,, .-.

-
l (UDENT NAME: Ir aV) a
Student Name: Q
Instructions for Students: Take a printed copy of this checklist to every lab, simulation, and clinical day. Ensure lab/simulation or clin ical faculty verify
demonstration or observation of skills by signing and dating in the appropriate box. Scan a copy of the signed Psychomotor Skills Checklist and upload it
into the appropriate drop box in LoudCloud at the end of every didactic course with skills lab experiences and every clinical course.
Note: Students are responsible for maintaining the original signed copy of this checklist throughout the duration of the program. Uploading the
document into the appropriate courses is required to advance from semester to semester and to graduate. Students are not requ ired to demonstrate
or observe every skill on this form in the clinical setting.

Instructions for Lab Faculty: Print, sign, and date below each skill to acknowledge the student's successful demonstration in the lab setting. Students
must be signed off by lab faculty for all required skills prior to demonstration in clinical.

Instructions for Clinicians: Sign and date in the appropriate box next to each skill to acknowledge the student's succe'ssful demonstration/ observat ion
of the skill. Students must be signed off by lab faculty on a required skills prior to demonstration in clinical. Students are not expected to observe or
demonstrate all listed skills in clinical, however, clinicians should look for opportunities for students to observe and demonstrate as many skills as

I
possible.

0r; / 0 I l aI~
I

J ; , ,tSignature~ IL_/II/LOl 5 Stud Signat Date - Level 2:

By signin acknowledge that I have demonstrated or observed the skills By signing, l cknowl dge tfi t I hl1ve demonstrated or
indicated. observed the skills indicated.

;;;;;,ignature an Level 3 O~/IS /l Q ~ J

Student Signature and Date - Level 4:

By signing, I trated or observed the skills

$-
,:• ;&, -·
<'
By signing, I acknowledge tha';;"Yave demonstrated or
indicated. observed the skills indicated.

Skill checklists can be found in the textbook Clinical Nur5fr;g SkiP~ and Techniques, 8th ed., by Perry, Potter, and Ostendorf

l :
STUDENT NAME:l r V) a n.
Lab Setting Clinical Setting
Student
Lab Faculty Printed Name, Signature, and Date (Include below after Demoed
Clinician Printed Name, Signature, and Date or
student has successfully demonstrated each skill in lab.)
Observed
I

Required Level 1 Lab SkillS-*these skills must be signed off in lab

prior to demonstration in clinical
Documentation and Informatics
*Giving a handoff report
D
q\11 kt 1Y~1l'brJ 0
* Documenting nurses'
D

0
*Adverse event/inci
D
Donna Carlson, MSN, R
0
Vital Signs 1
""'1- *Measuring body temperatur~/lJ ~
Kathfeen Yost RN MSN BSN MC .)t' D
<'i 7q \i
l - - -*-=A-1ss-e-ss-in+g.!. _r_a-:- 1s-e- - -7't-M-:-- ~
di-al:--p-u-=-- e
J onna Carlson, MSN, RN

-~,fvJ 4/ 6~
0

D
t \Lq {l 0
_ Carlson, M~N _t-,/---....,.-=..~~~-- - - -----:-lJ:--;/.--:-
0~ '& ---t------i
, µ 5,\f, ?4v D

0
--------+----.---- - - - - - - - - - - - ----t-----
Kathleen Yost RN MSN BSN MC D

I
iJ JDENT NAME,T r anq · no.,u L\).,Y\
¾ *Assessing blood Jressure ~ect~onically
/( Kathleen Yost RN MSN BSN MC

~)27\l'( ~ 0
Kathleen Yost RN MS N

0
*PBA- Vital Signs (Level 1)

u_;:;,,,.._..__.. ~~ ~6 s)
Health Assessment
*General survey en ost RN MSN BSN MC
D

D ~/ /Jq
1if!01
L-~-
T_o-ra-x-an
* _ - ~~lu-~-g a_s!!._
se~ss_m_~- ~-fZ--o}-- - - - :_/4_'/'_ _ _-----4'1k---~4'-~~,----------
0
T-:1 JC/1/ I/IQ
10
L - - - ~i.__ _ _ _ _ _1/----;--------,~----t4~~---------i-------;;-_;7i1
; 11/ HI
~Vl---0 tJ t?A)
1
//) >tlJ,,r :
*Abdominal assessment
- - - --+--------__,_.~--- - - - - - ---r~---=:---:--1

