student orientation forms 2017 nursing students …...demonstrates correct technique for quick...

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Student Orientation Forms – 2017

Nursing Students – PIH Health Hospital - Whittier

NURSING STUDENT

CONSENT FOR RELEASE OF INFORMATION

______________________________________ ___________________________ Name (Last, First, MI) Date of Birth The School may not disclose information contained in student’s records without the student’s written consent except under certain conditions. The employee’s record may be released to a third party by providing a written authorization or consent. Consent for Release of Information: I hereby give my consent for the following information to be released to PIH HEALTH (upon the hospital’s request) specifically for the calendar year: ____________________________.

1) Background Check 2) Immunization Records 3) TB Test Results 4) Drug Screen Results 5) Physical Examination by Licensed Provider

__________________________________ ________________________

Signature Date

Photocopies of this authorization may be made and used as duplicate originals. This authorization shall remain valid for as long as this Agreement remains in effect and/or School provides services to Hospital, whichever is longer.

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PIH HEALTH HOSPITAL WHITTIER, CALIFORNIA EDUCATION DEPARTMENT

UNIT/DEPARTMENT SPECIFIC ORIENTATION - Nursing Student

Student to initial when completed

UNIT NAME: _____________________

Department Overview:

Location of Departmental/Hospital Policies on Intranet

Review of unit specific policies and procedures as appropriate

Identify unit/department chain of command

Physical Set-up/Work Environment

Office equipment review / Identify location of supplies and forms

Review physical set-up of unit/department and review telephone system, beeper, VOCERA

Safety Issues

Identify location of fire exits and extinguishers and review fire and disaster plan

Workflow

Identify shift responsibilities and assignment including assigned resource person/buddy

Review documentation responsibilities and review admission/discharge processes (clinical only)

Human Resources Items

Meal breaks; identification badge visible and above waist; dress code

I acknowledge that I have been oriented to the following specific information. ____________________________________ _______________________________ _________________________ Student Signature/Initials Evaluator Signature Evaluator Print Name

Name_______________________________________ School______________________________________ Date________________________________________

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COMPETENCY ASSESSMENT: RESTRAINTS

Assessment Code (A.C.): Method of Evaluation: 1 = Performs skill independently & completely D = Return Demonstration 2 = Performs skill but requires supervision O = Clinical Observation 3 = Can verbalize theory/how to perform skill, V = Verbal Feedback

but has had minimal opportunity to practice skill

KNOWLEDGE BASE: Assessment Code

Method of Evaluation

Finds and reads Policy No. 87200.604 D O V

Assessment Code


Restraint Application Clinical Staff / Ancillary Support Staff

Roll Belt

Demonstrates correct application of the roll belt D O V

Demonstrates correct technique for securing the roll belt D O V

Demonstrates correct technique for releasing the roll belt buckles D O V

Vest (Bed) Restraint

Demonstrates correct application of vest restraint D O V

Demonstrates correct technique for securing vest ties D O V

Demonstrates correct technique for quick release ties D O V

Extremity Restraint

Demonstrates correct application of restraint to extremity D O V

Demonstrates correct technique for securing extremity restraint D O V

Demonstrates correct technique for quick release of extremity restraint D O V

Verbalizes that hard restraints will be used in CCC and ED only D O V

Finger Control Mitt Restraints

Verbalizes that a Mitt becomes a restraint when - Tied to the bed frame - used in conjunction with a wrist restraint - applied so as to immobilize hand or fingers

D O V D O V D O V

Demonstrates application of Mitt per manufacture instruction D O V

Torso (Chair) Restraint

Demonstrates correct application of the Torso Support D O V

Verbalizes process for choosing correct restraint size D O V

Verbalizes patient instruction as to sit with hips against the chair back D O V

Demonstrates wrapping chest strap around patient torso D O V

Demonstrates securely hooking chest straps together behind chair back D O V

Demonstrates bringing shoulder straps over patient shoulders and chair back and crossing in an “X” to secure to chest strap

D O V

Demonstrates checking for restraint fit using the flat of the hand D O V

I acknowledge that I have read & completed the competency criteria support document. ____________________________________ _______________________________ _________________________ Student Signature Evaluator Signature Evaluator Print Name

Name_______________________________________ School______________________________________ Date________________________________________

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COMPETENCY ASSESSMENT: GAIT BELT



Gait Belt Competency Assessment Code


Demonstrates appropriate application of gait belt D O V

Verbalizes indications for use of gait belt D O V

Demonstrates appropriate positioning and guarding techniques for utilization of gait belt D O V

Demonstrates or verbalizes the appropriate infection control technique with gait belt D O V


Name_______________________________________ School______________________________________ Date________________________________________

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Hand Hygiene

Checklist



Assessment A.C.

