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Skills > Fundamentals Skills Assessment > Flashcards

Fundamentals Skills Assessment Flashcards

1
Q

HAND HYGIENE (Soap and Water) (11)

A
  1. Stands in front of sink, keeping hands and uniform away from sink surface.
  2. Turns on water, regulating flow and temperature.
  3. Avoids splashing water against uniform.
  4. Wets hands and wrists thoroughly under running water.
  5. Keeps hands and forearms lower than elbows during washing.
  6. Applies 3-5 mL of antiseptic soap and lathers thoroughly.
  7. Uses friction for at least 15-30 seconds, interlacing fingers and rubbing palms and back of hand at least 5 times.
  8. Cleans under fingernails with nails of other hand.
  9. Rinses hands thoroughly, keeping hands down and elbows up.
  10. Dries hands thoroughly from fingers to forearms using clean paper towels or air dryer.
  11. Turns faucet off with clean, dry paper towel.
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2
Q

HAND SANITIZER (4)

A
  1. Dispenses adequate amount of sanitizer
  2. Rubs hands together covering all surfaces of hands and fingers (especially tips) with antiseptic.
  3. Rub hands together until alcohol is dry.
  4. Rub hands together for at least 15-30 seconds
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3
Q

DON STERILE GLOVES (8)

A
  1. Removes watch and rings, and pushes clothing above wrists.
  2. Opens outer package of sterile gloves by carefully separating and peeling open adhered package sides.
  3. Grasps inner glove package and lays it on a clean, dry, flat surface at waist level.
  4. Opens inner package and lays down so that it remains flat.
  5. Applies glove on dominant hand by grasping inside of cuff with thumb and first two fingers of non-dominant hand, touching only the inside of the glove. Pulls up over hand, ensuring the cuff does not roll up on wrist.
  6. Slips fingers of gloved hand under remaining cuff without contaminating sterile hand.
  7. Pulls remaining cuff over non-dominant hand with thumb abducted.
  8. Holds sterile hands away from body. Interlocks fingers being careful to only touch sterile objects
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4
Q

OPEN PACKAGE CREATING STERILE FIELD (7)

A
  1. Inspects package for integrity and sterility. Checks expiration date.
  2. Remove item from protective covering (bag).
  3. Grasps outer edge of tip of outermost flap and extends flap away from body, keeping arm outstretched and away from sterile field.
  4. Grasps outer edge of first side flap. Opens side flap pulling to side and allowing it to lie flat on table surface.
  5. Grasps outer edge of second side flap and repeats above step.
  6. Grasps outer edge of last and innermost flap carefully, avoiding contamination.
  7. Stands away from sterile package and pulls flap toward body while stepping back from table allowing it to fall flat on work surface
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5
Q

ADD ITEM TO STERILE FIELD (4)

A
  1. Inspects package for integrity and sterility. Checks expiration date.
  2. Opens sterile item by: Holding outside wrapper in non-dominant hand. Carefully peeling wrapper over non-dominant hand
  3. Does not allow wrapper to touch sterile field.
  4. Places item onto field at an angle without flipping or throwing item and taking care not to reach arm over sterile field.
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6
Q

PULSE/RESPIRATORY ASSESSMENT (4)

A
  1. Apical pulse rate within 4 pulsations per minute of a simultaneous count obtained by evaluator.
  2. Radial pulse is assessed for 30 seconds.
  3. FOLLOWED IMMEDIATELY BY: Respiratory rate assessed for 30 seconds.
  4. The counted rate is within 2 breaths per minute of a simultaneous count obtained by evaluator
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7
Q

BLOOD PRESSURE ASSESSMENT (5)

A
  1. Cuff size is appropriate for the client. Palpatory systolic pressure is obtained and verbalized.
  2. Thirty seconds is allowed to elapse between obtaining the palpatory systolic pressure and the blood pressure.
  3. The stethoscope diaphragm is placed over the brachial artery.
  4. The cuff is inflated at least 30 mmHg above palpated pressure.
  5. Blood pressure reading is within 6 mmHg of evaluator. Allows 2 minutes to elapse prior to repeating B.P. on the same arm
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8
Q

NEUROLOGICAL ASSESSMENT (Demonstrated and Verbalized)

A
  1. Level of consciousness determined.
  2. Orientation determined.
  3. Speech assessed for clarity.
  4. Mood and affect evaluated.
  5. Pain assessment performed.
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9
Q

CIRCULATORY ASSESSMENT(Demonstrated and Verbalized) (6)

