BULACAN STATE UNIVERSITY City of Malolos, Bulacan College of Nursing Name:___________________________ Year and Section:___________________ Group:____ STATION 1 AIRWAY

MANAGEMENT Description: This station deals Objectives: At the end of this station, the student nurse will be able to: Differentiate oxygen delivery system Perform proper suctioning technique using oropharyngeal airway, nasal trumpet, endotracheal tube and tracheostomy tube. Provide tracheostomy care Demonstrate correct pulse oxymetry technique Administering oxygen by nasal cannula and face mask ARTIFICIAL AIRWAY SUCTIONING Steps: 1. Check physicians order. 2. Gather materials needed. 3. Greet the patient & explain the procedure. 4. Wash your hands. 5. Provide privacy. 6. Assess the patients breath sounds. 7. Prepare patient for suctioning. Positioning to 3045 degrees or in semi-fowlers position. 8. Turn on suction device. 9. Open catheter package (French 10-16 for adults) and fill basin with sterile saline solution. 10. Don sterile gloves and pick-up sterile catheter with dominant hand and attach end to suction tubing. 11. Check equipment by suctioning small amount of saline from basin. 12. Hyperoxygenate the patient. 13. Insert catheter ( without applying suction) until resistance is met or patient coughs. 14. Slowly withdraw catheter in a rotating motion, applying suction intermittently. 15. Allow patient to recover; clear tubing with saline. 16. Reassess patient after at least 1 minute and repeat procedure if needed. Total Perfect Score = 25 Weight 1 1 1 1 1 1 1 1 2 3 Rating: ________ Score Remarks

1 1 2 4 2 2

Using a Pulse Oximeter Steps: 1. Check physicians order. 2. Gather materials needed. 3. Greet the patient & explain the procedure. 4. Select an appropriate finger making sure to avoid thumb or an edematous site. Note: Remove nail polish or artificial nails. 5. Assess the pulse and capillary refill. 6. Clean the area with alcohol swabs. 7. Attach the prove to patients finger and make sure that both sensor probes are aligned directly opposite each other ( oximeter sensor contain both red and infrared light emitting diodes LEDS and a photo detector. the photo detector registers light passing through the vascular bed, the basis for microprocessor determination of oxygen saturation. 8. Connect the sensor probe unit. 9. Check for alarms 10. Read pulse oximeter. 11. Refer for any abnormal reading. Total Perfect Score = Administering Oxygen by Nasal Cannula and by face mask Steps: 1. Explain procedure to the patient and review safety precautions necessary when oxygen is in use. Place a No smoking signs in appropriate areas. 2. Perform hand hygiene. 3. For nasal cannula: Connect nasal cannula to oxygen set up humidification, if one is in use, adjust flow rate as ordered by physician. Check that oxygen is flowing out of prongs. Provide tracheostomy care Place prongs on patients nostrils, adjust according to type of equipment. Over and behind ear with adjuster comfortably under chin or around the Patients head. 4. For face mask: Attach face mask to oxygen set up humidification. Start flow of oxygen at specified rate. For a mask with a reservoir, allow oxygen to fill bag before placing a mask over patients nose and mouth. Position face mask over patients nose and mouth. Adjust it with the elastic strap so mask fits snugly but comfortably of on face.

Rating: ________ Weight Score 1 1 2 2

Remarks

2 1 2

1 1 1 1 15 Rating: ________ Score Remarks

Weight 3

1 7

Adjust the flow rate. 5. Use gauze pads at ear beneath tubing as necessary to reduce irritation on patients ear and scalp. 6. Encourage patient to breath through the nose with mouth closed for nasal cannula. 7. Wash hands 8. Remove mask and dry skin every 2 to 3 hours if oxygen is running continuously. do not powder around the mask. 9. Assess and chart patients response to therapy 10. Document the type of mask used, the amount of oxygen used, the oxygen saturation, the lung sounds and the rate/pattern of respirations. Total Perfect Score = 25 1

