Skills Exam
Skills Lab
Perineal care for a female
Warm (not hot) soapy water
Outsides then the inside
Move in a downward direction so no bacteria from the rear is moved up
Front to back, clitoris to anus
Side, side, and middle
A nursing task that involves cleaning a patient's genital and anal area. Place a bath blanket over the abdomen so that one corner is pointing in the direction of the head and the other corner is covering the perineal care. Clean the perineal area from front to back to prevent contamination from the rectal area to the urethra. ( Always use a separate area of the washcloth for each area or a new washcloth).
Don't forget to dry patient!
Perineal care for a male (circumcised vs uncircumcised)
Before cleaning, check whether the patient is circumcised/uncircumcised
Circumcised
Adjust clients to a comfortable position
Using a washcloth, soap, and water—or perineal wipe—cleanse the urinary meatus first, using a circular motion.
Gently clean down the shaft of the penis and scrotum
Clean butt
Uncircumcised
Uncircumcised ( retract the foreskin and clean the tip of the penis at the urethral meatus in a circular motion from the center outward). Return the foreskin to its original position.
Dont interfere with pts beliefs if they dont believe in circumsision
Don't forget to dry patient!
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Types of baths (complete, partial, etc.)
Complete/full body Bath: For patients who are dependent (completely bedridden - a nurse does all the cleaning). These reduce the risk of infection by disease-producing gram-negative organisms.
Head to toe
Start with eyes; new clothe for each eye
Partial Bed Bath: For patients who can complete partial baths. Includes the hands, face, axillae, back, and perineal area.
Usually preformed daily
Therapeutic Bath: For treatment plans for conditions like skin disorders, burns, elevated, oatmeal, cornstarch, and commercial bath products are added to the bath water to relieve irritation.
Tub Bath: Providing more thorough washing and rinsing than a bed bath can provide.
Self-bath: patients who can give themselves a bath.
How do you safely get a patient up from the bed?
Safety for pt and safety for yourself
How many ppl needed to safely get pt up from bed
E.g., if pt is 500 pounds? Multiple ppl
To get a patient out of bed safely, make sure, the height is pretty good at the low bottom and you have another person to help if the patient weighs more than a person also ask the patient if they are able to assist in getting the patient off the bed.
What safety measures are done before/when you reposition the patient?
Before
Raise the bed
After
Lower the bed
And make sure all but one rail is up
Call light
Patients have a gait belt if they are heavy and help to assist with bending, lifting, and walking. Also making sure they are in the right position that can assist with repositioning the bed. Also, there is the fact of having another health care worker in with you to help reposition them if they are more than 35 pounds.
Make sure to assess the patient's weight and have proper equipment before getting them up, and assess any necessary assistance.
Proper procedure for Catheterization (male & female)
Be able to identify if situation is correct or incorrect (making sure you have an order)
Palpate and scan bladder
If u suspect urinary retention-> may need catheter
Anticipatory order
Tell doc u may need order for straight cath
Straight cath
Patient Identifiers
Patient level of pain 0-10
Allergies assessment
Explain the procedure to the patient
Provide privacy, hand hygiene
Assess bladder for fullness
Inspect and clean the area
inner → outer for bio. Male, top → bottom
away→ near→ middle for bio. female
Position patient on back with knees bent and legs spread open
Sterile field, clean with iodine swabs (left, right, middle), lube and insert a catheter
Remove the catheter and clean the perineal area full of fluid
Male, hold the base
Female spread
THIS IS A STERILE PROCEDURE = sterile gloves + sterile field
to prevent infection, make sure the catheter is below the waist or below the bed but not on the floor
Never above waist-> urine flows back
Why would a patient need a catheter?
Urinary incontinence (leaking urine or being unable to control when you urinate) Urinary retention (being unable to empty your bladder when you need to) Surgery on the prostate or genitals.
Types of Incontinence
Functional means there is something in the way even though you are normally able to.
Stress, laughing, coughing, and sneezing puts pressure/ stress on the bladder.
Urge urinary incontinence
Total incontinence: inability to urinate
Indwelling catheter?
Same process to insert as straight cath
Indwelling an inch- inch and half further to blow up balloon
Straight cath cant stay in
How do you collect specimens?