A
  1. Point of maximum impulse identified by palpation of landmarks.
  2. Heart sounds auscultated at point of maximum impulse.
  3. Apical pulse auscultated for one full minute.
  4. Capillary refill assessed at fingers and toes bilaterally.
  5. Radial and dorsalis pedis pulses are assessed bilaterally for strength and equality.
  6. Radial pulse is within 4 beats per minute of evaluator. Pedal pulse identified and strength verbalized
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10
Q

CHEST/LUNG SOUND ASSESSMENT(Demonstrated and Verbalized) (4)

A
  1. Chest is inspected for symmetrical movement.
  2. Lungs are auscultated anteriorly and posteriorly in at least 6 places.
  3. A deep breath is assured with each time the stethoscope is moved.
  4. Stethoscope is properly placed during auscultation.
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11
Q

ABDOMEN/BOWEL SOUND ASSESSMENT (Demonstrated and Verbalized) (5)

A
  1. Abdomen is visualized for symmetry.
  2. All four quadrants are auscultated for bowel sounds.
  3. Stethoscope is properly placed during auscultation.
  4. Abdomen is palpated after auscultation for tenderness and firmness.
  5. Patient history for las bowel movement is completed.
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12
Q

SKIN INTEGRITY (3 areas)

UPPER BODY (6)

(Pressure points assessed for lesions and overall integrity including color, moisture, and temperature)

A
  1. Occipital
  2. Bilateral Ears
  3. Bilateral Shoulders
  4. Bilateral Elbows
  5. Bilateral Wrists
  6. Fingers Bilateral Hands
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13
Q

SKIN INTEGRITY (3 areas)

MID BODY (6)

(Pressure points assessed for lesions and overall integrity including color, moisture, and temperature)

A
  1. Scapulas
  2. Spinous Processes
  3. Sacrum
  4. Bilateral Ischiums
  5. Bilateral Iliac Crests
  6. Bilateral Trochanters
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14
Q

SKIN INTEGRITY (3 areas)

LOWER BODY (7)

(Pressure points assessed for lesions and overall integrity including color, moisture, and temperature)

A
  1. Bilateral Medial Knees
  2. Bilateral Lateral Knees
  3. Bilateral Medial Malleolus
  4. Bilateral Lateral Malleolus
  5. Bilateral Lateral Foot
  6. Bilateral Heels
  7. Toes Bilateral Foot
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15
Q

BLOOD GLUCOSE (15)

A
  1. Perform hand hygiene.
  2. Identify patient using 2 identifiers.
  3. Explain procedure.
  4. Apply clean gloves.
  5. Insert reagent strip into glucose monitor.
  6. Identifies safe, appropriate puncture site.
  7. Holds selected finger or forearm in dependent position.
  8. Cleans site well with alcohol and allows to dry completely.
  9. Holds lancet perpendicular to site and performs puncture.
  10. Wipes away first droplet.
  11. Lightly squeezes site to create a large drop of blood.
  12. Applies blood to reagent strip according to manufacturer’s instructions.
  13. Reads result.
  14. Safely discards strip, lancet, and gloves.
  15. Documents result in EHR
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16
Q

INTAKE AND OUTPUT (9)

A
  1. Performs hand hygiene.
  2. Identifies patient using 2 identifiers.
  3. Explains and educates patient.
  4. Applies clean gloves.
  5. Uses individual appropriately sized graduated containers.
  6. Measures intake of all fluids and foods which become liquid at room temperature, as well as IV fluids (including blood and blood products, tube feedings, and medication).
  7. Measures output.
  8. Removes gloves and disposes properly.
  9. Correctly calculates and documents I&O
17
Q

REPOSITIONING (to side-lying) (7)

A
  1. Perform hand hygiene.
  2. Explains procedure to patient.
  3. Raises bed to appropriate height. Raises side rail on unprotected side (if applicable).
  4. Positioned patient in side-lying position in center of bed.
  5. Placed appropriate padding: Behind back, Under head, Between legs, Supporting dependent arm
  6. Ensures good body alignment.
  7. Raises side rails (if appropriate) and lowers bed
18
Q

ORAL HYGIENE (8)

A
  1. Perform hand hygiene and apply clean gloves.
  2. Explains procedure and positions patient.
  3. Cleans oral cavity using appropriate oral hygiene products.
  4. Rinses oral cavity.
  5. Repeats cleaning and rinsing 3-4 times until oral cavity is clean.
  6. Cleans and rinses dentures if applicable.
  7. Cleans and dries mouth area.
  8. Removes and properly disposes of gloves
19
Q

PASSIVE RANGE OF MOTION (7)