1 1 1

2 1

STATION 2 TUBE MANAGEMENT Description: This station introduces procedures in providing respiratory care to prevent respiratory complications and to promote effective gas exchange. Objectives: At the end of this station, the student nurse will be able to: Assist in Nasogastric tube insertion Determine proper placement of NGT Administer tube feeding Discontinue NGT Perform catheterization for both male and female patients (indwelling or straight catheter) Assisting in Nasogastric Tube Insertion Rating: ________ Steps: Weight Score 1. Check physicians order. 1 2. Gather materials needed. 1 3. Greet the patient & explain the procedure. 2 4. Place the patient to semi to high fowlers 1 position with pillows behind head and shoulders. 5. Examine nostrils and select the most patent 1 nostrils by having the patient breath through each one. (the student nurse will mention steps 6, 7, 8, & 9 instead of performing the steps ). 6. Determine length of tube to be inserted and 1 mark with tape. For placement in stomach, measure distance from tip of the nose, to ear lobe, to xiphoid process of the sternum. 7. Wearing clean gloves, lubricate the tube using 5 KY jelly and begin insertion gently through the nostrils to back of throat (posterior nasopharynx) with the patient position with head up. When the tube reaches back of throat, allow the patient to relax a moment. 8. Encourage the patient to swallow the tube. (if 3 possible, give water with straw to facilitate swallowing ). Advance tube as patient swallows until desired length has been passes. 9. Check position of tube in the back of throat 7 with tongue blade. Remarks

Check placement of tube; proper placement is essential With catheter tip syringe, inject 10-15 ml of air through the NG tube and listen with the stethoscope over for a rush of air or whoosh sound or gently aspirate for gastric fluid; measure pH. Gastric pH ranges 1 to 4. If tube is not in the stomach, advance another 2.5-5 cm(1-2 inches) and again check position. 1 1 25 Weight 1 2 Rating:________ Score Remarks

10. Secure tube to nose with tape. 11. Document the procedure. Total Perfect Score = Checking for NGT Placement Steps: 1. Gather materials needed 2. Identify the type of feeding tube used by the patient. Note: the top of the Salem sump (for irrigation) lies in the stomach while the tip of the Duofeed (for feeding) lies in the duodenum. 3. Wash hands. 4. Ask the patient to speak. if the patient is unable to talk, the tube is in the trachea. 5. Inspect the posterior pharynx for presence of coiled tube. 6. Draw up to 10-20 ml of air into catheter tipped syringe and attached at the end of the tube. Auscultate the left upper quadrant of the patients abdomen while quickly ejecting air into the tube. 7. Aspirate gently back on syringe to obtain gastric contents, Observe the color 8. Measure and return aspirated gastric content to prevent metabolic alkalosis. 9. Document the findings Total Perfect Score = Administering Tube Feeding Steps: 1. Check physicians order. 2. Gather materials needed. 3. Greet the patient & explain the procedure. 4. Assess the type of tube used for enteral feeding (nasoenteric tube, gastrostomy tube, or jejunostomy tube) 5. Elevate patients head of bed 6. Verify tube placement and measure residual. 7. Aspirate the gastric secretions with syringe noting volume and pH. Return aspirated contents 25

