skills documentation

Question 1

NG insertion

Answer 1

pt tolerance, size and type of NG tube, pre assessment findings, indication/reason for tube, verification of placement, assess any drainage (color, amount, consistency, odor), suction level, date and time

Question 2

NG removal

Answer 2

drainage (amount, color, consistency, clarity, odor), date and time, abdominal assessment, pt tolerance

Question 3

central line

Answer 3

date, time, cleaning device used, site assessment, pt tolerance, dressing applied, catheter length

Question 4

foley

Answer 4

size and type, date and time, pt tolerance, any urine (amount, color, clarity, odor, consistency), verification of placement, peri care performed, pre assessment findings, reason

Question 5

IM/SQ

Answer 5

site, pt tolerance, what was it, amount, strength, date/time, site assessment (if SSI: FSBS and units given)

Question 6

straight catheter

Answer 6

reason, size and type, date/time, amount of urine/was bladder emptied, color and clarity, pre assessment findings, pt tolerance, pericare

Question 7

IV start

Answer 7

site, disinfectant used, site assessment before/during/after, any extra methods to find vein, flushes, size of catheter, SL or attached to fluids (kind, rate), dressing used, date/time, patency, pt tolerance

Question 8

IV push and IVPB

Answer 8

date/time, location, SL or existing line, what was running, rate of push, concentration and what was it, amount, site assessment before/during/after, line patency, fluids restarted, flushes documented in I+O, desired effects

Question 9

trach suction

Answer 9

date/time, size and type, pt tolerance, pre assessments (resp and signs of decreased gas perfusion, how many suctions passed, secretions (color, consistency, amount), resp assessment after

Question 10

trach care

Answer 10

stoma assessment, face plate assessment, trach size and type, date/time, pt tolerace, what was used to clean, VS before and after (o2 sat) and resp status

Question 11

wound

Answer 11

measure, exudate, appearance/approximation, smell, undermining/tunneling, rate pain, erythema/edema/edges, staging

Question 12

wound vac

Answer 12

date/time, location, intact, leaking, black foam present, negative P therapy and 125mmHg, no leaks, mLs, color and consistency, periwound color, moisture, intact, pt tolerance