EXAM OF PRACTICAL SKILLS I
STUDENTS MUST BE ABLE TO PERFORM FOLLOWING PRACTICAL SKILLS:
PHYSICAL ASSESSMENT
1. Taking a temperature
2. Taking a pulse
3. Counting respirations
4. Taking blood pressure
MEDICATION ADMINISTRATION
1. Administering oral, sublingual, and buccal medications
2. Administering eye and ear medications
3. Administering skin/topical medications
4. Administering nasal medications
5. Administering rectal medications
6. Administering vaginal medications
7. Administering nebulized medications
8. Administering an intradermal injection
9. Administering a subcutaneous injection
10. Administering an intramuscular injection
11. Administering medication via z-track injection
12. Withdrawing medication from a vial
13. Withdrawing medication from an ampoule
14. Mixing medications from two vials into one syringe
15. Preparing an IV solution
16. Adding medications to an iv solution
17. Administering medications via secondary administration sets (piggyback)
18. Administering medications via iv bolus or iv push
19. Managing controlled substances
PROCEDURE CHECKLISTS
Assessing Body Temperature
PROCEDURE STEPS
1. Selects appropriate site and thermometer type.
2. “Zeroes” or shakes down glass thermometer as needed.
3. Inserts thermometer in sheath or uses thermometer designated only for the patient.
4. Inserts in chosen route/site.
a. Oral: Places thermometer tip under the tongue in the posterior sublingual pocket (right or left of frenulum). Asks patient to keep lips closed.
b. Rectal: Lubricates thermometer; uses rectal thermometer; inserts 1 to
c. Axillary: Dries axilla; Places thermometer tip in the middle of the axilla; lowers patient’s arm.
Tympanic membrane:
Positions the patient’s head to one side and straighten the ear canal.
1) For an adult, pulls the pinna up and back.
2) For a child, pull the pinna down and back
5. Leaves glass thermometer recommended time (oral 3–5 min, rectal 2 min, axillary 6–8 min).
6. Holds rectal thermometer securely in places; does not leave patient unattended.
7. Leaves electronic thermometer until it beeps.
8. Reads temperature. Holds glass thermometer at eye level to read.
9. Shakes down (as needed) and cleans or stores thermometer.
ASSESSING PERIPHERAL PULSES
PROCEDURE STEPS
NOTE: You can use this checklist to evaluate one peripheral pulse, or to evaluate the student’s ability to locate all the peripheral pulses.
Used sites:
ü radial,
ü brachial,
ü carotid,
ü temporal,
ü popliteal,
ü femoral,
ü posterior tibial,
ü dorsalis pedis
1. Selects, correctly locates, and palpates site.
2. Uses fingers (not thumb) to palpate.
3. Counts for 30 sec. if regular; 60 sec. if irregular.
4. Notes rate, rhythm, and quality.
5. Compares bilaterally.
6. Carotid pulse: Palpates only on one side at a time.
7. Correctly locates the following sites:
a. radial
b. brachial
c. carotid
d. temporal
e. popliteal
f. femoral
g. posterior tibial
h. dorsalis pedis
ASSESSING RESPIRATIONS
PROCEDURE STEPS
1. Flexes patient’s arm and places patient’s forearm across chest, or otherwise counts unobtrusively.
2. Counts for 30 seconds if respirations regular; 60 seconds if irregular.
3. Observes rate, rhythm, and depth.
ASSESSING THE APICAL PULSE
PROCEDURE STEPS
1. Selects, correctly locates, and palpates apical site (5th intercostal space at the midclavicular line).
2. Uses diaphragm of stethoscope.
3. Counts for 60 seconds.
4. Notes rate, rhythm, and quality.
5. Identifies S1 and S2 heart sounds.
MEASURING BLOOD PRESSURE
PROCEDURE STEPS
1. If possible, positions patient sitting, feet on floor, legs uncrossed; alternatively, lying down.
2. Measures BP after patient has been inactive for 5 min.
3. Exposes arm (does not auscultate through clothing).
4. Supports patient’s arm at the level of the heart.
5. Uses appropriately sized cuff. (The width of the bladder of a properly fitting cuff will cover approximately 2/3 of the length of the upper arm for an adult, and the entire upper arm for a child. Alternatively, the length of the bladder encircles 80% to 100% of the arm in adults.)
