Skills Performance Checklists for Clinical Nursing Skills & Techniques 9th Edition

h Edition

Skills Performance Checklists for Clinical Nursing Skills& Techniques

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Skills Performance Checklists for Clinical Nursing Skills& Techniques Perry, Potter, Ostendorf 9th edition ELSEVIER

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CCoonntteennttss CHAPTER 1 USING EVIIDDENCE IN PRRAACTICE /[NO CHHEECCKKLLISTS IIN TTHHIIS CHHAAPPTTEERR]} CHAPTER 2 ADMITTTIING,, TRRAANSFERR,, AAND DISCHHAARGE Skill 2.1 Admitting Patients, 1 Skill 2.2 Transferring Patients, 4 Skill 2.3 Discharging Patients, 6 CHAPTER 3 CCOOMMMUUNICATION AAND COLLAABORRAATION Skill 3.1 Establishing the Nurse-Patient Relationship, 9 Skill 3.2 Communicating With Patients Who Have Difficulty Coping, 12 Skill 3.3 Communicating With a Cognitively Impaired Patient, 15 Skill 3.4 Communication With Colleagues, 17 CHAPTER 4 DOCUMENTATION AND INFORRMAATICS Procedural Guideline 4.1 Giving a Hand-Off Report, 19 Procedural Guideline 4.2 Documenting Nurses'’ Progress Notes, 20 Procedural Guideline 4.3 Adverse Event Reporting, 21 Procedural Guideline 4.4 Guidelines for Meaningful Use of an Electronic Health Records (EHR), 22 CHAPTER 5 VITAAL SIGNS Skill 5.1 Measuring Body Temperature, 23 Skill 5.2 Assessing Radial Pulse, 27 Skill 5.3 Assessing Apical Pulse, 29 Skill 5.4 Assessing Respirations, 31 Skill 5.5 Assessing Arterial Blood Pressure, 33 Procedural Guideline 5.1 Noninvasive Electronic Blood Pressure Measurement, 36 Procedural Guideline 5.2 Measuring Oxygen Saturation ((Pulse Oximetry), 38 CHAPTER 6 HEALTH ASSESSMENT Skill 6.1 General Surveyy, 40 Skill 6.2 Head and Neck Assessment, 43 Skill 6.3 Thorax and Lung Assessment, 46 Skill 6.4 Cardiovascular Assessment, 49 Skill 6.5 Abdominal Assessment, 54 Skill 6.6 Genitalia and Rectum Assessment, 57 Skill 6.7 Musculoskeletal and Neurological Assessment, 60 Procedural Guideline 6.1 Monitoring Intake and Output, 64 CHAPTER 7 SPECIMEN COLLECTION Skill 7.1 Urine Specimen Collection: Midstream (Clean-Voided) Urine; Sterile Urinary Catheter, 66 Procedural Guideline 7.1 Collecting a Timed Specimen, 69 PPrroocceedduurraall GGuuiiddeelliinnee 77..22 aUUnrrdiinnPeeHSScc, rr7ee0eenniinngg ffoorr GGlluuccoossee,, KKeettoonneess,, PPrrootteeiinn,, BBlloooodd,, Skill 7.2 Measuring Occult Blood in Stool, 71 Skill 7.3 Measuring Occult Blood in Gastric Secretions (Gastroccult), 73 Skill 7.4 Collecting Nose and Throat Specimens for Culture, 75 Skill 7.5 Obtaining VVaginal or Urethral Discharge Specimens, 77 Procedural Guideline 7.3 Collecting a Sputum Specimen by Expectoration, 80 Skill 7.6 Collecting a Sputum Specimen by Suction, 81 vV

Skill 7.7 Obtainingg WWound Drainage Specimens, 83 Skill 7.8 Collecting Blood Specimens and Culture by Venipuncture (Syringe and VVacutainer Method), 86 Skill 7.9 Blood Glucose Monitoring, 91 Skill 7.10 Obtaining an Arterial Specimen for Blood Gas Measurement, 93 CHAPTER B8 DIAGNOSTIC PROCEDURES Skill 8.1 Intravenous Moderate Sedation, 96 SSkill 8.2 Contrast Mediaa Studies: Arteriogram (Angiogram), Cardiac Catheterization, and Intravenous Pyelogram, 98 Skill 8.3 Assisting with Aspirations: Bone Marrow Aspiration/Biopsy, Lumbar Puncture, Paracentesis, and Thoracentesis, 101 Skill 8.4 Care of Patient Undergoing Bronchoscopyy, 103 Skill 8.5 Care of Patient Undergoing Endoscopyy, 105 CHAPTER S9 MEDICAL ASEPSIS Skill 9.1 Hand Hygiene,, 107 Skill 9.2 Carinngg for Patients Under Isolation Precautions, 109 Procedural Guideline 9.1 Caring for Patients with Multidrug-Resistant Organisms (MDRO) and CClloossttrriiddiiuumm ddiiffffiicciillee,, 112 CHAPTER 10 STERILE TECHNIQUE Skill 10.1 Applying and Removing Cap, Mask, and Protective Eyewear, 113 Skill 10.2 Preparing A Sterile Field, 115 Skill 10.3 Sterile Gloving,, 118 CHAPTER 11 SAFE PATIENT HANDLING, TRANSFER, AAND POSITIONING SSkill 111.1 UUsing Safe and Effective TTransfer Techniques, 120 PPrrocedural Guideline 11.1 Wheelchair TTransfer TTechniques, 125 SSkill 111.2 Movingg and Positioning Patients in Bed, 127 CHAPTER 12 EXERCISE AND MOBILITYY Skill 12.1 PPrromoting Early Activity and Exercise, 132 Procedural Guideline 12.1 Performing Range-of-Motion Exercises, 135 PPrrocedural Guideline 12.2 Monitoring Patient on a Continuous Passive Motion Machine, 136 Proceduurraall Guidelinnee 12.3 Applying Graduated Compression (Elastic) Stockings and Sequential Compression Device, 138 Procedurraall Guidelinnee 12.4 Assisting With Ambulation ((Without Assist Devices), 140 Skillll 12.2 Assisting WWith Use of Canes, WWalkers, and Crutches, 143 CCHHAAPPTTEERR 1133 SSUUPPPPOORRTT SSUURRFFAACCEESS AANNDD SSPPEECCIIAALL BBEEDDSS Procedural Guideline 13.1 Selection of Pressure-Redistributed Support Surface, 147 Skill 13..11 Placing A Patient on a Support Surface, 149 Skill 13..22 Placing A Patient on a Special Bed, 151 CCHHAAPPTTEERR 1144 PPAATTIIEENNTT SSAAFFEETTYY Skill 14.1 Fall Prevention in Health Care Agencies, 153 Skilll 14.2 Designing A Restraint-Free Environment, 157 SSkkiillll 1144..33 AAppppllyyiinngg PPhhyyssiiccaall RReessttrraaiinnttss,, 116600 Proceduurraall Guideline 14.1 Fire, Electrical, and Chemical Safetyy, 163 Skilll 14.4 Seizure Precautions, 165 CCHHAAPPTTEERR 1155 DDIISSAASSTTEERR PPRREEPPAARREEDDNNEESSSS Skill 15.1 Care of a Patient After Biological Exposure, 168 Skilll 15.2 Care of a Patient After Chemical Exposure, 170 Skill 15.3 Care of a Patient After RRadiation EExxpposure, 172 vvii

