skill 1-1 performing hand hygiene using an excellent satisfactory...
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Copyright © 2015 by Wolters Kluwer. Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach, 4th edition, by Pamela Lynn.
Skill Checklists for Taylor's Clinical Nursing Skills:A Nursing Process Approach, 4th edition
Name Date
Unit Position
Instructor/Evaluator: Position
SkIll 1-1
Performing Hand Hygiene Using an Alcohol-Based Handrub
Goal: Transient microorganisms are eliminated from the hands. Comments
1.Removejewelry,ifpossible,andsecureinasafeplace.Aplainweddingbandmayremaininplace.
2.Checktheproductlabelingforcorrectamountofproductneeded.
3.Applythecorrectamountofproducttothepalmofonehand.Rubhandstogether,coveringallsurfacesofhandsandfingers,andbetweenfingers.Alsocleanthefingertipsandtheareabeneaththefingernails.
4.Rubhandstogetheruntiltheyaredry(atleast15seconds).
5.Useoil-freelotiononhands,ifdesired.
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Skill Checklists for Taylor's Clinical Nursing Skills:A Nursing Process Approach, 4th edition
Name Date
Unit Position
Instructor/Evaluator: Position
Exce
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Nee
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Copyright © 2015 by Wolters Kluwer. Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach, 4th edition, by Pamela Lynn.
1. Gatherthenecessarysupplies.Standinfrontofthesink.Donotallowyourclothingtotouchthesinkduringthewashingprocedure.
2. Removejewelry,ifpossible,andsecureinasafeplace.Aplainweddingbandmayremaininplace.
3. Turnonwaterandadjustforce.Regulatethetemperatureuntilthewateriswarm.
4. Wetthehandsandwristarea.Keephandslowerthanelbowstoallowwatertoflowtowardfingertips.
5. Useabout1teaspoonliquidsoapfromdispenserorrinsebarofsoapandlatherthoroughly.Coverallareasofhandswiththesoapproduct.Rinsesoapbaragainandreturntosoaprackwithouttouchingtherack.
6. Withfirmrubbingandcircularmotions,washthepalmsandbacksofthehands,eachfinger,theareasbetweenthefingers,andtheknuckles,wrists,andforearms.Wash at least 1 inch above area of contamination.Ifhandsarenotvisiblysoiled,washto1inchabovethewrists.
7. Continuethisfrictionmotionforatleast20seconds.
8. Usefingernailsoftheoppositehandoracleanorange-woodsticktocleanunderfingernails.
9. Rinsethoroughlywithwaterflowingtowardfingertips.
10. Pathandsdrywithapapertowel,beginningwiththefin-gersandmovingupwardtowardforearms,anddiscarditimmediately.Useanothercleantoweltoturnoffthefaucet.Discardtowelimmediatelywithouttouchingothercleanhand.
11.Useoil-freelotiononhands,ifdesired.
SkIll 1-2
Performing Hand Hygiene Using Soap and Water (Handwashing)
Goal: The hands will be free of visible soiling and transient microorganisms will be eliminated. Comments
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Skill Checklists for Taylor's Clinical Nursing Skills:A Nursing Process Approach, 4th edition
Name Date
Unit Position
Instructor/Evaluator: Position
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Nee
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Copyright © 2015 by Wolters Kluwer. Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach, 4th edition, by Pamela Lynn.
1.Checkmedicalrecordandnursingplanofcarefortypeofprecautionsandreviewprecautionsininfectioncontrolmanual.
2.Plannursingactivitiesbeforeenteringpatient’sroom.
3.Performhandhygiene.
4.Provideinstructionaboutprecautionstopatient,familymembers,andvisitors.
5.Putongown,mask,protectiveeyewear,andglovesbasedonthetypeofexposureanticipatedandcategoryofisolationprecautions.
a. Putonthegown,withtheopeningintheback.Tiegownsecurelyatneckandwaist.
b.Putonthemaskorrespiratoroveryournose,mouth,andchin.Securetiesorelasticbandsatthemiddleoftheheadandneck.Ifrespiratorisused,performafitcheck.Inhale;therespiratorshouldcollapse.Exhale;airshouldnotleakout.
c. Putongoggles.Placeovereyesandadjusttofit.Alter-nately,afaceshieldcouldbeusedtotaketheplaceofthemaskandgoggles.
d.Putoncleandisposablegloves.Extendglovestocoverthecuffsofthegown.
6.Identifythepatient.Explaintheproceduretothepatient.Continuewithpatientcareasappropriate.