Urine?
Urine specimens are collected by either a clean-catch method or from a catheter to obtain diagnostic information and to assess clients' status.
The clean-catch method is suitable for clients who are able to understand instructions for depositing a urine sample into a sterile cup or receptacle.
Perform a straight catheterization if prescribed to obtain a sample from a client who is unable to urinate.
If male
clean urethra from inner to outer-> start streat-> collect into cup
If female
Clean urethral from front to back-> tell pt to spread labia-> start stream-> catch urine
Stool?
Stool specimens are collected both for screening and diagnostic tests. A commonly used point-of-care test for stool is the fecal occult blood test (FOBT). Stool specimens can also be sent to a laboratory for analysis for detection of bacterial infectious agents, such as Clostridium difficile, ova, or parasites, or for other diagnostic tests.
collected by bedpan or toilet, will be given some sort of container (plastic bin, bedpan, paper for inside the toilet etc) and can collect from there
The proper position for enema administration
Left lateral sims- correct position
Differs from left later bc hip will be bent up and over
Before administering an enema, position the client on their left side in the left side-lying position or left lateral position with the right knee flexed (left sims) which will adequately expose the anus.
If pt complains of cramps slow the enema down by lowering bag or if there is stopcock/slowing device, use that
For older patients, keep a bedpan nearby because they can poop
Cannot turn off enema
if a patient can do it by themselves, they do it on a toilet
if there is lots of discomfort, slower and take deep breaths
Proper procedure for administering enteral feedings
Patient identifiers
Allergies
Level of pain
Assess the nasal cavity for any blockage
Clean gloves, insert the tube through the naris towards the back of the throat. When the tube is passed the nasopharynx, have the client flex her head toward the chest and swallow as the tube advances.
Proper procedure for placing nasogastric and small-bore feeding tubes
Nasogastric Tubes (salem sump tube) and Small-Bore Feeding Tubes
How to measure nasogastric Tubes (salem sump tube)
place the tube tip at the patient's nostril, extend it to their earlobe, and then down to the xiphoid process (the bony point at the bottom of the breastbone), marking the tube at this length
Inspect client nares and check for patency
High-fowlers and towel on chest
Measure from nose to ear to xiphoid process
Inject 10ml of water, prepare the fixation device
Gloves and lubricate the tip, anesthetics are policy says so
Give the client a drink with a straw to suck on while inserting
Insert and rotate, ensure that the tube is not stuck
Have the client flex their chin, and stop if stuck, coughing, or unable to speak
Check aspirate for pH, x-ray
Nasogastric- test for gastric pH
Small bore: cannot aspirate bc it will collaspe, check x-ray
Secure and hand hygiene
X-ray conformation
Store tube feed at room temp!
Complaints of abd pain- slow rate down
Make sure tube is in right place
If pt is at risk for aspiration-> put them at higher position
Intermittent tube feeds
Administered by gravity
CHECK PLACEMENT
For pts who:
Have difficulty swallowing (dysphagia), Have gastrointestinal disorders that affect eating, Are critically ill or recovering from surgery, and Need nutritional support for an extended period.
Proper procedure for tracheal suctioning
Semi-fowlers or high-flowers
Place a drop on the client's chest
Using an aseptic technique, open the package and attach the catheter
Connect one end of the tubing to the suctioning and the other
Finish connecting the supplies
Hyperoxygenate
10-15 seconds only
Twist and pull the catheter out while providing intermittent suction
Wait one minute before suctioning again
If pt coughed airway up, what is our first step and priority?
Must be a tracheostomy device near trach pt
Now we put a new device in
Know the various types of suctioning.
Yankauer Catheter
Tonsil Tip
A suction catheter that helps clear secretions from the mouth or oropharynx
Length of time to leave suction in: 10-15 seconds
Tracheostomy Suctioning
Above
Long term airway management
NO LUBRICATION
Closed (in-line) suction system
Involves a multi-use catheter enclosed in a plastic sheath
Most commonly used with clients who are mechanically ventilated and have an endotracheal or tracheostomy tube
Does not require ventilation
Endotracheal tube
Short term
Up to 5 days
Stop suction and put o2 tx back on if pt is desatting
ALWAYS HYPEROXYGENATE BEFORE SUCTIONING
Take breaks in between suctions so pt can rexoygenate
Diff types of suctioning: nasotracheal, oropharyngeal, nasopharyngeal
Nasotracheal Suctioning (NTS)
Where does it go?
