NURS 220 Putting It All Together Day Evaluation

Student_____________________Signature________________________ Date___________ Scenario#______

Start time:________ Stop time:_________ Evaluator:____________________________________

Additional Skill Performed:________________________________________ Rev 3/13 PASS REDO

HANDWASHING Ø SEE Ø DO PASS

1. Removes unnecessary jewelry, moves watch up arm
2. Inspects hands for cuts, sores or breaks in skin integrity
3. Wets hands thoroughly before applying soap
4. Lathers hands and wrists with good friction for at least 15 seconds
palms
back of hands
fingers
between fingers
fingernails
wrists
5. Rinses all surfaces of:
hands
wrists
fingers - which are pointed DOWN
no contamination occurs
6. Uses clean, dry paper towel to dry all surfaces of:
fingers
palms
wrists
no contamination occurs - dries from fingertips DOWN
5. Uses clean, dry paper towel to turn off water

GIVING A BED BATH TO A DEPENDENT CLIENT Ø SEE Ø DO PASS

1. Check Nursing Care Plan (NCP) and doctor's orders
2. Wash hands - see above check list
3. Knocks on patients door

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 NURS 220 Putting It All Together Day Evaluation
4. Enters room and introduces self, explain morning care routine
5. Checks name band for pt. identifiers and verbalizes them
6. Gathers supplies needed for am care
places linen in appropriate area
protects bedside table
provides privacy by closing door, curtain and blinds
raises bed to working level
7. Establishes need for bedpan or brief change ***see bedpan or brief application checklist***
8. Places bath blanket over patient and then roll down bedspread and sheet to foot of bed
9. Places 2 plastic bags at end of bed for disposal of linen
10. Puts on gloves and removes clients gown and places it in plastic bag
*at this time if the incontinent pad was dirty, it would be changed here - student can verbalize procedure here*
11. Removes gloves
12. Lowers bed
13. Washes hands
14. Obtains bath water without contaminating hands
15. Raises bed
16. Provides privacy
17. Washes face
eyes - inner to outer canthus with new section of washcloth with each stroke
face
neck
behind ears
does not use soap (unless specified by patient)
18. Washes, rinses and dries upper body:
hands
arms
axilla
upper chest
abdomen
19. Applies lotion to arms and hands as desired by client
20. Washes, rinses and dries lower extremities
legs

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 NURS 220 Putting It All Together Day Evaluation
feet
21. Applies lotion to legs and feet as desired by resident (avoid lotion between toes)
22. Turns client on side
23. Places towel on mattress behind clients back
24. Washes, rinses and dries back
25. Lotions back as desired by client
26. Applies gloves
27. Washes, rinses and dries back of thighs, buttocks and crease
**discards linens directly into plastic bag after use**
28. Applies ordered barrier cream to thighs, buttocks and crease as needed
29. Removes one glove, with ungloved hand pick up tube of barrier cream, applies to gloved hand and apply PRN
30. Place client on back
31. Remove gloves
32. Lowers bed (may verbalize)
33. Puts on new gloves
34. Discards bath water into toilet
35. Rinses bath basin and empties into toilet
36. Obtains fresh water
37. Places basin on bedside stand
38. Removes gloves
39. Performs hand hygiene
40. Raises bed to working level (may verbalize)
41. Ensures privacy
42. Applies gloves
43. Positions client and blanket to ensure warmth and privacy
44. Places towel underneath perineum
45. Cleans area of catheter where enters urethra with a half circular motion
ensure both sides of catheter are clean
46. Holds the clean area and wipes away from meatus with washcloth
repeat cleaning if necessary - (student never lets go of catheter until done)
uses new spot on wash cloth with each stroke
47. Washes, rinses and dries perineal area
Women: strokes are from front to back

