Safety Measures for All Clinical Skill Performances
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I. Verify Health Care Provider's (HCP's) orders and/or hospital policy.
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II. Gather all needed equipment and supplies. Check expiration dates as needed.
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Entry Measures:
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1.
Perform hand hygiene, put on PPE, if indicated.
2.
Provide privacy - close door or close curtain
3.
Greet patient and introduce self (Name, ACC Nursing Student)
4.
Identify patient using two acceptable identifiers (ask patient their name & assess MR#)
5.
Ask patient if they have any allergies.
6.
Explain the procedure to the patient and why this intervention is needed. Answer any questions as needed.
7.
Raise bed to a working height and put down side rail.
Exit Measures:
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1.
Verbalize to patient that you are leaving.
2.
4 P's (Pain, Potty, Possessions and Position).
3.
Bed in lowest position.
4.
Two side rails up.
5.
Call bell within reach.
6.
Perform hand hygiene as exit room.
Performance Summary Measures:
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1.
Maintain Patient Safety at all times - Perform procedures in safe, logical, organized manner.
2.
Demonstrate asepsis, infection control, and/or sterile technique
3.
Follow the "8 rights" of medication administration.
The
End
Hand Hygiene Using Soap and Water
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Equipment Needed: Antimicrobial soap, paper towels, running water.
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1.
Push watch and sleeves above wrists, remove any rings.
2.
Stand in front of sink without hands or clothing touching the sink during washing.
3.
Turn on water, adjust water force (avoid splashing water against uniform), and regulate temperature until water warm. Wet the hands and wrist area keep hands lower than elbows; allow flow water to drain downward toward the fingertips.
4.
Apply soap using about 3-5 mL of liquid antiseptic soap from dispenser. Lather your hands by rubbing together with the soap being sure to cover all areas of hands with soap product.
5.
Wash hands using mechanical friction and circular motions to lather the soap going from clean to dirty, for at least 15-20 seconds.
a.
Wrist
b.
Back of hands / Palms/ Fingers
c.
In between fingers- web areas
d.
Fingertips and Nails
6.
Rinse hands under clean running water so that the soap drains from the forearm to the fingertips (clean to dirty).
7.
Using a fresh dry paper towel, pat hands dry wiping from wrists to the fingers. Dry hands thoroughly. (May use another dry paper towel if needed to ensure hands get dry).
8.
Dispose wet paper towels into proper waste container.
9.
Use another dry paper towel to turn off the faucet. Dispose in proper waste container.
**Handwashing with antimicrobial soap is used before eating, after using the restroom and after removing gloves when hands have been working with contaminated items and body fluids.
END
Hand Hygiene Using Alcohol-Based Handrub
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Equipment Needed: Alcohol-based Handrub
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1.
Push watch and sleeves above wrists, remove any rings.
2.
Dispense ample amount of product to palm of one hand, using about 1-3 mL.
3.
Rub hands together, making sure to cover all surfaces of the palms, back of hands, thumb and wrists, fingers, and fingertips.
4.
Continue rubbing hands for several seconds until alcohol is completely dry, at least 15 seconds
note **Handwashing with Alcohol-based Handrub is used mainly when entering a patient's room and anytime that hands have not been working with contaminated items.
THE END
Personal Protective Equipment (PPE)
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Verify HCP orders to determine which PPE are to be used.
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Equipment Needed: Gloves, masks, impervious gown, protective eyewear (when appropriate).
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Putting on PPE
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1.
Gown: Put on gown, with opening in the back taking care to cover the entire front and back of
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uniform. Tie gown securely at back of gown (tie neck first and then waist).
2.
Mask: Put on mask, with blue facing outward and wire on top. Secure it over the nose, mouth and chin. If mask has ties - tie head first then at neck. If elastic, pull around ears. Press wire around nose.
3.
Goggles: Put on goggles or face shield when appropriate.
4.
Gloves: Pull cuffs of gown down over part of hands prior to applying gloves. Apply gloves, making sure extending gloves to cover the cuff of the gown sleeve. No exposed skin!
