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Nursing Practice Skills

for

Registered Nurses
Caring for

Adult Intensive Care Unit Patients


during a

Pandemic Flu Outbreak

July 2009
Version 3

Index of Nursing Practice Skills

Orientation to Intensive Care Unit

1. Bedside Safety

2. Admission, Transfer and Discharge Checklist

3. Bedside and Patient Care Planning


Planning and co-ordination of care

4. Patient Care Issues


Essential patient care
Skin Care
Safe Moving and handling
Monitoring of vital signs

5. Documentation
Observation chart
Fluid balance chart
Care plan

6. Respiratory Care (Airway and Breathing)


Airway management
Manual Ventilation
Care of Endotracheal Tube / Tracheostomy Tube
Respiratory Support
Ventilation / Extubation

7. Cardiovascular Care (Circulation)


Arterial lines
Central lines
Fluid management
Emergency clinical situations (shock, cardiac arrest)

8. Neurological Care (Disability)


Level of consciousness (AVPU / GCS)
Sedation and analgesia

9. Nutritional Care
Enteral nutrition
Glycaemic control

10. Psychosocial / Spiritual Care

11. Infection Control

12. Laboratory Investigations

CCaNNI 1
ICU Nursing Skills
July 2009
Version 3
Introduction

The following skills document has been developed by the Education Sub
Group of the Critical Care Network (NI)

It is important to note that this framework relates to the introduction to and


knowledge and understanding of the key practical skills required within adult
critical care nursing. It does not suggest or assess any level of competency
within the areas outlined.

The following is based upon the assumption that level 3 care (Intensive Care)
will be at least doubled within each Trust and that the normal standards of
care and staff ratios will be altered during a pandemic escalation.

The remit was to identify additional skills that are needed by non ICU staff at
the same time recognising the skills that are already available. In this light we
assume staff will have up-to-date core skills such as; administration of IV
drugs, blood administration, safe handling etc and have therefore not included
these in our recommendations.

Signatures are used to signify that the skills have been demonstrated
/discussed with a member of staff and NOT as an assessment of competence.
This process can be delivered in own work place by an appropriate member of
staff (nurse, doctor, technician)

Orientation to Intensive Care Unit

Nursing practice skills Description of achievement Date Date


(Signature) (Signature)
Orientation Familiarise self with ♦ Fire escapes and fire fighting equipment
location ♦ Physical layout of unit
♦ Fluid and drug cupboards, linen stores, sluice
and equipment stores
♦ Emergency equipment / trolleys
♦ Oxygen and air cylinders
♦ Unit guidelines and guidance sheets
♦ Patient cohort plans
♦ Staff changing facilities
♦ Systems of reporting to ICU nurse / Nurse in
charge

Nursing Practice Skill 1 Bedside Safety Checklist

Has awareness of : Description of achievement Date Date


(Signature) (Signature)
Bedside Gas Points ♦ Check oxygen and air point connections
and Re-Breathing Circuit ♦ Check circuit intact, connected and ready for
Emergency /Ambu bag use
Equipment ♦ Check for leaks/damage
Safety ♦ Inflate bag

CCaNNI 2
ICU Nursing Skills
July 2009
Version 3
Checks Suction ♦ Ensure suction assembled, attached to
patient and working effectively
♦ Ensure various sizes of closed/open suction
catheters available
Intubation Tray / ♦ Aware of location, contents and purpose of
Trolley equipment.
Cardiac Arrest trolley ♦ Aware of location, contents and purpose of
equipment.
Alarms ♦ Check monitor, pump and ventilator alarms
are activated and responded.
Lines & ♦ Check all lines/infusions labelled & dated
Infusions according to local policy
♦ Check all infusions
rate/volume/dose/additives/expiratory
date/connections
Pressure ♦ Check and change pressure bags/systems as
bag/transducer per local policy

Patient Identification ♦ Ensure patient armband applied, accurate


and legible (as per Trust policy)