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 NURS 220 Putting It All Together Day Evaluation
starts with inner labia and works outwards towards thigh
uses new spot on wash cloth with each stroke
Men: retracts foreskin and washes tip of penis at urethral meatus first
using circular motion, cleans from meatus outward
return foreskin to its natural position - do not dry tip of penis
gently cleanse shaft of penis and scrotum, paying close attention to underlying surfaces
48. Removes one glove, picks up tube of barrier cream w/ gloved hand & place a dab to gloved hand-apply PRN
49. Removes other glove
50. Repositions client
51. Dons new pair of gloves
52. Changes incontinent pad if it became wet during bath/dirty from patient accidently voiding or +BM
turns pt. on side
rolls dirty incontinent pad towards patient
places new incontinent pad on bed and tuck below dirty pad
rolls client over to other side
removes dirty incontinent pad and places in linen bag
smoothest out clean incontinent pad ensuring no wrinkles towards client skin
53. Removes gloves
54. Dresses patient in gown
55. Removes bath blanket and places in linen bag
56. Ensures sheet and comforter are neatly placed over client
57. Lowers bed
58. Gives client call button
59. Opens curtains, blinds &/or door
60. Cleans area - placing toilet articles back in bedside stand and wiping off bedside table
61. Disposes of bath water in toilet, rinses and dries basin and places basin in bedside stand
62. Takes dirty linen and places in hampers
63. Ask client if they need anything before you leave the room
64. Perform hand hygiene
65. Document any unusual findings

GENERAL EXPECTATIONS THROUGHT BEDBATH Ø SEE Ø DO PASS

1. Privacy and warmth of client are maintained at all times

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 NURS 220 Putting It All Together Day Evaluation
2. Washing, rinsing and drying of client is gentle but thorough (to include body folds/creases all areas exposed to urine and feces)
3. Washing movements are from distal to proximal
4. Wash cloth ends are contained so that water is not being dripped on the client, floor or bedside table
5. Limbs are held by the palm of the hand (cradling) vs. the fingers
6. The principle of clean to dirty is consistently followed
7. The rinse cloth is not soapy (soapy washcloth hung over side of wash basin and rinse cloth in water)
8. The bed is always in the lowest position when student not at bedside

COMMUNICATION Ø SEE Ø DO PASS

1. Encourages client's active participation in all care given
2. Explain procedures to client, speaks clearly, slowly and directly while maintaining face-to-face contact whenever possible
3. Engages client in therapeutic conversation (as disease process allows)
4. Student always knocks before entering/announces self or "nursing"

REMOVING GLOVES Ø SEE Ø DO PASS

1. Removes first glove by grasping in center of palm, pulling off hand and wadding into palm of hand
2. Places ungloved thumb under cuff of gloved hand
3. Removes second glove without touching outside of glove and contaminating either hand
4. Discards gloves in appropriate container and performs hand hygiene

COMMENTS:
Instructor: Student self evaluation:

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NURS 220 Putting It All Together Day Evaluation

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 NURS 220 Putting It All Together Day Evaluation
o#______

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Student_____________________Signature____________________Date___________

Start time:________ Stop time:_________ Peer: Faculty:

Additional Skill Performed:****___________________________________Rev 3/13, 6/17

HANDWASHING
1. Removes unnecessary jewelry, moves watch up arm
2. Inspects hands for cuts, sores or breaks in skin integrity
3. Wets hands thoroughly before applying soap
4. Lathers hands and wrists with good friction for at least 15 seconds
palms
back of hands
fingers
between fingers
fingernails
wrists
5. Rinses all surfaces of:
hands
wrists
fingers - which are pointed DOWN
no contamination occurs
6. Uses clean, dry paper towel to dry all surfaces of:
fingers
palms
wrists
no contamination occurs - dries from fingertips DOWN
7. Uses clean, dry paper towel to turn off water