Remove PPE
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1.
Remove gloves:
a.
Free your Wrists - Grasp gown near cuff area and pull up exposing about an inch of skin, do this on both sides.
b.
Glove to glove - Pinch palm area (stay away from cuff), with opposite gloved hand and pulls off glove turning glove inside out holding dirty glove in palm of gloved hand. (dirty to dirty)
c.
Finger to skin - Slide clean finger of ungloved hand under cuff of dirty glove and remove turning inside out, taking care not to touch the outer surface. (clean to clean)
d.
Dispose in proper waste container.
2.
Remove goggles/face shield (only if appropriate):
a.
Grasp goggles/face shield by head band or earpieces
b.
Lift away from face
c.
Dispose in proper waste container.
3.
Remove gown:
a.
Unfasten ties of waist and then tie at neck. Pull gown off shoulders by just holding ties and then let go.
b.
Slide clean finger under gown cuff, pull gown down over hand making a mitt. (clean to clean)
c.
With mitt hand, grasps opposite gown sleeve and pull gown down, (dirty to dirty) allowing gown to fall away from shoulder, making a mitt.
d.
Keeping hands on inner surface of gown pull from arms and remove gown without touching outside surface.
e.
Turn gown inside out
f.
Fold or roll gown into a bundle, stopping about 12 inches before the bottom edge and discard in proper waste container.
Important: Remove all PPE at the patient's doorway except for N95 Respirator Mask. Remove N95 Respirator Mask after leaving the patient room, closing the door, and entering the anteroom.
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4.
Remove mask:
a.
For elastic - grasp elastic loops and pull off, being careful to touch only the elastic.
b.
For tie mask - Grasp the neck ties first and then the head ties and remove. Take care to avoid touching front of mask.
c.
Discard in proper waste container.
5.
Perform hand hygiene immediately after removing PPE.
Applying an Extremity Restraint
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Equipment Needed: Cloth restraint, padding for bony prominences if necessary Prior to Application:
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1.
Determine need for restraints. Assess patient's physical condition, behavior, and mental status. e.g., confusion, disorientation, agitation, repeated removing of tubing or dressings
2.
Make sure that all alternatives have been tried prior to use of restraints and determine failure of the alternative measures.
3.
Confirm agency policy for application of restraints. Secure a health care provider's order or validate that the order has been obtained within the past 4 hours.
4.
Explain reason for use to patient and family. Explain that it is a temporary measure. Determine if a signed consent for use of restraint is necessary.
Implementation:
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5.
Be sure patient is in a comfortable position and in proper body alignment.
6.
Inspect area where restraint is to be placed. (nearby equipment, tubing, condition of patients skin)
7.
Apply restraint according to manufacturer's directions:
a.
Choose the least restrictive type of device that allows the greatest possible degree of mobility.
b.
Pad bony prominences if needed.
c.
Wrap the restraint around the extremity with the soft part in contact with the skin.
d.
Secure restraint with the Velcro� straps or quick release buckle or knot at the extremity, ensuring that it does not tighten around the extremity upon movement.
8.
Ensure that two fingers can be inserted between the restraint and patient's wrist or ankle.
9.
Maintain restrained extremity in normal anatomic position. Use a quick-release knot to tie the restraint strap to the bed frame, not side rail.
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The restraint strap may be attached to chair frame. The site should not be accessible to patient.
10.
If appropriate, demonstrate use of call button and make sure patient can access.
Evaluation:
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11.
After application, assess the patient for signs of injury every 15 minutes or according to facility policy and should include:
a.
The placement of restraint, neurovascular assessment of affected extremity, and skin integrity.
b.
Assess for signs of sensory deprivation, such as increased sleeping, daydreaming, anxiety, panic, and hallucinations.
c.
Readiness for discontinuation
12.
Release restraint at least every 2 hours, or according to agency policy and for patient need for toileting, nutrition, hygiene. Assess extremity and fingers/toes perform ROM as needed.
13.
Evaluate patient for continued need of restraint. Reapply restraint only if continued need is evident and order is still valid.
