LORENZO WALKER INSTITUTE OF TECHNOLOGY

Progressive Clinical and Lab Skills Competency Record

Medical/Surgical Skills

Student______

A. Basic Care
1.Bed Bath(30.02)
2.Make bed:
·  Unoccupied/occupied(31.05)
Surgical(31.06)
3.Maintain patient environment(29.02)
4. Oral hygiene to unconscious patient(30.11)
5.Skin care: apply dressing(30.05)
(Comfeel, Duoderm, etc.)
6.AROM & PROM exercises(31.09)

B. COMFORT AND SAFETY

1.Adjust bed and side rails:(29.06)
for patient safety/for self
2.Call Bell
3.Seizure Precautions
4.Fall Precautions
5. Apply protective devices:(29.11)
wrist restraints/posey restraints
6.Special beds/mattresses(29.12)
C. Body Mechanics
1.Transfer patient to Chair/commode(29.07,29.29,30.12)
2.Transfer patient to stretcher(29.09)
3. Turn and position patient/body alignment(29.10)
4. Assist patient to dangle(29.13)
5. Assist patient to ambulate(29.14)
6. Assist patient using cane/walker(29.16, 29.17)
7. Assist patient using wheelchair (29.29
D. Nutrition & Fluids
1. Assist with meals(30.16)
2. Maintain Calorie Count(33.0)
3. Enteral feeding tubes:(31.57)
·  Check placement
·  Check residual
·  Flush/Instill water
4. Gavage Feeding:(31.39)
·  Bolus Feeding
·  Intermittent Feeding
5. Swallowing precautions(Thickened liquids)
6. Fluid Restrictions
E. INFECTION CONTROL
1. Proper Hand washing
2. Standard Precautions
3. Provide care for patients with infectious diseases: (38.01, 38.03, 38.04, 38.05, 38.06)
·  Respiratory Isolation
·  Contact Precautions: MRSA/VRE
4. Chemo Precautions
F. Monitor patients & Document on Graphics/Flow Sheets/Nurses Notes:
1.Vital Signs:

Temperature

·  Oral
·  Rectal
·  Axillary

Pulse

·  Apical
·  Radial
·  Doppler
·  Pedal
BP
Respirations
2.Lung Sounds
3.Bowel Sounds
4.Intake & Output (31.16)
5.Emesis (31.17)
6.Ht & Wt-standing scale/bed scale (31.08)
7.24 hour nursing Flow sheet

8. Diabetic

9. Neurological checks (31.40)
10.Neurovascular check
11.PCA/Epidural
12.Pre-op check list (39.04)
13. Special procedures:
Post-op, Transfusion, Endo, etc(31.24)
14.Nurses notes/narrative comments
15.Assist with patient Admission ( 24.05, 31.01, 31.60)
16.DC/Transfer patient (31.03, 31.04)
17.Teaching:
·  pre-op/post-op (39.01)
·  discharge (39.06, 32.19)
·  breathing exercises:
TCDB/Incent Spir (31.58)