GIVING AM CARE TO A CLIENT

1. Check Nursing Care Plan (NCP) and doctor's orders
2. Wash hands - see above check list
3. Knocks on patients door
4. Enters room and introduces self, explain morning care routine
5. Checks name band for pt. identifiers and verbalizes them
6. Do VITAL SIGNS - ****See VS tab
7. Do FULL BEDBATH - ****See FULL BB tab (vebalize oral care, no dressing client, do on Mannequin)
8. Gather AM care supplies: Warm wash cloths, toothbrush, dentures, glasses, hearing aids, brush, comb, clothes.
places linen in appropriate area
protects bedside table
provides privacy by closing door, curtain and blinds
raises bed to working level
9. Establishes need for bedpan or brief change - ***see BEDPAN or BRIEF CHANGE tab
Place 1 plastic bag at end of bed for disposal of dirty linen
 Puts on gloves and removes clients gown and places it in plastic bag
*at this time if the incontinent pad was dirty, it would be changed here - if student draws BRIEF CHANG
10. Removes gloves
11. Wash hands
12. Ask patient preference regarding order of AM care
13. Provide ORAL CARE -DENTURE CARE - ****see ORAL-DENT CARE
14. Wash client's face
eyes - inner to outer canthus with new section of washcloth with each stroke
face
neck
behind ears
does not use soap (unless specified by patient)
15. Offer wash cloth for patient to wash hands, arms and axilla, as desired and assist as desired.
hands
arms
axilla
16. Applies lotion to arms and hands as desired by patient
17. Do upper extremity PROM - ***See PROM tab
18. Perform PERI-RECTAL CARE - (do on Mannequin)
19. Apply gloves
20. Turn client to side
21. Wash and dry back of thighs, buttocks and crease
**discard linens directly into plastic bag after use**
22. Apply ordered barrier cream to thighs, buttocks and crease as needed
Remove one glove, with ungloved hand pick up tube of barrier cream, apply to gloved hand and apply PR
23. Remove remaining glove
24. Place client on back
25. Lower bed (can verbalize)
26. Wash hands (can verbalize)
27. PERI-CARE - (do on Mannequin)
28. Ensure privacy
29. Apply gloves
30. Position client and blanket to ensure warmth and privacy
31. Place towel underneath perineum
32. Clean area where catheter enters urethra with a half circular motion
ensure both sides of catheter are clean
33. Hold the clean area and wipe away from meatus with washcloth
repeat cleaning if necessary - (student never lets go of catheter until done)
use new spot on wash cloth with each stroke
34. Wash and dry perineal area
Women: cleanse from front to back
start with inner labia and work outwards towards thigh
use new spot on wash cloth with each stroke
Men: retract foreskin and wash tip of penis at urethral meatus first
use circular motion, clean from meatus outward
 return foreskin to its natural position - do not dry tip of penis
gently cleanse shaft of penis and scrotum, pay close attention to underlying surfaces
35. Remove one glove, pick up tube of barrier cream w/ gloved hand & place a dab to gloved hand-apply PRN
36. Remove other glove
37. Perform Colostomy care - ****See COLOSTOMY tab

38. Reposition client

39. Don a new pair of gloves
40. Change incontinent pad if it became wet during peri-care/dirty from patient accidently voiding or +BM
turn pt. on side
roll dirty incontinent pad towards patient
place new incontinent pad on bed and tuck below dirty pad
roll client over to other side
remove dirty incontinent pad and places in linen bag
smooth out clean incontinent pad ensuring no wrinkles towards client skin
41. Remove gloves
42. Apply TED hose - ****See TED Hose tab
43. Dress patient in preferred clothing, sitting on the side of the bed.
44. Ensure sheet and comforter are neatly made
45. Lower bed
46. Give client call button
47. Open curtains, blinds &/or door
48. Clean area - placing toilet articles back in bedside stand and wiping off bedside table
49. Take dirty linen and place in hampers
50. Ask client if they need anything before you leave the room
51. Perform hand hygiene
52. Document any unusual findings
53. Perform wound care/dressing change according to orders. *** See DSG Change tab
54. Check Blood Glucose Level - ****See GLUCOSE tab