CHAPTER 16 PAIN MANAGEMENT vviiii Skill 16.1 Pain Assessment and Basic Comfort Measures, 174 Skill 16.2 Patient-Controlled Analgesia, 176 Skill 16.3 Epidural Analgesia, 179 Skill 16.4 Local Anesthetic Infusion Pump for Analgesia, 183 Skill 16.5 Nonpharmacological Pain Management, 186 CHAPTER 17 PALLIATIVE CARE Skill 17.1 Supporting Patients and Families in Grief, 190 Skill 17.2 Symptom Management at the End of Life, 192 Skill 17.3 Care of a Body After Death, 196 CHAPTER 18 PERSONAL HYGIENE AND BED MMAKKIING Skill 18.1 Complete or Partial Bed Bath, 199 Procedural Guideline 18.1 Perineal Care, 204 Procedural Guideline 18.2 Use of Disposable Bed Bath, Tub, or Shower, 206 Skill 18.2 Oral Hygiene, 209 Procedural Guideline 18.3 Care of Dentures, 211 Skill 18.3 Performing Mouth Care for an Unconscious or Debilitated Patient, 212 Procedural Guideline 18.4 Hair care-—combing and shaving, 214 Procedural Guideline 18.5 Hair Care-—Shampooing, 217 Skill 18.4 Performing Nail and Foot Care, 219 Procedural Guideline 18.6 Making an Occupied Bed, 222 Procedural Guideline 18.7 Making an Unoccupied Bed, 225 CHAPTER 19 CARE OFF THE EEYE AND EAR Procedural Guideline 19.1 Eye Care for Comatose Patients, 227 Procedural Guideline 19.2 TTaking Care of Contact Lenses, 228 Skill 19.1 Eye Irrigation, 231 Skill 19.2 Ear Irrigation, 233 Skill 19.3 Care of Hearing Aids, 235 CHAPTER 20 SAFE MEDICINE PPRREEPAARATION /[NO CHEECCKKLIISTSS IIN TTHHIIS CHAPTTEERR]} CHAPTER 21 ADMINISTRATION OOFF NONNPARENTERAL MMEEDDIICCAATTIIONNSS Skill 21.1 Administering Oral Medications, 238 Skill 21.2 Adminstering Medications Through a Feeding Tube, 242 Skill 21.3 Applying Topical Medications to the Skin, 245 Skill 21.4 Administering Ophthalmic Medications, 249 Skill 21.5 Administering Ear Medications, 253 Skill 21.6 Administering Nasal Instillations, 255 Skill 21.7 Using Metered-Dose Inhalers, 258 Procedural Guideline 21.1 Using Dry Powder-Inhaled Medications, 261 Skill 21.8 Using Small-VVolume Nebulizers, 263 Skill 21.9 Administering VVaginal Instillations, 266 Skill 21.10 Administering Rectal Suppositories, 269 CCHHAAPPTTEERR 2222 AADDMMIINNIISSTTRRAATTIIOONN OOFF PPAARREENNTTEERRAALL MMEEDDIICCAATTIIOONNSS Skill 22.1 Preparing Injections: Ampules and Vials, 272 SPPkrrooilcclee2dd2uu.1rraall GGPruueiipddaeerlliiinnneeg 22In22..j11ectioMMnsii:xxAiinnmgg pPPuaalrreeesnnatteenrrdaallVMMiaeeldsd,iicc2aa7tt2iioonnss iinn OOnnee SSyyrriinnggee,, 227755 Skill 22.2 Administering Intradermal Injections, 278 Skill 22.3 Administering Subcutaneous Injections, 281 Skill 22.4 Administering Intramuscular Injections, 284 Skill 22.5 Administering Medications by Intravenous Bolus, 287 Skill 22.6 Administering Intravenous Medications by Piggyback, Intermittent IInnffuussiioonn SSeettss,, aanndd MMiinnii--IInnffuussiioonn PPuummppss,, 229900 Skill 22.7 Administering Continuous Subcutaneous Medications, 294

CHAPTER 23 OXYGEN THERAPY SSkkiillll 23..11 Applying an Oxygeenn Delivery Device, 297 SSkkiillll 23.2 Administering Oxygen Therapy to a Patient WWith an Artificial Airrwwayy, 299 Skillll 23..33 Usingg Incentivvee Spiromettrryy,, 301 Skillll 23.4 Care of a Patient RReceiving Noninvasive Positive-Pressure VVentilation, 303 Procedurraall Guideline 23.1 Use of a Peak Flowmeter, 305 Skillll 23.5 Care of a Patient on a Mechanical VVentilator, 306 CHAPTER 24 PERFORMING CHEST PHYSIOTHERAPY SSkkiillll 24.1 Performing Postural Drainage, 309 Proceduurraall Guideline 24.1 Using an Acapella Device, 311 Prrocedurraall Guideline 24.2 Performing Percussion and VVibration, 312 CHAPTER 25 AIRWAY MANAGEMENT SSkkiillll 2255..1 Performing Oropharyngeal Suctioning, 315 Skiillll 25.2 Aiirrwwaayy Suucctioning, 317 Proceduurraall Guideline 25.1 Closed (In-Line) Suctioning, 322 Skillll 25..33 Performing Endotracheaall TTube Care, 324 Skillll 25.4 Performing TTrraacheostomy Care, 327 CHAPTER 26 CARDIAC CARE SSkkiillll 26.1 Obtaining a 12-Lead Electrocardiogram, 331 SSkkiillll 26.2 Applying a Cardiac Monniittoorr, 333 CHAPTER 27 CLOSED CHEST DRAINAGE SYSTEMS SSkkiillll 27.1 Managing Closed Chest Drainage Systems, 335 SSkkiillll 27.2 Assistingg WWith Removal of Chest Tubes, 338 Skillll 27.3 Autotransfusion of Chest Tubee Drainage, 340 CHAPTER 28 EMERGENCY MEASURES FOR LIFE SUPPORT SSkkiill 28..11 Inserting an Oropharyngeal Airwayy, 342 SSkkiillll 28.2 Usingg an Automated External Defibrilllaattorr, 344 Skillll 28.3 Code Managemenntt,, 346 CHAPTER 29 INTRAVENOUS AND VASCULAR ACCESS THERAPY SSkkiillll 29..11 Insertion of a Short-Peripheral Intravenous Device, 349 SSkkiillll 29..22 Regulating Intravenous Floww Rates, 354 Skillll 29.3 Changingg Intravenous Solutions, 357 Skillll 29.4 CChanging Infusion TTubing, 359 Skillll 29.5 Changingg a Short-Peripheral Intravenous Dressing, 362 Proceduurraall Guideline 29.1 Discontinuing A Short-Peripheral Intravenous Access, 364 Skillll 29.66 Managinngg Centrraall VVascular Access Devices, 366 CCHHAAPPTTEERR 3300 BBLLOOOODD TTHHEERRAAPPYY Skillll 30.1 Initiating Blood TTherapyy, 372 Skillll 30.2 Monitorinngg for Adversee Transfusion Reactions, 376 CCHHAAPPTTEERR 3311 OOSSRRkkiiAAllllLL3311NN..1UUTTRRPeIITTrfIIoOOrNNming a Nutritional Screening and Physical Examination, 378 SSkkiillll 31..2 Assistingg an Adult Patient with Oral Nutrition, 380 SSkkiillll 31..3 Aspirattiioonn Precautioonnss,, 383 vviiiiii

CHAPTER 32 ENTERAL NUTRITION Skill 32.1 Inserting and Removing a Small-Bore Nasogastric or Nasoenteric Feeding TTube,, 386 Skill 32.2 VVerifying Feeding TTube Placement,,390 Skill 32.3 Irrigating a Feeding Tube,, 392 Skill 32.4 Administering Enteral Nutrition: Nasoenteric,,Gastronomyy,, or Jejunostomy Tube,, 394 Procedural Guideline 32.1 Care of a Gastrostomy or Jejunostomy Tube,,397 CHAPTER 33 PARENTERAL NUTRITION Skill 33.1 Administering Central Parenteral Nutrition,,398 Skill 33.2 Administering Peripheral Parenteral Nutrition With Lipid ((Fat) Emulsion,, 400 CHAPTER 34 URINARYY ELIMINATION Procedural Guideline 34.1 Assisting With Use of a Urinal,, 402 Skill 34.1 Insertion of a Straight or Indwelling Urinary Catheter,,403 Skill 34.2 Care and Removal of an Indwelling Catheter,,408 Procedural Guideline 34.2 Bladder Scan and Catheterization to Determine Residual Urine,, 411 Skill 34.3 Performing Closed Urinary Catheter Irrigation,,413 Skill 34.4 Applying A Condom-Type Exterrnnal Catheter,, 416 Skill 34.5 Suprapubic Catheter Care,, 418 CHAPTER 35 BOWEL ELIMINATION AND GASTRIICC INNTTUBATIONN Skill 35.1 Providing a Bedpan,, 420 Skill 35.2 Removing Fecal Impaction Digitallyy,,423 Skill 35.3 Administering an Enema,, 426 Procedural Guideline 35.1 Applying a Fecal Management System,,429 Skill 35.4 Insertion,, Maintenance,, and Removal of a Nasogastric Tube for Gastric Decompression,,431 CHAPTER 36 OSTOMYY CARE Skill 36.1 Pouching a Colostomy or an Ileostomy,,436 Skill 36.2 Pouching a Urostomyy,, 438 Skill 36.3 Catheterizing a Urinary Diversion,,440 CCHHAAPPTTEERR 3377 PPRREEOOPPEERRAATTIIVVEE AANNDD PPOOSSTTOOPPEERRAATTIIVVEE CCAARREE Skill 37.1 Preoperative Assessment,,442 Skill 37.2 Preoperative TTeaching,,444 Skill 37.3 Physical Preparation for Surgery,,448 Skill 37.4 Providing Immediate Anesthesia Recovery in the Postanesthesia Care Unit,,450 Skill 37.5 Providing Early Postoperative and Convalescent Phase Recovery,,454 CCHHAAPPTTEERR 3388 IINNTTRRAAOOPPEERRAATTIIVVEE CCAARREE Skill 38.1 Surgical Hand Antisepsis,, 457 Skill 38.2 Donning a Sterile Gown and Closed Gloving,,459 CCHHAAPPTTEERR 3399 PPRREESSSSUURREE IINNJJUURRYY PPRREEVVEENNTTIIOONN AANNDD CCAARREE Skill 39.1 Risk Assessment,,Skin Assessment,,and Prevention Strategies,,461 SSkkiillll 3399..22 TTrreeaattmmeenntt ooff PPrreessssuurree IInnjjuurriieess,,446633 CCHHAAPPTTEERR 4400 WWOOUUNNDD CCAARREE AANNDD IIRRRRIIGGAATTIIOONNSS Procedural Guideline 40.1 Performing a Wound Assessment,, 466 Skill 40.1 Performing a Wound Irrigation,,468 Skill 40.2 Removing Sutures and Staples,, 470 Skill 40.3 MMaannaaggiinngg WWoouunndd DDrraaiinnaaggee EEvvaaccuuaattiioonn,,447733 Skill 40.4 Negative-Pressure Wound Therapyy,, 475 ix

