Skills check script – SEM 3

Attire:
- PN scrubs (clean)
- Mohawk One ID (worn and displayed)
- Running shoes (non-mesh, neutral)
- No long coloured polish

Secondary IV med preparation:

- Mini bags
- Needles – different sizes
- Syringes – different sizes
- Alcohol swabs
- Secondary line
- Medication label
- Medication administration reference book
- Non-scientific calculator
- Pen and pencil for documentation

*Hand Hygiene prior to initial contact*

Pre-procedure:
Hi, my name is insert your name, I’m a semester 3 practical nursing student with mohawk
college, and I will be taking care of you today. Can you confirm your name, DOB, and any
allergies please? Thank you insert client name, is there anything I can do to help you get
comfortable or would like you to be repositioned? Ok, now that you’re comfortable, I’m going to
close the door to ensure your privacy. I would like to inform you that this is confidential, and will
remain between you, myself, and the rest of the healthcare team. The information from today
will only be shared if you are a harm to yourself or others. Today I am going to completing insert
assigned skills check with brief explanation, do I have your consent to continue? Should you
have any questions along the way, please let me know and we can take a break so I can answer
them. I’m just going to step out to grab the materials needed, I’ll be right back. Perform hand
hygiene.

Procedure:
Review order, and incorporate the principles of the CNO decision tree – order is complete and
clear (state the order has a medication, dose, frequency, and route), I have the knowledge, skill,
and judgement (use medication reference guide to inform self and the CNO decision tree).
Complete first check – pt MAR w/ medication drawer. Complete second check – right med with
order. Verbalize 10 rights – right med, right dose, right pt, right route, right reason, right time &
frequency, right to refuse, right pt education, right documentation, right evaluation. Use IV
formulary to prepare medication properly - ensure compatibility, and bag size. Select proper
syringe/needle, provide rationale – blunt tip needle for medication preparation, syringe size
based on medication dose. Wipe surface of vial and port of mini bag with alcohol swab and
allow to dry. Pull air into plunger, equivalent to the volume of medication required – show
evaluator. Inject into airspace of vial, invert vial and withdrawal proper medication amount –
show evaluator. Inject medication into mini bag port and use scoop method to recap needle.
Gently rotate mini bags between hands to mix medication. Fill out medication label and place
on mini bag – name and dose of med, date, and initials. Perform hand hygiene, knock on pt door
and re-enter room with proper materials. Complete third check and raise bed to working height
– confirm client ID band with MAR and verbalize. State purpose, action, and 2 side effects of
medication and provide health teaching – medication administered via existing line, report any
symptoms and discomfort at the IV site, and provide an opportunity to ask any questions. Ensure
primary line is running at correct order, and lower primary line. Apply gloves, perform IV
assessment, and verbalize findings – free from pain, tenderness, redness, or swelling. Maintain
aseptic technique to prime secondary line – roller clamp is closed, insert spike, compress, and
fill drip chamber, slowly release roller clamp to prime, close roller clamp and clear line of any air
bubbles, place secondary bag above primary IV, cleanse port and connect tubing without
contaminating. Set secondary line correctly as per IV formulary and verbalize to evaluator.
Provide health teaching to pt – explain potential side effects, and please let me know if you’re
experience any discomfort at the site; painful or burning. Perform hand hygiene.
Post-procedure:

Ask if the client if comfortable or if they wish to change position, lower bed back to lowest
setting, and place call bell within reach. Verbalize – I will come back to check your IV in an hour
to monitor for any expected or unexpected outcomes.
Document on MAR with initials to medication administered, complete signature PN student
designation (MohColPN3)

Catheter insertion preparation:

- Catheter
- Catheter kit

*Hand Hygiene prior to initial contact*

Pre-procedure:
Hi, my name is insert your name, I’m a semester 3 practical nursing student with mohawk
college, and I will be taking care of you today. Can you confirm your name, DOB, and any
allergies please? Thank you insert client name, is there anything I can do to help you get
comfortable or would like you to be repositioned? Ok, now that you’re comfortable, I’m going to
close the door to ensure your privacy. I would like to inform you that this is confidential, and will
remain between you, myself, and the rest of the healthcare team. The information from today
will only be shared if you are a harm to yourself or others. Today I am going to completing insert
assigned skills check with brief explanation, do I have your consent to continue? Should you
have any questions along the way, please let me know and we can take a break so I can answer
them.