WllvJ-urvvJ
~ - - - - - - - - - - - : - - - = - -- - ~ -- - ---· - ·---4--- -..,....,.-- - - - - -- -- - - - - - - - t - -0
-,

~ ~ :~as~;;~--.----,;t f
*Monitoring intake and output ;i)_
D
0
1-ll.. 114
D

0
*PBA - Head-to-Toe Assessment (Level 1)
 ~ .t:'.
z o
r- ...
z
~
ST~U~D~EN
~ T!_!N ~I_V~ll~Yl-4_
~A~M~E:..:_: ___'._'._~~:::::(\~--- - - - - - - - - - - - -- - - - - - -- - - - - - - -~
*
Medical Asepsis
* Hand hygiene

~\Iq ,~ &ti~
Donna Carlson MSN RN
Kathleen Yosr ~1,
f"'\1vMsN ~ D

0
*Isolation precautions
D

0
Sterile Technique arson, MSN RN
D

0
* Sterile gloving
D

o\\~ \ 0
Safe Patient Handling, Transfer and Positioning
0

..,Y *Using safe and effective transfer techni

Kathleen Yost RN MSN BSN MC j< D
D
* * Moving and positioni n
athleen Yost RN MSN BSN MC
o

D 0
Personal Care and Bed Making

;iP 'Bathing aclie~\s\d Kathleen Yost RN MSN BSN iviC

~ D

~_$_N, R1...!.!~~·j ---+-- --

&t/~ e
Donna Carisa~ - - -- -- () 0
- - - - - - - - - - - - t ---;;;-

Kathleen Yost D
l3SN Mc
\) 0
LJ . LlDENTNAME, lv~f'lq,,
* Oral hygiene ~
D

0
MSN BSN MC :t' D

0\ Donna Carlson, MSN RI\! 0

• Assist with/ ~ •; ~~ D

0
* Use of a urinal
,/,~ fi-f/S D

0
* Making an occupied bed
J!r- D C,/1 ! Ill
0
Jo/; v!l
' Positioning client on a bedpan or fr•s~ •
i4f'J,__._~----- -------------'-----
D

0
~
Oxygen Therapy
--'-=-- - - - ' - - - ' - - - - - - - ~ ~- - - -
* Applying a nasal cannula or oxyg

~
1-----__:_ {-+
b-------1--"'-ometry
* Using incenti
-~----L~ .u;L..l,,,LloU.lscm MSN R '=>-.,..-------,~ ~ - J - - - - - - - - - - - + - - -o_
D
(DJO I( Donna Carlson MSN ---'--
RN 0
-----------------~------'
 ~ j "hl \
-----nQ-~~----,-__'~ ~
STUDENTNAME:Tvan~ n/q/.4(,{,l,V\ --
I a
MedkaUon Administratio w
I~ , ~ ~ ~-
*Administering oral medications

~~ f£rJ ///Zo-1g 0

'Administ~;•~~•~~ions t h r o u g h ; u ~ D

0
*Applying topical medications to th r son SN tt 0~
>-<.~,\{ w D

D
'!J I II~
0
* Administering nasal instillations
D

0
*Using metered-dose inhalers
D
~ ~m~?d,,ZAJ lt/2.g/ 1~
0
*Administering rectal suppositories
D

0
Parenteral Medications

fe
*Preparing injections: Ampules and vials

~,ndi-}z'd,l<'IJ iz/s/,B
-- ------- -- i - - - - - - - - - - ----L--_Q__J
* Administering intradermal injections

~/dl!JS;/ IJ.. -5=- Jg 0

r------:1".:-;----:-:-----:----:---- - - --
* Administering subcutaneous injections D j /11/t4
17-/4/1 f ~ /1/4/N /tit) rlJP~ 0
~
~
,UDENTNAME:lvetnq, n4/A~
* Administering intrf musculf inj~ctions <a) / 1q
~ ~ff/SIV-cd., ~ tz.Jsj;~
D

0
Therapeutic Use of Heat and Cold
* Applying heat , D

¥ ~~6S~
* Applying cold
0

D
0
1 -8'-rt 0

Specimen Collection
* Urine specimen collection: Midstream urine; rine specimen from
existing indwelling catheter
D O I~
1~/2) ;- 0

