Skill Assessment 9-1
Student NameSKILL / Sellick’s Maneuver
Objective / Student will demonstrate knowledge and application of Sellick’s maneuver.
Instructions / Instructor will demonstrate maneuver. Practice Sellick’s maneuver with your partner. When ready, notify instructor and schedule the check-off. Skills Assessment check-off must be completed satisfactorily by ______(due date).
Supplies / •None / •Mannequin
Note: Student must perform skill independently without prompting.
Practice with Partner Date: / Skills Testing Date:
PROCEDURAL STEPS / COMMENTS
1.Defines Sellick’s maneuver. / Correct / Needs Review
2.States purpose of Sellick’s maneuver. / Correct / Needs Review
3.Gives two examples in which Sellick’s maneuver may be indicated. / Correct / Needs Review
4.Positions self at patient’s right side. / Correct / Needs Review
5.Identifies correct anatomy. Uses self to demonstrate how to find anatomical structures. / Correct / Needs Review
6.Positions hand properly. / Correct / Needs Review
7.Applies adequate pressure. / Correct / Needs Review
8.Maintains cricoid pressure until asked to release by instructor (anesthesia). / Correct / Needs Review
Performance Evaluation Criteria / RATING
•Assembled necessary supplies and equipment
•Described Sellick’s maneuver correctly as the application of cricoid pressure to reduce the risk of aspiration by closing the esophagus. Examples: Emergency surgery when patient has eaten recently, NPO status cannot be verified, or patient is experiencing GI bleeding. May be used during CPR as needed.
•Student prepared and performed procedure independently.
•Performed each step in appropriate sequence.
•Demonstrated correct technique—firm pressure with the thumb and index finger forming a V on the cricoid cartilage. States cricoid pressure is applied prior to induction of anesthesia as instructed by anesthesia personnel until endotracheal tube is placed, placement verified, cuff inflated, and waits for instruction to release by anesthesia personnel.
Overall Rating (Satisfactory; Must Redo; Fail):
Instructor Comments
Student Signature / Date
Instructor Signature / Date
Skill Assessment 9-2
Student NameSKILL / Draw Up Medication in a Syringe (Off the Sterile Field)
Objective / Student will demonstrate knowledge and application of drawing up medication in a syringe (off the sterile field).
Instructions / Instructor will demonstrate maneuver. Practice skill with your partner. When ready, notify instructor and schedule skills check-off. Skills assessment must be completed satisfactorily by ______(due date).
Supplies / •Medication bottle
•Label and skin marker
•Syringe 3 2
•Withdrawal needle (18 gauge) 3 2
•Injection needle (22–25 gauge) 3 2
•Ampule—labeled for medication
•Vial—labeled for medication / •Mannequin with armband
•Preference card with medication listed
•Chart with allergies noted
•Potential medications as assigned by instructor—know medication classification and any precautions for ______.
Note: Student must perform skill independently without prompting.
Practice with Partner Date: / Skills Testing Date:
PROCEDURAL STEPS / COMMENTS
1.Identifies medication correctly. / Correct / Needs Review
2.Assembles all necessary supplies. / Correct / Needs Review
3.Demonstrates application of the “Six Rights.” / Correct / Needs Review
4.Verifies allergies of patient and that patient is not allergic to drug. / Correct / Needs Review
5.Prepares medication container for withdrawal of medication. / Correct / Needs Review
6.Withdraws medication correctly for container (ampule and vial). / Correct / Needs Review
7.Needle for injection is applied to syringe. / Correct / Needs Review
8.Medication label is rechecked for accuracy. States vial/ampule is kept in room until end
of case. / Correct / Needs Review
9.Medication is labeled correctly according to local policy. / Correct / Needs Review
Performance Evaluation Criteria / RATING
•Assembled necessary supplies and equipment.
•Described medication appropriately. Possible medications: Lidocaine—local anesthetic or antiarrhythmia medication; monitor for lidocaine toxicity; lidocaine with epinephrine is never injected into digits. Heparin—anticoagulant for irrigation; reversal agent protamine sulfate. Bacitracin—antibiotic; stored in refrigerator; check for allergies. And/or medication as assigned by instructor
•Demonstrated application of “Six Rights.” Ensures right patient, right drug, right dose, right route of administration, right time, and right label/documentation. Uses preference card to identify right drug, right dose, right route of administration, right time, and right label/documentation. Identifies right patient and verification of allergies using simulated chart and patient ID band.
•Student prepared and performed procedure independently.
•Performed each step in appropriate sequence.