1 2 1 3

2 2 1

Rating: ________ Weight Score 1 1 2 1

Remarks

1 2 3

and flush with 30cc of water. 8. If aspirate volume is >100 ml, do not return the contents; hold feeding and notify the physician (or as per institutional policy.) 9. If pH suggest improper placement of tube, hold feeding and notify the physician. 10. Initiate feeding. Intermittent Feeding: Obtain desired amount of formula (room temperature) If using a feeding bag, place formula in the bag and prime tubing. Attached distal end of tubing to proximal end of feeding; adjust rate flow with the roller clamp or feeding clamp. Infusion time varies depending on volume. If using a syringe, remove barrel of syringe and insert syringe tip into the feeding tube. Pour desired amount of formula in upright syringe held 12-18 in above the insertion site. Allow formula to flow in by gravity. upon completion of feeding, follow with 30 ml flush of water (or as specified), and clamp tubing. Continuous Feeding: Pour formula (no more than volume to be delivered in 4 hours) in feeding bag and prime tubing. Connect tubing through the feeding pump and attached distal end of feeding tube. Set hourly rate and begin infusion rate. Flush tube with 30 ml of water every 4-6 hours. 11. Monitor for complications Intolerance of feeding (nausea, fullness, gastric residual >100 ml). Aspiration formula. Diarrhea for than 3 times in 24 hours. Hyperglycemia (monitor in glucose) Fluid imbalance (monitor I&O) 12. Document the findings Total Perfect Score = Discontinuing NGT Steps: 1. Check physicians order for NGT removal and materials needed. 2. Greet the patient & explain the procedure. 3. Wash your hands and provide privacy 4. Provide tissue and place towel over the patients chest. 5. Flush NGT with 20 ml water to clear tube so that the GI contents do not inadvertently drain into 6. esophagus on tube removal. 7. Follow water flush with a bolus air to free tube from the stomach lining. 8. Loosen the tapes that secure tube to the patients nose. 9. Turn off suction and disconnect NGT. 10. Plug tube or clamp it by folding it over in your 30 Rating: ________ Weight Score 1 2 2 2 1 Remarks 3

3 7

1 1 2 2

gloved hand. 11. Pinch tube close to the patients nares, have patient take a deep breath and hold it a while you withdraw the tube. Holding breath closes the glottis and helps prevent aspiration. 12. Wrap tube in paper towel to remove the patients view. 13. Offer oral and nasal hygiene. 14. Empty and record the amount and character of drainage. 15. Discard disposable equipment and reusable equipment to appropriate area. return 6

1 1 2 2 2 2 30

16. Remove and dispose of gloves and wash hands. 17. Document the findings and patients response. Total Perfect Score = Insertion of a Urinary Catheter Steps: 1. Check physicians order. 2. Gather materials needed. 3. Greet the patient & explain the procedure. 4. Wash hands and provide privacy. 5. Position the patient in supine for male and dorsal recumbent for female to provide good visualization of urinary meatus. 6. Drape to provide maximum modesty. 7. Set up equipment. Open catheterization kit. Do sterile gloves Organize supplies within the kit. Test balloon (if inserting indwelling catheter)

Rating: ________ Weight Score 1 1 2 2 1

Remarks

1 4

8. Apply sterile drape, maintaining sterile technique. Female: tuck under the buttocks. Male: place over thighs just below the penis. 9. Clean urethral meatus. Female: Spread labia with non dominant hand (maintain this position until catheter is inserted); pick up povidone iodine soaked cotton ball with forceps; wipe from back (clitoris to anus) on each side of the labia, then directly over center of urethral meatus (using a new cotton ball for each wipe). Male: Grasp the penis at the shaft just below the glans with non dominant hand; pick up povidone iodine soaked cotton ball with forceps; clean tip of the penis in circular motion from meatus down to the base of glans- repeat at least 3 times (using a new cotton ball each time)

10. Insert the catheter. Pick up lubricated catheter with dominant hand and insert distal end through urethral meatus. Advance catheter until urine flows (2-3 inches females, 7-9 males); upon flow, advance another 1-2 inches. Straight catheterization: drain urine from bladder using basin; when bladder is empty, ask the patient to hold breath and gently remove the catheter. Indwelling catheter: inflate balloon and place drainage bag below level of bladder; secure catheter to patients leg (female) or abdomen (male). 11. Complete procedure. Remove supplies, remove providone iodine from skin. 12. Document the procedure noting the color and volume of urine and patients response to procedure. Total Perfect Score = 30