6. Positions cuff correctly; wraps snugly.
7. Palpates radial artery, closes sphygmomanometer valve, and inflates cuff to determine mm Hg at which radial artery cao longer be felt.
8. Places stethoscope on brachial artery and continues to inflate cuff rapidly to
9. Ensures that stethoscope tubing is not touching anything.
10. Releases pressure at 2–3 mm Hg/second.
11. Reads mercury manometer at eye level
12. Records at least systolic/diastolic (first and last sounds heard—e.g., 110/80). Records level of muffling, if possible.
13. If necessary to remeasure, waits at least 2 minutes.
MEDICATION ADMINISTRATION
ADMINISTERING ORAL MEDICATIONS
PROCEDURE STEPS
1. *Wash hands.
2. Gather equipment: medication administration sheet (MAR), client’s container of medications, calculator, and medication cups.
3. *While noting for any allergies remove ordered medication from supply while comparing the label on the medication with the ordered medication on the MAR.
4. *Prepare medication using the five rights of medication administration: right medication, right client, right dose, right time and right route.
5. Place packaged medication in the cups without unwrapping. Place tablets from a multidose bottle into bottle cap and then transfer into cup. Pour liquid medications by holding label against palm of hand, remove cap and place countertop inside up and fill medicine cup until bottom of meniscus is at desired level. Dispose of any excess liquid into sink.
6. Take medication and MAR to client’s room.
7. * Compare name on MAR with name on client’s identification bracelet. Use one other identifier found both on bracelet and MAR such as medical record number or date of birth.
8. Complete any pre-administration assessment such as blood pressure or pulse.
9. *Using the five rights recheck each medication with the MAR while unwrapping the unit-dose medications.
10. Allow client to sitting position and provide with a glass of water to assess swallowing ability.
11. Explain the purpose of the medications and assist client as needed in taking tablets from cup. Stay with client until all of medication is swallowed.
12. *Dispose of soiled supplies and wash hands.
INTRAMUSCULAR INJECTION
PROCEDURE STEPS
1. Gather supplies: MAR, alcohol swabs, vial or ampule of medication, clean gloves and 3 ml syringe, #20 to #22 gauge 1″ to 1 1/2» inch needle.
2. *Calculate the correct amount of medication to administer.
3. *Wash hands.
4. *Using five rights of medications check against MAR and note any allergies.
4. Withdraw correct medication from vial or ampule and recap using one-handed method.
Use filter needle to withdraw medication from an ampule, replace with injectioeedle after drawing up medication.
5. Label syringe with the name of the drug using tape or preprinted medication labels.
6. *Identify client using two identifiers found on MAR and ID bracelet. Recheck medication against MAR.
7. Explain procedure and reason for medication to client.
SC INJECTION
PROCEDURE STEPS
1. Gather supplies: MAR (medication administration record), alcohol wipes, clean gloves, 1-3ml syringe, 3/8 – 5/8 inch and 25-27 guage needle, and medication to be administered.
2. *Wash hands.
3. *Calculate the correct amount of drug to be administered.
4. *Using the five rights and three checks prepare the correct dose of medication to be administered.
5. *identify client using two identifiers. Explain procedure and provide for privacy.
6. Apply clean gloves and select an injection site.
7. Cleanse site with alcohol swab in circular motion starting from center outward. Allow to dry.
8. Remove needle guard and hold syringe in dominant hand. Use nondominant hand to pinch subcutaneous tissue to be injected.
9. While holding syringe between thumb and forefinger inject in a dart like fashion at a 45-90 degree angle.
10. Release bunched skin and use nondominant hand to stabilize syringe while using dominant hand to aspirate gently on plunger. If blood appears in syringe withdraw needle and prepare new injection.
Do not aspirate when injecting anticoagulants, (Ex: heparin, lovenox),or insulin.
11. Slowly inject medication and remove needle while applying pressure over site with alcohol swab.
12. Gently massage site with alcohol swab.
Do not massage site when injecting anticoagulants as this may cause bleeding at the injection site. It is appropriate to massage following insulin injections.
13. Do not recap needle. Dispose of needle and syringe in sharps container.
14. *Wash hands.
15. Using the sixth right of medication administration document medication administration on MAR according to agency policy.