Method of Evaluation Comments

D O V

Performed hand hygiene before patient contact.

Pushed long sleeves above wrists

Inspected surface of hands for breaks or cuts in skin or cuticles.

Implementation: Hand washing using plain or antimicrobial soap and water

A.C.


Comments

D O V

Stood in front of sink, kept hands and uniform away from sink surface. (If hands touched sink during hand washing, repeated hand washing).

Turned on water. Turned faucet on, or pushed knee pedals laterally, or pressed pedals with foot to regulate flow and temperature.

Avoided splashing water against uniform.

Regulated flow of water so that temperature was warm.

Wet hands and wrists thoroughly under running water. Kept hands and forearms lower than the elbows during washing.

Applied a small amount of soap or antiseptic, lathered thoroughly.

Performed hand hygiene by using plenty of lather and friction for at least 15 seconds. Interlaced fingers and rubbed palms and back of hands with circular motion at least 5 times each. Kept fingertips down to facilitate removal of microorganisms.

Noted that areas underlying fingernails are often soiled. Cleansed them with the fingernails of other hand and additional soap, or cleansed with a disposable nail cleaner.

Policy 100.87500.614

Name: ________________________________

School: _____________ Date: _____________

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Hand Hygiene (cont.) A.C.


Comments

D O V

Rinsed hands and wrists thoroughly, kept hands down and elbows up.

Dried hands thoroughly from fingers to wrists with paper towel, single-use cloth, or warm air dryer.

Discarded paper towel, if used, in proper trash receptacle.

Turned off hand faucet using a clean, dry paper tower, and avoided touching handles with hands. Turned off water with foot or knee pedals (if applicable).

If lotion applied to hands, used the facility-provided lotion available. Avoided petroleum-based lotions.

Implementation: Hand antisepsis using an instant alcohol waterless antiseptic rub

A.C.


Comments

D O V

Dispensed ample amount of product into the palm of one hand.

Rubbed hands together, covered all surfaces of hands and fingers with antiseptic rub.

Rubbed hands together until the alcohol is dry.

Allowed hands to completely dry before gloves applied.


________________________________ __________________ _____________ Student Name: School: Date:

Copyright © 2006 - 2015 Elsevier Inc. All Rights Reserved.

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COMPETENCY ASSESSMENT: PPE - ISOLATION PRECAUTIONS



PLANNING Assessment Code


Chosen barrier protection that is appropriate for the type of isolation. - Contact/MDRO: Standard precautions plus gloves and gown - Droplet/Respiratory: Standard precautions plus mask - Airborne: Standard precautions plus an N-95 respirator

D O V

Gathered equipment D O V

IMPLEMENTATION

Performed hand hygiene D O V

Applied/Don a gown when giving direct patient care. - Ensured the gown covers the torso from the neck to knees, arms to the end of

the wrists and wraps around the back. - Pulled the sleeves of the gown down to the wrist - Fastened the gown securely at the back of the neck and the waist

D O V

Applied /Don either a surgical mask or a fitted N-95 respirator around the mouth and nose. (if indicated) - Secured the ties or elastics at the middle of the head and neck or the elastic

ear loops around the ears. - Fitted the flexible band to the nose bridge. - Ensured the mask fits snug to the face and below the chin.

D O V

Applied /Don eye protection (goggles or face shield), if needed, around the face and eyes. Adjusted to fit.

D O V

Applied /Don gloves when giving direct patient care. - Cuff of glove brought over the edge of the gown sleeves.

D O V

Identified patient D O V

Explained reason for isolation to patient D O V

Kept patients’ door open D O V

Performed patient care D O V

Removed PPE (personal protective equipment) prior to leaving patient room with the exception of the N-95 respirator. D O V

Removed/Doff gloves - Using gloved hand, grasped the palm area of the other gloved hand and

peeled off the first glove. - Held the removed glove in the gloved hand. - Slid the fingers of the ungloved hand under the remaining glove at the wrist - Peeled the second glove off over the first glove. - Discarded gloves.

D O V

Name_______________________________________ School______________________________________ Date________________________________________

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PPE - ISOLATION PRECAUTIONS COMPETENCY (CONT.)