SkIll 1-3
Using Personal Protective Equipment
Goal: The transmission of microorganisms is prevented. Comments
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Copyright © 2015 by Wolters Kluwer. Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach, 4th edition, by Pamela Lynn.
SkIll 1-3
Using Personal Protective Equipment (Continued)
Comments
Remove PPE
7.RemovePPE:Exceptforrespirator,removePPEatthedoor-wayorinananteroom.Remove respirator after leaving the patient’s room and closing the door.
a. Ifimperviousgownhasbeentiedinfrontofthebodyatthewaistline,untiewaiststringsbeforeremovinggloves.
b.Grasptheoutsideofoneglovewiththeoppositeglovedhandandpeeloff,turningthegloveinsideoutasyoupullitoff.Holdtheremovedgloveintheremainingglovedhand.
c. Slidefingersofunglovedhandundertheremaininggloveatthewrist,taking care not to touch the outer surface of the glove.
d.Peeloffthegloveoverthefirstglove,containingtheonegloveinsidetheother.Discardinappropriatecontainer.
e. Toremovethegogglesorfaceshield:Handlebythehead-bandorearpieces.Liftawayfromtheface.Placeindesig-natedreceptacleforreprocessingorinanappropriatewastecontainer.
f. Toremovegown:Unfastenties,ifattheneckandback.Allowthegowntofallawayfromshoulders.Touching only the inside of the gown,pullawayfromthetorso.Keepinghandsontheinnersurfaceofthegown,pullgownfromarms.Turngowninsideout.Foldorrollintoabundleanddiscard.
g. Toremovemaskorrespirator:Graspthenecktiesorelastic,thentoptiesorelasticandremove.Take care to avoid touching front of mask or respirator.Discardinwastecontainer.Ifusingarespirator,saveforfutureuseinthedesignatedarea.
8.PerformhandhygieneimmediatelyafterremovingallPPE.
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Skill Checklists for Taylor's Clinical Nursing Skills:A Nursing Process Approach, 4th edition
Name Date
Unit Position
Instructor/Evaluator: Position
Copyright © 2015 by Wolters Kluwer. Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach, 4th edition, by Pamela Lynn.
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1.PerformhandhygieneandputonPPE,ifindicated.
2.Identifythepatient.Explaintheproceduretothepatient.
3.Checkthatpackagedsteriledrapeisdryandunopened.Alsonoteexpirationdate,makingsurethatthedateisstillvalid.
4.Selectaworkareathatiswaistlevelorhigher.
5.Opentheoutercoveringofthedrape.Removesteriledrape,liftingitcarefullybyitscorners.Holdawayfrombodyandabovethewaistandworksurface.
6.Continuetoholdonlybythecorners.Allowthedrapetounfold,awayfromyourbodyandanyothersurface.
7.Positionthedrapeontheworksurfacewiththemoisture-proofsidedown.Thiswouldbetheshinyorblueside.Avoidtouchinganyothersurfaceorobjectwiththedrape.Ifanyportionofthedrapehangsofftheworksurface,thatpartofthedrapeisconsideredcontaminated.
8.Placeadditionalsterileitemsonfieldasneeded.RefertoSkill1-6.Continuewiththeprocedureasindicated.
9.Whenprocedureiscompleted,removePPE,ifused.Performhandhygiene.
SkIll 1-4
Preparing a Sterile Field Using a Packaged Sterile Drape
Goal: The sterile field is created without contamination and the patient remains free of exposure to potential infection- causing microorganisms. Comments
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Skill Checklists for Taylor's Clinical Nursing Skills:A Nursing Process Approach, 4th edition
Name Date
Unit Position
Instructor/Evaluator: Position
Copyright © 2015 by Wolters Kluwer. Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach, 4th edition, by Pamela Lynn.
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1. PerformhandhygieneandputonPPE,ifindicated.
2. Identifythepatient.Explaintheproceduretothepatient.
3. Checkthatthepackagedkitortrayisdryandunopened.Alsonoteexpirationdate,makingsurethatthedateisstillvalid.
4.Selectaworkareathatiswaistlevelorhigher.
5. Opentheoutsidecoverofthepackageandremovethekitortray.Placeinthecenteroftheworksurface,withthetopmostflappositionedonthefarsideofthepackage.Discardoutsidecover.