CHECKLIST FOR THE ADMINISTRATION OF TOPICAL MEDICATIONS:
EYE OINTMENT
1. Wash hands.
2. Assemble equipment necessary.
3. State purpose, side effects and warnings of the assigned medication(s).
4. Check that the label on the medication container corresponds with the medication listed on the medication sheet three times:
5. when taken from the individual’s supply;
6. when placed on medication tray or table, etc.;
7. when instilled in the individual’s eye.
8. Check for expiration date to be sure the medication is current.
9. Identify the individual prior to administration of the medication.
10. Explain the procedure to the individual.
11. Have the individual sit or lie down.
12. Put on gloves.
13. Observe the affected eye(s) for any unusual condition which should be reported to the clinic or the nurse prior to the medication application.
14. Position individual with head back and looking upward.
15. Retract the lower lid of the eye to be medicated.
16. Approach eye from below, outside the individual’s field of vision, using due care to avoid contact with the eye.
17. Apply prescribed ointment in a thin layer along inside lower lid.
18. Hold lid open a few seconds.
19. Close eyes gently. Ask individual to keep eyes closed for a few minutes. Wipe excess medication with a clean wipe.
20. Dispose of gloves.
21. Position individual comfortably.
22. Check label on the container when returning to the individual’s supply.
23. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
24. Wash hands.
25. Observe the individual if the medication was given for specific results and chart.
CHECKLIST FOR THE ADMINISTRATION OF TOPICAL MEDICATION:
EYE DROPS
1. Wash hands.
2. Assemble equipment.
3. State purpose for use, side effects and warnings of prescribed medication.
4. Check that the label on the medication container corresponds with the medication listed on the medication sheet 3 times:
a. When taken from the individual’s supply.
b. When placed on the medication tray or table, etc.
c. Prior to instilling in the individual’s eye.
5. Check for expiration date to be sure it is current.
6. Identify individual prior to administration of medication.
7. Explain procedure to individual.
8. Put on gloves.
9. Cleanse eye with a clean wipe, wiping from inner corner outward once. When drops are instilled into both eyes, cleanse each eye with a clean wipe.
10. Have individual sit or lie down.
11. Observe affected eye(s) for any unusual condition which should be reported to the clinic or the nurse prior to administration.
12. Draw up the correct ordered amount of medication into dropper (if applicable).
13. Position individual with head back and looking upward.
14. a. Separate lids of the affected eye by raising upper lid with forefinger and lower lid with thumb. Approach eye with dropper or bottle from below the eye, outside the individual’s field of vision. Avoid contact with the eye. OR
b. Gently draw lower lid down with forefinger; steady hand on forehead, and hold dropper or bottle, avoiding contact with eye.
15. Apply drop(s) gently near center of lower lid not allowing drop(s) to fall more than one inch before striking eye.
16. Close eyes gently. Ask individual to close their eyes for a few minutes.
17. Wipe excess medication with a clean wipe using a separate clean wipe for each eye.
18. Remove gloves.
19. Position individual comfortably.
20. Wash hands.
21. Check the label when returning the medication to the individual’s supply.
22. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
23. Observe individual for specific results and chart.
CHECKLIST FOR THE ADMINISTRATION OF TOPICAL MEDICATIONS: EAR DROPS
1. Wash hands.
2. Assemble equipment.
3. State the purpose, side effects, and warnings of prescribed medication.
4. Remove the medication from the individual’s supply checking that the label on the container corresponds with the medication listed on the medication sheet.
5. Place the medication on the medication tray, table, etc. Include a dropper, if one is required.
6. Identify individual prior to administration of medication.
7. Explain procedure to the individual.
8. Put on gloves.
9. Position the individual: a. if lying in bed, have individual turn head to opposite side; b. if sitting in a chair, tilt head sideways until ear is as horizontal as possible.
10. Clean entry to ear canal with clean cotton ball.
11. Observe affected ear for any unusual condition prior to ear drop instillation which should be reported to the clinic or the nurse.
12. Draw up the medication ordered into the dropper, (if applicable) checking that the label on the medication container corresponds with the medication sheet.
13. Administer the ear drops by gently pulling the ear backward and upward and instilling the number of drops ordered into the ear canal. Do not contaminate the dropper by touching any part of the ear canal.
14. If individual desires a cotton ball, place a clean cotton ball loosely in the ear.
15. Instruct individual to maintain the required position for 2-3 minutes.
16. If drops are ordered for both ears, wait at least 5 minutes before putting drops in second ear; repeat same procedure.