STATION 3 INTRAVENOUS MANAGEMENT Description: This station introduces procedures that would ensure that correct intravenous fluid and amount is administered to the patient using the appropriate equipment.. Objectives: At the end of this station, the student nurse will be able to: Described and state principles and procedures in IV management Assist in inserting a peripheral IV for fluid and electrolyte, medication and blood access Monitor and evaluate an IV infusion and using of infusion pump Change IV solutions, IV tubings, IV dressings, and IV sites Discontinuing IV lines Initiating, maintaining and terminating a blood transfusion Flushing a central venous catheter Changing the central venous dressing. Assisting in Peripheral IV Insertion Steps: 1. Check Physicians order 2. Gather Materials needed appropriate needs/catheter and choose Rating: ______ Weight Score 1 1 1 2 2 Remarks

3. Greet the patient and explain the procedure. 4. Wash hands before and after procedure. 5. Hang solution bag and primed administration set within easy reach. (Since only IV Therapists are allowed to do IV insertion, students nurse is required to mention the following steps in number 6,7,8,9,10,11,12 & 13). 6. Choose site for IV. If possible, select a vein on the patients non dominant arm. Distal end of the vein should be selected first while reserving the proximal areas for future IV therapy. 7. Apply tourniquet 5-12 cm. (2-6 inch) above

injection site depending on condition of patient. Tourniquet traps blood and Engorges vein for better visibility. 8. Check radial pulse below tourniquet. 9. Prepare site with antiseptic solution according to hospital policy or cotton wipes with alcohol in a circular motion and below 30 seconds to dry. Do not touch the disinfected site. 10. Using the appropriate IV cannula, pierce skin with needle positioned in 15-30 degree angle. Insert the IV cannula in the direction of venous return or towards the heart to avoid damaging the venous valve 11. Upon flashback Visualization, decrease the angle and advance the catheter and stylet (1/4 inch) into the vein 12. Position the IV catheter parallel to the skin. Hold stylet stationary and slowly advance the catheter. Until the hub nearly meets the puncture site. Use the one hand technique or 2 hand technique. Never insert the catheter cannula until the hub for patient safely 13. Slip sterile gauze under the hub. Release the tourniquet; remove the stylet while applying digital pressure over the catheter with one finger about inches from the tip of the inserted catheter 14. Open the clamp, regulate the flow rate 15. Anchor needle firmly in place with the use of: Transparent tape/dressing directly on the puncture site Tape using any appropriate anchoring stylet Note: Never place unsterile tape directly on IV insertion site, instead place a small piece of sterile gauze & then secure it with adhesive tape 16. Tape a small loop of IV tubing for additional anchoring; apply splint. 17. Calibrate the IVF bottle and regulate flow of infusion according to prescribed duration. 18. Label on IV tape near the IV site to indicate the date of insertion, type and gauge of IV catheter and countersign 19. Label with tape or appropriate label on the IV tubing to indicate the date when to change the IV tubing 20. Observe and report any untoward effect 21. Discard sharps and waste according to hospital policy. 22. Document in the patients chart and endorse to the incoming shift.

1 2

4 2 1

2 1 1

1 1 1

Total Perfect Score = 40

Using an Electronic Flow-Control Device (Infusion Pump) Rating: ______ Steps: Weight Score Remarks 1. Explain every step of the procedure to 1 the patient 2. Wash hands 3. Spike IV solution bag 4. Fill drip chamber to maximum full. This amount allows sufficient air space in drip chamber 5. Prime tubing by opening and regulating the clamp slowly and allowing tubing to fill with IV solution. If using cassette tape tubing, follow package instructions to connect the cassette portion of the tubing that edges into the control device If alarm sounds, check the following: Infusion complete when the exact volume to be delivered is set and volume limit has been reached, alarm sounds and machines goes to KVO or Keep Vein Open mode. Establish if the total volume of the container is delivered; change the solution container if needed, and reset the volume to be infused. Occlusion all devices sounds an alarm when they cannot maintain delivery in the face of increasing resistance. In this instance, check the insertion site for infiltration, and look for position problems, pinched tubing, and closed clamp. Turned stopcock or clogged filter Other problems other messages may indicate air in the line, Low battery, cassette,(Improper loaded), or free flow Nursing action: check trouble spot carefully, readjust and restart the infusion 6. Follow manufacturers instruction to load administration set into device, taking care to fit tubing and cassette into appropriate receptor sites. (the multiplechannel pump can infuse 3 different IV solutions at one time) 7. Close device door to latch 8. Don gloves 9. Check that the patients venipuncture site if free from signs of vein irritation or infiltration 10. Connect administration set tubing to established infusion site protective cap using a needleless cannula 1 1 1 2 1 1 1

