Equipment: admission forms. 5. Undertake a risk assessment, if indicated. 6. Perform hand hygiene. 7. Put on personal protective equipment (PPE), if indicated. 8. Ensure that patient privacy is maintained and the patient is comfortable. Ensure that interruptions are minimal. 9. Assess the situation for any potential danger to you or the patient. 10. Approach the patient, observing the patient’s response, airway, breathing and circulation, and conscious state. (Primary survey) 11. Invite significant others to be present for the history taking, if appropriate. 12. Commence the patient interview using appropriate styles of questioning and non-verbal communication and focusing techniques. 13. Collect bibliographical data. 14. Collect data regarding the patient’s physical symptoms. 15. Collect data regarding the patient’s past health history. 16. Collect data regarding the patient’s family history. 17. Collect data regarding the patient’s health and lifestyle practices. 18. Ensure all data are documented. 19. Clarify the important information collected and paraphrase to confirm understanding.

____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

skill 2-1 Taking a patient history (continued)

Comments

Excellent

Satisfactory

Needs practice

____ ____ ____ ____ ____ ____

20. Indicate to the patient that the interview is coming to a close. 21. Close the interview and advise the patient what to expect next regarding their care. 22. Remove used PPE/equipment and dispose of them in the appropriate receptacle. 23. Document your findings on the patient’s chart and make any necessary referrals. Report any abnormal results to a senior nurse, medical officer or endorsed nurse practitioner immediately.

____ ____ ____

skill 2-2 Performing a general survey

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

Goal: The assessment is completed without the patient experiencing anxiety or discomfort, an overall impression of the patient is formulated, the findings are documented and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation. 1. Identify the patient. 2. Check the medical order or clinical pathway/care plan. 3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent. 4. Gather the necessary equipment. Equipment: scales, height measure, tape measure, stethoscope, sphygmomanometer, thermometer with probe covers, watch with second hand, oximeter, alcohol wipes. 5. Undertake a risk assessment, if indicated. 6. Perform hand hygiene. 7. Put on personal protective equipment (PPE), if indicated. 8. Ensure that patient privacy is maintained and the patient is comfortable. Ensure that interruptions are minimal. (a) Assess skin colour, temperature, moisture and turgor. (b) Observe whether they appear to be their stated age. (c) Note their mental status. Is the person alert and oriented, responsive to questions and responding appropriately? (d) Note whether the facial features are symmetrical. (e) Note any signs of acute distress, such as shortness of breath, pain or anxiousness. 11. Assess the patient’s body structure. (a) Does their height appear within the normal range for the stated age and genetic heritage? (b) Does their weight appear within the normal range for their height and body build? (c) Is body fat evenly distributed? (d) Do their body parts appear equal bilaterally and relatively proportionate? (e) Is their posture erect and appropriate for their age? 9. Undertake a health history, as per Skill 2-1. 10. Assess the patient’s physical appearance.

Comments

Excellent

Satisfactory

Needs practice

____ ____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____ ____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____

____ ____ ____

skill 2-2 Performing a general survey (continued)