17. Remove gloves.
18. Leave individual comfortably positioned.
19. Return medication to individual’s supply checking that the label on the medication container corresponds with the medication sheet.
20. Wash hands.
21. Clean and replace equipment.
22. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
23. Observe individual for specific results and chart.
CHECKLIST FOR ADMINISTRATION OF TOPICAL MEDICATIONS: SKIN MEDICATIONS
1. Wash hands.
2. Assemble necessary equipment.
3. State purpose for use, side effects, and warnings of prescribed medications.
4. Remove the medication from the individual’s supply, checking that the label on the medication container corresponds with the medication sheet.
5. Check for expiration date to be sure the medication is current.
6. Identify the individual prior to administration of medication by verifying his/her name.
7. Explain procedure to the individual.
8. Position the individual as necessary.
9. Put on gloves.
10. Observe any unusual conditions of the affected area of the body prior to medication administration which should be reported to the clinic or the nurse.
11. Cleanse affected area as indicated.
12. Check that the label on the medication container corresponds with the medication listed on the medication sheet.
13. Administer the correct medication according to prescribed directions.
14. Leave individual in a comfortable position.
15. Remove gloves.
16. Wash hands.
17. Check that the label on the medication container corresponds with the medication listed on the medication sheet and return medication to the individual’s supply.
18. Clean and replace (or discard) equipment.
19. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
20. Observe the individual if the medication was given for specific results and chart.
CHECKLIST FOR ADMINISTRATION OF RECTAL MEDICATIONS
1. Wash hands.
2. Assemble equipment necessary.
3. State purpose, side effects and warnings of the assigned medication(s).
4. Check the label on the medication container to see that it corresponds with the medicine listed on the medication sheet three times.
a. When taken from the individual’s supply.
b. When removed from the container.
c. When returning the remaining suppositories to the individual’s supply.
5. Check for expiration date to be sure it is current.
6. Follow directions as to whether medication should be chilled before using.
7. Identify individual prior to administration of the medication by verifying his/her name.
8. Explain procedure to the individual.
9. Provide privacy, as necessary.
10. Position individual on side with top leg flexed.
11. Put on rubber glove or finger cot.
12. Check for correct medication and remove suppository from the wrapper.
13. Lubricate tip of suppository unless contraindicated.
14. Encourage the individual to relax by instructing to breathe through the mouth or take deep breaths.
15. Insert suppository, pointed end, along the wall of the rectum beyond the sphincter, pushing it gently with gloved finger.
16. Administer prescribed medication and dose.
17. Slowly withdraw finger, press tissue against anus until urge to expel subsides.
18. Remove and discard glove or finger cot.
19. Position individual comfortably.
20. Give individual any specific instructions.
21. Wash hands.
22. Clean and replace equipment.
23. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
24. Observe the individual if the medication was given for specific results and chart.
CHECKLIST FOR ADMINISTRATION OF NEBULIZER MEDICATION
1. Wash hands.
2. Assemble equipment necessary.
3. State purpose, side effects and warnings of the prescribed medication.
4. Check that the label on the medication container corresponds with the medicine listed on the medication sheet when removing from the individual’s supply.
5. Identify the individual prior to administration of medication.
6. Empty vial/bottle into nebulizer cup, checking label.
7. Assemble nebulizer machine and plug into outlet.
8. Place facemask over individual’s mouth and nose or insert mouthpiece into individual’s mouth.
9. Turn on nebulizer machine.
10. Instruct individual to take deep breaths for entire treatment (usually lasts approximately 10 minutes).
11. Wash parts in hot soapy water and allow to air dry.
12. Wash hands.
13. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
14. Observe the individual if the medication was given for specific results and chart.
CHECKLIST FOR THE ADMINISTRATION OF NASAL MEDICATION
1. Wash hands.
2. Assemble equipment necessary.
3. State purpose, side effects and warnings of the prescribed medication.
4. Check that the label on the medication container corresponds with the medicine listed on the medication sheet when removing from the individual’s supply.
5. Check for expiration date to be sure it is current.
6. Identify individual prior to administration of medication.
7. Explain procedure to individual.
8. Position the individual in a sitting position with head tilted backward, or to the side if the medicatioeeds to reach one or the other sinuses. If the individual is unable to sit, place a rolled towel or pillow beneath the neck.