11. Open regulating clamp on administration set 12. Turn device on 13. Measure device parameters for operation, again following manufacturers instructions or machines set ups prompts

4 Parameters may include: Infusion (e.g primary) Volume to be infused Rate (ml/hr) Vary; mmHg, cmH2O or psi 14. Start device when parameters are set 15. Observe that infusion is running properly 1 16. Remove Gloves and wash hands 2 17. Check the frequently patients infusion site 1 18. Document procedure Total Perfect Score = Changing IV Solutions and Tubing Steps: Note: IV solutions are change every 24 hours while IV tubing is change every 48-72 hours 1. Check Doctors order for the new solution to infused 2. Gather Materials needed 3. Greet t5he patient and explain the procedure. 4. Wash hands 5. Clamp the tubing on the administration set 6. Invert the solution bag and remove the spike 7. Remove protective cap from the new tubing 8. Spike the new tubing to the solution bag 9. Reopen the clamp and adjust the flow rate 10. Release the clamp to allow IV flow through tubing 1 11. Remove old administration set and insert new IV tubing into extension tubing 2 1 25 Rating: ___________ Weight Rating Remarks 2 1

1 2 1 1 2 1 1 2

12. Open clamp of new tubing, with short extension tubing taped in place. Label the tape on the IV tubing to indicate the date when to change the IV tubing

Total Perfect Score = 20 Steps: 1. Check physicians order. Weight Score 1 REMARKS

2. Gather equipment. 1 3. Wash hands and don clean gloves. 2 4. Explain every step of the procedure to 1 the patient. 5. Turn off IV infusion. 1 6. Loosen dressing and tape, peeled 2 dressing edges back toward puncture site. Minimize trauma to puncture site. 7. Stabilize needle or catheter while 2 removing dressing and tape. Stabilizing the site prevents unnecessary movement that could injure the vein. 8. Remove needle/catheter carefully and 3 smoothly, keeping it almost flush with the skin. Do not press down on top of the needlepoint while it is in the vein. 9. Quickly press the sterile pad over the 3 venipuncture site and hold firmly. Pressure on the puncture site prevents bleeding. 10. Apply clean pad and tape in place. 2 11. Elevate but do not bend arm at elbow. 2 Bending elbow causes hematoma formation while elevating arm reduces pressure and helps to collapse vein. 12. Observe venipuncture site for redness, 3 swelling or hematoma. 13. Dispose of equipment and gloves 2 according to hospital policy. 14. Wash hands. 1 15. Check the site again in 15 minutes. 1 16. Record volume infused on Input & 1 Output sheet. Discontinuing IV Lines Rating:_____________ Total Perfect Score = 30 Adding Medication to an Intravenous Solution Rating: ______________