14.
Reassure patient at regular intervals. Provide continued explanation of rationale for interventions and reorientation if necessary. Keep call bell within easy reach.
15.
Document restraint alternatives attempted, patient's behavior prior to application, type of restraint applied, location of restraint, time, and assessments.
Assisting a Patient With Turning in Bed
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Equipment Needed: Friction-reducing sheet or draw sheet, pillows to help the patient maintain the desired position after turning and to maintain proper body alignment. Additional caregivers to assist based on assessment. If unable to turn patient with ass
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1.
Remove positioning devices, such as pillows.
2.
Loosen top sheet and leave to cover the patient.
3.
If not already in place, position a friction-reducing sheet or draw sheet under the patient.
4.
Using the friction-reducing sheet or draw sheet, move the patient to the edge of the bed, opposite the side to which he or she will be turned. Raise the side rails.
5.
If able, have patient grasp side rail on the side of the bed toward which he or she is turning. Alternately, place patient's arms across their chest and cross their far leg over the leg nearest you.
6.
Stand with feet spread about shoulder width, tighten gluteal and abdominal muscles and flex knees. Use leg muscles to do the pulling.
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Place a hand on the patient's shoulder and the other on the patient's hip and pull the patient over toward you.
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Instruct the patient if able to pull on the bed rail at the same time. Use the friction-reducing sheet to gently pull the patient over on his or her side.
7.
Place pillows behind the patients back and between knees.
8.
Pull the shoulder blade forward and out from under the patient.
9.
Ensure patient is comfortable, covered, and in proper body alignment.
Moving a Patient Up in Bed with Assistance from another Staff Member
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Equipment Needed: Pillows, friction-reducing sheet or draw sheet. If unable to move patient without assistance, use of additional caregivers, stand-assist device, and/or mechanical device lift etc. should be used.
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1.
Review the medical record for conditions that may influence the patient's ability to move or be positioned. Assess for any tubes, IV lines, or equipment that may alter the positioning procedure.
2.
Seek the assistance of other personnel, if needed, insure Patient Ergonomics
3.
Remove pillow from patient and place at head of bed in upright position so it pads the headboard
4.
Position at least one nurse on either side of the bed, and lower both side rails.
5.
If a friction-reducing sheet or device is not in place under the patient, place one under the patient's midsection.
6.
Ask the patient if able to bend his or her legs and put his or her feet flat on the bed to assist with the movement.
7.
Have the patient fold the arms across the chest.
8.
Have the patient (if able) lift the head with chin on chest.
9.
Grasp the friction-reducing sheet or draw sheet securely, close to the patient's body.
10.
Flex your knees and hips. Tighten your abdominal and gluteal muscles and keep your back straight.
11.
Shift your weight back and forth from your back leg to your front leg and point feet in direction of movement. Count to three. On the count of three, move the patient up in bed.
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If possible, the patient can assist with the move by pushing with the legs. Repeat the process, if necessary, to get the patient to the right position.
12.
Assist the patient to a comfortable position and readjust the pillows and supports, as needed. Ensure patient is covered, and in proper body alignment.
Assisting a Patient from Bed to a Chair
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Equipment Needed: Chair or wheelchair, gait belt, non-skid shoes or slippers, cover sheet or
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Blanket. If unable to move patient without assistance, use of additional caregivers, stand-assist device, and/or mechanical device lift etc. should be used.
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1.
Review the medical record for conditions that may influence the patient's ability to move. Assess for any tubes, IV lines, or equipment that may alter moving the patient.
2.
Assess patient mobility status. Seeks the assistance of other personnel, if needed.
3.
Move any equipment to make room for the chair and a clear path to the chair.
4.
Make sure the bed brakes are locked. Place chair at 45? to 90? angle to the bed. If available, lock the brakes of the chair. If the chair does not have brakes, brace the chair against a secure object.
5.
Place the bed in lowest position. Raise the head of the bed to a Fowler's position (sitting).
6.
