NCLEX: Clinical Skills Performance Checklists

Clinical Skills Performance Checklists: Feeding

Focus topic: Clinical Skills Performance Checklists

  • Follow agency policy for proper identification of the resident to ensure that the meal is the correct one prepared for the resident.
  • Position resident in sitting position.
  • Offer and assist resident to wash hands before feeding.
  • Sit at eye level with resident for feeding.
  • Protect clothing from spills.
  • Provide fluids (at least every 3–4 bites of food) to drink during feeding.
  • Use a spoon to feed resident.
  • Make sure resident has swallowed before offering additional bites of food.
  • Encourage resident to complete meal to receive maximum benefit of diet.
  • Talk with resident during feeding to encourage interaction and increase satisfaction with feeding experience.
  • Leave area around resident’s mouth clean and dry.
  • Record food intake in percentages.
  • Document I & O for fluids as ordered for the resident.
  • Report any resident problems with feeding procedure.

 

Clinical Skills Performance Checklists: Offering the Bedpan

Focus topic: Clinical Skills Performance Checklists

  • To protect bed linens, place a protective pad directly under resident buttocks.
  • Using the correct size bedpan to fit the resident (a fracture pan might be necessary for immobilized resident), ask the resident to roll to opposite or position resident on side opposite you and place the bedpan under resident to allow for comfort and collection of urine or stool.
  • After the bedpan is in place, raise the head of bed to resident’s comfort level.
  • Provide resident with toilet tissue before removing the bedpan.
  • Before removing the bedpan, lower the head of the bed.
  • Empty bedpan contents into toilet.
  • Cleanse and dry the perineal area as necessary to remove urine or stool.
  • Rinse, dry, and store bedpan in bottom drawer of bedside cabinet.
  • Record output (record total urine output in cc or mL, according to facility procedure; if recording stool, estimate the amount expelled).
  • Report unusual amount, color, odor, and consistency of stool or resident discomfort.

Clinical Skills Performance Checklists: Performing Ostomy Care

Focus topic: Clinical Skills Performance Checklists

  • Carefully remove ostomy appliance that is attached to the skin.
  • Gently but firmly cleanse the skin around the stoma with soap and water, and dry the area thoroughly.
  • Apply skin protector around the stoma as ordered.
  • Empty the collection bag and note the amount, color, and consistency of the stool.
  • Wash thoroughly with soap and water.
  • Re-attach the appliance per manufacturer’s instructions and fasten the clamp to prevent leakage.
  • Record the procedure and report any redness, irritation, open lesions, or resident discomfort to the nurse.

Clinical Skills Performance Checklists: Administering a Cleansing Enema

Focus topic: Clinical Skills Performance Checklists

  • Assemble equipment and supplies at the bedside; prepare the cleansing enema solution: Keep water temperature at 105°F; add manufacturer’s soap to water (do not use bar soap); flush enema tubing with water to expel air from tubing; clamp tubing securely.
  • Raise the side rails and raise the bed to a comfortable working position.
  • Assist the resident onto the left side in the Sim’s position and cover with a bath blanket.
  • Position an I.V. pole beside the bed and raise the side rail.
  • Hang the enema bag on I.V. pole with the tubing at the bottom of the bag. Hang
    no higher than 18 inches above the bed or 12 inches above the resident’s anus.
  • Apply gloves.
  • Lower the side rail and place a protective pad under the resident’s buttocks.
  • Lubricate four inches of the tip of the enema tubing.
  • Ask the resident to breathe deeply to help relieve cramping during the procedure.
  • With one hand, lift the upper buttock to expose the anus; with other hand, carefully insert the tubing tip into the rectum, rotating it approximately 2–4 inches into the rectum. If you feel resistance or the resident complains of pain, stop the procedure and notify the nurse.
  • Unclamp the tubing and allow the solution to flow slowly into the rectum. If the resident complains of cramping, clamp the tubing and stop the flow; resume in a minute or so to instill as much liquid as possible.
  • Ask the resident to hold the solution inside the rectum as long as possible.
  • Lower the bed position and assist the resident to the bathroom or the bedside commode; if unable to leave the bed, place the resident on a bedpan to expel the enema fluid and stool; place the call light within easy reach.
  • Discard the equipment and supplies in the garbage receptacle and clean area.
  • Return to the bedside or bathroom when the resident has completed the toileting
    process.
  • Provide perineal care.
  • Observe the expelled stool; flush toilet or empty commode or bedpan.
  • Apply clean gloves; wash and disinfect commode or bedpan and return for storage; remove gloves and wash hands.
  • Lower the bed and raise the side rails per facility policy.
  • Record the amount, color, and consistency of the expelled stool.

Clinical Skills Performance Checklists: Recording Intake and Output (I & O)

Focus topic: Clinical Skills Performance Checklists

  • Identify foods considered to be liquid and estimate intake by the resident.
  • Record amount of liquid taken by the resident in cubic centimeters (cc) or milliliters (mL), according to facility policy.
  • Measure output by pouring the contents of the urine receptacle (urinal or bedpan) into a graduate.
  • Holding the graduate with one gloved hand, remove the glove from the other hand
    and flush the urine down the toilet.
  • Rinse and disinfect the graduate and bedpan or urinal according to facility policy.
  • Using a pen, record the amount of urine in the Output column of the I & O form.
  • Report any unusual color, amount, odor, or particles noted in the urine to the nurse.