CHAPTER 41 DRESSINGS,, BANDAGES,, AND BINDERS SSkkiillll 41.1 Applying a Dressing (Dry and Damp-to-Dry), 478 SSkkiillll 41.2 Applying a Pressure Bandage, 481 SSkkiillll 41.33 Applying a Transparent Dressing,, 483 SSkkiillll 41.44 Applying a Hydrocolloid, Hydrogel, Foam, or Alginate Dressing, 485 Procedduurraall GGuideline 41.1 Applying Gauze and Elastic Bandages, 488 Prrocedduural GGuideline 41.22 Applying an Abdominal Binderr, 490 CHAPTER 42 WARM AND COLD THERAPY SSkkiillll 42.11 Appliccaattiioonn of Moist Heat (Compress and Sitz Bath), 492 SSkkiillll 42.22 Applying Aqquuathermia and Dry Heat, 495 SSkkiillll 42..33 Appliccaattiioonn of Cold, 4977 SSkkiillll 42.44 Carinngg forr Patients Requiring Hypothermia or Hyperthermia Blankets, 500 CHAPTER 43 HOME CARE SAFETY SSkkiillll 43.1 Home EEnnvironment Assessment and Safetyy, 502 SSkkiillll 43.2 Adapting the Home Setting for Patients With Cognitive Deficits, 506 SSkkiillll 43.3 Medicaattiioonn and Medicaall Device Safetyy, 509 CHAPTER 44 HOME CARE TEACHING SSkkiillll 44.11 TTeachingg Clients to Measure Body TTemperature, 512 SSkkiillll 44.22 TTeaching Blood Pressure and Pulse Measurement, 515 Skillll 44.33 TTeachingg Intermittent Self-Catheterization, 519 Skillll 44.4 Usingg Home Oxygen Equipment, 521 Skillll 44.55 TTeachingg Home Tracheostomy Care and Suctioning, 524 Skillll 44.6 TTeachinngg Medicattiioonn Self-Administration, 526 SSkkiillll 44.77 Managinngg Feedinngg TTubes in the Home, 529 Skillll 44.88 Managinngg Parenterall Nutrition in the Home, 532 Xx

SStudent______________________________________________________________________________ Date____________________________________ Instructor_________________________________________________________________________ _ DDaattee____________________________________ PERFORMMAANCE CHECKLIST SKILL 2.11 ADMITTING PATIENTS sS Uu NP Comments ROOM PREPARATION 1.. Performed hand hygiene, prepared room equiippmmeenntt.. ____ ____ ____ __________________________ 2.. Ensured equipment is in working order, assem-­ bled aany special equipment in patient'’s room. ____ ____ ____ __________________________ ASSESSMENT ____ ____ ____ __________________________ 1.. Identified patient using two identifiers. 2.. Greeted patient and familyby name, introduced selff andd jjoob title, explained responsibilities in ppatient'’s carre. ____ ____ ____ __________________________ 3.. Arranged for translation service or speech and ____ ____ ____ __________________________ language pathologist if neceesssarryy.. 4.. Assessed patient'’s general appearance, noted ____ ____ ____ __________________________ signs or symptoms of phyyssiccaal distress. 5.. Determined patient'’s ability to understand and ____ ____ ____ __________________________ iimmpplleemmeenntt hheealth iinnffoorrmmation. 6.. Assessed patient'’s and family'’s psychological status byy noting vveerrbbal and nonverbal behav­- ____ ____ ____ __________________________ iorrss andd rresponnsseess.. 7.. Assessed patient'’s vital signs, height and ____ ____ ____ __________________________ weighhtt,, and levveell off discomfortt.. 8.. Assessed for fall risk using scale with grading ____ ____ ____ __________________________ ccrriitteerria, considerred ppaattient'’s rriisk factors. 9.. Had family or friends leave room unless pa­- tient wishes to hhaavve thheemm assist with changing, pprroviddeedd pprriivvaaccyy,, hheelped patient uunddrress, as­- ____ ____ ____ __________________________ ssiissted ppaattient innto ccoommffoorrtable position. 10.. Obtained nursing history as soon as possible, applliieedd sstandards of nursing carre adopted by hhoossppiittaall:: a. Assessed patient'’s perception of illness and ____ ____ ____ __________________________ health ccaarre needs. bb.. AAsssseesssseedd ppaattiieenntt'’ss ppaasstt mmeeddiiccaall hhiissttoorryy.. ____ ____ ____ __________________________ ____ ____ __________________________ c. Assessed presenting signs and symptoms ____ and reason for hospitalization. d. Assessed the completed review of health status ____ ____ ____ __________________________ based on appropriate standards. Copyright ©© 201188 by Elsevier Inc.. All rightss reserved. 1

sS Uu NP Comments e.. Assessed risk factors for illness. ____ ____ ____ __________________________ f. Assessed historyy of allergies. ____ ____ ____ __________________________ g.. Obtained detailed medication historyy. ____ ____ ____ __________________________ h. Assessed patient'’s knowledge of health problems and expectations of care. ____ ____ ____ __________________________ 11.. Conducted phyysical assessment of appropriate bodyy syystems.. ____ ____ ____ __________________________ 12.. Checked healthh care providers'’ orders for treatment measures to initiate immediatelyy. ____ ____ ____ __________________________ 13.. Asked patient to identifyy values regarding health care and expectations of care. ____ ____ ____ __________________________ 14.. Oriented patient to nursing division: a. Introduced staff members, introduced patient ____ ____ ____ __________________________ appropriatelyy. b. TTold patient and familyy the name of nurse managerr, explained that person’'s role in solving problems. ____ ____ ____ __________________________ c. Explained visiting hours and their purpose. ____ ____ ____ __________________________ d. Discussed smoking policyy, identified smoking ____ ____ ____ __________________________ areas if available. e.. Demonstrated use of equipment. ____ ____ ____ __________________________ f. Showed patient nurse call light, positioned it near patient, had patient demonstrate use ____ ____ ____ __________________________ and call for assistance if needed. g. Escorted patient to bathroom if appropriate. ____ ____ ____ __________________________ h. Explained hours for mealtime. ____ ____ ____ __________________________ i. Describedd services available.. ____ ____ ____ __________________________ PPLLAANNNNIINNGG ____ ____ ____ __________________________ 1.. Identified expected outcomes. IIMMPPLLEEMMEENNTTAATTIIOONN 1.. Completed patient medication reconciliation byy checking home medication list, updated medication list based on health care provider'’s ____ ____ ____ __________________________ orders for treatment. 2.. Informed patient about upcoming procedures or ____ ____ ____ __________________________ treatments. 3. Performed basic comfort measures and admin­ 3. iPseterrfoedrmaednablgaessicicc, omremfoortvmedeaasundresdainspdoasdedminof- ____ ____ ____ __________________________ gloves. 4.. Completed learning needs assessment for patient ____ ____ ____ __________________________ and familyy. 2 Copyright©© 2018 by Elsevier Inc. All rights reserved.