Nursing Practice Skill 2 Admission, Transfer and Discharge Checklist

Has awareness of: Description of achievement Date Date


(Signature) (Signature)

Preparing Emergency Prepare bed space equipment for admission:


for equipment  Rebreathing circuit
admission of  Oxygen
a new  Suction equipment
patient with  Ventilator & infusion pumps
assistance  Locker/trolley stocked
Monitor ♦ Ensure all cables attached to monitor
♦ Ensure electrodes present
♦ Set up monitor
Charts Prepare: (for example)
♦ Observation / fluid charts
♦ ICNARC forms
♦ Nursing documentation
♦ Admission book
♦ Blood forms etc.
Receive new ♦ Receive hand over from appropriate person
admission with ♦ Attach patient to oxygen therapy / ventilator
assistance ♦ Attach patient to monitor
♦ Document observations/assessments
♦ Obtain blood specimens
♦ Complete documentation
Discharge / Discharge ♦ Obtain confirmation from consultant / nurse in
transfer to charge
ward ♦ Liaise with nurse in charge or ICU nurse
♦ Communicate with patient and family
♦ Complete transfer form
♦ Ensure all charts complete and transferred
CCaNNI 3
ICU Nursing Skills
July 2009
Version 3
♦ Ensure ICNARC form and admission book
complete
After discharge ♦ Decontaminate bed space
♦ Clean equipment and bed area
♦ Restock & prepare bed space for admission

Practice Skill 3 Bedside & Patient Care Planning

Has awareness of: Description of achievement Date Date


(Signature) (Signature)

Planning & Co- Effective ♦ Ensure all electrical equipment plugged in,
ordination Bedside switched on and leads secured.
of Care management ♦ In the event of equipment failure calls for
help.
♦ Aware of need to maintain a clean
uncluttered bedside/unit environment
♦ Remove equipment for decontamination
when no longer required
♦ Aware of need to maintain bedside stock
♦ Ensure vacant bed spaces ready for new
admissions at all times.
♦ Do not leave patient unobserved

Nursing Practice Skill 4 Patient Care Issues

Has awareness of: Description of achievement Date Date


(Signature) (Signature)
Patient Essential Patient ♦ Mouthcare
Care Care ♦ Eyecare
Issues ♦ Urinary Catheter care
♦ Bowel management
♦ Patient hygiene
♦ DVT Prophylaxis

Skin Care ♦ Braden Scale


♦ Pressure area management
♦ Wound management
♦ Specialist beds/mattresses
Safe Moving & ♦ Manual handling assessment
Handling ♦ Re-positioning & mobilisation
♦ Log rolling technique
Comprehensive ♦ A,B,C,D,E approach (elaborated upon under
Patient assessment other practice skills sections)
Monitoring and ♦ Able to use monitoring equipment
interpretation of vital ♦ Monitor, assess and interpret RR, O2 Sats,
signs HR, BP, CVP, Temp as per unit protocol
♦ Able to recognise significance of changes &
seek help.
CCaNNI 4
ICU Nursing Skills
July 2009
Version 3

Nursing Practice Skill 5 Documentation / Charting

Has awareness of: Description of achievement Date Date


(Signature) (Signature)

Accurate, Observation ♦ Undertake and document frequency of


timely and Chart observations according to patient condition
legible and unit policy.
documentation
Fluid balance ♦ Document hourly intake & output
chart ♦ Document running total

Care Plan ♦ Record, date and sign, assessment, planning,


implementation & evaluation of care

Nursing Practice Skill 6 Respiratory Care (Airway and Breathing)

Has awareness of: Description of achievement Date Date


(Signature) (Signature)

Airway Airway ♦ Recognise causes of airway obstruction


Management assessment ♦ Undertake airway assessment (look, listen,
feel):
- Airway sounds
- Air entry
- Equal rise and fall of chest wall
- Synchronous chest movement