Ask patient to move to the side of the bed and push self-up from a side-lying position or assist patient to pivot around by placing your hands across patient knees and swing around. Keep your back straight; avoid twisting.
7.
Dangle patient on the side of the bed by ensuring both feet touch the floor (patient might have to slide buttock to edge of bed for feet to touch floor) and arms on bed at each side.
8.
Allow the patient's legs to dangle a few minutes before continuing to prevent orthostatic hypo-tension. While patient is dangling, assess for any balance problems or complaints of dizziness or nausea.
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If dizzy or nauseated, do not get the patient up, assist patient back in bed. If not dizzy, assist patient with putting on a robe and non-skid footwear.
9.
Wrap the gait belt around the patient's waist, based on assessed need and facility policy.
10.
Lower the side rail, if necessary, and stand in front of patient with knees flexed touching patient's knees and feet shoulder width apart.
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Position yourself as close to patient as possible, with your feet positioned on the outside patient's feet.
11.
Have patient hands on your upper arms, NOT around your neck.
12.
Place your arms on patient's waist or grasp gait belt from underneath.
13.
Rock back and forth while counting to three. On the count of three, have patient look up while use your legs (not your back) to help raise the patient to a standing position. If indicated, brace your front knee against the patient's weak extremity as he o
14.
Pivot on your back foot and assist the patient to turn until the patient feels the chair against his or her legs.
15.
Instruct the patient to use the armrests for support and assist the patient to sit. (If no arm rest have patient feel back of chair against legs than assist the patient to sit in chair).
16.
Assess the patient's alignment in the chair. Remove gait belt and cover with sheet if needed.
Assisting a Patient with Ambulation
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Equipment Needed: Gait belt, non-skid shoes or slippers. If unable to ambulate patient without assistance, use of additional caregivers, stand-assist device, and/or mechanical device lift etc. should be used.
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1.
Lower the bed, lock the wheels on the bed, lower side rail, raise patient to fowlers position.
2.
Encourage the patient to make use of a stand-assist aid, either freestanding or attached to the side of the bed, if available, to move to the side of the bed. Assist the patient to the side of the bed, if necessary.
3.
Have the patient dangle with feet touching the floor. Sit on the side of the bed for several minutes to prevent orthostatic hypo-tension.
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Assess for dizziness or lightheaded-ness. Have the patient take several deep breaths until balance is obtained. Stay sitting on side of bed until he or she feels secure.
4.
Ask the patient to move feet in circles, and then put on non-skid footwear and a robe, if desired.
5.
Wrap the gait belt around the patient's waist, based on assessed need and facility policy.
6.
Encourage the patient to make use of the stand-assist device. Assist the patient to stand, using the gait belt, if necessary. Assess the patient's balance and leg strength. If the patient is weak or unsteady, return the patient to the bed or assist to a c
7.
If you are the only nurse assisting, position yourself to the side and slightly behind the patient. Support the patient by one hand on the patient's waist or transfer belt, and the other hand on the patient's upper arm bicep
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Be sure you have good support of the patient's body, not just holding the patient's gown.
a.
When two nurses assist, position yourself to the side and slightly behind the patient, supporting the patient by the waist or gait belt and upper arm.
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Have the other nurse carry or manage equipment or provide additional support from the other side.
b.
Alternatively, when two nurses assist, stand at the patient's sides one nurse on each side with near hands grasping the gait belt and far hands holding the patient's upper arm
8.
Take several steps forward with the patient. Continue to assess the patient's strength and balance. Remind the patient to stand erect and to look up.
9.
Continue with ambulation for the planned distance and time. Return the patient to the bed or chair based on the patient's tolerance and condition.
10.
Remove gait belts. Clean transfer aids per facility policy, if not indicated for single patient use. Prevention of a fall when ambulating.
11.
If the patient begins to fall, gently ease him or her to the floor by holding firmly onto the gait belt, standing with your feet apart to provide a broad base of support, extending your leg, and letting the patient gently slide to the floor.
12.
As the patient slides, bend your knees to lower his or her body. Protect the patients head.