Comments

Excellent

Satisfactory

Needs practice

12. Assess the patient’s behaviour. (a) Are their facial expressions appropriate for the situation? (b) Do they maintain eye contact, based on cultural norms? (c) Do they appear comfortable and relaxed with you? (d) Is their speech clear and understandable? 13. Observe the patient’s hygiene and grooming. (a) Is their clothing appropriate for the climate? (b) Do their clothes fit well? Are the clothes clean and appropriate for the person’s culture and age group? (c) Does the person appear clean and well groomed, appropriate for their age and culture? 14. Assess the patient’s mobility. (a) Is their gait smooth, even, well-balanced and coordinated? (b) Is joint mobility smooth and coordinated with a general full range of motion (ROM)? (c) Are involuntary movements evident? 15. Assess for pain. (Refer to Chapter 10 on comfort.) 16. Have the patient remove their shoes and heavy outer clothing. Weigh the patient using scales. Compare the measurement with previous weight measurements. 17. With shoes off, and standing erect, measure the patient’s height using a wall-mounted measuring device or measuring pole. Compare height and weight with recommended averages on a standardised chart. 18. Use the patient’s weight and height measurements to calculate the body mass index (BMI). Body mass index = weight in kilograms height in metres 2 19. Using a tape measure, measure the patient’s waist circumference. Place the tape measure snugly around the patient’s waist at the level of the umbilicus. 20. Measure the patient’s temperature, pulse, respirations, blood pressure and oxygen saturation. (Refer to Chapter 1 on vital signs and Chapter 14 on oxygenation for specific techniques.) 21. Continue with assessments of specific body systems as appropriate or indicated.

____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____

skill 2-2 Performing a general survey (continued)

Comments

Excellent

Satisfactory

Needs practice

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

22. Assist the patient to a position of comfort. 23. Remove used PPE/equipment and dispose of them in the appropriate receptacle. 24. Perform hand hygiene. 25. Document your assessment findings on the patient’s chart and report any abnormal results to a senior nurse, medical officer or endorsed nurse practitioner immediately.

skill 2-3 Assessing the skin, hair and nails

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

1. Identify the patient. 2. Check the medical order or clinical pathway/care plan. 3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent. 4. Gather the necessary equipment. 5. Undertake a risk assessment, if indicated. 6. Perform hand hygiene. 7. Put on personal protective equipment (PPE), including gloves. 8. Ensure that patient privacy is maintained and the patient is comfortable. Ensure that interruptions are minimal. 9. Undertake a health history, as per Skill 2-1. 10. Ask the patient to remove all clothing. The patient remains in the sitting position for most of the examination but will need to stand or lie on their side when the posterior part of the body is examined, exposing only the body part being examined. Use a blanket or drape to cover any exposed area other than the one being assessed. 11. Ensure the lighting is adequate. Inspect the skin for colour, lesions, vascularity, bleeding and body odours. If lesions are present, palpate them. Note any bruises, scratches, cuts, insect bites and wounds. (Refer to Skill 8-2 on assessing a wound.) If present, note the size, shape, colour, exudates and distribution/pattern. 12. Palpate the skin using the backs of your hands to assess temperature. 13. Palpate for texture and moisture. 14. Assess for skin turgor by gently pinching the skin under the clavicle. 15. Palpate for oedema, which is characterised by swelling, with taut and shiny skin over the oedematous area. Goal: The skin, hair and nails are assessed accurately without the patient experiencing anxiety or discomfort, the findings are documented and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation.

Comments

Excellent

Satisfactory

Needs practice

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____

____ ____ ____

skill 2-3 Assessing the skin, hair and nails (continued)

Comments

Excellent

Satisfactory

Needs practice

____ ____ ____

16. Inspect the nail condition, including the shape, texture and colour, as well as the nail angle, noting if any clubbing is present. 17. Palpate the nails for texture and capillary refill. 18. Inspect the hair and scalp for colour, distribution and texture. 19. Assist the patient to a position of comfort. 20. Remove used PPE/equipment and dispose of them in the appropriate receptacle. 21. Perform hand hygiene. 22. Document your assessment findings on the patient’s chart and make any appropriate referrals as required. Report any abnormal results to a senior nurse, medical officer or endorsed nurse practitioner immediately.