A
  1. Performs hand hygiene and applies clean gloves if applicable.
  2. Raises bed height and lowers side rails if needed.
  3. Demonstrates 3 different range of motion movements: Flexion and extension, Abduction and adduction, Pronation and supination, Dorsal and plantar flexion, Opposition, Internal and external rotation, Radial deviation and ulnar deviation
  4. Supported the proximal and distal ends of the extremity or the joint itself.
  5. Assess patient response during procedure.
  6. Demonstrated or verbalized the need to stop ROM if patient c/o pain or resistance was noted.
  7. Raises side rails and lowers bed as appropriate
20
Q

RESUSCITATION (8)

A
  1. Checks for responsiveness. Calls for help and AED/crash cart.
  2. Assesses and determines there is no respiratory effort.
  3. Assesses pulse (< 10 seconds). Determines presence of pulse.
  4. Applies clean gloves. Opens airway with head tilt-chin lift.
  5. Provides 2 rescue breaths with the bag and mask, noting rise and fall of chest.
  6. Begins rescue breathing with bag and mask at the rate of 10-12 breaths/min.
  7. Reassesses pulse after 2 minutes.
  8. Spontaneous respiration present and stops mechanical respirations. Position patient in recovery position (side-lying)
21
Q

CHEST COMPRESSIONS (8)

A
  1. Checks patient for responsiveness.
  2. Calls for help and AED/crash cart.
  3. Assesses respirations. Determines that there is no respiratory effort.
  4. Applies clean gloves and opens airway with head tilt-chin lift.
  5. Assesses for pulse (< 10 seconds). Determines absence of pulse.
  6. Properly positions hands on chest and begins compressions at the rate greater than 100/minute. Compressions one-half to two thirds the depth of patient’s chest.
  7. Reassess after 5 cycles.
  8. Positions patient in recovery position (side-lying).
22
Q

MEDICATION ADMINISTRATION (9)

A
  1. Two medication checks in the Med Room. Checks expiration date.
  2. Correct medication dosage calculated.
  3. All medications taken to patient bedside are to be labeled.
  4. Third medication check at bedside.
  5. OPTHALMIC–Stabilize the head. ORAL-The head of the bed is elevated. TOPICAL–D.C. previous dose prior to application and assure that skin is clean and dry.
  6. The medication is given within ½ hour of the prescribed time.
  7. The medication is administered by the prescribed route: Oral, Lower conjunctival sac, Topical. Gloves worn during Topical and Eye drops.
  8. Principles of medical asepsis are observed.
  9. Principles of safety are observed. (medication is not left unattended/Lacrimal duct pressure for 30-60 seconds
23
Q

MEDICATION ADMINISTRATION

General Tasks (9)

A
  1. Two medication checks in the Med Room. Checks expiration date.
  2. Correct medication dosage calculated.
  3. All medications taken to patient bedside are to be labeled.
  4. Third medication check at bedside.
  5. NG MEDICATION–head of bed iselevated 30-45 degrees.
  6. Correct site used.
  7. The medication is administered by the prescribed route: Gloves worn:-Subcutaneous, -NG tube, -IM
  8. Principles of medical asepsis are observed.
  9. Principles of safety are observed. (medication is not left unattended/ Lacrimal duct pressure for 30-60 seconds
24
Q

MEDICATION VIA NG TUBE (8)

A
  1. Successfully completes all general medication administration tasks.
  2. Verifies that medication is compatible with feedings. If not, feeding is stopped 1-2 hours prior to medication administration and restarted 1-2 hours after medication administration.
  3. Explains procedure to patient.
  4. Assesses gastric residual by aspirating stomach contents, determines volume, and re-instills.
  5. Clamps tube when attaching and removing syringe.
  6. Flushes tube with 30 mL of water immediately before and after medication administration
  7. Administers medication by pouring dissolved or liquid medication into syringe and allowing to flow by gravity into tube WITHOUT allowing syringe to completely empty.
  8. Clamps tubing after procedure is completed
25
Q

IM INJECTION (11)

A
  1. Successfully completes all general medication administration tasks.
  2. Chooses correct syringe size (1 mL or 3 mL) and attaches needle if necessary. Pulls correct amount of air into syringe.
  3. VIAL/AMPULE: Cleans rubber seal of vial or exterior of ampule for 15-30 seconds and allows to dry.
  4. VIAL/AMPULE: Inserts needle through middle of rubber seal or uses filter needle/straw for vials. Injects air. Withdraws correct dose.
  5. Positions patient in comfortable position for injection. Selects appropriate injection site using landmarks. Assesses site skin integrity and muscle mass.
  6. Cleans area with antiseptic wipe, beginning at the center and moving outward in a circular direction. Allows site to dry completely.
  7. IM: Injection site is appropriately stabilized.
  8. IM: Aspirates unless pneumonia or flu vaccination. If no blood appears, injects medication slowly at a rate of 10 seconds/mL. (If blood appears, removeneedle and dispose of syringe. Prepare new medication).
  9. Smoothly removes needle and applies pressure to injection site.
  10. Z-TRACK METHOD: An air lock of 0.2-0.3 mL is used. Two separate needles are used; one to draw medication and one to administer. Tissue is displaced and held until needle is removed. 10 seconds elapse between medication injection and needle removal.
  11. Properly disposes of needle and syringe
26
Q