A flexible catheter is inserted through the nose and advanced into the trachea (lower airway).
Continuous or Intermittent?
Intermittent suctioning while withdrawing the catheter to prevent mucosal damage.
How long does it stay down?
No longer than 10–15 seconds per suction attempt. Allow 30 seconds–1 minute between attempts, with oxygenation in between if needed.
Oropharyngeal Suctioning
Where does it go?
A rigid suction catheter (Yankauer) is placed into the oropharynx (mouth and throat).
Continuous or Intermittent?
Continuous suction is typically used.
How long does it stay down?
No strict time limit, but it should be done quickly and efficiently, ensuring the patient can tolerate it.
3. Nasopharyngeal Suctioning (NPS)
Where does it go?
A flexible catheter is inserted through the nose and into the pharynx (upper airway, behind the nose and mouth but above the trachea).
Continuous or Intermittent?
Intermittent suction while withdrawing the catheter to prevent tissue damage.
How long does it stay down?
No longer than 10–15 seconds per suction attempt. Allow 30 seconds–1 minute between attempts.
The proper procedure for changing trach ties
While holding the tracheostomy tube in place, cut the ties of the tube to be removed.
Remove the tracheostomy tube from the stoma and immediately insert the sterile tracheostomy tube. During insertion, the obturator should be held securely inside the outer cannula.
After insertion of the tube, withdraw the obturator immediately.
Rinse and dry.
IV drop/min calculations
Kinds of drip factors
Micro= 60 drops = 1 ml
Macro= 10 drops= 1ml and 15 drops=1 ml
Differs according to the manufacturer
Induction Pump
Enter the ml to be infused AND the number of ml/hr
Formulas
ml/hr
(ml/hr)x TF/60
mlxTF/min
Formulas & Calculations
Universal Formula (V sometimes used as "S")
Formula #1 (Pump Formula)
Formula #2 (Gravity/Continuous Fluid Formula)
TF = Tubing Factor
Since measured in drops or gH, you MUST round to a whole number
Formula #3 (Intermittent Fluid Formula)
TF: Tubing Factor
Make Sure to Round the Tenths Place
Tubing Factor
The amount of drops through the tube
Micro drip Tubing: 60 drops per 1 ml
Macro drip Tubing: 15 drops per 1 ml OR 20 drops per 1 ml
The proper procedure for inserting an IV
Palpate and inspect for a vein
Once a vein has been located, use alcohol or iodine to sterilize the area
Dawn gloves as PPE
Have patient make a fist and wrap tourniquet around their arm
With the bevel up, carefully insert IV at a 10-30 degree angle as you stretch the skin taught
Wait for blood flashback in IV
Once blood flashback, advance catheter and remove needle
Keeping pressure on the IV, dress the area with translucent IV tape
Tape a couple more areas of the IV along patient’s arm
Assess for any complications
Assessing an IV site for complications
If the patient is going home you take it out, if it is swollen and cool to touch, you take it out, if it is red and swollen, take it out.
Issues: discharge, phlebitis, infiltration
Need to know the correct time + situation to take it out
How do you calculate IV fluids?
Formulas
ml/hr
(ml/hr)x TF/60
mlxTF/min
Proper procedure for medication administration
Tablets, scored tablets, enteric-coated tablets, extended-release, sublingual, capsules, caplets
YOU CAN NOT SPLIT CAPSULES in a capsule for a reason
Liquids
Pour in the medicine cup to the line or use a syringe
Eye level to the meniscus (lower curve) on the line
Rounding
5 or higher: round up
Less than 5: round down
Must check vital signs before drug administration
Rights of Medication Administration
Patient
Medication
Dosage
Route
Time
Documentation
Proper calculation of pediatric medication
1. Put weight into kg, lbs/2.2
2. Safety
3. Calculate
D/H x S
Desired amount, what you Have, Supply of medication
Proper procedure for administering medications via a nasogastric tube
Sometimes we’re going to crush those
Put it down the tube
Clamp the tube off (nasogastric tube)
Allows us to leave the medicine inside of the stomach
Absorbed into the stomach lining to go through the whole body
The purpose of clamping tubing is to absorption
The proper procedure for IM, Sub Q, and intradermal injections
IM/3ml (intramuscular)
Locations: ventral gluteal, deltoid, vastus lateralis, rectus femoris (more painful), NO dorsogluteal
Angle: 90 degrees
Needle size: 22, 23 gauge: 1-1 1/2 inch length
Special Notes: Aspirate, Z tracks
Pink NOT BRIGHT RED?