Clinical Skills Performance Checklists: Measuring and Recording Output from a Urinary Drainage Bag

Focus topic: Clinical Skills Performance Checklists

  • With gloved hand, open drain (at bottom of urinary drainage bag) and empty urine bag into graduate without touching drain to the graduate.
  • Wipe drain with alcohol swab after emptying urine and return drain to the cover on the urinary drainage bag, being careful not to touch the drain to the bag while inserting it into the cover.
  • Secure urinary drainage bag to the bed frame; never hang the bag on the side rail or other movable part of the bed.
  • Place graduate at eye level on a flat surface covered with a paper towel to read the level of urine collected.
  • Empty urine into toilet; rinse and store the graduate; discard the paper towel.
  • Remove gloves and wash hands.
  • Record output.
  • Report any unusual odor, color, consistency, or particles noted in the urine to your supervisor.

Clinical Skills Performance Checklists: Indwelling Catheter Care

Focus topic: Clinical Skills Performance Checklists

  • Position the resident: For a female, position dorsal recumbent (on back) with head slightly elevated and knees bent; for a male, use the supine or Fowler’s position.
  • Place waterproof pad under resident’s buttocks.
  • Cover resident to expose only the perineal area.
  • For a female, use your non-dominant hand to gently pull open labia to fully expose urethral meatus and catheter insertion site, keeping hand in this position throughout procedure. For a male, use your non-dominant hand to retract the foreskin if not circumcised, and hold penis firmly at shaft just below the glans (end of penis), keeping hand in this position throughout procedure.
  • Observe urethral meatus and tissue for color, odor, swelling, and consistency of discharge.
  • Cleanse perineal tissue: For a female, use clean, soapy cloth and cleanse around urethral meatus and catheter, from top of meatus toward anus. For a male, while spreading urethral meatus, cleanse around catheter first, then wipe in circular motion around meatus and glans to base of the penis. Dry well.
  • While holding the catheter with your non-dominant hand, cleanse length of the catheter from meatus to connective tubing in a circular motion.
  • For uncircumcised male residents, replace the foreskin over the glans.
  • Position resident for comfort.
  • Report and record characteristics of drainage, appearance of perineal area, or any discomfort reported by the resident.

Clinical Skills Performance Checklists: Applying a Condom Catheter

Focus topic: Clinical Skills Performance Checklists

  • Provide perineal care.
  • Remove the protective backing from the catheter’s adhesive surface.
  • Roll the catheter onto the penis, moving from the end of the penis (glans) toward the body.
  • Leave one inch of space between the penis and the end of the catheter.
  • Apply tape in spiral direction to secure the catheter. Never completely encircle the penis (to avoid a tourniquet effect).
  • Connect the catheter to the drainage bag.
  • Tape the catheter to the resident’s inside thigh to prevent traction on the catheter.
  • Fasten the drainage bag to the bed frame. Never fasten the drainage bag to a movable part of the bed.
  • Record the procedure and the resident’s response.
  • Remove the catheter for perineal care at least once daily; report any redness, swelling, or discomfort to the nurse.
  • Add the specimen amount to the output total.

Clinical Skills Performance Checklists: Collecting Specimens

Focus topic: Clinical Skills Performance Checklists

Prepare specimen label and follow the procedures for the different specimens documented in the sections that follow.

Clinical Skills Performance Checklists: Routine Urine Specimen

Focus topic: Clinical Skills Performance Checklists

  • Assisting if necessary, ask the resident to urinate into a clean bedpan, urinal, or specimen collection pan (hat).
  • Carefully remove the specimen container lid and lay the lid on a solid surface with the inside up.
  • Pour at least 5 ccs (mLs) of urine from the bedpan, urinal, or hat into the specimen container.
  • Carefully replace the lid on the container to avoid touching the inside of the lid or the container.
  • Clean and store the bedpan or urinal in the bottom drawer of the bedside table;
    never place the urinal or the bedpan on the overbed table.
  • Attach the label to the container and take the container to the designated location.

Clinical Skills Performance Checklists: Clean Catch Urine Specimen

Focus topic: Clinical Skills Performance Checklists

  • Provide perineal care.
  • Position the resident on a bedpan, provide a urinal, or assist to the bathroom.
  • Carefully remove the specimen container lid and lay the container lid on a solid surface with the inside up.
  • Instruct the resident to begin voiding and then stop.
  • Holding the specimen container under the resident, instruct him or her to resume
    voiding and collect at least 5 ccs of urine.
  • Instruct the resident to finish voiding.
  • Carefully replace the lid on the container to avoid touching the inside of the lid or the container.
  • Clean and store the bedpan or urinal in the bottom drawer of the bedside table;
    never place the urinal, bedpan, or hat on the overbed table.
  • Attach the label to the container and take the container to the designated location.