Total Perfect Score = 25 Adding a Bolus Intravenous Medication to an Existing Intravenous Line Steps: Weight 1. Gather equipment and bring to patients 3 bedside. Check medication order against physicians order. Check a drug resource to clarify if medication needs to be diluted before administration. 2. Explain procedure to the patient. 3. Perform hand hygiene. Don gloves. Steps: 1. Gather all equipment and bring to hand on 4. Identify patient by checking the patients bedside. Check medication order against the patients wrist and asking his or her physicians order. name. 2. Perform hand hygiene. 5. Assess IV site for presence of inflammation or infiltration. 3. Identify patient by checking the band on 6. the patients injection port onpatienttubing Select the wrist and asking the his or her name. Check for any allergies the closest to the venipuncture site. Clean patient may have. port with alcohol swab. 4. Explain the procedure to the patient. 7. Uncap syringe. Steady port with your non 5. dominant hand while inserting that is Add medications to IV solution needleless infusing. needle into the center of port. device or Check that the volume in bag or bottle is 8. adequate. non dominant hand to the Move your section of IV tubing just beyond the Close IV clamp. injection port. Fold the tubing between Clean medication port with alcohol swab. your fingers to temporarily stop the flow of Steady container. Uncap needle or IV solution. device and insert into the port. needleless Inject medication. 9. Pull back slightly from plunger and gently Remove container on IV pole just until blood solution. in tubing between your rotate appears fingers to temporarily stop the and of IV Rehang container, open clamp flow solution. flow rate. readjust Attach label to container so that dose of 10. Inject medication is apparent. added medication at the recommended rate. 6. Add medication to IV solution before 11. Remove needle. Do not cap it. Release infusion. tubing and allow any protective cover and Carefully remove IV fluid to flow at the proper injection port. Clean with alcohol locate rate. swab. 12. Dispose of syringe in proper device and Uncap needle or needleless receptacle. insert into port. Inject medication. 13. Remove needle and insert spike intohand Withdraw gloves and perform hygiene. proper entry site on bag or bottle. With tubing clamped, gently rotate IV 14. Chart administration of medication. IV solution in the bag or bottle. Hang the bag. 15. Evaluate patients response to medication Attach the label to the container so that within appropriate time frame. dose of added medication is apparent. 7. Dispose of equipment according to agency policy. 8. Perform hand hygiene. 9. Chart addition of medication to IV solution. 10. Evaluate the patients response to medication within appropriate time frame. 1 2 Weight 2 1 Score REMARKS Rating: __________ Score Remarks

1 3

1 2

1 8 2

1 6 3

1 2 1 1

1 1 1 1

Total Perfect Score = 25 Administering a Blood Transfusion Steps: 1. Determine whether the patient knows reason for transfusion. Ask if patient has had a transfusion or transfusion reaction in the past. 2. Explain procedure to the patient. Make sure there is a signed consent for transfusion, if required by the agency. Advice the patient to report any chills, itching, rash or unusual symptoms. 3. Perform hand hygiene and put on gloves. 4. Hang container of 0.9% normal saline with blood administration set to initiate blood infusion and follow procedure for administration of blood. 5. Start IV with a gauge 18 or 19 catheter, if not already present, start an IV infusion. Keep IV line open by starting flow of normal saline. 6. Obtain blood product from blood bag according to agency policy. 7. Complete identification and checks as required by agency: Identification number Blood group and type Expiration date Patients name Unit and hospital number Type of blood product compared with doctors order Inspect blood for clots 8. Wash hands and put on gloves. 9. Take baseline set of vital signs before beginning transfusion. 10. Open blood administration kit and move roller clamps to off position, 11. For Y-tubing set: Spike the 0.9% sodium chloride bag and open roller clamp on Y-tubing connected to bag and roller clamp on unused inlet tube until tubing from 0.9% sodium chloride bag is filled. Close clamp on unused tubing. Squeeze sides of drip chamber and allow filter to partially fit. Open roller clamp and allow tubing to fill with 0.9% sodium chloride. Close tower clamp. Invert blood bag once or twice. Spike Rating: _______________ Weight Score Remarks 2

2 2

1 8

2 1 1 6

blood 5bag and open clamps on inlet tube to allow blood to cover filter completely. Close lower clamp. 5