sS uU NP Comments 5. Gave patient and familyy chance to ask questions about procedures or therapies. ____ ____ ____ __________________________ 6. Collected valuables patient chooses to keep at facilityy, completed listing sheet, had patient or familyy sign it, placed values in safe or sent home witthh familyy.. ____ ____ ____ __________________________ 7. Ensured patient and familyy have time together alone if desired. ____ ____ ____ __________________________ 8. Ensured call light is within reach and bed is in low position.. ____ ____ ____ __________________________ 9. Performed hand hyygiene. ____ ____ ____ __________________________ EVALUATTION ____ ____ ____ __________________________ 1. Had patient explain fall risks, hospital policies, ____ ____ ____ __________________________ ____ ____ ____ __________________________ tests, and procedures. ____ ____ ____ __________________________ 2. Asked patient to rate severityy of pain. ____ ____ ____ __________________________ ____ ____ ____ __________________________ 3. Had patient demonstrate use of call light. 4. Monitored patient'’s abilityy to ambulate inde- pendentlyy.. 5. Checked patient'’s room setup regularlyy.. 6. Identified unexpected outcomes. RECORDING AND REPORTING 1. Recorded historyy and assessment findings in appropriatee log, began to develop nursing plan of care.. ____ ____ ____ __________________________ 2.. Placed advance directive in medical record if ____ ____ ____ __________________________ available.. 3. Notified health care provider of patient'’s arrival, reported unusual findings, secured admission ____ ____ ____ __________________________ orders if necessaryy.. Coppyyright ©© 201188 by Elsevier Inc.. All rights reserved.. 33

SSttuuddeennt______________________________________________________________________________ Date____________________________________ IInnssttrruuccttoorr_________________________________________________________________________ _ DDaattee ____________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT SSKKIILLLL 22..22 TRANSFERRING PPATIENTS sS uU NP Comments ASSESSMENT ____ ____ ____ __________________________ 1.. IIddeennttiiffiieedd ppaatient usingg twoo identifiers. 22.. Obttaineedd aand reviewed transfer order from sendingg health care provider. ____ ____ ____ __________________________ 33.. AAsssseesssedd rreason for patient'’s transfer in collabo­- ration with health care provider and appropriate team members. ____ ____ ____ __________________________ 44.. AAsssseesssed iinnddiivviidduuaals at higghh risk for transitional care problems.. ____ ____ ____ __________________________ 55.. EExxppllaaiinneedd purrppoossee off transsffeerr, provided time to discuss patient'’s and family'’s feelings, obtained ____ ____ ____ __________________________ written consent if necessary.. 66.. AAssssessed ppaattient'’s ccurrrrent physical condition, ____ ____ ____ __________________________ determined method for transport. 77.. AAssssessed iiff patient rrequires pain relief or other ____ ____ ____ __________________________ medications. 88.. EEnnssuurred that staaffff havvee notified patient'’s family ____ ____ ____ __________________________ of transfer as desired by patient. PPLLAANNNNIINNGG ____ ____ ____ __________________________ 1.. IIddeennttiiffiieedd exxppeeccttedd outtccommeess.. 22.. Arrraannggeedd fforr patient'’ss transportt to an aaggeennccy by ____ ____ ____ __________________________ chosen vehicle. 33.. Coonnttaacctteedd new ageennccyy and arranged for bed iin appropriate setting if necessaryy, confirmed ____ ____ ____ __________________________ willingness of agency to accept patient. IIMMPPLLEEMMEENNTTAATTIIOONN ____ ____ ____ __________________________ 1.. Enssuurreedd ppaattient'’s recorrdd is compleettee withh individualized care plan. 22.. Compleettedd nursing ccaarree transferr form ____ ____ ____ __________________________ appropriaatelyy.. 33.. Completed mediiccaatioonn reconciliation appropri­- atelyy, checked patient'’s current orders against mmoosstt rreecceenntt MMAARR aanndd oorriiggiinnaall mmeeddiiccaattiioonn lliisstt,, ____ ____ ____ __________________________ communicated updated medication list to next provider of care. 44.. HHaadd NNAAPP gatheerr and secure patient'’ss personall items, checked entire room and storage areas. ____ ____ ____ __________________________ 44 Copyright©© 2018 by Elsevier Inc. All rights reserved.

sS uU NP Comments 5. Anticipated problems patient mayy develop before or during transfer, performed necessaryy therapies. ____ ____ ____ __________________________ 6. Assisted in transferring patient safely to stretch­- er or wwheelcchhaaiirr. ____ ____ ____ __________________________ 7.. Performed and documented final assessment of patient'’s phyysical stabilityy. ____ ____ ____ __________________________ 8. Accompanied patient to transport vehicle. ____ ____ ____ __________________________ 9.. Called receiving agencyy and notified of transfer and patient'’s status. ____ ____ ____ __________________________ EVALUATTION 1. Compared data with previous findings during final assessment.. ____ ____ ____ __________________________ 2. Inspected patient'’s alignment and positioning on wheelchair or stretcherr. ____ ____ ____ __________________________ 3. Ensured equipment for transfer is functioning. ____ ____ ____ __________________________ 4. Confirmed patient understands transfer and procedures. ____ ____ ____ __________________________ 5. Determined if receiving agencyy had questions ____ ____ ____ __________________________ about patient'’s care. 6. Identified unexpected outcomes. ____ ____ ____ __________________________ RECORDING AND REPORTING 1. Documented pertinent information if sending patient.. ____ ____ ____ __________________________ 2. Documented pertinent information if receiving ____ ____ ____ __________________________ patient.. Coppyyright ©© 201188 by Elsevier Inc.. All rights reserved. 55

SSttuuddeenntt______________________________________________________________________________ Date____________________________________ Insttrruuccttoorr_________________________________________________________________________ _ DDaattee ____________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT SSKKIILLLL 22..33 DIISSCHAARRGING PPAATIENTS sS uU NP Comments ASSESSMENT ____ ____ ____ __________________________ 1.. IIddeennttiiffiied ppaattiient uussing two iiddeennttiifiers. 22.. AAssssessed ppaattiient'’s ddiissccharge needs ffrrom time of admission, used care plan to focus on ongoing ____ ____ ____ __________________________ assessments needed. 33.. IIddeennttiiffiied rriisk factors that may iinncrease risk of patient being rreadmitted after discharge. ____ ____ ____ __________________________ 44.. AAssssessed patient'’s and family'’s learnniing needs related to hhome care, asked patient and family ____ ____ ____ __________________________ to identiify concerns about discharge. 55.. AAssssesssedd fforr barriierrss tto learning and patient'’s ____ ____ ____ __________________________ hhealtthh literacy.. 66.. AAsssseesssedd fforr eennvviirroonnmmeennttaall factors within home ____ ____ ____ __________________________ that interrffeerree withh self-care. 77.. AAsssseesssedd patientt'’ss antiicipatedd needdss afterr ____ ____ ____ __________________________ discharge andd eligibility for home care reimbursement. 88.. AAsssseesssedd ppaattiientt'’s aanndd family'’s perceptions of healtthh carree needs outside the hospital, assessed family caregivers'’ perceived ability to provide ____ ____ ____ __________________________ care. 99.. AAsssseesssseddppaattiieenntt'’ssaaccceptaannccee offhheealth problems. ____ ____ ____ __________________________ PPLLAANNNNIINNGG ____ ____ ____ __________________________ 1.. IIddeennttiiffiied exxppeectedd outtccoommeess.. IIMMPPLLEEMMEENNTTAATTIIOONN 1.. PPrreppaarredd bbeeffoorree day of discharge:: aa.. DDiiscussed wwiitthh patient and family arranging ____ ____ ____ __________________________ thhee hhoomme to suit patient needs. b.. PPrrovviided pattiientt aand ffaammiilyy witthh iinformation ____ ____ ____ __________________________ about community healthh care resources. cc.. Conductedd tteeaacchhing lessons with patient and ffamily as soon as possible, reviewed and gave ppaattiieenntt ddiisscchhaarrggee mmaatteerriiaallss,, rreeffeerrrreedd ppaattiieenntt ttoo ____ ____ ____ __________________________ appropriiattee Internet resources. dd.. Communicated patient'’s and family'’s re­- ssponse to teaching and discharge plans to ____ ____ ____ __________________________ ootther tteeam members. 66 Copyright©© 2018 by Elsevier Inc. All rights reserved.