SC/Subcutaneous/ 1ml (sometimes called tuberculin)
Locations: Back of upper arms, thighs, lower abdomen, scapular area,
Angle: 45 or 90 degrees (decision-based upon the amount of pt fatty tissue)
Needle size: 25, 26, 28 gauge: 3/8 – 5/8 inch length
Special Notes: no aspiration
Intradermal (uses 1ml syringe)
Locations: lower inner aspect of the forearm
Angle: 10-15 degrees
Usually 15 degrees
Needle size: 26, 28 gauge: 1/4 -5/8 inch length (may be the same as for SC injections)
Special Notes: no aspiration
Intravenous Medications
Most are diluted and given over time according to the drug book or hospital policy.
Injections from Powders
Some medications are prepared in dry form, powder, or crystal. This is because they are unstable as a liquid. These types of drugs are “reconstituted” right before administration.
Reconstitution directions are included with the drug
Most drugs are premixed so reconstitution is rare
Resources/directions will tell you specifically how to reconstitute and with what liquid.
Proper procedure for hand hygiene and PPE
Think about situations where you would have to perform hand hygiene again
Hand
Warm water
Wet hands and keep them below the elbow
3 to 5ml of soap
Rub for at least 15 seconds
Rinse well, point fingers down
Dry from fingers to wrist
PPE
Put on
Hand hygiene, gown, mask, goggles/face shield, gloves
Take Off
Gloves, gown, hand hygiene, face shield/goggles, mask
The proper procedure for performing a sterile dressing change (removing the old, cleaning, measuring, redressing, etc.)
Use clean non sterile gloves to remove the old dressing FOR EXAMINATION
Assess the wound for drainage, redness, swelling, width, length, depth
TALK PT THROUGH THE ENTIRE PROCESS
Check for pain level
Hand hygiene
Set up sterile field with drape and putting equipment on field
Put on sterile gloves away from the filed
Clean wound from inside to outside
Lead contaminated to most contaminated
Inner to outer, pts germs are their germs and are sterile to them
Take gauze, damp it in sterile saline solution
Place gauze inside wound
Once wound is filled, take sterile wound cover and tape all sides (make sure there is no open space)
Time, date, initials
Call button cause its so cute
4 Types of open Wounds
NON STERILE (SURGICAL ASEPSIS) ARE FOR NON STERILE PROCEDURES- NG TUBES, INJECTIONS, ENEMA, CHANGING PT, CHANGING PT BED, EXAMINING WOUND, IV
STERILE GLOVES- STERILE PROCEDURES LIKE WOUND CHANGE
Sergical Asepsis = sterile
Medical Asepsis = clean
The proper procedure for administering ear medications
Wear gloves
Side-lying with ear to be treated facing up
*Straighten ear canal
Adults= up and out
Children = down and back
Instill drops by holding dropper 1/2 inch above ear canal
Remain side lying for ~ 3 min
Apply gently massage to the tragus
May use cotton ball at the exit of the ear canal only; remove it after 15 minute
Proper procedure for administering eye medications
Wear gloves
Roll eye drop container between hands
Gently cleanse eye from inner to outer if needed
Instill drops into conjunctival sac (hold dropper 1/2 to 3/4 inch above sac)
*Instill ointment in conjunctival sac from inner to outer
Proper procedure for putting on sterile gloves
Open Technique
Open packaging, waist height
Fold back the edges to expose the gloves, do not touch the inside
Using the thumb and forefinger of the nondominant hand, pinch the cuff of the dominant hand glove. Only touch the inside surface of the glove
Lift the glove off of the wrapper and carefully apply it to the dominant hand without touching the outside surface of the glove. If the glove is not aligned with the fingers correctly, do not adjust the glove.