Assessment Code


Removed/Doff gown (Front and sleeves are contaminated) - If hands got contaminated during gown removal, immediately washed hands

or used alcohol based hand sanitizer. - Unfastened gown ties, taking care that sleeves didn’t contact your body when

reaching for ties. - Pulled gown away from neck and shoulders, touching inside of gown only. - Turned gown inside out - Folded or rolled into a bundle and discarded in a waste container.

D O V

Removed/Doff eye protection from the back by lifting the head band or ear pieces. D O V

Removed/Doff mask. D O V

Performed hand hygiene D O V



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COMPETENCY ASSESSMENT: NOVA BLOOD GLUCOSE MONITORING



PRE-ASSESSMENT Assessment Code


Checks Quality Control and battery status D O V

Performs quality control (if needed)

States policy on “dating” for all test strips, notes expiration dates on control and strips.

Once opened, test strips are stable up to 6 months

D O V D O V D O V

ASSESSMENT and PLANNING Assessment Code


Reviews physician’s order D O V

Explains procedure to patient D O V

Gathers needed supplies D O V

IMPLEMENTATION Assessment Code


Performs hand hygiene D O V

Applies gloves D O V

Identifies patient using 2 identifiers (name and MR#) D O V

Turns meter on D O V

Scans operator ID badge or uses keypad to enter manually and presses “Accept” D O V

Selects “patient test” screen and presses “Accept” D O V

Scans the strip lot number and “Accepts” if correct D O V

Scans patient armband barcode by pressing the “Scan” key on the screen and positioning bottom of the meter above the patient’s armband bar code. If scanning fails, enters pt. account (visit) number manually. Presses “Accept” when correct patient ID appears on the screen

D O V

Places the test strip into the meter as shown on the screen D O V

Selects puncture site, cleanse site with alcohol wipe, allows to dry D O V

Punctures the fingertip of either the middle or ring finger, or infant heel with lancet D O V

Squeezes the finger to form a drop of blood. Wipes off the first drop with a gauze D O V

Places a drop of blood on the test strip while the meter is in a horizontal position D O V

Applies gauze to skin to cover puncture site D O V

Views result on screen and “Accept” or “Reject” the result. The result will appear in 6 seconds.

D O V

Removes test strip when analysis is complete and dispose of in regular trash D O V

Disposes Lancet in sharps container D O V

Verbalizes patient testing process in isolation room D O V

Name_______________________________________ School______________________________________ Date________________________________________

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NOVA BLOOD GLUCOSE MONITORING COMPETENCY (CONT.)

EVALUATION, RECORD AND REPORT Assessment Code


Evaluates results and follows doctor order in coverage D O V

Documents results in eMAR D O V

Identifies critical ranges and states corrective action by pressing “Comment” key and choosing a comment that corresponds to the patient’s current situation.

D O V

Follows nursing procedural protocol for hypoglycemic or hyperglycemic follow up if needed

D O V

Documents date, time and person notified of the critical value D O V

Screen will display “Hi” for result over 600 mg/dL. Repeat test if result does not correlate with patient medical condition.

D O V

QUALITY CONTROL TESTING Assessment Code


Presses the QC soft key from the patient test screen

Both high and low solutions must be performed every 24hrs or if meter is dropped

Solutions are stable for 3 months after first opening

D O V

Scans the Strip Lot Number barcode

To scan the barcode press the “Scan” key

Press the “Accept” key if the lot number is correct

D O V

Scans the QC lot number

Select from the QC Lot List screen (press the List button) or

Scan the barcode (press the Scan key)

Press the “Accept” key if the lot number is correct

D O V

Inserts a Test Strip at the top of the meter in the test strip port D O V

Gently mixes the Stat Strip Glucose Control Solution before each use D O V

When the meter completes the test, the QC results will be displayed along with a PASS or FAIL

To add a comment to the result, press the “Comment” key

To accept the result, press the “Accept” key

D O V

CLEANING METER Assessment Code


Performs hand hygiene D O V

Applies gloves D O V

Using a germicidal wipe, thoroughly wipe the external surface of the meter thoroughly avoiding the meter’s bar code scanner and electrical connector

Gently wipe the surface areas of test strip port making sure no fluid enters the port

D O V

Dock the meter in a Data Docking Station to automatically upload stored meter data, download updated setup information, and to charge meter battery.