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

skill 2-4 Assessing the head and neck

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

1. Identify the patient. 2. Check the medical order or clinical pathway/care plan. 3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent. 4. Gather the necessary equipment. Equipment: penlight, ophthalmoscope, otoscope, tuning fork, watch with a second hand, Snellen eye chart, tongue blade, stethoscope. 5. Undertake a risk assessment, if indicated. 6. Perform hand hygiene. 7. Put on personal protective equipment (PPE), including gloves. 8. Ensure that patient privacy is maintained and the patient is comfortable. Ensure that interruptions are minimal. 9. Undertake a health history, as per Skill 2-1. 10. Inspect the head and then the face for colour, symmetry, lesions and distribution of facial hair. Note facial expression. Palpate the skull. 11. Inspect the external eye structures (eyelids, eyelashes, eyeball, lacrimal glands and eyebrows), cornea, iris, conjunctiva and sclera. Note colour, oedema, symmetry and alignment. 12. Examine the pupils for equality of size, shape and reaction to light by darkening the room and using a penlight to shine the light on each pupil. 13. To test for pupillary accommodation and convergence, ask the patient to focus on your finger as you bring it closer to their nose: ask the patient to look directly forwards at your forefinger held 10–15 cm from their nose, then at a distant object and back to your finger. Following this, move your forefinger towards their nose. 14. Using an ophthalmoscope, check the red reflex. Goal: The assessment is completed without the patient experiencing anxiety or discomfort, the findings are documented and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation.

Comments

Excellent

Satisfactory

Needs practice

____ ____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____

____ ____ ____

skill 2-4 Assessing the head and neck (continued)

Comments

Excellent

Satisfactory

Needs practice

____ ____ ____

15. Test the patient’s visual acuity with a Snellen chart. Ask the patient to read the smallest possible line of letters, first with both eyes and then with one eye at a time. Note whether corrective lenses are worn. 16. With the patient about 60 cm away, ask them to focus on your finger and follow it with their eyes through the six cardinal positions of gaze. 17. Test peripheral vision. With the patient 60 cm away, ask them to cover one eye with a hand or card and look directly at your nose. Cover your own eye opposite the patient’s closed eye. Holding one arm outstretched, at equal distance from you and the patient, move your fingers into the visual fields from various peripheral points. Ask the patient to tell you when they first see your fingers. Repeat for the other eye. 18. Inspect the external ear bilaterally for shape, size and lesions. Palpate the ear and mastoid process. 19. Perform an otoscopic examination. For an adult, pull the auricle up and back; for a young child, pull the auricle down and back. Note any cerumen (wax), oedema, discharge or foreign bodies and the condition of the tympanic membrane. 20. Test hearing. Stand about 30–60 cm away from the patient out of the patient’s line of vision. Ask the patient to cover the ear not being tested while you talk into the other ear using a whisper. Ask the patient to repeat what was said. Perform the test on each ear. 21. Use a tuning fork to performWeber’s test and the Rinne test (if the patient reports diminished hearing in either ear). (a) Weber’s test: hold the tuning fork at its base and strike it against your palm so that the fork vibrates. Place the base of the fork on the centre of the top of the patient’s head. Ask the patient where the sound is heard best. (b) Rinne test: strike the tuning fork as for Weber’s test. Hold the base of the fork against the mastoid process and ask the patient to tell you when the sound can no longer be heard. Immediately place the still-vibrating fork close to the external ear canal for one ear and ask whether the patient can still hear the sound; the normal ear will do so. Repeat with the other ear. 22. Inspect and palpate the external nose, nares and turbinates.

____ ____ ____

skill 2-4 Assessing the head and neck (continued)