SUBCUTANEOUS INJECTION (10)

A
  1. Successfully completes all general medication administration tasks.
  2. Chooses correct syringe size (1 mL or 3 mL) and attaches needle if necessary. Draws up correct amount of air.
  3. VIAL/AMPULE: Cleans rubber seal of vial or exterior of ampule for 15-30 seconds and allows to dry.
  4. VIAL/AMPULE: Inserts needle through middle of rubber seal or uses filter needle/straw for vials. Injects air. Withdraws correct dose.
  5. Positions patient in comfortable position for injection. Selects appropriate injection site using landmarks. Assesses site skin integrity.
  6. Cleans area with antiseptic wipe, beginning at the center and moving outward in a circular direction. Allows site to dry completely.
  7. Pinch skin. Uses a quick motion with needle at 45-90 degree angle to patient body (depending on patient size) when inserting needle.
  8. Smoothly removes needle and applies pressure to injection site.
  9. INSULIN: The vial of modified insulin is mixed by rotating prior to use. The vial of regular insulin is not contaminated with modified insulin. (Inject airinto modified insulin first). Verify insulin dose with another nurse.
  10. Properly disposes of needle and syringe
27
Q

INSULIN PEN (14)

A
  1. Successfully completes all general medication tasks.
  2. Cleans rubber seal of vial or exterior of ampule for 15-30 seconds and allows to dry.
  3. Screw needle straight and tightly into pen.
  4. Pull off OUTER and INNER caps. KEEP OUTER CAP to cover needle
  5. Pull off inner needle cap and dispose of it.
  6. Turn the dose selector to 2 units.
  7. Hold with needle up to make any air bubbles move to top of cartridge. Keeping the needle upwards, press the push-button all the way in. The dose selector returns to 0.
  8. Turn the dose selector to the prescribed number of units. Verify dose with another nurse.
  9. Positions patient in comfortable position for injection. Selects appropriate injection site using landmarks. Assesses site skin integrity.
  10. Cleans area with antiseptic wipe, beginning at the center and moving outward in a circular direction. Allows site to dry completely.
  11. Pinch skin. Uses a quick motion with needle at 45-90 degree angle to patient body (depending on patient size) when inserting needle
  12. Inject by pressing the push-button all the way in until 0 lines up with the pointer.
  13. Keep button depressed after the injection until the needle has been withdrawn. THE NEEDLE MUST REMAIN IN FOR AT LEAST 6 SECONDS.
  14. Properly disposes of needle and syringe
28
Q

MEDICATION RECONSTITUTION (7)

A
  1. Successfully completes all general medication administration tasks.
  2. Gathers appropriate supplies (correct syringe and needle size).
  3. Removes caps from unused vials (diluent and powder). Cleans both rubber seals as described above.
  4. Verbalizes desired medication concentration and draws up appropriate amount of diluent.
  5. Injects diluent into powder vial and mixes by rotating between palms. Examines solution for clarity, color, and consistency.
  6. Draws up correct amount of reconstituted solution.
  7. Properly disposes of needle, syringe, and vials
29
Q

OXYGEN ADMINISTRATION (9)

A
  1. Places “oxygen in use” sign on patient door.
  2. Identifies patient with at least identifiers.
  3. Explains benefits and dangers of oxygen use to patient.
  4. Inserts flow meter into correct wall receptacle.
  5. Attaches nasal cannula to oxygen source.
  6. Places tips of cannula properly into patient’s nares and adjusts plastic slide so cannula fits comfortably.
  7. Sets flow rate to prescribed rate.
  8. Allows sufficient slack in tubing.
  9. Assesses respiratory status and oxygen saturation
30
Q

REGULATING IV FLOW RATE (6)

A
  1. Identifies patient using two identifiers.
  2. Assesses IV site and states IV catheter size. GRAVITY:
  3. Calculates desired drop rate based on drops per minute.
  4. Manually Regulates Flow: Counting drops in drip chamber for 1 minute by watch. Adjusting roller clamp to increase or decrease fluid flow. IV PUMPS:
  5. Program pump to infuse a prescribed rate. Visualize drops in drip chamber.
  6. Places indicator tape on IV bag next to volume markings
31
Q

