Checklists for Clinical Nursing Skills

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

skill 2-10 Assessing the peripheral vascular 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 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: tape measure, Doppler ultrasound device, conductivity gel (if indicated). 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. Begin with a survey of the patient’s overall hygiene and physical appearance. 12. Inspect the upper extremities for skin colour, oedema, venous pattern, hair distribution and the presence of lesions, rashes or ulcers. Measure circumference of limb and compare bilaterally. Inspect the nail beds for colour and clubbing. Compare bilaterally. 13. Palpate the radial and brachial pulse points noting the strength of the pulse (use ultrasound Doppler if required), the skin temperature and texture and the presence of masses. Compare bilaterally. 14. Assist the patient to a supine position. Examine the lower extremities. Inspect the legs and feet for skin colour, oedema, hair distribution, muscle mass and the presence of lesions, ulcers and varicosities. Measure the circumference of each limb and compare bilaterally.

Comments

Excellent

Satisfactory

Needs practice

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