GENERAL EXPECTATIONS THROUGHT AM CARE

1. Privacy and warmth of client are maintained at all times
2. Washing and drying of client is gentle but thorough (to include body folds/creases all areas exposed to urine and feces)
3. Washing movements are from distal to proximal
4. Limbs are held by the palm of the hand (cradling) vs. the fingers
5. The principle of clean to dirty is consistently followed
6. The bed is always in the lowest position when student not at bedside

COMMUNICATION
1. Encourages client's active participation in all care given
2. Explain procedures to client, speaks clearly, slowly and directly while maintaining face-to-face contact whenever possible
3. Engages client in therapeutic conversation (as disease process allows)
4. Student always knocks before entering/announces self or "nursing"

REMOVING GLOVES
1. Removes first glove by grasping in center of palm, pulling off hand and wadding into palm of hand
2. Places ungloved thumb under cuff of gloved hand
3. Removes second glove without touching outside of glove and contaminating either hand
4. Discards gloves in appropriate container and performs hand hygiene
INSTRUCTOR
Feedback: YES NO
1. Did the student communicate effecitvely and therapeutically with the client?
2. Did the student maintain a safe environment for the client?
3. Did the student maintain client warmth and privacy?
4. Did the student complete the care session competently?
5. Did the student complete tasks in an efficient and organized manner?
6. Did the student complete the tasks in the designated time frame?

COMMENTS:
INSTRUCTOR: Student self evaluation:

PEER COMMENTS:
_________ Scenario#______

Faculty:

REDO PASS

Ø SEE Ø DO PASS

Ø SEE Ø DO PASS

ush, comb, clothes.

 student draws BRIEF CHANGE

y to gloved hand and apply PRN

nd-apply PRN

ding or +BM

Ø SEE Ø DO PASS

Ø SEE Ø DO PASS

whenever possible

Ø SEE Ø DO PASS
 PEER
YES NO
ADDITIONAL SKILLS TO SELECT:
BEDBATH
BEDPAN
BRIEF CHANGE
COLOSTOMY CARE
DENTURE CARE
DRESSING CHANGE
GLUCOMETER TESTING
ORAL CARE
PROM
RANGE OF MOTION
TED HOSE
VITAL SIGNS
 Ø SEE Ø DO PASS
VITAL SIGNS
1. Gathers equipment
2. Performs hand hygeine
3. Identifies correct patient
4. Explains procedure
5. Takes temperature
removes probe from base
places probe cover over probe
inserts into patients mouth - S/L pocket
instruct client to close mouth
wait for beep
annotes reading
discards probe cover in trash can
replaces probe in base
6. Takes radial pulse
places fingertips on thumb side of client's wrist to locate pulse
counts for 30 sec x 2, if irregular feel for 1 full minute
if still irregular, ascultate apical pulse for 1 minute
7. Takes respiratory rate/effort
moves seamlessly from P to R
accutrately counts for 30 sec x 2, if irregular count for 1 full minute
if still irregular, ascultate lungs for 1 full minute
8. Takes blood preassure using One-step method
cleans diaphragm and earpices of stethoscope with alcohol
postitions clients relaxed arm at heart level with palm up
locates brachial artery
places BP cuff snugly on client's upper arm with arrow 1/2" above brachial artery
places sphygmomanometer at eye level
holds diaphragm between thumb and index fingers
locates brachial pulse with middle two fingers
inflates cuff 30 mmHg above point to where brachial pulse is no longer palpated
places diaphragm over brachial artery
slowly deflates cuff and notes BP
fully delfates and removes cuff
8. BP reading is accurate (within 2 mmHg of that observed by instructor)
9. Assess SaO2 with pulse oximeter.
place oximeter on finger (make sure finger has adequate circulation)
read monitor for % oxygen saturation
clean pulse oximeter monitor
10. Ask client to rate pain on a scale of 1-10
11. Ask patient if you can do anything else for them while in room
12. Give call bell
13. Perform hand hygeine
14. Document findings
ASEPTIC DRY DRESSING CHANGE Ø SEE Ø DO PASS