D O V



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PIH HEALTH HOSPITAL NOVA BLOOD GLUCOSE MONITORING QUIZ

Name:__________________________________ School: _________________________ Date:___________

Circle the correct answer(s). 1. Once opened, the test strips are stable for up to _______ months. 2. What should you do if the meter scanner won’t scan the patient’s armband barcode? a. Manually input patients 9 digit medical number b. Manually input patients 8 digit account number without leading zeros c. Manually input patients 12 digit account number d. Manually input patients 5 digit medical number without leading zeros 3. What should you do if quality control result falls outside the expected range? a. Press the “Comment” key and select the appropriate comments b. Repeat that level of control c. Put the meter back in the docking station d. A & B 4. Quality Control should be performed: a. Once a week b. Once every 24 hours c. If the meter was dropped d. B & C 5. What should you do if the patient result is critical? a. Press “Comment” to select appropriate action b. Turn off meter to avoid entering comment c. Repeat test if critical result does not correlate with patient medical condition d. A & C 6. Docking the meter uploads meter data, downloads updated setup information, and keeps the battery charged.

a. True b. False

7. If the meter displays “Hi” it indicates the patient result is greater than ________ mg/dL. 8. The “Accept” key must be utilized once the patient’s result is obtained to ensure data is captured and billed to the patient. a. True b. False 9. The meter will lock out if a QC is not performed within 24hrs as required, however the meter will alert the user during the last 4hrs prior to lockout. a. True b. False 10. If at any time a glucose test is repeated, do NOT accept the first result, and instead reject the result so that the patient

is NOT billed twice.

a. True

b. False

Score: ___/ 10 Answers are reviewed with student. _______________________________ _________________________ Evaluator Signature Evaluator Print Name

12


COMPETENCY ASSESSMENT: MEDICATION ADMINISTRATION FOR STUDENTS


but has had minimal opportunity to practice skill 4 = Unable to perform skill

PROCEDURE Assessment Code


Review physician orders closely for medications. Medication orders must be complete with name, dosage, frequency, route, date, time, and signature of the prescriber. All “PRN” orders must include indication for administration.

D O V

Patient height and weight must be entered in the computer. D O V

PREPARATION

Log into EMD D O V

Located patient and access eMAR D O V

Verified patient D O V

Check for allergies. D O V

Locate scheduled medications due (time critical versus non time critical) D O V

PREPARING MEDICATIONS FROM OMNICELL (with Instructor or RN Preceptor)

Instructor/Preceptor logged into Omnicell D O V

Locate patient by NAME D O V

Selected medication to be administered D O V

Performed 6 rights (right patient, medication, dose, route, time, and documentation) D O V

Proceeded to patient’s room D O V

PREPARING NARCOTIC MEDICATION (no waste)

Entered narcotic dose to be administered D O V

Removed medication(s) from Omnicell D O V

Proceeded to patient’s room D O V

PREPARING NARCOTIC MEDICATION (waste)

Entered narcotic dose to be administered D O V

Removed medication from Omnicell D O V

Wasted at this time with another RN and Instructor/Preceptor D O V

Documented waste in the Omnicell D O V

Proceeded to patients room D O V

PREPARING MEDICATIONS FROM PATIENT MEDICATION BIN

Located patient bin by ROOM NUMBER D O V

Selected medication to be administered D O V


Performed 2 RN dose verification if applicable D O V

Name_______________________________________ School______________________________________ Date________________________________________

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MEDICATION ADMINISTRATION FOR STUDENTS COMPETENCY (CONT.)

MEDICATION ADMINISTRATION IN PATIENT ROOM Assessment Code


Logged into eMD D O V

Located patient and access eMAR D O V

Verified patient by verbally confirming with the patient their name and through a second verification process by matching the patient name and medical record number on the eMAR with the patient’s wristband.

Reviewed patient’s allergies

D O V

D O V

Reviewed medication to be administered D O V


Accessed KBMA through eMAR D O V

Scanned patient wristband using the 2D barcode

Through KBMA, the correct patient is identified by scanning only the 2D barcode on the patient identification band worn by the patient

If the 2D bar code on the identification band cannot be scanned, notify primary RN

D O V

D O V

D O V

Scanned all medication (s) using barcode on mediation, pharmacy label or pharmacy flag label

Through KBMA, the correct medication is identified by scanning the barcode on the medication package while at the patient bedside.

D O V

D O V

Acknowledged alerts D O V

Administered medication D O V

Documented medication (s) administer in the MR D O V

Documented necessary assessment/data D O V

MISCELLANEOUS

Primary RN will be notified of any medication without a barcode, D O V

Crushing and cutting of tablets will occur at the patients bedside after first scanning the medication barcode.