Using the gloved (dominant) hand, slide fingers under the cuff of the remaining glove.
Lift the glove off of the wrapper by touching only the outside surface of the glove.
Apply to nondominant hand
Adjust gloves if needed
Closed Technique
Uses sterile gown
Proper procedure for setting up a sterile field
Hand hygiene
Open the sterile drape by removing the outer wrapping.
Place a sterile kit or tray in the center of the work surface
Open the flap farthest from the body by reaching around the sterile area.
Open the side flaps, then the flap closest to the body
Using your fingertips, pick up the sterile drape, touching only the 1-inch margin.
Lay the drape on the work surface with the fluid-resistant side facing down.
When adding items to the sterile field, open the item without touching the inside and drop from 6 inches above
Alternative meds (watch video)
Skills Review Video
Perineal Care
Female
Top to bottom
Male
Check if it is circumcised or not, if not move the foreskin, and put it back
Clean in a circular motion starting in the center
Both
Carefully wash with warm soap and water
Rinse thoroughly
Dry thoroughly
Types of baths
Self bath
Can do it all on their own
Complete bed bath
They cannot do anything for themselves, we do it all
Partial Bed bath
Can do some of their own but not all, and can't reach their feet or their back
Make sure we have the proper equipment, assess weight, and assistance
Reasons for a catheter
Urinary retention
Blockage
Main goal is to prevent infection, keep it below the bed/ below the level of the waist, do not put it on the floor
Catheter Lab
Cleanse the perineum
Sterile procedure
Male, inner to outer
Female, outer to inner, top to bottom
Your patient needs one when they cannot urinate
Prevent infection
It has to stay below the waist/bed!
Do not put the bag on the floor
When containing a specimen
Urine, cleanse, male inner to outer
Female, hold the labia open, start the stream and then retrieve
Enema
Left Simms position, left decubitus enema
If the patient is giving it to themselves, you do it over the toilet
If you are doing it to an older patient, have a bedpan
If they start going then put them in a dorsal recombinant position
If someone is complaining of discomfort you can slow down the flow which will decrease the pressure or slow deep breaths
Nasogastric tube
Tip of nose to tip of the ear lobe to the xiphoid process = how far you need to put the tube in
Droplet and standard precautions
Droplet
Gloves, Goggles, gown, mask
Inspect the nares and lubricate with water-soluble lubricant
Insert until it gets to the back of the throat, and ask the patient to swallow. Say “1 2 3 swallow”
When we put the tube in the first thing we verify is tube placement
Aspirate the contents by checking the pH
Small Bore
Totally different than a nasogastric tube
These are your Kio feeds dob hoff (brand names)
These are too small to aspirate contents so they must be checked by an X-ray.
Both
Tube feeding must be at room temperature
Cold tube feeding = cause massive diarrhea
If the patient ℅ cramping, slow the tube feeding/rate
Start with a slow rate and then gradually increase it
Suctioning
Measuring
5 deep breaths before inserting tube
Go down until you meet resistance and then pull back a few CM
The other way is to measure with a spare inner cannula at the bedside
Do not move the inner cannula that the patient is using!!!!
Only remove the inner cannula if you are changing it (sterile) or cleaning it.
If the patient has a tracheostomy, ALWAYS have a spare tracheostomy device at the bedside in case it ever becomes dislodged.
Limit trach suctioning to 10 to 15 seconds because you are sucking out the oxygen.
Giving Medications Rights
5 major rights
6 = documentation
Happens with every drug you give!
Know all of them! + Be able to identify a situation where one of them is missing!
IV’s
If the patient is going home you take it out, if it is swollen and cool to touch, you take it out, if it is red and swollen, take it out.
Issues: discharge, phlebitis, infiltration
Need to know the correct time + situation to take it out
Oral Medication Administration
Rights
Separate medications based on assessment
No assessment meds go in one cup
The meds with assessment go in the other cup (requires questioning)
Only open medications in the patient's room + scan in the room
IV meds
If a medication is an infusion for 5-10 minutes, we can stand there and push it over this time or we can connect it to a separate tubbing and put it on a mini infusion pump, and then I can set the syringe in it, can schedule it over that period of time, beep when finished (the better choice)
Pediatric dosages
Know if it is safe to give or not
Calculate an IV or two
If you draw up medications and accidentally touch the needle = get a new one!