1. Checks doctor's orders & NCP for specifics to dsg change

2. Premedicates patient PRN
3. Assembles supplies needed
4. Performs hand hygiene
5. Enters pt room/ID correct patient using two identifiers
6. Explains procedure
7. Provides privacy
8. Raises bed to working level
9. Positions patient - perserve dignity and warmth
10. Puts on clean, disposable gloves
11. Places barrier between patient and bed (chux)
12. Removes tape or dsg change label
13. Unwraps gauze or cut dsg off - place in garbage
14. Removes old dressing one layer at a time - place in garbage
if dsg sticks, leave in place for removal later
15. Notes size, shape, color and any drainage from wound or on dsg
16. Removes gloves
17. Performs hand hygiene
18. Assembles field for dsg change
open dsg change kit
add pick-up to field
19. Dons sterile gloves
if dsg stuck to wound, irrigate until loosend w/ sterile saline
take pick ups and remove loosend dsg and discard in trash
20. Cleanses wound with saline until debris removed
21. 'Pats' wound dry (place 4x4 on wound and apply light pressure to absorb saline)
throws 4x4 in trash
22. Dry surrounding area w/ gauze in kit
23. Cover wound with 4x4 included in kit
24. Place ABD pad over 4x4's
***may remove gloves at ths point***
25. Wraps wound on limb with gauze and secure
use tape or dsg change label
time/date/initials
26. Removes chux/protective pad
27. Removes gloves if not done earlier
28. Cleans area
29. Lowers bed and place call bell within reach
30. Documents - appearance of wound and how pt tolerated procedure
COLOSTOMY CARE Ø SEE Ø DO PASS

1. Gathers equipment needed

2. Knocks, enters room and identifies correct patient
3. Explains procedure to client
4. Washes hands
5. Dons gloves
6. Raises bed to working level
7. Places barrier between patient and bed, isolating colostomy bag
8. Places container under bag
9. Unclips bag
10. Expresses contents of bag into container
11. Cleans fecal matter off end of bag
12. Clips bag/secures closure
13. Empties contents of container into toilet
14. Rinses container and empties into toilet
15. Stores container for next use
16. Removes barrier
17. Removes gloves
18. Lowers bed and provides pt call light
19. document findings
***If patient or condition requires bag removal to empty:***
removes bag from appliance
empties into toilet
rinses/flushes bag prn
replaces bag on wafer ensuring it 'snaps' into place
BEDPAN Ø SEE Ø DO PASS
***Provides privacy***
1. Lowers head of bed
2. Raises bed to working level
3. Applies gloves
4. Places bedpan correctly under client's buttocks
5. Removes gloves
6. Raises head of bead to client's comfort
7. places bed in lowers position
8. Places call bell within reach
9. Ask client to signal when finished
10. Washes hands
11. Ensure client you will return shortly to check their status
12. Upon return to patient's room
a. shut off call light
13. Don gloves
14. Assist client with cleansing self if necessary
15. Remove 1 glove to lower head of bed
16. Replace glove on that hand
17. Hold onto bedpan while client lifts off
18. Removes bedpan, takes to bathroom, empties, rinses and stores item
19. Lowers bed
20. Removes and disposes of gloves
21. Assist client to wash hands after using bedpan
24. Washes hands
25. Documents BM in book
BRIEF CHANGE Ø SEE Ø DO PASS

1. Determines need for brief change

2. Gathers needed supplies
3. Ensures correct size (obtain from either pt. or NCP)
4. Provides privacy
5. Positions patient
6. Dons gloves
7. Unsecure dirty brief and tuck between legs
8. Rolls client on side
9. Wipes off fecal matter/debris with clean part of brief
10. Cleans and dries bottom
11. Places linen used in plastic bag
12. Applies barrier cream as ordered
13. Centers clean brief
14. Rolls client to other side
15. Ensures brief placement is correct (centered)
16. Brings brief up between legs, ensuring no pinching or bunching of skin
17. Secures brief with attached adhesive or Velcro strips
18. Informs client procedure is done once verifying brief is correctly placed per patient
19. Lower bed and provide call light
20.Documents as needed (skin/size of BM)
TED HOSE APPLICATION Ø SEE Ø DO PASS