9. Remove the cap from the nasal medication and check the label.
10. Drop form: Aim the tip of the dropper toward the nasal passage and squeeze the rubber portion of the cap to administer the number of prescribed drops. Instruct the individual to breathe through the mouth as the drops are instilled.
11. For Spray form: Place the tip of the container just inside the nostril. Occlude the opposite nostril. Instruct the individual to inhale as the container is squeezed. Repeat in the opposite nostril.
12. Advise the individual to remain in position for approximately 5 minutes.
13. Recap the container and replace where medication is stored and check the label.
14. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
15. Wash hands.
16. After 5 minutes, position the individual as necessary.
17. Observe the individual if the medication was given for specific results and chart.
CHECKLIST FOR ADMINISTRATION OF INHALANT MEDICATION
1. Wash hands.
2. Assemble necessary equipment.
3. State purpose, side effects, and warnings of the prescribed medication.
4. Check that the label on the medication container corresponds with the medicine listed on the medication sheet when removing from the individual’s supply.
5. Check for expiration date to be sure it is current.
6. Identify individual prior to administration of medication.
7. Explain procedure to individual.
8. Check the label and attach the stem of the canister into the hole of the mouthpiece so that the inhaler looks like an “L”.
9. Shake the canister to distribute the drug within the pressurized chamber.
10. Instruct the individual to slowly exhale through pursed lips.
11. Instruct the individual to seal lips around the mouthpiece.
12. Compress the canister between thumb and fingers and instruct the individual to inhale at the same time.
13. Release pressure on the canister, but instruct the individual to continue inhaling as much as possible.
14. Withdraw mouthpiece.
15. Instruct the individual to hold breath for a few seconds.
16. Instruct the individual to exhale slowly, through nose.
17. Recap the canister and replace where medication is stored and check the label.
18. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
19. Wash hands.
20. Observe the individual if the medication was given for specific results and chart.
CHECKLIST FOR ADMINISTRATION OF VAGINAL MEDICATION
1. Assemble equipment necessary for administration.
2. State purpose, side effects, and warnings of the prescribed medication.
3. Have individual empty bladder prior to medication application.
4. Wash hands.
5. Check that the label on the medication container corresponds with the medicine listed on the medication sheet when removing from the individual’s supply.
6. Check for expiration date to be sure it is current.
7. Know the individual prior to administration of the medication.
8. Explain procedure to individual.
9. Provide necessary privacy.
10. Check label, put on gloves, remove suppository or tablet from wrapper, or uncap cream. Insert suppository, cream into applicator, lubricate tip, as necessary.
11. Position individual on back with knees bent and legs spread.
12. Encourage the individual to relax by instructing to breathe through the mouth or take deep breaths.
13. Separate the labia and insert the applicator into vagina as far as it will go comfortably without using force. (2-
14. Slowly push in plunger of applicator until it stops automatically, inserting the medication.
15. Carefully remove applicator from vagina, holding the barrel (outer cylinder). Discard if disposable.
16. Apply a sanitary pad, to prevent staining.
17. Wash applicator with warm, soapy water (do not boil). For easy cleaning it may be disassembled by pulling the plunger from the barrel. Rinse and dry.
18. Keep the individual on their back for at least 10 to 30 minutes.
19. Discard rubber gloves and wash hands.
20. Check the medication label when returning medication to individual’s medication tray.
21. Chart the medication administered on medication sheet and initial unit dose pack if applicable.
PROCEDURE CHECKLIST
Mixing Medications in One Syringe, Using Two Vials
PROCEDURE STEPS
1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.”
2. Checks compatibility of medications.
3. Before beginning, determines total volume of all medications to be put in the syringe and whether that volume is appropriate for the administration site.
4. Recaps needles throughout, using a needle capping device or approved one-handed technique that has a low risk of contaminating the sterile needle (see Procedure Checklist Chapter 23: Recapping Needles Using One-Handed Technique).
5. Maintains sterility of needles and medication throughout the procedure.
6. Avoids contaminating a multi-dose vial with a second medication.
7. Cleanses tops of vials with alcohol prep pad (according to agency procedure).
8. Places needle cap on opened, sterile alcohol wipe.
9. Draws up same amount of air into syringe as the total medication doses for both vials (e.g., if the order is for 0.5 mL for Vial A and 1 mL for Vial B, draws up 1.5 mL of air).