Comments

Excellent

Satisfactory

Needs practice

____ ____ ____ ____ ____ ____

23. Palpate and lightly percuss over the frontal and maxillary sinuses. 24. Occlude one nostril externally with a finger while the patient breathes through the other; repeat for the other side. 25. Inspect the internal nostrils using an otoscope with a nasal speculum attachment. 26. Palpate the temporomandibular joint by placing your index fingers over the front of the patient’s ears as you ask them to open and close their mouth. 27. Inspect the lips, oral mucosa, hard and soft palates, gingivae, teeth and salivary gland openings by asking the patient to open their mouth wide, then using a tongue blade and penlight. 28. Inspect the tongue. Ask the patient to stick out their tongue. Place a tongue blade at the side of the tongue while the patient pushes it to the left and right with their tongue. Inspect the uvula by asking the patient to say ‘ahh’ while sticking out their tongue. Palpate the tongue for muscle tone and tenderness. 29. Palpate from the forehead to the posterior triangle of the neck for the posterior cervical lymph nodes using your finger pads in a slow, circular motion. 30. Inspect and palpate in front of and behind the ears, under the chin and in the anterior triangle for the anterior cervical lymph nodes. 31. Inspect and palpate the left and right carotid arteries. Palpate one carotid artery at a time. Use the bell of the stethoscope to auscultate the arteries. 32. Inspect and palpate the trachea. 33. Palpate the thyroid gland by standing behind the patient and placing your hands around their neck with your fingertips over the lower half of the trachea. Ask the patient to swallow and feel for enlargement of the gland as it rises. Palpate each lobe of the thyroid by having the patient turn their head slightly towards the side to be examined and then gently displace the trachea with one hand. Ask the patient to swallow and palpate the thyroid with your other hand. Feel for size, shape, symmetry, tenderness and any nodules. Repeat for the other side. If enlarged, auscultate the thyroid gland using the bell of the stethoscope.

____ ____ ____

____ ____ ____ ____ ____ ____

skill 2-4 Assessing the head and neck (continued)

Comments

Excellent

Satisfactory

Needs practice

____ ____ ____ ____ ____ ____

34. Inspect and palpate the supraclavicular area. 35. Inspect the patient’s ability to move the neck. Ask the patient to touch their chin to their chest and to each shoulder, each ear to the corresponding shoulder and then tip the head back as far as possible. 36. Assist the patient to a position of comfort. 37. Remove used PPE/equipment and dispose of them in the appropriate receptacle. 38. Perform hand hygiene. 39. Document your assessment findings on the patient’s chart. Report any abnormal results to a senior nurse, medical officer or endorsed nurse practitioner immediately.

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

skill 2-5 Assessing the thorax and lungs

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

Goal: The assessment is completed without causing the patient to experience anxiety or discomfort, the findings are documented and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation. 1. Identify the patient. 2. Check the medical order or clinical pathway/care plan. 3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent. 4. Gather the necessary equipment. Equipment: stethoscope. 5. Undertake a risk assessment, if indicated. 6. Perform hand hygiene. 7. Put on personal protective equipment (PPE), if indicated. 8. Ensure patient privacy is maintained and that interruptions are minimal. 9. Undertake a health history, as per Skill 2-1. 10. Help the patient to undress, if needed, and provide a patient gown. Assist the patient to a sitting position and expose the posterior thorax. Use a blanket or sheet to cover any exposed area other than the one being assessed. 11. Inspect the posterior thorax. Examine the skin, bones and muscles of the spine, shoulder blades and back, as well as symmetry of expansion and accessory muscles used during respiration. 12. Assess the anteroposterior (AP) and lateral diameters of the thorax. 13. Palpate over the spine and posterior thorax. (a) Use the palmar surface of your hand to palpate for temperature, moisture, tenderness, muscle development and masses. (b) Instruct the patient to take a deep breath. Assess for tactile fremitus by using the ball of your hand to palpate over the posterior thorax while the patient says ‘ninety-nine’.

Comments

Excellent

Satisfactory

Needs practice

____ ____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____

skill 2-5 Assessing the thorax and lungs (continued)