D O V

Wasting of medications will occur in the medication room, with a licensed care provider as a wtiness.

D O V

Medications packaged in multi-dose contatiners will be stored with barcode labels provided by paharmacy and applied to syringe/medicaiton cup by the licensed care provider administering the medication.

D O V

Medications without a barcode or a barcode which cannot be scanned should be adminstered using the No Scan process in KBMA. The medication must be reported to the primary nurse who will then notify pharamcy immediately after for corrective actions.

D O V

All medications identified by the pharmacy, will be placed in the patient’s medication bin. All controlled substances will be locked up in the nursing narcotic storage/Omnicell container.

D O V



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COMPETENCY ASSESSMENT:

PLUM A+ INFUSION SYSTEM WITH HOSPIRA MEDNET™ SOFTWARE



Scenario: Mr. Jones was admitted for VTE, hypokalemia and dehydration. The admitting orders include Normal Saline with 20 mEQ of KCL to run at 150 cc/hr and Heparin (25,000 units in 500 ml) to run at 1200 units per hour. Program your PLUM A+ Infusion pump with MedNet safety software with IVF infusing on line “A” and Heparin infusing on Line “B”. Follow the check off sheet below to guide you through the programming process.

Assessment Code


Press the ON/OFF button to turn the Plum A+ ON. D O V

Select the “TRAINING” CCA

Press Enter

D O V

Select line A on the Main Menu

Press Drug List (Drug Library)

Locate IVF w/KCL and Press ENTER

Choose STANDARD Program

Program pump per orders with a VTBI of 900 mls.

Confirm Program and start infusion

D O V

Select line B on the Main Menu

Change Mode to “CONCURENT”

Press Drug List (Drug Library)

Locate heparin 25000 unit/500 ml and Press ENTER

Choose STANDARD Program

Enter a dose of 12000 units

Hard limit has been reached indicated by a beeping sound and three --- Press the “Clear” button and reprogram the pump.

Now enter a dose of 12 units

Soft limit has been reached indicated by a beeping sound a message “Dose < 50, override?” Press the “NO” button and reprogram the pump for 1200 units and start the infusion

Both Tear drops should be flashing green.

The programmed medications should be visible on the Main Screen

D O V

Remember to document dosing and mls/hour in medical record. D O V


Name_______________________________________ School______________________________________ Date________________________________________

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PRECEPTEE AGREEMENT

Dear Preceptee: We are pleased to have you here at PIH Health. Assisting in the growth and development of the next generation of nurse leaders is a very important commitment for our organization. Over time we have found the following guidelines ensure a valuable and positive learning experience for both our preceptees and PIH Health nursing preceptors. Please review the following and acknowledge your acceptance of these guidelines by signing below.

Strictly follow the RN preceptors work schedule. Do not seek additional hours with other nurses.

Notify preceptor in advance either the night before or no later than 2 hours before the shift begins (5:00am) if you will be calling off.

Arrive promptly and be prepared at 7:00am to begin your shift. Tardiness delays patient care and prevents you from receiving a thorough report with your preceptor. Tardy is considered 7:01am/pm.

Adhere to the PIH Dress Code, Policy #86500.718.

Cell phone, iPods, and other electronic devices will not be used in patient care areas. Such items will only be allowed in break areas such as the nurse’s lounge or patio areas. Please use Lexi-comp or Expert Advice for drug referencing needs.

If the student fails to adhere to any of the aforementioned guidelines the preceptor will counsel the student and the instructor will be notified.

If the student is unable to adhere to the preceptee guidelines following counseling by the preceptor and instructor, termination of preceptorship will be considered.

_____________________________________________________ Student Signature

Name_______________________________________ School______________________________________ Date________________________________________

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STUDENT PRECEPTEES – EMERGENCY CONTACT INFORMATION

GENERAL INFORMATION Name

Address

City, State, Zip Code

Telephone Numbers: Home Phone: Cell Phone:

Company/School

Supervisor/Instructor Name: Phone:

EMERGENCY INFORMATION Notify/Relationship Contact Number

Notify/Relationship Contact Number

INSURANCE/MEDICAL CONTACT INFORMATION Medical Insurance Medical Record #

Policy # Contact Number

Physician Contact Number

Where non-emergent care is to be provided

MEDICAL INFORMATION Important Medical History:

Critical Allergies

Any additional information

RETURN TO EDUCATION DEPARTMENT IF YOU ARE A PRECEPTEE