2.. Performed procedures on day of discharge: sS Uu NP Comments a.. Encouraged patient and family to ask ques­- tions and discuss home care. ____ ____ ____ __________________________ b.. Checked health care provider'’s discharge orders for prescriptions, treatment changes, or needd for speciall equipment, arranged for de­- liveryy and setup of equipmentt before patient aarrrriivvaall.. ____ ____ ____ __________________________ c.. Determined whether patient or family has ar-­ rraanged for transportation. ____ ____ ____ __________________________ d.. Provided privacyy, assisted as patient dressed aand packed personal belongings, checked cclosets and drawers, obtained copy of valu­- aables list and had items delivered to patient. ____ ____ ____ __________________________ e.. Completed medication reconciliation ap-­ propriatelyy,, checked discharge medication order against MARR and home medication list,, provided patient with prescriptions or medicatiioonnss ordered,, offered final review of information.. ____ ____ ____ __________________________ f.. Provided information on follow-up appoint-­ ments to health care provider'’s office.. ____ ____ ____ __________________________ g.. Contacted agency'’s business office to determine ppaattient need to finalize ppaayment arrangements, arrraannggeed for patient or family to visit business ____ ____ ____ __________________________ office.. h.. Acquired utility cart to move belongings, ob­- ____ ____ ____ __________________________ tained wheelchair or stretcher for patient. i.. Assisted patient to wheelchair or stretcher properlyy, escorted patient to transportation, locked wwhheeelchair wheels, assisted patient ____ ____ ____ __________________________ and belongings into vehicle.. j.. Returned to divisions, notified appropriate ggrroups of time of discharge, notified house­- ____ ____ ____ __________________________ kkeeeeppiing to clean patientt'’s room. EEVVAALLUUAATTIIOONN 1.. Asked patient or family member to describe naturre of illness, treatment, and symptoms to be ____ ____ ____ __________________________ reported.. 2.. Had patient or family members perform any ____ ____ ____ __________________________ treatments that will continue at home. treatments that will continue at home. 3. If a home care nurse, inspected home, identified ____ ____ ____ __________________________ obstacles, and recommended revisions. 4.. Identified unexpected outcomes. ____ ____ ____ __________________________ Coppyyrriightt ©© 201188 by Elsevier Inc.. AAll rights reserved. 77

sS Uu NP Comments RECORDING AND REPORTING 1.. Completed discharge summaryy form, provided patient with a signed copyy. ____ ____ ____ __________________________ 2.. Documented unresolved problems and de­- scription of arrangements made for resolution in appropriate log. ____ ____ ____ __________________________ 3.. Documented patient'’s vvitals and status of health problems at time of discharge in nurses’' notes. ____ ____ ____ __________________________ 8 Copyright©© 2018 by Elsevier Inc. All rights reserved.

SStuuddent______________________________________________________________________________ Date____________________________________ Instructor_________________________________________________________________________ _ DDaattee____________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT SSKKIILLLL 33..11 ESTABLISHING THE NURSE-PAATIENT RELAATIONSHIP sS Uu NP Comments ASSESSMENT 1.. Formulated patient goals and assessment quueesstiioonnss.. ____ ____ ____ __________________________ 2.. Addressed patient by name, introduced self and rroole, used cclleearr specific communication. ____ ____ ____ __________________________ 3.. Assessed patient'’s needs, coping strategies, ddeeffeennsseess,, and adaptation styles.. ____ ____ ____ __________________________ 4.. AAsssessed ppatient'’s need to communicate. ____ ____ ____ __________________________ 5.. Assessed rreason patient needs health care. ____ ____ ____ __________________________ 6.. Assessed factors about self and patient that nor-­ ____ ____ ____ __________________________ mally iinnfflluueennce ccoommmuniication. 7.. AAssessed personal barriers to communicating ____ ____ ____ __________________________ wwiitthh ppaattiieent.. 8.. AAssessed patient'’s language and ability to sppeeaakk.. ____ ____ ____ __________________________ 9.. Assessed patient'’ss literacy level.. ____ ____ ____ __________________________ 10.. AAsssessed patient'’s ability to hhear, ensured hearing aiidd iis ffuunnccttiioonnal iff wornn, ennssuurredd ppatient hears ____ ____ ____ __________________________ aanndd uundderstaanndds wwords. 11.. Observeedd patient'’ss pattern of communication ____ ____ ____ __________________________ andd vveerrbbaall or nonverbal bbeehhaviioorr. 12.. Assessed resources aavailable in selecting commu­- ____ ____ ____ __________________________ nniiccaattiioonn mmethods. 13.. Assessed patient'’s readiness to work toward ____ ____ ____ __________________________ gooaall attainmenntt.. 14.. Considered when patient is due to be discharged ____ ____ ____ __________________________ orr ttrraannssfferrrred.. PPLLAANNNNIINNGG ____ ____ ____ __________________________ 1.. Identified expected outcomes. 2.. Prepared patient physicallyy, maintained privacyy, ____ ____ ____ __________________________ aand reduced diisstractions.. 3.. Planned working phase appropriatelyy. ____ ____ ____ __________________________ IIMMPPLLEEMMEENNTTAATTIIOONN 1.. Observed patient'’s nonverbal behaviors, sought ____ ____ ____ __________________________ cclariiffiiccaatiion wherre needed. Copyright ©© 201188 by Elsevier Inc.. All rights reserved. 9

2.. Explained purpose of interactiion when infor­- Ss Uu NP Comments mation was being shared. ____ ____ ____ __________________________ 3.. Continued therapeutic communication skills. ____ ____ ____ __________________________ 4.. Identified patient'’s expectations in seeking health care. ____ ____ ____ __________________________ 5.. Encouragedd patient to ask for clarification at any time. ____ ____ ____ __________________________ 6.. Set mutual goals:: a. Used therapeutic communication skills. ____ ____ ____ __________________________ b. DDiiscussed and prioritized problem areas. ____ ____ ____ __________________________ c. Provided information to patient, helped patient express needs and feelings. ____ ____ ____ __________________________ d. Used questions carefully and appropriatelyy, asked one question at a time, used direct questions and open-ended statements as much as possible. ____ ____ ____ __________________________ e. AAvoided communication barriers. ____ ____ ____ __________________________ 7.. Communicated with patient during termination phase: a. Prepared methods of summarizing information ____ ____ ____ __________________________ pertinent for patient'’s aftercare. b. Used therapeutiic communication skills to dis­- cuss discharge or termination issues, guided discussion to patient changes in thoughts and ____ ____ ____ __________________________ behaviors. c. Summarized with patient what was discussed ____ ____ ____ __________________________ during the interaction. EEVVAALLUUAATTIIOONN 1.. Observed patient'’s verbal and nonverbal re­- sponses to communication, noted patient’'s willingness to share information and concerns. ____ ____ ____ __________________________ 2.. Noted your response to patient and patient'’s response to you, reflected on effectiveness of ____ ____ ____ __________________________ techniques. 3.. Evaluated ppatient'’saability to work toward identi­- fiable goals, reevaluated and identified barriers if ____ ____ ____ __________________________ patient goals are not met. 4.. Summarized and restatedd goals, reinforced pwpaaottriieeknn, ttdevsstterrleeonnpggettdhhssa,,n aoocuutttilloiinnneepddlaniiss. ssuueess rreeqquuiirriinngg ____ ____ ____ __________________________ 5.. Identified unexpected outcomes. ____ ____ ____ __________________________ 10 Copyright ©© 2018 by Elsevier Inc. All rights reserved.

sS uU NP Comments RECORDING AND REPORTING 1. Recorded pertinent communication, responses to illness or therapies, and responses that demon­- strate understanding or lack thereof. ____ ____ ____ __________________________ 2. Reported relevant information to team members. ____ ____ ____ __________________________ Coppyyright ©© 201188 by Elsevier Inc.. All rights reserved.. 1111

SSttuuddeenntt______________________________________________________________________________ Date____________________________________ IInnssttrruuccttorr_________________________________________________________________________ _ DDaattee ____________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT SSKKIILLLL 33..22 COMMUNICAATING WITH PAATIENTS WHO HAAVE DIFFICULTY COPING sS uU NP Comments AASSESSMENTT 1.. IInnttrroduuccedd sself appropriaattellyy, explained pur­- ____ ____ ____ __________________________ ppoosse off interaction.. 22.. AAsssseesssseedd faacctors influencing communication wwiitthh patient. ____ ____ ____ __________________________ 3.. AAsssseesssseedd forr ppossible factors causing patient aannxxiieettyy.. ____ ____ ____ __________________________ 4.. DDiissccussed wwiitthhfaamily possible ccauses of patient'’s ____ ____ ____ __________________________ anxxiieettyy.. 5.. Obserrvveedd for physical, behavioral, and verbal ____ ____ ____ __________________________ cuess tthat inddiiccaattee patient is anxxious.. 6.. OObbsseerrvveedd for physical, behavioral, and verbal cuess tthat inddiiccaattee patient is depressed. ____ ____ ____ __________________________ 77.. AAsssseesssseedd forr possibllee factors caausing patient'’s ____ ____ ____ __________________________ deeppression.. 8.. OObbsseerrvveedd for behaviorrss that indicate thee patient ____ ____ ____ __________________________ is angryy.. 9.. AAsssseesssseedd faacctors that influueennccee angry patient'’s ____ ____ ____ __________________________ communicattioonn.. 100.. AAsssseesssseedd for rresources availabbllee to help inn com­- ____ ____ ____ __________________________ munniiccaattiinngg wwiitthh potentially violent patient. 1111.. AAsssseesssseedd forr underlyyiinngg medical condition that ____ ____ ____ __________________________ maayy ppotentially lead too violent bbeehhaavviioorr. PPLLAANNNNIINNGG ____ ____ ____ __________________________ 1.. IIddeennttiiffiieedd exxppeeccttedd oouuttccomes.. 22.. PPrreeppaarreedd for communicattiioonn by considering ____ ____ ____ __________________________ patient goals, time allocation, and resources. 3.. Reeccooggnniizzedd pperrssonnaall levveell of anxietyy, tried to ____ ____ ____ __________________________ remain ccalm. 4.. PPrreeppared a qquuiieet, calm area; allowed ample ____ ____ ____ __________________________ ppeerrssoonnaall ssppaaccee.. ____ ____ ____ __________________________ 5.. PPrreeppaarred ffoor ddee--eescalation for ann angry patient: ____ ____ ____ __________________________ aa.. PPaauusseedd too ccollleecct thoughts andd feelings. bb.. DDeetterrmmiinneedd wwhhaat ppattienntt is saying.. 112 Copyright ©© 2018 by Elsevier Inc. All rights reserved.