* Collecting a timed urine specime~ L / jl ~ 1

/ D
c._)t --~ / ~ <.3/ lcf'
0

*Blood glucose monitori g *(Level 1 an D

o 10 l1
•Urine screening for glu ose, ketone,, protei ) ;;rz,
0

0
sTuoENT NAME: 1 Ya nq,, r 14'1)..~
Optional Additional ikills t& DerAonstrate in Clinical
Anytime During or After Level 1

Health Assessment
Genitalia and rectum assessment
D

Exercise and Ambulation

Performing range-of-motion
D

\\.'b Donna Carlson, MSN, RN

D

0
Assisting with ambulati fc.nitch~s-; and walker

0
Support Surfaces and Special Beds arisen M
Utilizing support surfaces

¥ ~ /.,,J 65J 0-5'-I~

D

Placing a client on an air-suspension or air-fluidized bed

D

0
Safety and Quality Improvement
Applying a physical restraint
D

0
1 - - - - - - - - - - - - - - -- - - - - --···- - - - - - f- - - - - - - - - - - - - - - - - - - - - - - - +- - - - - f
Seizure precautions
D

... - ·· ____ ___ - - - - - - - -- - - - - -- - - -- - ~ -0- ~

__._
, (UDE NT NAME: run e n~
Pain Management and Basi1 Comfori Me~sures
Nonpharmacologic pain management
/.2 D
¥ ~ N65/J q <6-1& 0
Providing pain relief
;J D
1 -J.5° -11
~ ~
Care of the Eye and Ear
v /J.,J /3 5°;J
0

Eye care for nonresponsive clients .. ~

D

0
Care of hearing aids
D

, 0
Airway Management
Performing ~ ro~haryngeal s u c ~ g ~ ~ e D

l8 {() / Y _ -- -
UIC'~I Qt\) 0
Dressings and Bandacl!s UO
nna \Ji::il lO VI , , , .. , .... ,

ct 14 it /J &4~
~ Applying a dressing

Applying a pressu re bandage

n - - -- ,._ _ __ , ___ ••""' ......
e
..., ,_,," IU ' - ' - • •v'-'1 1 1 IV,_,, '11 I I I ,
r Ur:n l1N----- K"fh.!een
\Y

I
/((~,-
'-
Yost RN MSN BSN A.JR

4-··?1?1/
I(:;;:QZ, ..
..~
D

o
D

0
Applying a transparent bandage
D

I /\~ ") 0
Applying gauze and elastic bandages
\t41' , ( c;,u,, U"2{ XSA!. RJJ D
6L le
I
--·---·-·
0
 z
STUDENT NAME:
Specimen Collect ion
Measuring occult blood in stool
"I
0

~putum Collection D

0
Elimination

14 /t1/4Jt
Emptying of ostomy b~ / 2 D
0
I
Required Level 2 Lab SkillS-*these skills must be signed off in lab
prior to demonstration in clinical -On Insertion of an G Tube-in the required
section-Add peak flow as optional in level 2
Parenteral Medications
* Ad minist ering medications by intravenous bolus
D

~~ I ,- 0
"
* Administ ering intravenous medication by piggyback, intermittent
\f:),~ ~ ~( ~ ~- NH,~ fJl I D
3/11 'IQ
i~ ; ~,~~s, ~nw ~us;ITTJ})N AVP- c_ I

0
*PBA - Peripheral Intravenous Insertion (Level 2)
~

/1'7
77' -__;;> v,ms~ lm 1
/id I~
/
* PBA - Medication Administration (Level 2)
D
~ ffe:JD EJ;N, ~ If 2L\(19
-- ·----
0
Urinary Eliminat ion ·-- -- --
*J/'A - Foley Catheter Insertion (Level 2)
D
T/
1

~ 11100---'&J, RN 2./,4/1°1
r -·-·- - -- --- 0

I
JJ
/
UDENTNAME:

Additional Optional Skills to be Demonstrated in Clinical

Anytime During or After Level 2
Intravenous and Vascular Access Therapy
Initiating intravenous therapy
D ~ 9
I--\7 -A 0 ·1i
Regulating intravenous flow rate
D

0
Changing IV solutions
D

00>1 ~ 0
Changing infusion tubing
D

illv~ 0
Discontinuing short peripheral intravenous access
D

1·- 17-(4 FiJ P --C 0

Enteral Nutrition
Inserting and removing a small-bore nasogastric/nasoenteric
D
feeding t u,6} 1 ~) /"J ,., , 1/Jtfj; 9
~ Y / X 51-/~ 0
Verifying f
D