•Demonstrated correct technique with no contamination. Ampule—opens correctly; inserts 18-gauge needle, bevel down; withdraws. Vial—cleans top/
alcohol, injects equal amount of air, inverts and withdraws appropriate amount of solution. Labels correctly according to local policy.
Overall Rating (Satisfactory; Must Redo; Fail):
Instructor Comments
Student Signature / Date
Instructor Signature / Date
Skill Assessment 9-3
Student NameSKILL / Draw Up Medication in a Syringe (Onto the Sterile Field)
Objective / Student will demonstrate knowledge and application of drawing up medication in a syringe (onto the sterile field).
Instructions / Instructor will demonstrate. Practice skill with your partner. When ready, notify instructor to schedule the check-off. Skills assessment must be completed satisfactorily by ______(due date).
Supplies / •Medication bottle: Ampule—labeled and/or vial—labeled***
•“Sterile” half-sheet
•“Sterile” gown/glove setup
•“Sterile” pack (three wrappers)
•Mannequin with armband
•Preference card - medication listed
•Chart with allergies noted
•Circulator—(second student who follows directions of STSR) / •Potential medications as assigned by instructor—know medication classification and any precautions for ______
lLabel(s) and skin marker
lSyringe 3 2
lWithdrawal needle (18 gauge) 3 2
lInjection needle (22–25 gauge) 3 2
lContainer(s)
lHemostat 3 1–2
Note: Student must perform skill independently without prompting.
Practice with Partner Date: / Skills Testing Date:
PROCEDURAL STEPS / COMMENTS
1.Identifies medication correctly. / Correct / Needs Review
2.Assembles all necessary supplies. / Correct / Needs Review
3.Opens sterile supplies without contamination. / Correct / Needs Review
4.Scrubs in correctly; dons sterile gown/gloves. / Correct / Needs Review
5.Demonstrates application of the “Six Rights.” Identifies total amount of medication given at end. / Correct / Needs Review
6.Verifies allergies of patient and that patient is not allergic to drug. / Correct / Needs Review
7.Circulator is instructed by STSR and prepares for withdrawal of medication correctly. / Correct / Needs Review
8.STSR and circulator verify visually and verbally identification of medication. / Correct / Needs Review
9.STSR withdraws medication correctly for container (ampule and/or vial). States vial/ ampule is kept in room until end of case. / Correct / Needs Review
10.Needle for injection is applied to syringe. / Correct / Needs Review
11.Medication is labeled correctly according to local policy. / Correct / Needs Review
12.Medications passed to surgeon/instructor as requested. STSR identifies medication. / Correct / Needs Review
Performance Evaluation Criteria / RATING
•Assembled necessary supplies and equipment
•Identifies medication information (classification, dose, strengths, administration precautions, etc.) correctly. Medication(s) as assigned by instructor:
______
•Demonstrates application of “Six Rights.” Ensures right patient, right drug, right dose, right route of administration, right time, and right label/documentation. Uses preference card to identify right drug, right dose, right route of administration, right time, and right label/documentation. Identifies right patient and verification of allergies using simulated chart and patient ID band. Identifies for documentation the total amount of medication administered at end of “case.”
•Student prepared and performed procedure independently.
•Performed each step in appropriate sequence.
•Demonstrated correct sterile technique. Guards sterile field. Sterile items transferred correctly.
•Demonstrated correct technique with no contamination: Ampule—opens correctly; inserts 18-gauge needle, bevel down; withdraws. Vial—circulator cleans top/alcohol, STSR injects equal amount of air into inverted container and withdraws correctly. Labels correctly according to local policy.
Overall Rating (Satisfactory; Must Redo; Fail):
Instructor Comments
Student Signature / Date
Instructor Signature / Date
Skill Assessment 9-4
Student NameSKILL / Accept Medication into the Sterile Field (Into a Container)
Objective / Student will demonstrate knowledge and application of accepting medication into the sterile field (into a container).
Instructions / Instructor will demonstrate maneuver. Practice skill with your partner. When ready, notify instructor and schedule the check-off. Skills assessment must be completed satisfactorily by ______(due date).
Supplies / •Medication bottle: vial/container, labeled
•“Sterile” half sheet
•“Sterile” gown/glove setup
•“Sterile” pack (three wrappers)
•Mannequin with armband
•Preference card—medication listed
•Chart with allergies noted
•Circulator—(second student who follows directions of STSR) / •Potential medications as assigned by instructor, know medication classification and any precautions for______
lLabel(s) and skin marker
lSyringe 3 2
lWithdrawal needle (18 gauge) 3 2
lInjection needle (22–25 gauge) 3 2
lContainer(s)
lHemostat 3 1–2
Note: Student must perform skill independently without prompting.