12. For single tubing set: Spike blood unit. Squeeze sides of drip chamber and allow filter to partially fill. Open roller clamp and allow tubing to fill with 0.9% sodium chloride. Open roller clamp and allow tubing to fill with blood to hub. Prime another IV tubing with 0.9% sodium chloride and piggyback it to blood administration set with a needle, secure all connections with tape. 13. Attach tubing to venous catheter using sterile precautions and open lower clamps. 14. Start infusion of blood product. 15. Prime in-line filter with blood. Start administration slowly (no more than 25-50 ml for first 15 minutes). Stay with patient for first 5 to 15 minutes of transfusion. Check vital signs at least every 15 minutes for the first half hour after start of transfusion. Follow the institutions recommendations for vital signs during the remainder of the transfusion. Observe patient for flushing, dyspnea, itching, hives, or rash. Use a blood-warming device if indicated, especially with rapid transfusions through a central venous catheter. 16. Maintain prescribed flow rate as ordered or as deemed appropriate by the patients overall condition, keeping in mind the outer limits for safe administration. Assess frequently for transfusion reaction. Stop blood transfusion and allow saline to flow if you suspect a reaction. Notify physician and blood bank. 17. When transfusion is complete, infuse 0.9% normal saline. 18. Record administration of blood and patients reaction as ordered by agency. Return blood transfusion bag to blood bank according to agency policy. Total Perfect Score =
Blood Glucose Monitoring Steps:

1 4

1 2

50
Rating: _____________ Weight Score 1 Remarks

1. Determine the specific condition needed to

met before sample physicians order.

collection.

Check
3

2. Prepare needed equipment and supplies: a. Blood Glucose chart b. blood glucose reagent strip c. disposable gloves d. sterile lancet e. alcohol wipes f. cotton balls 3. Wash your hands and instruct the client to wash hands with soap, warm water, if able. 4. Remove reagent strip from the container and tightly seal the cap. 5. Apply disposable gloves. 6. Choose the puncture site: side of the finger (adult) or outer aspect of the heel (infant). 7. Hold the finger to be punctured. 8. Smear the strip after 1 minute. 9. Apply pressure to puncture site. 10. Wait 60 seconds and compare test strip with the color scale 11. Wait for additional 60 seconds and match the color chart for result. 12. If color chart indicates reading darker than 240 mg/dl, wait for another 60 seconds and compare the test strip with the color scale. 13. Check physicians order and glucose level, describe response including appearance of puncture site. Report abnormal blood glucose levels to physician. 14. Document the procedure and glucose level; describe response including appearance of the puncture site. Report abnormal glucose level to the physician.
Total Perfect Score =

2 1 1 2 2 2 3 3 1 1

25

STATION 4 CRITICAL CARE AND MANAGEMENT Description: This station deals with carrying out emergency resuscitation procedures, whether in the street, at home, or in any healthcare facility. Objectives: At the end of this station, the student nurse will be able to: 1. Apply ECG leads properly. 2. Obtain cardiac tracing via ECG machine. 3. Apply Cardiac Monitor appropriately. 4. Obtain a clear waveform that is free from artifact displayed on the cardiac monitor. 5. Perform Cardiopulmonary Resuscitation without complications. 6. Perform Emergency Defibrillation. (Asynchronous) properly. 7. Elaborate the mechanism of action of drugs commonly used in medical emergency situations. Obtaining an Electrocardiogram Steps: 1. Place the electrocardiogram ( ECG ) machine close to the patients bed and plug the power cord into the wall outlet. 2. Perform hand hygiene. Check the patients Rating: _____________ Weight Score Remarks 1