Nasogastric tube medications
Sometimes we’re going to crush those
Put it down the tube
Clamp the tube off (nasogastric tube)
Allows us to leave the medicine inside of the stomach
Absorbed into the stomach lining to go through the whole body
The purpose of clamping tubing is to absorption
If the patient is crying and in pain but there are still 2 hours until medications, you can call the prescriber, and SOAP notes. Explain the situation and ask for a stat order.
Administration of IM (intermuscular) medications, we use a z-tract method
Clean the skin, pull over the skin, insert the needle, aspirate, and look in the barrel for color, if we get blood then we know we are in a blood vessel (if this happens we withdraw it throw it away, and repeat)
We aspirate to let us know if we are in the right place because it needs to be in the muscle and not in the blood vessel
Washing hands, isolation, blood-borne pathogens
BBP
What if we are discontinuing something (foley, ng tube, IV) and we get something on our skin?
Wash the site with soap and running water and then seek guidance
As a nurse, you seek guidance from your manager on the floor, whoever that may be
As a student nurse, you go to your instructor ASAP
Hand hygiene
If you wash your hands and then accidentally touch the sink or something, you need to wash your hands again.
REALLY important if you're doing an antiseptic wash prior to assisting in a procedure
Wound lab
When we remove the dressing, we use examination gloves (non-sterile)
Then assess the wound for drainage, redness, swelling, width, length, depth
Prepare supplies for sterile field
Set up sterile field
If you touch anything or move out of the sterile field then you need new sterile gloves.
Clean from inner to outer
AKA least contaminated to most contaminated
WHENEVER YOU DO A PROCEDURE, ALWAYS EXPLAIN IT FROM BEGINNING TO END SO YOUR PATIENT IS NOT ANXIOUS
Tracheostomy Device
If you have a patient that is struggling to breathe and you think they need a long-term respiratory device = Tracheostomy Device
An incision is made into the trach and it has stitches until it heals
Endotracheal Tube
Short-term respiratory assistance = Endotracheal Tube
Go down the nose or mouth, into the trachea, into the carina and it allows us to ventilate our patient on mechanical ventilation (as does the tracheostomy)
Oropharengeal and Nasopharengeal
The amount of time that you stay down suctioning is different than the tracheal suctioning (tracheal = 10-15 sec)
You can apply intermittent suctioning for 5-10 minutes because that is an airway.
You can lubricate with water-soluble lubricant but never lubricate a tracheal suctioning.
If their O2 stats start to drop, get restless, tachycardia, STOP, put O2 back on, wait, and attempt it later
Other medication administration
Rectal, vaginal, topical
Eye
Drops do not go on the cornea, they go on the lower conjunctival sac
Ear
Lift the pinna, up and out or down and back (depending on the age of the patient) then gently drop it into the ear. Massage the tragus and leave them side lying for 3-5 minutes
We do not apply any kind of cotton tip applicators or cotton balls because it acts as a wick and sucks it out.
Catheterizationintran
Retention/Foley catheters
Knowing how to put in, is very common in the maternity unit
Once you get urine, insert another half of an inch and then inflate the balloon
Most of the time we will do straight catheters
In a male, the urethra is normally coiled
The best way to do that is to apply light traction to the penis while you are inserting the catheter.
If you don’t do that, then you will never be able to get your catheter in
Sterile gloves
Know how to grasp the first and second glove
Put fingers at the top edge of the glove and then put your hand in when you grasp the second glove, take sterile fingers of the first glove and slide them under the cuff of the sterile glove.
Things that can get in the way
Dropping something
Putting sterile gloves on the sterile field
Turning back, hands below the waist, touching glasses, then they are contaminated
50 questions
Most are multiple-choice
3 next gen
2 matching
Skills regarding sterility
List of psychomotor skills and a column that says sterile and nonsterile applicable, DO NOT USE NOT APPLICABLE.
Are these skills sterile or not sterile?
Know all of the injection sites
Intradermal (15 degrees), intramuscular (90 degrees), and subcutaneous (45 degrees)
3 to 4 questions are selected all that apply
Not that difficult