sS uU NP Comments c. Prepared environment to de-escalate a poten­- tiallyy violent patient byy removing people or factors that provoke angerr,, maintaining an open exit,, and providing privacyy.. ____ ____ ____ __________________________ IMPLEMENTATION 1. UUsed appropriate nonverbal behaviors and active listening skills, focused on understanding patient’'s issues.. ____ ____ ____ __________________________ 2. Used appropriate verbal techniques that are clear and concissee in responses,, acknowledged patient'’s feelings, provided direction to patient. ____ ____ ____ __________________________ 3. Helped patient acquire alternative coping strategies. ____ ____ ____ __________________________ 4. Provided necessary comfort measures. ____ ____ ____ __________________________ 5.. Used open-ended questions. ____ ____ ____ __________________________ 6.. Encouraged and rewarded small decision, made decisions patient is not readyy to make. ____ ____ ____ __________________________ 7. Accepted patient as he or she is, focused on positive feedback, provided positive decision making. ____ ____ ____ __________________________ 8. Showed honestyy and empathyy. ____ ____ ____ __________________________ 9. De-escalated an angryy patient appropriatelyy:: a. Maintained personal space and an open exit, ppoositioned self bbetween patient and exit. ____ ____ ____ __________________________ b. Maintained nonthreatening approach with a calm voice, open bbodyy language, and deliberate ____ ____ ____ __________________________ gesturres.. c. Used therapeutic silence, allowed patient to vent,, used active listening. ____ ____ ____ __________________________ d. Responded to anger therapeuticallyy, encour­- ____ ____ ____ __________________________ aged verbal expression of angerr. e. Answered questions calmlyy and honestlyy, informed patient of potential consequences ____ ____ ____ __________________________ and followed through if necessaryy. f. Responded professionallyy and set limits if patientt makes verbal threats to harm others.. ____ ____ ____ __________________________ g. Explored alternatives to anger when patient is ____ ____ ____ __________________________ calm. EEVVAALLUUAATTIIOONN 1. Observed for continuing presence of signs and behaviors reflecting anxietyy, anger, or depression. ____ ____ ____ __________________________ 2.. Asked patient to describe ways to cope with ____ ____ ____ __________________________ anxietyy, anger, or depression. Coppyyright ©© 201188 by Elsevier Inc.. All rights reserved.. 1133

Ss Uu NP Comments 3.. Evaluated patient'’s ability to discuss factors causing anxiety, anger, or depression. ____ ____ ____ __________________________ 4.. Noted patient'’s ability to answer questions and problem solve. ____ ____ ____ __________________________ 5.. Asked patient to discuss ways to cope in the future and make decisions about own care. ____ ____ ____ __________________________ 6.. Identified unexpected outcomes. ____ ____ ____ __________________________ RECORDING AND REPORTING 1.. Recorded cause of patient'’s anxiety, anger, or depression and any exhibited behaviors. ____ ____ ____ __________________________ 2.. Recorded de-escalation techniques used and patient'’s response. ____ ____ ____ __________________________ 3.. Reported methods used to relieve anxiety, anger, ____ ____ ____ __________________________ and depression and patient'’s response. 1144 Copyright ©© 2018 by Elsevier Inc. All rights reserved.

Studen_t ____________________________________________________________________________ Date____________________________________ Instructor _________________________________________________________________________ Date ___________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT SSKKIILLLL 33..33 COMMUNICATING WITH A COGNITIVELY IMPAAIRED PATIENT sS Uu NP Comments ASSESSMENT 1.. Approached patient from the front; assessed physical, bbeehavioral, and verbal cues; assessed orientation status of patient and performed mini-­ mmental examination.. ____ ____ ____ __________________________ 2.. Assessed for possible factors causing patient’'s cognitive impairment. ____ ____ ____ __________________________ 3.. Assessed factors influencing communication ____ ____ ____ __________________________ with patient. 4.. Discussed possible causes of patient’'s cognitive impairment with family and caregivers. ____ ____ ____ __________________________ 5.. Discussed with family how patient typically ____ ____ ____ __________________________ communicates with them. 6.. Ascertained most effective means of communi- ____ ____ ____ __________________________ cation with patient. PLANNING ____ ____ ____ __________________________ 1.. Identified expected outcomes. 2.. Considered type of cognitive impairment, com-­ munication impairments, time allocation, and ____ ____ ____ __________________________ resources.. 3.. Remained nonjudgmentaal and aware of own ____ ____ ____ __________________________ nonverbaal cues. 4.. Provided a calm environment and reduced dis-­ ____ ____ ____ __________________________ tractions. IIMMPPLLEEMMEENNTTAATTIIOONN ____ ____ ____ __________________________ 1.. Approached patient from the front. 2.. IIntroduced self, explained purpose of interaction. ____ ____ ____ __________________________ 3.. Used appropriate nonverbal behaviors and ____ ____ ____ __________________________ aacctive llistening skills. 4.. Used clear and concise verbal techniques to respond to depressed patient, asked yes-or-no ____ ____ ____ __________________________ questionss.. 5.. Asked questions one at a time, allowed time for ____ ____ ____ __________________________ response.. 6.. Repeated sentences using a steady voice, avoided ____ ____ ____ __________________________ beiinngg too quick to guess patient response. Copyrigghhtt ©© 201188 by Elsevierr Inc.. All rights reserved. 15

7.. Used assistive and augmentative devices to Ss Uu NP Comments faciilliittate communication.. ____ ____ ____ __________________________ 8.. Provided assistive devices such as eyeglasses or hearing aids. ____ ____ ____ __________________________ 9.. Did not argue with or correct patient. ____ ____ ____ __________________________ 10.. MMaaiintained meaningful interactions with patient, used creative modes of communication based on patient'’s comfort and abilityy. ____ ____ ____ __________________________ 11.. Used individualized coping strategies. ____ ____ ____ __________________________ EVALUATTIION 1.. Observed for clarity and understanding of messages sent and received. ____ ____ ____ __________________________ 2.. Observed vverbal and nonverbal behaviors. ____ ____ ____ __________________________ 3.. Identifiedd unexpected outcomes. ____ ____ ____ __________________________ RECORDING AND REPORTING 1.. Recorded objective and subjective behaviors in nurses'’ notes. ____ ____ ____ __________________________ 2.. Recorded and reported methods used to com­- ____ ____ ____ __________________________ municate and ppatient’'s response. 16 Copyright ©© 2018 by Elsevier Inc. All rights reserved.

Studen_t ____________________________________________________________________________ Date____________________________________ Instructor _________________________________________________________________________ Date ___________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT SSKKIILLLL 33..44 COMMUNICATION WITH COLLEAGGUUES Ss Uu NP Comments ASSESSMENT 1.. Identified purpose of interaction with colleague. ____ ____ ____ __________________________ 2.. Assessed factors influencing communication with others. ____ ____ ____ __________________________ 3.. Considered level of stress in the situation. ____ ____ ____ __________________________ PLANNING 1.. Prepared for communication with team mem-­ bers who may have differing needs or concerns. ____ ____ ____ __________________________ 2.. Remained nonjudgmental and aware of own ____ ____ ____ __________________________ nonverbal cues. 3.. Prepared a qquiet, calm environment; reduced distractions. ____ ____ ____ __________________________ 4.. Maintained awareness of hierarchical differences ____ ____ ____ __________________________ as a barrier to communication. IIMMPPLLEEMMEENNTTAATTIIOONN 1.. Approached colleague from the front, main­- ____ ____ ____ __________________________ tained appropriate eye contact. 2.. Provided appropriate introduction, explained ____ ____ ____ __________________________ purpose of interaction. 3.. Maintained awareness of body language and ____ ____ ____ __________________________ tone.. 4.. Acknowledged and responded to a range of views, allowed equal timee for all parties to ____ ____ ____ __________________________ participate. 5.. Used appropriate oral communication skills and aactive listening, provided feedback and asked ____ ____ ____ __________________________ for clarification when necessaryy. 6.. Used a range of workplace written communica­- ____ ____ ____ __________________________ tion methods.. 7.. Encouraged discussion positive and negative ____ ____ ____ __________________________ feelings.. 88.. SsSouulmmutmmioaanrrsiizzteoeddthkekeeisyysuttehh.eemmeess,, hheellppeedd ttoo ddeevveelloopp ____ ____ ____ __________________________ Copyright ©© 201188 by Elsevier Inc.. All rights reserved. 1177

sS Uu NP Comments EVALUATTIION 1.. Conffiirmed clarity and uunderstanding of messages. ____ ____ ____ __________________________ 2.. Observedd verbal and nonverbal behaviors. ____ ____ ____ __________________________ 3.. Identified unexpected outcomes. ____ ____ ____ __________________________ RECORDING AND REPORTING 1.. Recorded successfull communication strategies and pertinent changes to patient’'s plan of care. ____ ____ ____ __________________________ 1188 Copyright ©© 2018 by Elsevier Inc. All rights reserved.