CHANGE CONTINUOUS IV TO SALINE LOCK (11)

A
  1. Identifies patient using 2 identifiers
  2. Uses a prefilled saline syringe. Opens saline lock, maintaining sterility of the tip and injection cap.
  3. Uses syringe to flush the saline lock, removing all air.
  4. Places saline lock within reach to maintain medical asepsis.
  5. Applies clean gloves. Places clean towel under extremity.
  6. Turns IV pump off. Closes clamp to IV bag.
  7. Carefully removes tape securing IV tubing and cannula.
  8. Applies pressure above IV cannula to prevent backflow of blood.
  9. Removes IV tubing and quickly replaces with saline lock.
  10. Cleans site and applies new dressing.
  11. Disposes of used equipment appropriately.
32
Q

STRAIGHT CATHETER INSERTION (10)

A
  1. Verify order. Review EHR for contraindications. Hand hygiene/clean gloves. Identify patient (2 identifiers). Explain procedure. Uses proper body mechanics.
  2. Positions patient comfortably. Provides warmth and privacy by applying bath blankets over exposed areas.
  3. Places waterproof drape under patient.
  4. Opens catheter kit maintaining sterility.
  5. Applies sterile gloves.
  6. Lubricate tip of catheter: Applies sterile drape.
  7. Retract labia or grasp penis and retract foreskin with non-dominant hand. FEMALE: With dominant hand clean perineal area using a front to back motion from clitoris toward anus. Uses new prep stick for each area–Far side–near side–center MALE: With dominant hand clean with prep stick, starting at the urethra and moving outward.
  8. Picks up catheter with dominant hand. Holds end of catheter loosely coiled in hand.
  9. Slowly inserts catheter until urine flows Then advances an additional 1-2 inches.
  10. Empties bladder. Removes catheter. Maintains sterile field throughout. Properly disposes contaminated items
33
Q

FOLEY CATHETER INSERTION (10)

A
  1. Verify order. Review EHR for contraindications. Hand hygiene/clean gloves. Identify patient (2 identifiers). Explain procedure. Uses proper body mechanics.
  2. Positions patient comfortably. Provides warmth and privacy by applying bath blankets over exposed areas.
  3. Opens catheter kit maintaining sterility.
  4. Applies sterile gloves.
  5. Attach sterile N.S. syringe to hub of balloon channel. Lubricate tip of catheter: Applies sterile drape.
  6. Retract labia or grasp penis and retract foreskin with non-dominant hand. FEMALE: With dominant hand clean perineal area using a front to back motion from clitoris toward anus. Uses new prep stick for each area–Far side–near side–center MALE: With dominant hand clean with prep stick, starting at the urethra and moving outward.
  7. Picks up catheter with dominant hand. Holds end of catheter loosely coiled in hand.
  8. Slowly inserts catheter until urine flows. Advances additional 1-2 inches. Inflate balloon
  9. Gently pull back on catheter until resistance is felt. Secure catheter. Place drainage bag below bladder.
  10. Maintains sterile field throughout. Properly disposes contaminated items
34
Q

INDWELLING URINARY CATHETER REMOVAL (9)

A
  1. Verify order. Review EHR for factors influencing removal. Hand hygiene/clean gloves. Identify patient (2 identifiers). Explain procedure. Uses proper body mechanics.
  2. Determines catheter type and balloon size.
  3. Positions patient comfortably. Provides warmth and privacy by applying bath blankets over exposed areas.
  4. Deflates balloon using syringe with the same mL as balloon.
  5. Withdraws catheter slowly and smoothly.
  6. Cleans and dries genitalia. Covers patient and assist to comfortable position.
  7. Empties drainage bag, noting output. Instructs patient to notify nurse before first voiding.
  8. Verifies voiding before 6-8 hours have elapsed or if patient experiences discomfort.
  9. Properly disposes contaminated items
35
Q

SIMPLE DRESSING CHANGE (8)

A
  1. Verify order. Hand hygiene/clean gloves. Identify patient (2 identifiers). Explain procedure. Uses proper body mechanics.
  2. Observes character and amount of drainage on dressings. Removes dressing and assesses wound.
  3. Creates a sterile field and opens sterile supplies.
  4. Applies sterile gloves.
  5. Applies sterile gauze dressing to wound.
  6. Secures dressing with tape.
  7. Properly disposes contaminated items.
  8. Writes date, time, and initials on tape

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