Airway adjuncts ♦ Know methods of maintaining a clear airway


in unconscious patient using head tilt, chin lift
and artificial adjuncts
Assessment of ♦ Undertake assessment of breathing:
breathing - Air entry
- Respiratory rate and depth
- Use of accessory muscles
- Equal rise and fall of chest wall
- Synchronous chest movement
- Patient comfort levels
(anxiety/restlessness/exhaustion
perspiring)
Intubation Prepare for and Identify purpose of equipment
assist with ♦ Prepare Suction
intubation ♦ Prepare and check tube
♦ Know how to inflate pilot balloon and know
importance of adequate cuff inflation
♦ Can apply cricoid pressure
Care of ET Tube Position ♦ At lips (21-23 cm)
Endotracheal ♦ Know method for tying & securing
tube / Trache tapes/tracheostomy collar
tube ♦ Identify need for two nurses to change tapes
Patency of ♦ Assess tube patency
Endotracheal / ♦ Recognise/call for help conditions that affect
CCaNNI 5
ICU Nursing Skills
July 2009
Version 3
Tracheostomy patency:
tube  Kinked / dislodged tube
 Blood / sputum plug
♦ Awareness of need for humidification

Suctioning ♦ Recognise when to suction


♦ Select appropriate suction catheter
♦ Perform open/closed suction
♦ Perform oral suctioning
♦ Monitors patient during suctioning
♦ Awareness of complications of suctioning

Respiratory Modes of Can identify main modes according to unit:


Support ventilation ♦ SIMV PC
♦ PRVC CPAP
♦ PSV
Assessment of ♦ ABGA (parameters)
ventilation ♦ Arterial blood gas
and ♦ FiO2
♦ Respiratory Rate
Monitor, and ♦ (controlled/spontaneous)
record ventilator ♦ Tidal volume / minute volume
parameters ♦ PEEP
♦ Pressure support
♦ Airway pressures
♦ Response to alarms
♦ Ventilator settings for patient admission
♦ Administration of bronchodilators
♦ Know when to call for help
Ventilator ♦ Recognise, call for help, and know action to
emergencies take in event of:
♦ Disconnection
♦ Loss of secure airway
♦ Loss of power
♦ Loss of oxygen supply
♦ Loss of suction
♦ Tension pneumothorax
♦ Sputum plug
Management Planned / ♦ Prepare for / assist with extubation:
of extubation Emergency ♦ Prepare patient
♦ Prepare equipment
♦ Know action to take in unplanned extubation
♦ Know post-extubation observations

Nursing Practice Skill 7 Cardiovascular Care (Circulation)

Has awareness of Description of achievement Date Date


(Signature) (Signature)

Arterial Lines Assist with ♦ As per unit policy


exertion ♦ Assist with insertion of cannula

CCaNNI 6
ICU Nursing Skills
July 2009
Version 3
Care of arterial ♦ NEVER INJECT VIA THIS ROUTE
line ♦ Dressing & site check (as per unit policy)
♦ Blood sampling
♦ Keep site exposed
♦ Correctly labelling
Arterial Line Positioning / ♦ Correct position transducer
Monitoring Patency ♦ Recognise normal trace / accuracy of
waveform
♦ Recognise when to call for help to
troubleshoot waveform, line problems
♦ Know how to flush line
♦ Understand importance of No air in line
♦ Check pressure bag
Check for:
♦ Thrombosis
♦ Peripheral ischaemia
♦ Haemorrhage
♦ Infection
♦ Call for help – if any of above present
Removal of ♦ Removal as per unit guidelines
Arterial line ♦ Aware of post line removal observations
Central Insertion Assist with insertion of catheter
venous procedure
Catheters Care of central ♦ Check line sutured in and secured
line ♦ Ensure lines labelled and dated and
documented accurately
♦ Perform dressing change and site check as
per unit protocol
Central Positioning / ♦ 4th intercostal space mid axilla line
Venous patency ♦ Recognise trace / accuracy of wave-form
Pressure ♦ Recognise when to call for help to
Monitoring troubleshoot wave-form / line problems
Flushing / no air in line