identification. 3. As you set up the machine to record a 12-lead ECG, explain the procedure to the patient. Tell him that the test records the hearts electrical activity and it may be repeated at certain intervals. Emphasize that no electric current will enter his body. Also tell the patient that the test basically takes at least 5 minutes. 4. Have the patient lie supine in the center of the bed with his arms at his sides. Raise the head of the bed if necessary to promote comfort. Expose the patients arms and legs and drape appropriately. Encourage the patient to relax the arms and legs. If the bed is too narrow, place the patients hands under his buttocks to prevent muscle tension. Also, use this technique if the patient is shivering or trembling. Make sure the feet are not touching the bed board. 5. Select flat fleshy areas to place the electrodes. Avoid muscular and bony areas. If the patient has an amputated limb, choose a site on the stump. 6. If an area is excessively hairy, clip it. Clean excess oil or other substances from the skin. 7. Apply the electrode paste or gel or the disposable electrodes to the patients wrist and to the medical aspects of his ankles. If using paste or gel, rub it into the skin. If using disposable electrodes, peel off the contact paper and apply the electrodes directly to the prepared site, as recommended by the manufacturers instructions. Position disposable electrodes on the legs with the lead connection pointing superiorly. 8. If using paste or gel, secure electrodes promptly after you apply the conductive medium. Never use acetone pads in place of the electrode paste or gel. 9. Connect the limb lead wires to the electrodes. The tip of each lead wire is lettered and color-coded for easy identification. The white or RA 8lead wire goes to the right arm; the green or RL lead wire, to the right leg; the black or LA lead wire, to the left arm, and the brown or V1 to V6 lead wires to the chest. Make sure the metal parts of the electrodes are clean and bright. 10. Expose the patients chest. Put a small amount of electrode gel or paste on a disposable electrode at each electrode position. Position chest electrodes as follows: V1: Fourth intecostal space at the right sterna border V2: Fourth intercostals space at the left sterna border V3: Halfway between V2 and V4 V4: Fifth intercostals space at midclavicular 5

2 3

line V6 Fifth intercostals space at anterior axillary line (halfway between V4 and V6) V6 Fifth intercostals space at midaxillary line, level with V4 11. Check to see that the paper speed selector is set to the standard 25 mm and that the machine is set to full voltage. 12. If necessary, enter the Appropriate patient identification data. 13. Ask the patient to relax and breathe normally. Tell him to lie still and not to talk when you record his ECG. 14. Press the AUTO button. Observe the tracing quality. The machine will record all 12 leads automatically, recording three consecutive leads simultaneously. 15. Some machines have a display screen so you can preview waveforms before the machine records them on paper. Adjust waveform if necessary. If any part of the waveform extends beyond the paper when you record the ECG, adjust the normal standardization and repeat. Note this adjustment on the ECG strip because this will need to be considered in interpreting the results. 16. When the machine finishes recording the 12lead ECG, remove the electrodes and clean the patients skin. 17. After disconnecting the lead wires from the electrodes, dispose off or clean the electrodes, as indicated. 18. Label the ECG recording with the patients name, room number, and facility administration, if not done by the machine. Also record the date and time as well as any clinical information on the ECG. Document the tests date and time as well as significant responses by the patient I the medical record. Total Perfect Score = 1

1 2

50

STATION 5 INTEGRATION OF CRITICAL THINKING SKILLS AND NURSING PROCESS Description: This station deals with the critical thinking abilities and decision making skills of the student nurse as she/he utilizes the nursing process in providing care to her/his patients. Objectives: At the end of this station, the student nurse will be able to: - Quickly assess the case presented - Identity priorities of care - Formulate possible nursing diagnoses - Rationalize relevant nursing interventions - Evaluate plan care HYPOTHETICAL CASES: 1. PNEUMONOCCAL PNEUMONIA 2. CARDIAC ARREST

3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

STATUS ASTHMATICUS SUBARACHNOID HEMORRHAGE STROKE RECTAL PAIN and BLEEDING RHEUMATOID ARTHRITIS DECUBITUS ULCER MULTIPLE SCLEROSIS INFECTIOUS HEPATITIS ACUTE ABDOMINAL PAIN OSTEOARTHRITIS WOMAN in LABOR REQUIRING FETAL MONITORING A HYSTERECTOMY PATIENT A POST MASTECTOMY PATIENT Rating: _____________

Instruction: Given a hypothetical situation, the student nurse will:

Steps: 1. Distinguish objective data and subjective data. 2. Identify one priority nursing diagnosis 3. Set objectives of care 4. Identify appropriate nursing interventions and rationalize. 5. Evaluate plan of care

Weight 6 2 2 5 5

Score

Remarks

Total Perfect Score= 20