6. Reacharoundthepackageandgrasptheoutersurfaceoftheendofthetopmostflap,holdingnomorethan1inchfromtheborderoftheflap.Pullopenawayfromthebody,keepingthearmoutstretchedandawayfromtheinsideofthewrapper.Allowthewrappertolieflatontheworksurface.
7. Reacharoundthepackageandgrasptheoutersurfaceofthefirstsideflap,holdingnomorethan1inchfromtheborderoftheflap.Pullopentothesideofthepackage,keepingthearmoutstretchedandawayfromtheinsideofthewrapper.Allowthewrappertolieflatontheworksurface.
8. Reacharoundthepackageandgrasptheoutersurfaceoftheremainingsideflap,holdingnomorethan1inchfromtheborderoftheflap.Pullopentothesideofthepackage,keep-ingthearmoutstretchedandawayfromtheinsideofthewrapper.Allowthewrappertolieflatontheworksurface.
SkIll 1-5
Preparing a Sterile Field Using a Commercially Prepared Sterile Kit or Tray
Goal: A sterile field is created without contamination, the contents of the package remain sterile, and the patient remains free of exposure to potential infection-causing microorganisms. Comments
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Copyright © 2015 by Wolters Kluwer. Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach, 4th edition, by Pamela Lynn.
SkIll 1-5
Preparing a Sterile Field Using a Commercially Prepared Sterile Kit or Tray (Continued)
Comments
9. Standawayfromthepackageandworksurface.Grasptheoutersurfaceoftheremainingflapclosesttothebody,holdingnotmorethan1inchfromtheborderoftheflap.Pulltheflapbacktowardthebody,keepingarmout-stretchedandawayfromtheinsideofthewrapper.Keepthishandinplace.Useotherhandtograspthewrapperontheunderside(thesidethatisdowntotheworksurface).Positionthewrappersothatwhenflat,edgesareontheworksurface,anddonothangdownoversidesofworksurface.Allowthewrappertolieflatontheworksurface.
10. Theouterwrapperofthepackagehasbecomeasterilefieldwiththepackagedsuppliesinthecenter.Donottouchorreachoverthesterilefield.Placeadditionalsterileitemsonfieldasneeded.RefertoSkill1-6.Continuewiththeprocedureasindicated.
11. Whenprocedureiscompleted,removePPE,ifused.Performhandhygiene.
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Skill Checklists for Taylor's Clinical Nursing Skills:A Nursing Process Approach, 4th edition
Name Date
Unit Position
Instructor/Evaluator: Position
Exce
llent
Satis
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ory
Nee
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ice
Copyright © 2015 by Wolters Kluwer. Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach, 4th edition, by Pamela Lynn.
1.PerformhandhygieneandputonPPE,ifindicated.
2.Identifythepatient.Explaintheproceduretothepatient.
3.Checkthatthesterile,packageddrapeandsuppliesaredryandunopened.Alsonoteexpirationdate,makingsurethatthedateisstillvalid.
4.Selectaworkareathatiswaistlevelorhigher.
5.PreparesterilefieldasdescribedinSkill1-4orSkill1-5.
6.Addsterileitem:
To Add an Agency-Wrapped and Sterilized Item
a. Holdagency-wrappediteminthedominanthand,withtopflapopeningawayfromthebody.Withotherhand,reacharoundthepackageandunfoldtopflapandbothsides.
b. Keepasecureholdontheitemthroughthewrapperwiththedominanthand.Grasptheremainingflapofthewrapperclosesttothebody,takingcarenottotouchtheinnersurfaceofthewrapperortheitem.Pulltheflapbacktowardthewrist,sothewrappercoversthehandandwrist.
c. Graspallthecornersofthewrappertogetherwiththenondominanthandandpullbacktowardwrist,coveringhandandwrist.Holdinplace.
d.Holdtheitem6inchesabovethesurfaceofthesterilefieldanddropontothefield.Becarefultoavoidtouchingthesurfaceorotheritemsordroppinganyitemontothe1-inchborder.
To Add a Commercially Wrapped and Sterilized Item
a. Holdpackageinonehand.Pullbacktopcoverwithotherhand.Alternately,carefullypeeltheedgesapartusingbothhands.
b.Aftertopcoveroredgesarepartiallyseparated,holdtheitem6inchesabovethesurfaceofthesterilefield.Con-tinueopeningthepackageanddroptheitemontothefield.Be careful to avoid touching the surface or other items or dropping an item onto the 1-inch border.
c. Discardwrapper.
