NURS 310: Introduction to Clinical Nursing Skill Validation

Student Information

  • Student Name: __

  • Section:

  • Date: __

  • Faculty Validator: ___

Critical Steps for Competency Scoring

  • Critical steps necessary for safe and successful completion of nursing skills are denoted by an asterisk (*).

Pre-validation Steps

  • Arrival and Preparation

    • _ Arrives on time

    • _ Signs in on computer

    • _ Dressed appropriately in the SU Nursing uniform

    • _ Prepared with appropriate supplies (stethoscope, pen, wristwatch, etc.)

Phase 1: Pre-Medication Administration Steps

  • Initial Procedures

    • _ Performs hand hygiene upon entering the room *

    • _ Introduces self to client

    • _ Confirms client identity using two identifiers *

    • _ Compares client ID band with verbalized information and written orders *

    • _ Assesses client allergies *

    • _ Performs environmental safety assessment

    • _ Explains the procedures

Phase 2: Pre-Medication Administration Assessment

  • Assessment and Education

    • _ Provides brief client education on the ordered medications

    • _ Performs hand hygiene

    • _ Completes appropriate client assessment based on the medication ordered

    • Antihypertensive: Obtains blood pressure

    • Beta blocker: Auscultates apical pulse for 1 full minute

    • Bronchodilator: Obtains heart rate, respiratory rate, pulse oximetry, auscultates lung sounds

  • Validation by Student

    • Student: "You will refer to Docucare and patients' EMR for relevant assessment data."

    • _ Verbalizes whether medication administration would be appropriate based on assessment data *

  • Student progresses to either:

    • Phase 3: Administration of Oral/Inhaled Medication

    • Phase 4: Administration of Injectable IM/SubQ Medication based on assessment data confirmed by validator.

Phase 3: Administration of Oral OR Inhaled Medication (Validator: circle one)

  • Medication Administration Process

    • _ Performs hand hygiene

    • _ Obtains medication and necessary supplies completing the first medication check *

    • _ Confirms client identity using two identifiers *

    • _ Compares client ID band with verbalized information and written orders, completing the second medication check *

    • _ Places client in proper position

    • _ Completes third medication check *

    • _ Administers medication *

    • _ Documents the administration of the medication immediately after administration *

Phase 4: Administration of Injectable IM OR SubQ Medication (Validator: circle one)

  • Preparation and Administration Steps

    • _ Obtains medication and necessary supplies completing the first medication check *

    • _ Selects and verbalizes appropriate needle length based on client characteristics (age, size)

    • _ Prepares medication by drawing up correct dose into syringe

    • _ Has second nurse (validator) confirm correct dosage for high-risk medication *

    • _ Performs hand hygiene when entering client’s room *

    • _ Discusses the procedure with the client

    • _ Performs second medication check *

    • _ Provides privacy

    • _ Places client in proper position

    • _ Performs third medication check *

    • _ Performs hand hygiene

    • _ Dons appropriate PPE

    • _ Verbalizes injection site that will be used, stating max amount that can be injected at the site

    • _ Cleanses the area around the injection site with an alcohol swab using circular motion while moving outward from the injection site *

    • _ Allows alcohol to dry *

    • _ Removes the needle cap with the nondominant hand, pulling it straight off.

If administering a subcutaneous injection:

  • _ Spread the skin taut at the site, based on assessment of the patient and needle length used for the injection

  • _ Hold the syringe in the dominant hand between the thumb and forefinger. Inject the needle quickly at a 45- or 90-degree angle, depending on the amount of underlying subcutaneous tissue *

  • _ Withdraw the needle quickly at the same angle at which it was inserted while supporting the surrounding tissue with your nondominant hand

If administering an intramuscular injection:

  • _ Verbalize what the Z-track technique is and why it is used (will not demo on manikin)

  • _ Identify landmarks for site chosen for injection *

  • _ Stretch the skin flat between two fingers and hold taut for needle insertion

  • _ Quickly dart the needle into the tissue so that the needle is perpendicular to the client’s body with the goal of an angle of 90 degrees *

  • _ Inject the medication slowly at a rate of 10 seconds/mL

  • _ Once the medication has been instilled, wait 10 seconds before withdrawing the needle

  • _ Withdraw the needle smoothly and steadily at the same angle at which it was inserted, supporting tissue around the injection site with your nondominant hand

  • _ Do not recap the used needle. Immediately engage the safety mechanism and dispose in the sharps container *

  • _ Use a gauze square to apply gentle pressure to the site (do not massage the area)

  • _ Removes gloves

  • _ Performs hand hygiene *

Phase 5: Demonstrating Knowledge of IV Therapy

  • IV Process and Assessment

    • _ Reviews medication order and compares order to what is infusing on pump, verbalizing any errors *

    • _ Verbalizes type of IV fluid ordered (isotonic/hypotonic/hypertonic)

    • Assessment of IV Site:

    • _ Verbalizes 4 signs of inflammation (phlebitis) *

    • _ Verbalizes 4 signs of infiltration *

    • _ Explains the difference between infiltration and extravasation *

    • _ Documents amount of IV fluid in mL that would infuse after 4 hours (intake) *

    • _ Places call light in client’s reach *

    • _ Ensures bed is in low position *

    • _ Performs hand hygiene upon exiting client’s room *

Faculty Feedback

Signatures

  • Student Signature: ___

  • Faculty Validator Signature: _