Inotropes Adrenaline Have awareness of:


and Noradrenaline ♦ Mode of action
Administration Antiarrhythmics ♦ Side effects
of IV infusions ♦ Safe administration
/drugs via ♦ Monitor blood pressure and heart rate
Central line
♦ Each inotrope via single lumen where
possible
♦ Do not bolus
♦ Check infusions beginning, during and end of
shift
♦ Check infusion rate hourly
♦ Alert ICU nurse at least 1hour before
infusions complete
♦ label infusion and line as per protocol
Complications ♦ Pneumothorax
of Central ♦ Infection
Lines ♦ Venous thrombosis and embolism
Removal of ♦ Assist with line removal as per unit guidelines
Central Line ♦ Aware of post line removal observations

CCaNNI 7
ICU Nursing Skills
July 2009
Version 3
Fluid Fluid replacement ♦ record fluid replacement
Management ♦ Recognise early signs of deteriorating renal
function and report same

Electrolyte ♦ Aware of safe management of electrolyte


imbalance replacement

Managing Shock ♦ Recognise changes im rhythm and call for


emergency help
Cardiovascular
clinical
situations

Nursing Practice Skill 8 Neurological Care (Disability)

Has awareness of: Description of achievement Date Date


(Signature) (Signature)

Level of GCS ♦ Know when and how to undertake a GCS


Consciousness ♦ Recognise altered level of conscious and call
for help
Sedation Sedation Scores ♦ Aware of use of sedation scores in ICU
and ♦ Document patient’s sedation score.
Analgesia ♦ Recognise complications of over / under
sedation

Analgesia ♦ Awareness of strategies for/accessing


optimising pain relief

Nursing Practice Skill 9 Nutritional Care

Has awareness of: Description of achievement Date Date


(Signature) (Signature)

Nutrition Enteral nutrition ♦ Awareness of care of nasogastric tube/ fine


bore feeding tube
♦ Management of enteral feeding as per unit
protocol
♦ Ability to operate enteral feeding pump
♦ Use of appropriate syringe to deliver NG
drugs
Glycaemic ♦ Monitor blood glucose as per unit protocol
control ♦ Management of insulin therapy as per unit
protocol

CCaNNI 8
ICU Nursing Skills
July 2009
Version 3
Nursing Practice Skill 10 Psychosocial / Spiritual Care

Has awareness of: Description of achievement Date Date


(Signature) (Signature)

Person centred Psycho/social ♦ Aware of visiting arrangements and


care needs of communication systems during the various
patients, phases of pandemic flu escalation plan
relatives and ♦ Understanding of needs of dying patient and
carers their relatives
♦ Caring for fellow professionals
♦ Aware of counselling / bereavement support
Colleagues services for staff

Spiritual needs ♦ Aware of hospital chaplaincy service


of patients & arrangements during pandemic flu
relatives
Ethical issues ♦ Awareness of ethical & legal issues during
pandemic flu

Nursing Practice Skill 11 Infection Control

Has awareness of: Description of achievement Date Date


(Signature) (Signature)

Infection control Legislation & Awareness of:


policies ♦ Appropriate application and removal of PPE -
gloves, aprons, gowns, eye protection, masks
♦ Hand hygiene techniques
♦ Aware of isolation precautions
Decontamination ♦ Decontamination of:
♦ Bedspaces
♦ Equipment

Nursing Practice Skill 12 Laboratory Investigations

Applies awareness of: Description of achievement Date Date


(Signature) (Signature)

Interpreting Obtaining and ♦ Obtain results by telephone/ electronically


laboratory interpreting ♦ Record and report results
investigations results

CCaNNI 9
ICU Nursing Skills
July 2009