Clinical Skills Performance Checklists: Urine Specimen from an Indwelling Catheter

Focus topic: Clinical Skills Performance Checklists

  • Carefully remove the specimen container lid and lay the container on a solid surface with the inside up.
  • Clamp the catheter below the collection port.
  • Swab collection port with alcohol swab.
  • Attach needleless syringe to collection port and slowly withdraw at least 5 ccs of urine.
  • REMOVE the clamp.
  • Slowly eject the urine specimen into the sterile container.
  • Carefully replace the lid on the container to avoid touching the inside of the lid or the container.
  • Attach the label to the container and take the container to the designated location.
  • Add the specimen amount to the output total.

Clinical Skills Performance Checklists: Stool Specimen

Focus topic: Clinical Skills Performance Checklists

  • Assist the resident to void if necessary.
  • Carefully remove the specimen container lid and lay the container on a solid surface with the inside up.
  • Place the resident on a bedpan or place a specimen pan (hat) under the toilet seat.
  • Instruct the resident not to dispose of toilet tissues into the bedpan or hat; provide a disposable bag for soiled tissues.
  • Place the call light within easy reach.
  • When the resident is finished, remove the resident from the bedpan or assist from the bathroom.
  • Provide perineal care.
  • With gloved hands, use a tongue depressor to transfer one to two tablespoons of stool from the bedpan to the specimen container.
  • Wrap the tongue depressor in paper towel and discard it in the disposable bag.
  • Remove gloves; carefully replace the lid on the container to avoid touching the inside of the lid or the container.
  • Clean and store the bedpan in the bottom drawer of the bedside table; never place the bedpan on the overbed table.
  • Place the disposable bag of tissues in a Biohazardous waste container.
  • Attach the label to the container and take the container to the designated location.
  • Add the stool elimination to the daily stool count.

Clinical Skills Performance Checklists: Heimlich Maneuver

Focus topic: Clinical Skills Performance Checklists

  • Ask the resident, “Are you choking?” or “Can you speak?” If yes, encourage resident to try to cough until the object clears the throat. Stay with resident and call for help immediately.
  • If the resident cannot speak or cough, perform the Heimlich maneuver immediately.
  • If resident is sitting or standing, stand behind him or her.
  • Wrap your arms around the resident, just above the waist.
  • Make a fist with your hand.
  • Place the thumb side of your fist in the center of the resident’s abdomen, just above the umbilicus (navel) and below the tip of the breastbone.
  • Grasp your fist with your other hand.
  • Quickly pull inward and upward on the abdomen with a quick thrust.
  • Repeat the upward thrusts until the foreign object comes out or the resident loses consciousness.
  • If the resident loses consciousness, ease to the floor and check respirations; if no respirations, begin rescue breathing until relieved; if no pulse, begin CPR and continue until relieved.
  • When the emergency is resolved, assist with preparing incident report.

Clinical Skills Performance Checklists: Isolation Procedures

Focus topic: Clinical Skills Performance Checklists

Isolation procedures follow CDC guidelines for various medical conditions that require protection among residents to control the spread of disease. The following guidelines apply to individual supplies and equipment that might be required for a particular type of isolation.

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Clinical Skills Performance Checklists: Putting on Disposable Gown, Gloves, Goggles, and Mask

Focus topic: Clinical Skills Performance Checklists

  • Remove watch and place on a paper towel for transport into resident room (keep on towel until needed for vital signs).
  • Wash hands and dry thoroughly.
  • Put on disposable gown with opening at the back; tie the neck ties.
  • Tie the gown’s waist ties, ensuring that the back edges of the gown cover your uniform.
  • Don a mask, adjusting it to cover your nose and mouth; tie the mask securely at the back of your head or slip elastic bands on the side of the mask over your ears.
  • Don goggles over eyes and adjust to fit well.
  • Don gloves, ensuring that the gown cuffs are covered by the cuff edges of the gloves.

Clinical Skills Performance Checklists: Removing Disposable Gown, Gloves, Goggles, and Mask

Focus topic: Clinical Skills Performance Checklists

  • Remove gloves, turning them inside out and placing them in the Biohazardous waste receptacle.
  • Holding them only by the elastic bands, remove goggles or face shield.
  • Without touching the outside of the gown, ease one hand inside the cuff of the gown on the opposite arm and pull the gown down over the other arm.
  • Using the same technique, pull the gown down from the other arm.
  • Fold and roll the gown away from you, with outside (contaminated side) folded to the inside.
  • Discard the gown in the Biohazardous waste receptacle.
  • Remove the mask by grasping only the ties or elastic bands at the mask sides.
  • Untie the bottom tie first, and then the top tie or slip the elastic bands over your
    ears.
  • Dispose the mask in a covered trash receptacle.
  • Wash and dry your hands.
  • Place your watch in your pocket; dispose of the paper towel in the trash receptacle.
  • Use a paper towel to open the door of the resident’s room.
  • Discard the towel inside the room.
  • Repeat handwashing per facility policy.
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FURTHER READING/STUDY:

Resources:

 

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