Practice with Partner Date: / Skills Testing Date:
PROCEDURAL STEPS / COMMENTS
1.Identifies medication correctly. / Correct / Needs Review
2.Assembles all necessary supplies. / Correct / Needs Review
3.Opens sterile supplies without contamination. / Correct / Needs Review
4.Scrubs in correctly; dons sterile gown/glove. / Correct / Needs Review
5.Demonstrates application of the “Six Rights.” Identifies total amount given at end of case. / Correct / Needs Review
6.Verifies patient is not allergic to drug. / Correct / Needs Review
7.Circulator is instructed by STSR and prepares medication for transfer to sterile field. / Correct / Needs Review
8.STSR and circulator verify visually and verbally identification of medication. / Correct / Needs Review
9.STSR presents or places container at edge of sterile field correctly to receive medication. States container kept in room for referral as needed. / Correct / Needs Review
10.Medication is transferred to sterile field. / Correct / Needs Review
11.Medication is correctly identified visually and verbally. Container is labeled correctly. / Correct / Needs Review
12.Medication is prepared for administration. Drawn up and diluted prn correctly. / Correct / Needs Review
13.Medication labeled according to local policy. / Correct / Needs Review
14.Medications passed to surgeon/instructor as requested. STSR identifies medication. / Correct / Needs Review
15.At end of exercise, STSR identifies correct amount administered during exercise. / Correct / Needs Review
Performance Evaluation Criteria / RATING
•Assembled necessary supplies and equipment
•Describes medication (classification, strength, dose, administration, etc.) appropriately. Medication as assigned by instructor:______
•Demonstrates application of “Six Rights.” Ensures right patient, right drug, right dose, right route of administration, right time, and right label/documentation. Uses preference card to identify right drug, right dose, right route of administration, right time, and right label/documentation. Identifies right patient and verification of allergies using simulated chart and patient ID band. Identifies for documentation the total amount used at end of “case.”
•Student prepared and performed procedure independently.
•Performed each step in appropriate sequence.
•Demonstrated correct sterile technique. Guards sterile field. Sterile items transferred correctly.
•Demonstrated correct technique with no contamination: Ampule—opens correctly; inserts 18-gauge needle, bevel down; withdraws. Vial—circulator cleans top/alcohol, STSR injects equal amount of air into inverted container and withdraws correctly. Labels correctly according to local policy.
Overall Rating (Satisfactory; Must Redo; Fail):
Instructor Comments
Student Signature / Date
Instructor Signature / Date
Skill Assessment 9-5
Student NameSKILL / Correctly Identify Medication Dosage
Objective / To correctly read and calculate medication amounts administered by syringe with 100% accuracy.
Instructions / Instructor will demonstrate testing station. Practice skill with your partner. When ready, notify instructor and schedule the check-off. Skills assessment must be completed satisfactorily by ______(due date).
Supplies / •TB syringe X 2
•Insulin syringe
•3-cc or 5-cc syringe(s) as used by local facilities
•10-cc syringe / •Larger syringes as used by local facilities
•Instructor/student fills syringes with different amounts of solutions
Note: Student must perform skill independently without prompting.
Practice with Partner Date: / Skills Testing Date:
PROCEDURAL STEPS / COMMENTS
1.Correctly identifies amount drawn up into a TB and/or insulin syringe correct. Correctly identifies each mark. / Correct / Needs Review
2.Correctly identifies how much has been administered if syringe was full at start of case.. / Correct / Needs Review
3.Correctly identifies amount drawn up into each 3-cc and/or 5-cc syringe. Correctly identifies each mark. / Correct / Needs Review
4.Correctly identifies how much has been administered if syringe was full at start of case. / Correct / Needs Review
5.Correctly identifies amount drawn up into each 10-cc syringe. Correctly identifies each mark. / Correct / Needs Review
6.Correctly identifies how much has been administered if syringe was full at start of case. / Correct / Needs Review
7.Correctly identifies amount drawn up into each large syringe. Correctly identifies each mark. / Correct / Needs Review
8.Correctly identifies how much has been administered if syringe was full at start of case. / Correct / Needs Review
Performance Evaluation Criteria / RATING
•Identifies each type of syringe and amount left in syringe.
•Demonstrates correct calculation of amount administered from a full syringe.
•Student prepared and performed procedure independently.
Overall Rating (Satisfactory; Must Redo; Fail):
Instructor Comments
Student Signature / Date
Instructor Signature / Date