SkIll 1-6
Adding Sterile Items to a Sterile Field
Goal: The sterile field is created without contamination, the sterile supplies are not contaminated, and the patient remains free of exposure to potential infection-causing microorganisms. Comments
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Copyright © 2015 by Wolters Kluwer. Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach, 4th edition, by Pamela Lynn.
SkIll 1-6
Adding Sterile Items to a Sterile Field (Continued)
Comments
To Add a Sterile Solution
a. Obtainappropriatesolutionandcheckexpirationdate.
b.Opensolutioncontaineraccordingtodirectionsandplace cap on table away from the field with edges up.
c. Holdbottleoutsidetheedgeofthesterilefieldwiththelabelsidefacingthepalmofyourhandandpreparetopourfromaheightof4to6inches(10to15cm).Never touch the tip of the bottle to the sterile container or field.
d.Pourrequiredamountofsolutionsteadilyintosterilecontainerpreviouslyaddedtothesterilefieldandposi-tionedatsideofsterilefieldorontodressings.Avoid splashing any liquid.
e. Touchonlytheoutsideofthelidwhenrecapping.Labelsolutionwithdateandtimeofopening.
7.Continuewithprocedureasindicated.
8.Whenprocedureiscompleted,removePPE,ifused.Performhandhygiene.
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Skill Checklists for Taylor's Clinical Nursing Skills:A Nursing Process Approach, 4th edition
Name Date
Unit Position
Instructor/Evaluator: Position
Exce
llent
Satis
fact
ory
Nee
ds P
ract
ice
Copyright © 2015 by Wolters Kluwer. Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach, 4th edition, by Pamela Lynn.
1. PerformhandhygieneandputonPPE,ifindicated.
2. Identifythepatient.Explaintheproceduretothepatient.
3. Checkthatthesterileglovepackageisdryandunopened.Alsonoteexpirationdate,makingsurethatthedateisstillvalid.
4. Placesterileglovepackageonclean,drysurfaceatoraboveyourwaist.
5. Opentheoutsidewrapperbycarefullypeelingthetoplayerback.Removeinnerpackage,handlingonlytheout-sideofit.
6. Placetheinnerpackageontheworksurfacewiththesidelabeled“cuffend”closesttothebody.
7. Carefullyopentheinnerpackage.Foldopenthetopflap,thenthebottomandsides.Take care not to touch the inner surface of the package or the gloves.
8. Withthethumbandforefingerofthenondominanthand,graspthefoldedcuffofthegloveforthedominanthand,touchingonlytheexposedinsideoftheglove.
9. Keepingthehandsabovethewaistline,liftandholdthegloveupandofftheinnerpackagewithfingersdown.Be careful that it does not touch any unsterile object.
10. Carefullyinsertdominanthandpalmupintogloveandpullgloveon.Leavethecufffoldeduntiltheoppositehandisgloved.
11. Holdthethumboftheglovedhandoutward.Placethefin-gersoftheglovedhandinsidethecuffoftheremainingglove.Liftitfromthewrapper,takingcarenottotouchanythingwiththeglovesorhands.
12. Carefullyinsertnondominanthandintoglove.Pullthegloveon,takingcarethattheskindoesnottouchanyoftheoutersurfacesofthegloves.
13. Slide the fingers of one hand under the cuff of the other and fully extend the cuff down the arm, touching only the sterile outside of the glove. Repeat for the remaining hand.
SkIll 1-7
Putting on Sterile Gloves and Removing Soiled Gloves
Goal: The gloves are applied and removed without contamination. Comments
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Copyright © 2015 by Wolters Kluwer. Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach, 4th edition, by Pamela Lynn.
SkIll 1-7
Putting on Sterile Gloves and Removing Soiled Gloves (Continued)
Comments
14. Adjustglovesonbothhandsifnecessary,touching only sterile areas with other sterile areas.
15. Continuewithprocedureasindicated.
Removing Soiled Gloves
16. Usedominanthandtograsptheoppositeglovenear cuff end on the outside exposed area.Removeitbypullingitoff,invertingitasitispulled,keepingthecontaminatedareaontheinside.Holdtheremovedgloveintheremain-ingglovedhand.
17. Slidefingersofunglovedhandbetweentheremaininggloveandthewrist.Take care to avoid touching the out-side surface of the glove.Removeitbypullingitoff,invertingitasitispulled,keepingthecontaminatedareaontheinside,andsecuringthefirstgloveinsidethesecond.
18. Discardglovesinappropriatecontainer.Removeaddi-tionalPPE,ifused.Performhandhygiene.
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