1. Obtain appropriate size for client

verbalize how to measure for calf and thigh high hose
2. Explain procedure to client
3. Perform hand hygiene
4. Provide privacy
5. Position client
6. Raise bed to working level if appropriate
7. Expose limb
8. Turn sock 'inside out'
9. Place end of sock over toes, avoiding scraping foot with kuckles
10. Pull sock up behind heal
11. Then take top of sock which is hanging over the toe, and pull up to knee
(while placing socks, put fingers on inside/top and knucles on outside)
12. Ensures no wrinkles are in socks
13. Ensures opening is on top - check capillary refill
14. Reposition client to comfort,lower bed and give call bell
15. Document as needed
GLUCOMETER TESTING Ø SEE Ø DO PASS
1. Check provider's orders for type and frequency of test ordered
2. Gather needed supplies
3. Perform hand hygiene
4. Knock, enter room and correctly ID patient (2 identifiers)
5. Provide privacy
6. Position patient so they are comfortable
7. Load lancet into device
8. Turn on glucometer (verbally stating QC has been done recently)
9. Engage test strip
10. Don gloves
11. Identifies site to be punctured and clean with alcohol
12. Place lancet device against site and push button
verbally states sites to be used
13. Squeeze finger gently or milk digit to create large blood drop
14. Place glucometer test strip close to blood drop
(machine will wick blood into strip)
15. Once a audible beep is heard, remove machine from test site
16. Provide patient with cotton ball or 2x2 to stop blood flow from site
17. Read results from machine
18. Disengages strip from machine into garbage
19. Removes gloves
20. Interpret the results
student states if too high/low and tx for both
21. Turn off glucometer
22. Dispose of sharps in sharps container
23. Clean up area replace equipment
24. Educates patient on results
25. Documents findings in chart
notifies provider if out of ordered range
MOUTH/ORAL CARE Ø SEE Ø DO PASS
1. Washes hands
2. Applies gloves
3. Organizes supplies needed on a waterproof barrier
4. Ensures client is in upright sitting position
5. Places barrier across client chest
6. Moistens and applies toothpaste to toothbrush/toothette as appropriate
7. Gently cleanses entire mouth (including tongue and all surfaces of teeth)
8. Assists client to rinse mouth, holds emesis basin to client’s chin, and wipes client’s mouth
9. Removes barrier and disposes of appropriately
10. Cleans, dries, and returns implements to proper storage
11. Maintains clean technique with placement of toothbrush or toothette throughout procedure
12. Removes gloves and washes hands

DENTURE CARE Ø SEE Ø DO PASS

1. Washes hands
2. Organizes supplies needed on a waterproof barrier
3. Applies gloves
4. Protects dentures from breakage at all times by lining the sink
5. Rinses dentures in cool running water
6. Brushes dentures on all surfaces with toothpaste or denture cleaner
7. Rinses dentures with cool running water
8. Rinses denture cup
9. Places dentures in cup
10. Assists client with placement in mouth
11.Cleans and dries implements
12. Stores implements
13. Cleans sink environment
14. Removes gloves
15. Washes hands
16. Maintains clean technique with placement of dentures and toothbrush throughout procedure
PASSIVE RANGE OF MOTION Ø SEE Ø DO PASS

1. Washes hands
2. Knocks on patients door, introduces self and checks pt. identifiers
3. Explains procedure
4. Provides privacy
5. Provides should ROM
a. supports arm at elbow
b. flexion and extension
c. abduction and adduction
d. rotation
6. Provides knee ROM
a. supports knee and ankle
b. flexion and extension
7. Provides ankle ROM
a. supports foot and ankle
b. flexion and extension
8. Provides support of all limbs
9. Moves joints gently, slowly and smoothly through the ROM to the point of resistance
and discontinues if pain occurs/patient discomfort
10. Leaves bed in lowest position with call bell in reach