Procedure:
Demonstrate and verbalize reviewing order. Provide assessment – ask client about last void,
demonstrate light palpation of bladder, level of awareness to limitations with catheter insertion,
verbalize consideration of client’s age and gender. Apply clean gloves and ask pt to lift gown –
verbalize findings for redness, perineum drainage, and odour. Verbalize determination of
catheter size and provide rationale – age and gender. Assess clients knowledge of
catheterization and verbalization rationale – ensure pt understands how a catheter works, and
what is to be expected. Remove gloves, perform hand hygiene, and gather necessary supplies –
verbalize supplies, findings, and rationale. Raise bed to appropriate working height, move table
to appropriate side of bed, lower bedside rail and verbalize rationale – to avoid
contamination/turning back on sterile field. Apply clean gloves and arrange bedside table with
equipment in an organized fashion. Assist pt to appropriate position – supine, with thighs
slightly abducted and provide rationale. Provide perineal wash while examining and identifying
the urethra. Recover pt perineum, discard gloves, and perform hand hygiene. Ensure placement
of supplies on bedside table, drainage bag, assess clamp and provide rationale – ensure bag is
free from damage and the clamp works. Apply clean gloves, open outer wrapper of catheter kit
and places kit on a clean surface, arrange garbage, provide rationale – to not contaminate
sterile field. Open catheter kit away from body, add additional supplies to sterile field with
sterile forceps – provide rationale for needed supplies. Place forceps on sterile field in
appropriate spot – provide rationale. *if sterile field is broken, we must restart* remove
blanket, and square drape with sterile forceps to drape around the client’s perineum, and place
other drape on the bed between pts thighs – remove gloves and perform hand hygiene. Apply
sterile gloves – verbalize steps to take if sterile field is broken. Place sterile field on sterile drape
between pt thighs. Add antiseptic solution into appropriate compartment containing sterile
cotton balls. Open the inner sterile wrapper of catheter and verbalize opening lubricant, place in
appropriate compartment – verbalize depth of lubrication and attach prefilled syringe and set
aside on sterile field, place catheter in lubricant. Clean urethral meatus: female - w/
nondominant hand, retract labia to fully expose urethral meatus, w/ dominant hand use sterile
forceps to hold one cotton ball per area; far labia fold, near labia fold, and centre of vagina,
from the clitoris to the anus. Male – w/ nondominant hand gently grasp the shaft of penis;
verbalize to retract foreskin if pt is uncircumcised, w/ dominant hand cleanse around the
meatus in a circular motion, 3 times – ensure to discard each cotton ball after use and place in
garbage without contaminated sterile field. Pick up catheter with dominant hand and hold 7.5-
10 cm from catheter tip – tell client to take a deep breath and bear down. Insert the catheter
through the urethral meatus advancing 5-7.5 cm – verbalize inserting catheter until urine flows
and then advance 2.5-5cm more. move nondominant hand to the catheter with catheter in
urine tray and inflate balloon slowly – verbalize rationale. Gently pull on catheter until
resistance felt – verbalize rationale. Connect catheter to collection tube of drainage, and apply
securement device on thigh, coil access tubing and assess urine is flowing with no
obstruction/kinking of tubing, and place drainage bag below bladder – provide rationale. Clear
area for any and all garbage, ensure metal forceps are placed in sharps, remove gloves, and
perform hand hygiene.

Post-procedure:
Ask if the client if comfortable or if they wish to change position, lower bed back to lowest
setting, and place call bell within reach. Verbalize – I will continue to monitor for any expected
or unexpected outcomes.
Surgical asepsis preparation:
- Dressing tray
- Abdo pad
- Sterile gloves
- 4x4 gauze
- 2x2 gauze
- Tape
*Hand Hygiene prior to initial contact*
Pre-procedure:
Hi, my name is insert your name, I’m a semester 3 practical nursing student with mohawk
college, and I will be taking care of you today. Can you confirm your name, DOB, and any
allergies please? Thank you insert client name, is there anything I can do to help you get
comfortable or would like you to be repositioned? Ok, now that you’re comfortable, I’m going to
close the door to ensure your privacy. I would like to inform you that this is confidential, and will
remain between you, myself, and the rest of the healthcare team. The information from today
will only be shared if you are a harm to yourself or others. Today I am going to completing insert
assigned skills check with brief explanation, do I have your consent to continue? Should you
have any questions along the way, please let me know and we can take a break so I can answer
them. I’m just going to step out to grab the materials needed, I’ll be right back. Perform hand
hygiene.

Procedure:
Demonstrate, verbalize reviewing order, and perform hand hygiene – check expiry date of said
supplies. Select appropriate workstation, apply clean gloves, and set up sterile field - open
dressing tray away from you – verbalize placement of additional sterile supplies, while
maintaining sterile field and what happens if sterile field is broken. Add cleaning solution to
dressing tray and place garbage within reach. Remove gloves, perform hand hygiene, apply
sterile gloves, and remove dressing by pulling tape away from skin – verbalize maintaining
clients comfortability during procedure, remind client to not touch wound when opened and
discard accordingly. Keeping elbows tucked at waist, and maintaining sterile field, use forceps to
remove excess liquid from gauze and cleanse wound from least contaminated area – verbalize
and dispose of soiled gauze after each use. Blot would dry with gauze – use 3 pieces to
complete. Clean around surgical drain using one piece of moistened gauze, moving in circular
motion moving outward – dispose accordingly. blot area dry again – use 3 pieces of gauze.
Reassess wound and verbalize findings – wound is healing well. Apply sterile gauze around
wound and drain, apply Abdo pad and tape attaches – provide rationale. Remove supplies,
gloves and dispose of bag. Perform hand hygiene.

Post-procedure:
Ask if the client if comfortable or if they wish to change position, lower bed back to lowest
setting, and place call bell within reach. Verbalize – I will continue to monitor for any expected
or unexpected outcomes.