Sttudent_____________________________________________________________________________ Date____________________________________ Instructor__________________________________________________________________________ _ DDaattee____________________________________ PERFORMANCE CHECKLIST PROCEDURAL GUIDELINE 4.11 GIVING A HAND-OFF REPORT sS uU NP Comments PPLLAANNNNIINNGG ____ ____ ____ __________________________ 1.. Gathered necessary equipment. PROCEDURAL STEPS 1.. Implemented an organized format for deliv­- ering aann apprropriate descripttiioon of patient'’s needdss aand pprroobblleems. ____ ____ ____ __________________________ 2.. Identified electrronic patient record using two idennttiiffiieerrss.. ____ ____ ____ __________________________ 3. Gathered information from relevant docu­- mmeennttss.. ____ ____ ____ __________________________ 4. Prioritized information based on patient'’s needdss aand pprroobblleemmss.. ____ ____ ____ __________________________ 5. Includdeedd SBAR documentation in report: a.. SSittuuaattiioonn:: Patient'’s name, genderr, age, com­- ppllaaiinnttss oon aaddmmiission, aand currrent situation. ____ ____ ____ __________________________ b.. BBaacckkggrround information: Allergies, code sta­- ttuuss,, hhiissttoorryy, ssppeeccial nneeeedds, and vaccinations. ____ ____ ____ __________________________ c.. Assessmentt data: Objectivvee data from shift ____ ____ ____ __________________________ wwiitthh eemmphhaasis onn cchhaannggees. d.. RReeccoommmendations: Explanation of priorities ____ ____ ____ __________________________ ffoorr oncoming nurrssee.. 6. Asked staff from oncoming shift if they have ____ ____ ____ __________________________ questioonnss regardingg information provided. Cooppyyrigghtt ©© 201188 by Elsevier Inc.. AAll rights reserved. 19

SSttuuddeenntt______________________________________________________________________________ Date____________________________________ IInnssttrruuccttoorr__________________________________________________________________________ _ Date____________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT PPRROOCCEEDDUURRAALL GGUUIIDDEELLIINNEE 44..22 DOCUMENTING NURSES'’ PROGRESS NOTES sS Uu NP Comments PPLLAANNNNIINNGG 11.. Gaattheerredd nneeccessssaarryy equiippmmeenntt.. ____ ____ ____ __________________________ PROCEDURAL STEPS ____ ____ ____ __________________________ 11.. IIddeenntiiffiieedd ppaatiient recorrd usiing at least two identifiers.. 22.. RRevviieewweedd assseessssmmeennt data, prroblems identi­- fiedd,, expected outcomes, nursing interven­- tionss,, and patient response. ____ ____ ____ __________________________ 33.. DDooccuummeennttedd patiient inforrmmaatiioonn in the appro­- priiaatte log, followed charting guidelines. ____ ____ ____ __________________________ 44.. IIddeenntiiffiieedd iinnffoorrmmaattiioonn to bbee ddooccuumented after patient contact. ____ ____ ____ __________________________ 55.. DDooccuummeenntteedd iinn aa timely aand orderly fashion, included date and time. ____ ____ ____ __________________________ 66.. DDooccuummeennttedd objectiivvee data, sseelect subjective data, nursing actions taken, patient responses, addiittiioonnaall plans to be implemented, and to ____ ____ ____ __________________________ whom information was reported. 77.. SSiiggnneedd pprrogrresss noottee aapppprropriiaattelyy,, indicated level of education and school if you are a stu­- ____ ____ ____ __________________________ denntt.. 88.. RReevviieewweedd pprrevviioouussllyy documented entries witth ownn entries, noted significant changes inn patient'’s status, reported any such changes ____ ____ ____ __________________________ too patient'’s health care provider. 20 Copyright ©© 2018 by Elsevier Inc. All rights reserved.

Student _______________________________________________________________________________ Date____________________________________ Instructor____________________________________________________________________________ Date____________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT PPRROOCCEEDDUURRAALL GGUUIIDDEELLIINNEE 44..33 ADVERSE EVENT REPORTING sS uU NP Comments PPLLAANNNNIINNGG ____ ____ ____ __________________________ 1.. Gathered necessaryy equipment. PROCEDURAL STEPS 1.. Identified the electronic patient record using at least two identifierss.. ____ ____ ____ __________________________ 2.. Determined what was involved in the incident and reported exact events appropriatelyy, noti­- fied risk management as necessaryy.. ____ ____ ____ __________________________ 3.. Assessed extent of injuryy to patient or others, included subjective and objective findings. ____ ____ ____ __________________________ 4.. TTook steps to restore individual'’s safetyy. ____ ____ ____ __________________________ 5.. Called health care provider. ____ ____ ____ __________________________ 6.. Referred injured visitors or staff to emergencyy department. ____ ____ ____ __________________________ 7.. Completed adverse event report form: a.. Recorded objective information about the iincidentt,, included victim interpretations in ____ ____ ____ __________________________ qquuootteess.. b.. Objectivelyy described patient'’s or staff mem-­ ber'’ss ccoonnddiition when incident was discov­- ____ ____ ____ __________________________ ered or observed. c.. Descrribed measures taken byy caretakers at ____ ____ ____ __________________________ the tiime.. d.. Sent completed report to designated depart-­ ____ ____ ____ __________________________ ment. 8.. Documented events in patient'’s chart when patient is involved:: a.. Entered onlyy objective description. ____ ____ ____ __________________________ b.. Recorded assessment or intervention activi-­ ____ ____ ____ __________________________ ties iinitiated as result off the event. c. Did not duplicate all information from re­ ____ ____ __________________________ c. pDpooidrrtt..not duplicate all information from re- ____ ____ ____ __________________________ d.. Did not record that report was completed. ____ 9.. Submitted report properlyy with risk manage-­ ____ ____ ____ __________________________ ment department or designated persons. Copyriigghhtt ©© 201188 by Elsevierr Inc.. AAll rights reserved. 21

Studdeenntt ______________________________________________________________________________ Date____________________________________ IInstructor____________________________________________________________________________ Date____________________________________ PPEERRFFOORRMMAANNCCEE CCHHEECCKKLLIISSTT PPRROOCCEEDDUURRAALL GGUUIIDDEELLIINNEE 44..44 GUIDELINES FOR MEANINGFUL USE OF AN ELECTRONIC HEALTH RECORDS (EHR) sS uU NP Comments PPLLAANNNNIINNGG ____ ____ ____ __________________________ 1.. IIddeennttiified ppuurrpose of intterraaccttiion with colleague. PROCEDURAL STEPS ____ ____ ____ __________________________ 1.. UUsedd oorrganized format for medical reconcilia­- tion. 2.. IIddeennttiiffiiedd electrroonniicc patient recordd using two identifiers.. ____ ____ ____ __________________________ 3.. Gathered iinforrmmattiion from electronic docu­- mentation sources. ____ ____ ____ __________________________ 4.. Includdeedd two nurses to complete medication reconciliation at time of care transition, as­- sessed current medications, compared to medi­- cations on admission if patient is going to be discharged. ____ ____ ____ __________________________ 5.. Assessedd discrepancies with two nurses. ____ ____ ____ __________________________ 6.. Reconcileedd medicattiioonn list if patient is to be discharged, provided patient with written ____ ____ ____ __________________________ reconciled list of medications. 7.. TTaught ppatient how to keep medication list ____ ____ ____ __________________________ current.. 8.. Educateedd patient about medications and im­- portance of sharing current list with health ____ ____ ____ __________________________ care providers. 222 Copyright ©© 2018 by Elsevier Inc. All rights reserved.