Comments

Excellent

Satisfactory

Needs practice

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14. Assess thoracic expansion by standing behind the patient, placing both thumbs on either side of the patient’s spine at the level of T9 or T10 and asking the patient to take a deep breath. Note the movement of your hands. 15. Percuss over the posterior and lateral lung fields for tone using a zigzag pattern, starting above the scapulae to the bases of the lungs. Note the intensity, pitch, duration and quality of sounds produced. Percuss for diaphragmatic excursion on each side of the posterior thorax. 16. Auscultate the lungs across and down the posterior thorax to the bases of lungs as the patient breathes slowly and deeply through the mouth. 17. Examine the anterior thorax. With the patient sitting, rearrange the gown so the anterior chest is exposed. Inspect the skin, bones and muscles, as well as symmetry of lung expansion and accessory muscle use. 18. Palpate the anterior thorax systematically. Palpate for tactile fremitus (as the patient repeats the words ‘ninety-nine’). 19. Percuss over the anterior thorax using the proper sequence. 20. Auscultate the lungs through the anterior thorax as the patient breathes slowly and deeply through the mouth. Listen for the duration, pitch and intensity of sounds. 21. Inspect the breasts and axillae with the patient’s hands resting on both sides of the body, placed on the hips and then raised above the head. 22. Palpate the axillae with the patient’s arms resting against the sides of the body. Assist the patient into a supine position. Place a small pillow or towel under the patient’s back. Palpate the breasts and nipples. Wear gloves if there is any discharge from the nipples or if a lesion is present. 23. Cover the patient’s chest and back and assist them into a position of comfort. 24. Remove used PPE/equipment and dispose of them in the appropriate receptacle. 25. Perform hand hygiene. 26. Document assessment findings on the patient’s chart and make any necessary referrals. Report any abnormal results to a senior nurse, medical officer or endorsed nurse practitioner immediately.

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skill 2-6 Assessing the cardiovascular system

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

Goal: The assessment is completed accurately and without causing the patient to experience anxiety or discomfort, the findings are documented and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation. 1. Identify the patient. 2. Check the medical order or clinical pathway/care plan. 3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent. 4. Gather the necessary equipment. Equipment: stethoscope, alcohol wipes. 5. Undertake a risk assessment, if indicated. 6. Perform hand hygiene. 7. Put on personal protective equipment (PPE), if indicated. 8. Ensure patient privacy is maintained and that interruptions are minimal. Ensure adequate lighting and a quiet environment in order to hear during auscultation. 9. Undertake a health history, as per Skill 2-1. 10. Help the patient to undress, if needed, and provide a patient gown. Assist the patient to a supine position with the head elevated about 30–45 degrees and expose the anterior chest. Use a blanket or drape to cover any exposed area other than the one being assessed. 11. Inspect and palpate the left and then the right carotid arteries. Palpate one carotid artery at a time. Use the bell of the stethoscope to auscultate the arteries. 12. Inspect the neck for jugular vein distension, observing for pulsations. 13. Inspect the praecordium for contour, pulsations and heaves. Observe for the apical impulse at the fourth to fifth intercostals spaces (ICS). 14. Using the palmar surface with four fingers held together, palpate the praecordium gently for pulsations. Remember that your hands should be warm. Palpation proceeds in a systematic manner, with assessment of specific cardiac landmarks: the aortic, pulmonic, tricuspid and mitral areas and Erb’s point. Palpate the apical impulse in the mitral area. Note its size, duration, force and location in relationship to the midclavicular line.

Comments

Excellent

Satisfactory

Needs practice

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skill 2-6 Assessing the cardiovascular system (continued)

Comments

Excellent

Satisfactory

Needs practice

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15. Auscultate systematically, beginning at the aortic area, then moving to the pulmonic area, Erb’s point, the tricuspid area and finally the mitral area. Ask the patient to breathe normally. Use the stethoscope diaphragm to listen for high-pitched sounds and then use the bell to listen for low-pitched sounds. Focus on the overall rate and rhythm of the heart and the normal heart sounds. 16. Inspect the extremities for colour, temperature, continuity, lesions, venous patterns and oedema. 17. Palpate the peripheral pulses. 18. Assist the patient in replacing the gown and then assist them into a position of comfort. 19. Remove used PPE/equipment and dispose of them in the appropriate receptacle. 20. Perform hand hygiene. 21. Document your assessment findings on the patient’s chart and make any necessary referrals. Report any abnormal results to a senior nurse, medical officer or endorsed nurse practitioner immediately.