G. SPECIMEN COLLECTION

1. Urinalysis:
·  Routine urinalysis (31.11)
·  Midstream (31.15)
·  Catheter (31.33)
·  24 hour (31.13)
2. Strain Urine (31.12)
3. Stool Specimen: (31.43)
·  Occult Blood
·  O&P/C&S
4. Sputum Specimen(31.44)
5. Blood Glucose (31.59)
6. Wound Culture
H. Wound Care
1. Apply medical and surgical asepsis (27.01)
2. Apply and remove sterile gloves (27.02)
3. Apply sterile dressing:
DSD, W-D (27.03)
4. Apply bandage (31.25)
5. Open sterile supplies (27.04)
6.Maintain sterile field (27.05)
7. Skin Care/Apply clean dressing:
·  Comfeel, DuoDerm, etc. (30.05, 31.31)
8. Check incision
9. Remove Staples/Sutures
10.Irrigate wound (31.54)
11.Monitor/Care of Wound Drains:
·  J Pratt/Hemovac
·  Penrose
12. D/C Wound Drains
I. Catheters
1. Foley/Straight:
·  Monitor and assist with care of (31.20)
·  Monitor drainage (31.14)
·  Insertion: (31.32)
·  Discontinuation (31.35)
·  Irrigation/Instillation (32.17, 31.48)
·  Continuous Bladder Irrigation (31.49)
2. Cystocath
J. Provide Medical Nursing Care:
1. Apply hot and cold applications (31.18)
2. Monitor chest drainage system: (31.23)
3. Give enema: (31.41)
TWE/Fleets
4. Suctioning:
·  Perform naso-oral-pharyngeal suction (31.46)
·  Perform tracheostomy care (31.47)
5. Irrigate vaginal canal (31.53)
6. Administer and maintain oxygen (31.63)
7. Assist with postmortem care (31.68)
8. Intravenous:
·  Adjust IV flow rate (31.64)
·  Monitor pump (31.65)
·  Monitor insertion site (31.66)
·  Disc IV (31.66)
K. Provide Orthopedic/Post-operative care (39.05)
1. Apply anti-embolic hose: (31.10)
·  Thigh/Knee
·  Sequential compression devices
2. Apply pelvic traction (31.21)
3. Apply brace (31.27)
4. Apply Splint/Immobilizer (31.28)
5. Care for skin/skeletal traction (31.29)
6. Apply Abductor pillow
7. CPM machine
8. Slings & Springs:
·  Set up/remove
·  Leg exercises
9. Clean Tong/Pin Site (31.30)
10.Logroll patient (31.42)
11.Nasogastric tube:
·  Check placement
·  Connect to suction: (31.37)
·  Wall/Gomco
·  Remove (31.38)
·  Irrigate (31.52)
12.Ostomy appliance, change: (31.36)
13.Colostomy: Irrigate (31.56)
L. Medication Administration (32.0)
Demonstrate the 6 rights (32.02)
Respond to patient’s need for PRN meds (32.03)
Document administration of (32.20)
Observe and communicate patient's
Response on MAR (32.21)
Properly obtain, monitor, & document
Controlled drugs/Accudose (32.16)
Administer the following types of medication:
·  oral (32.06)
·  sublingual (32.07)
·  topical:
·  ointment (32.04)
·  dermal patch
·  inhalants (32.05)
·  Suppository:
·  rectal (32.08)
·  vaginal (32.09)
·  eye medications (32.10)
·  ear drops (32.11)
·  nose drops (32.12)
·  intramuscular injection (32.13)
·  Z-tract (32.13)
·  Intradermal injection (32.14)
·  Administer subcutaneous injection: (32.15)
·  Insulin
·  Heparin
·  NG/PEG Tube Meds
·  Care of supplies used: (32.18)
·  no recapping needles
·  sharps disposal

Rev. 6/08 JP/FA/MC/ML Section O, Page 1 of 9

System - Medical / Surgical
Respiratory (43.06)
Cardiovascular (34.07)
Muscular-Skeletal (34.08)
Neuro-Sensory/Integumentary (34.09)
Reproductive (34.10)
System - Medical / Surgical
Urinary (34.11)
Gastrointestinal (34.12)
Endocrine (34.13)
Observations & Assistance with Diagnostic Procedures (31.61) / Date / Instructor’s Initials
1. Operating Room
2. Post Anesthesia Care Unit
3. Day Surgery
4. Respiratory Therapy
5. Physical Therapy
6. Occupational Therapy
7. Endoscopy
8. Radiation Therapy
9. Chemotherapy/Outpatient Infusion
10. Radiology
11. Dialysis
12. Physician’s Office
13. Wound Care
14. Special Procedures

Instructors:

Initials Name Date

Rev. 6/08 JP/FA/MC/ML Section O, Page 1 of 9