Student______________________________________________________________________________ Date ____________________________________ Instructor__________________________________________________________________________ DDaattee ____________________________________ PERFORMMAANCE CHECKLIST SKILL 5.11 MEASURING BODY TEMPERATURE sS uU NP Comments ASSESSMENT ____ ____ ____ ___________________________ 1.. Identified patient using two identifiers. 2.. Determined need to measure patient'’s body temperature: a. NNooted patient'’srisk for temperature alterations. ____ ____ ____ ___________________________ b. Assessed for other symptoms that accom-­ pany temperattuure alteration. ____ ____ ____ ___________________________ c. Assessed for factors that normally influence ____ ____ ____ ___________________________ tteemmppeerraattuure. 3.. Determined appropriate measurement site ____ ____ ____ ___________________________ and device for patient. ____ ____ ____ ___________________________ 4.. Determined previous baseline temperature ____ ____ ____ ___________________________ and measurement site from patient'’s record. 5.. Assessed patient'’s knowledge of procedure. PPLAANNNNIINNGG ____ ____ ____ ___________________________ 1.. Identified expected outcomes. ____ ____ ____ ___________________________ ____ ____ ____ ___________________________ 2.. Explained to patient how you will measure ____ ____ ____ ___________________________ temperattuure and importance of maintaining proper position.. 3.. Collectedd and brought supplies to patient'’s beddsidde.. 4.. VVerified patient has had no food, drink, gum, or ciggarettes iin the past 20 minutes before measur-­ iinngg oral temperature. IIMMPPLLEEMMEENNTTAATTIIOONN ____ ____ ____ ___________________________ 1.. PPerformed hand hygiene. 2.. Assisted patient to a comfortable position that ____ ____ ____ ___________________________ provides access to ttemperature site. 3.. Obtained tteemperature reading: a. Assessed oral temperature (electronic). ((11)) AApppplliieedd cclleeaann gglloovveess iiff nneecceessssaarryy.. ____ ____ ____ ___________________________ (2) Removed thermometer pack frrom charger, aattttached pprrobe sstem, ggrrasped top of probe ____ ____ ____ ___________________________ stem appropriatelyy.. Copyright ©© 201188 by Elsevier Inc.. All rights reserved.. 23

sS uU NP Comments (3) Slid disposable probe cover over probe stem until cover locked in place. ____ ____ ____ __________________________ (4) Asked patient to open mouth, placed thermometer probe under tongue ap-­ propriatelyy. ____ ____ ____ __________________________ (5) Asked patient to hold thermometer probe with lips closed. ____ ____ ____ __________________________ (6) Left thermometer in place until signal sounded and patient'’s temperature ap­- peared on displayy, removed thermom-­ eter probe from under patient'’s tongue. ____ ____ ____ __________________________ (7) Pushed ejection button to discard probe in the appropriate receptacle. ____ ____ ____ __________________________ (8) Removed and disposed of gloves if necessary. Performed hand hygiene. ____ ____ ____ __________________________ (9) Returned thermometer probe stem to ____ ____ ____ __________________________ storage position. b. Assessed rectal temperature (electronic). (1) Provided privacyy, assisted patient to appropriate position, moved bed lin-­ ens to expose only anal area. ____ ____ ____ __________________________ (2) Applied clean gloves, cleansed anal region if necessaryy, removed soiled ____ ____ ____ __________________________ gloves, reapplied clean gloves. (3) Removed thermometer pack from charger, attached rectal probe stem to unit, grasped ____ ____ ____ __________________________ top of probe stem. (4) Slidd disposable probe cover over probe ____ ____ ____ __________________________ stem until cover locked in place. (5) Used single-use package, squeezed lu­- bricant on tissue, dipped probe cover into lubricant and covered appropri-­ ____ ____ ____ __________________________ atelyy. (6) Exposed patient'’s anus with nondomi­- nant hand, asked patient to breathe ____ ____ ____ __________________________ and relax. (7) Inserted thermometer appropriatelyy ____ ____ ____ __________________________ into anus, did not force. (8) WWithdrew if resistance was felt. ____ ____ ____ __________________________ ((9) Held probe in position until signal sounded and temperature appeared on ____ ____ ____ __________________________ displayy, removed probe from anus. (10) Discarded probe cover appropriatelyy, ____ ____ ____ __________________________ wiped probe with alcohol swab. 24 Copyright ©© 2018 by Elsevier Inc. All rights reserved.

((1111)) Discarded probe cover appropriatelyy, sS uU NP Comments wiped probe with alcohol swab. ____ __________________________ ____ ____ ((1122)) WWiped patient'’s analarea with soft tissue, ____ __________________________ discarded tissue, assisted patient to a ____ ____ ____ __________________________ comforrttable position. ____ ____ ____ __________________________ ((1133)) Removed and disposed of gloves, per- ____ ____ formed hand hygiene. ____ __________________________ ____ ____ ____ __________________________ c. Assessed axillary temperature (electronic). ____ ____ (11) Provided privacyy, assisted patient to ____ __________________________ appropriattee position, moved clothing orr ____ ____ gown away from shoulder and arm. ____ __________________________ ____ ____ ____ __________________________ ((22)) Removed thermometer pack from charg- ____ ____ ____ __________________________ err, attached oral thermometer probe stem ____ ____ ____ __________________________ to unit, grasped top of probe stem. ____ ____ ____ __________________________ ____ ____ ((33)) Slid disposable probe cover over stem ____ __________________________ until cover locked in place. ____ ____ ____ __________________________ ____ ____ ____ __________________________ ((44)) Raised patient'’s arm away from torso, in- ____ ____ sspected skin for lesions and perspiration, ____ __________________________ dried axilla if needed, inserted thermome- ____ ____ ____ __________________________ terr intoo center of axilla, lowered arm prop- ____ ____ erlyy.. ((55)) Held thermometer in place until signal sounded and temperaturre appeared on displayy, removed probe fromm axilla. ((66)) Discarded probe cover appropriately. ((77)) Returned thermometer stem to storage positioonn.. ((88)) Assisted patient to comfortable position, replaced gown.. ((99)) Performed hand hygiene. d. Assessed tympanic membrane temperature. ((11)) Assisted patient to appropriate posi- tion, obtained temperature from the appropriate earr. ((22)) Noted presence of earwax. ((33)) Removed thermometer unit appropri- ately from charging base. ((44)) Slid disposable speculum cover over lleennss ttiipp uunnttiill iitt lloocckkeedd iinn ppllaaccee,, ddiidd nnoott touch the lens coverr. ((55)) Inserted speculum into ear canal, fol- lowed instructions for probe positioning. Copyright ©© 2018 by Elsevier Inc.. All rights reserved. 25

sS uU NP Comments ((66)) Once positioned, pressed scan button, left speculum until signal sounded and patient'’s temperature appeared on dis- playy. ____ ____ ____ __________________________ ((77)) Removed speculum from auditory me- atus, discarded speculum cover appro- priatelyy. ____ ____ ____ __________________________ ((88)) If second reading was necessaryy, re- placed probe cover and waited 2 min- utes before repeating either in same ear or in other ear, considered alternative method. ____ ____ ____ __________________________ ((99)) Returned unit to thermometer base. ____ ____ ____ __________________________ ((1100)) AAssssisted patient to comfortable position. ____ ____ ____ __________________________ ((1111)) Performed hand hygiene. ____ ____ ____ __________________________ e. Assessed temporal artery temperature. ____ ____ ____ __________________________ ((11)) Ensured forehead was dryy. (2) Placed sensor firmly on patient'’s fore- ____ ____ ____ __________________________ head. (3) Pressed red scan button, slowly slid ther­- mometer across forehead, kept sensor flat on skin, lifted sensor after sweeping forehead, touched sensor on neck behind earlobe. Read temperature, released scan ____ ____ ____ __________________________ button.. (4) Cleaned sensor with alcohol swab. ____ ____ ____ __________________________ 4.. Informed patient of temperature reading and ____ ____ ____ __________________________ record measurement. 5.. Returned thermometer to chargerr. ____ ____ ____ __________________________ EEVVAALLUUAATTIIOONN ____ ____ ____ __________________________ 1.. Established temperature as a baseline if neces­- ____ ____ ____ __________________________ saryy. ____ ____ ____ __________________________ ____ ____ ____ __________________________ 2.. Compared reading with baselinee and accept­- able range. 3.. TTook temperature 30 minutes after administer­- ing antipyretics and every 4 hours until tem-­ perature stabilized if patient has a fever. 4.. Identified unexpected outcomes. RECCORDIING AANDD REEPPOORTTIINGG ____ ____ ____ __________________________ 1.. Recorded temperature and route in appropri­- ____ ____ ____ __________________________ ate record. 2.. Reported abnormal findings to nurse in charge or health care provider. 26 Copyright ©© 2018 by Elsevier Inc. All rights reserved.