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skill 2-7 Assessing the abdomen

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

Goal: The assessment is completed accurately without causing the patient to experience anxiety or discomfort, the findings are documented and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation. 1. Identify the patient. 2. Check the medical order or clinical pathway/care plan. 3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent. 4. Gather the necessary equipment. Equipment: stethoscope, alcohol wipes. 5. Undertake a risk assessment, if indicated. 6. Perform hand hygiene. 7. Put on personal protective equipment (PPE), if indicated. 8. Ensure patient privacy is maintained and that interruptions are minimal. Ensure adequate lighting. 9. Undertake a health history, as per Skill 2-1. 10. If possible, have the patient empty their bladder. Help the patient to undress, if needed, and provide a patient gown. Assist the patient to a supine position with the head slightly elevated and a pillow under the knees. Expose the abdomen. Use a blanket or drape to cover any exposed area other than the one being assessed. 11. Inspect the abdomen for skin colour, contour, peristalsis, pulsations and masses, and inspect the umbilicus and other surface characteristics (rashes, lesions, masses, scars). 12. Auscultate all four quadrants of the abdomen systematically for bowel sounds using the diaphragm of the stethoscope. 13. Auscultate the abdomen for vascular sounds using the bell of the stethoscope. 14. Percuss the abdomen for tones. 15. Palpate the abdomen lightly in all four quadrants and then use deep palpation. If the patient complains of pain or discomfort in a particular area of the abdomen, palpate that area last. 16. Palpate the kidneys on each side of the abdomen, the liver at the right costal border and the spleen at the left costal border.

Comments

Excellent

Satisfactory

Needs practice

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skill 2-7 Assessing the abdomen (continued)

Comments

Excellent

Satisfactory

Needs practice

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17. If the patient reports pain, assess for rebound tenderness last by pressing deeply and gently into the abdomen with your hand and fingers pointing downwards and then withdrawing your hand rapidly. 18. Assist the patient in replacing the gown and then assist them into a position of comfort. 19. Remove used PPE/equipment and dispose of them in the appropriate receptacle. 20. Perform hand hygiene. 21. Document your assessment findings on the patient’s chart and make any necessary referrals. Report any abnormal results to a senior nurse, medical officer or endorsed nurse practitioner immediately.

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skill 2-8 Undertaking a neurological examination

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

Goal: The assessment is completed accurately without causing the patient to experience anxiety or discomfort, the findings are documented and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation. 1. Identify the patient. 2. Check the medical order or clinical pathway/care plan. 3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent. 4. Gather the necessary equipment. Equipment: pen torch, different scents, tendon hammer, tongue depressor, cotton wool, blunt needle, two objects familiar to the patient, reading material, tuning fork. 5. Undertake a risk assessment, if indicated. 6. Perform hand hygiene. 7. Put on personal protective equipment (PPE), if indicated. 8. Ensure patient privacy is maintained and that interruptions are minimal. 9. Undertake a health history, as per Skill 2-1. 10. Help the patient to undress, if needed, and provide a patient gown. Assist the patient to a supine position. Use a blanket or drape to cover any exposed area other than the one being assessed. 11. Survey the patient’s overall hygiene and physical appearance. 12. Assess the patient’s mental status. 13. Evaluate level of consciousness (Glasgow Coma Scale— GCS). (a) Assess eye opening. (b) Evaluate the patient’s best verbal response: orientation to person, place and time. (c) Assess the patient’s best motor response. (d) Assess pupil response and size. (e) Document the GCS score. (f) Assess memory (immediate recall and past memory). (g) Assess abstract reasoning by asking the patient to explain a proverb, such as ‘The early bird catches the worm’.

Comments

Excellent

Satisfactory

Needs practice

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