0
· uals
D
~
L _ _ - - - - = - - - - - - - - - -- - - - - - - _____j___ _ _ _ __ 0- - ~
_ _ _ _ _ _ _ _ _ _- - ' - - -
STUDENT NAME:
Administering enteral nutrition: Nasoenteric, gastrostomy, or
D
jejuno~ o / ~ ~- j ~ Ylf/;7
ii 0
Ostomy Care
Pouching a colostomy or an ileostomy
D

0
Perioperative Care
Preparing a client for surgery
D

0
Wound Care
Performing a wound assessment
D

0
Wound irrigation
D

0
Managing wound drains
D

-· --~
0
Urinary Elimination
··- -- -
Insertion of a straight or indwelling urinary' catheter

~N,f21'l 2.J,I I (;f

\tfu~
vv
a.., 11/) _ Jr D

0
Care and removal of an indwelling catheter
H,rn ~ ,.VL t 0 S/~D /lq
~ j
w 2{7/ /9 V

0
------
---
----- 1UDENT NAME:

Required Level 3 Lab SkillS-*these skills must be signed off in lab

prior to demonstration in clinical
Medication Administration
.A _.;-PB - ministration (Level 3)
Mlf :}J... A / ')--/; D ~I /14
0
Intravenous and Vascular Access Therapy
*PBA - Central line dressing change
D

0 5/ 6/ lq
Airway Manag
*Performing tracheostomy care_s: ·
D

0
Closed Chest Drainage Systems
*Managing closed-chest drainage system
D

sn~: ;;:;:J"vel1 3)
Specimen Collection

and D

Ante partu m/1 ntrapa rtu m/Postpa rtu m

*Gestational assessment
D
0
STUDENT NAME: D
*Perineum assessment
0

Newborn/Pediatric
*Newborn head to toe assessment
D

0 0
igns (TPR, BP, pain management, pulse oximetry)
D

Il q 0

~ - - - - - - - - - - -- - - -- - - ··- -· ·- - _ _ __ _..____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __1__ ____:::

0_ _J
l i1oENf NAME:

- ct· . A .
optional Skills to be Demonstrated 10
.
During or After Level 3
mica 1 nyt1me

Oxygen Therapy

Administering oxygen to a client with an artificial airw

D

Using a peak flow Meter

' .__,..;~ · ;q 0
I
D

Care of a client on a mechanical ventilato~ ,- q,_ 0

0- · 2 2-/C) 0
Airway Management /
J
Airway suctioning ~ D ~/ l6/il
0
Performing endotracheal tube care . D
. 0
Parenteral Nutrition I
Administering parenteral nutrition through a central line D
0
Administering parenteral nutrition through a peripheral line D
0
Newborn/Pediatric
Medication administration to p:~tric client - parenteral D
Wv. _t?_ -
1 - - - - - - - - -- - - - -- - - - - · · · ---··--- --
~ - ~ 0 ---l
+ - - - - - - + --+-=-:..._..=....!._ _ _ _ _ _ _ _ _ _ _ _ _+ - - -
1
D
Medication ~ ~ t~ lient - )ral ··-- _ . ~"-'A---
0
- - -- - + - - - - - --+-
'-.J
-1--- - - - - - - - - - - - - ----+----------1
Required Level 4 Lab SkillS-*thest ,. kf!(~ :-i,•;t l~.. ~iened o'ff in
lab prior to demonstration in clinical
1 - - - - - - - = - - - - - - - - - -- - -- - - -· - ---· . - - - - - -~ - - - - -- -- -- - - - - - - - - - - -- - - - ' -- - - - !
Medication Administration
·-----~---~ - - - - - - - - -- - - - - - - - - - ----,----~
*PBA - Medication Administrafam (Level 4) D

' - - - - - - - - - - - - - - - - ----------- ---- ~- 0 _J

------------------------'---___
STUDENT NAME:

• ~ 1~\\j\\ ~ ~ ~ ~ ~~L ~
j(,;rf,lh rf/ r1J h /2N ·°;&sAJ

Donna Carlson, MSN, RN

~·tJa)a~,~~,
BsrJ ' ~ 0 ~\~er (O\?v'-ti\-,

~ (!5;;?, us,r:,_,.; ~CtJ, 1-lS~W

j) I ~ Pfirt°U / ~
~+. • c:;:,-;;-
~~~ WIS 1\J I r2,rJ dS. , 7 l oi
~ A.A A O~- -
,..,-t1;:r--'