10. Maintaining sterility, inserts needle or vial access cannula into vial without coring (or uses a filter needle):
a. Places the tip of the needle or vial access cannula in the middle of the rubber top of the vial with the bevel up at a 45°–60° angle.
b. While pushing the needle or vial cannula device into the rubber top, gradually brings the needle upright to a 90° angle.
11. Keeping the tip of the needle (or vial access device) above the medication, injects amount of air equal to the volume of drug to be withdrawn from the first vial (e.g., 0.5 mL for Vial A in step 9; then injects the rest of the air into the second vial.
NOTE: If one vial is a multi-dose vial, injects air into the multiple-dose vial first.
NOTE: If mixing two types of insulin, puts air into the regular insulin last. Refer to Technique 23-
12a. Without removing the needle (or access device) from the second vial, inverts the vial and withdraws the ordered amount of medication.
12b. Using correct technique expels any air bubbles and measures dose at eye level.
12 c. Removes needle from vial and pulls back on the plunger enough to pull all medication out of the needle (or access device) into the syringe.
12d. Reads dose at eye level; holds syringe vertically to eject all air; tips syringe horizontally if any medication must be ejected.
13a. Inserts needle into first vial, inverts, and withdraws the exact ordered amount of medication, holding syringe vertical (when finished, the plunger should be at the line for the total/combined dose.
13b. Keeps index finger on the flange of the syringe to prevent it being forced back by pressure. Does not draw excess medication into the syringe.
13c. If excess medication is inadvertently drawn into syringe, recognizes error, discards the medication in the syringe, and starts over. (The “total” amount calculated initially should be in the syringe.)
14. If a filter needle or VAD was used, draws air into syringe to clear medication from needle and proceeds according to Technique 23-
15. Removes needle from vial and recaps needle, using needle capping device or approved one-handed scoop method.
16. Places a new sterile needle on the syringe to be used to give the injection.
17. Next holds syringe vertically and re-checks the dosage at eye level.
PROCEDURE CHECKLIST
Mixing Medications in One Syringe, Using Two Vials
1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.”
2. Checks compatibility of medications.
3.Before beginning, determines total volume of all medications to be put in th
e syringe and whether that volume is appropriate for the administration site.
4.Recaps needles throughout, using a needle capping device or approved one-handed technique that has a low risk of contaminating the sterile needle
5.Maintains sterility of needles and medication throughout the procedure.
6.Avoids contaminating a multi-dose vial with a second medication.
7.Cleanses tops of vials with alcohol prep pad (according to agency procedure).
8.Places needle cap on opened, sterile alcohol wipe.
9.Draws up same amount of air into syringe as the total medication doses for both vials (e.g., if the order is for 0.5 mL for Vial A and 1 mL for Vial B, draws up 1.5 mL of air).
10.Maintaining sterility, inserts needle or vial access cannula into vial without coring (or uses a filter needle):
a.Places the tip of the needle or vial access cannula in the middle of the rubber top ofthe vial with the bevel up at a 45°–60° angle.
b. While pushing the needle or vial cannula device into the rubber top, gradually bringsthe needle upright to a 90° angle.
11.Keeping the tip of the needle (or vial access device) above the medication, injects amount of air equal to the volume of drug to be withdrawn from the first vial (e.g., 0.5 mL for Vial A in step 9; then injects the rest of the air into the second vial.
NOTE: If one vial is a multi-dose vial, injects air into the multiple-dose vial first.
NOTE: If mixing two types of insulin, puts air into the for mixing two types of insulin.
12a. Without removing the needle (or access device) from the second vial, inverts the vial and withdraws the ordered amount of medication.
12b. Using correct technique expels any air bubbles and measures dose at eye level.
12 c. Removes needle from vial and pulls back on the plunger enough to pull all medication out of the needle (or access device) into the syringe.
12d. Reads dose at eye level; holds syringe vertically to eject all air; tips syringe horizontally if any medication must be ejected.
13a. Inserts needle into first vial, inverts, and withdraws the exact ordered amount of medication, holding syringe vertical (when finished, the plunger should be at the line for the total/combined dose.
13b. Keeps index finger on the flange of the syringe to prevent it being forced back
by pressure. Does not draw excess medication into the syringe.
13c. If excess medication is inadvertently drawn into syringe, recognizes error, discards the medication in the syringe, and starts over. (The “total” amount calculated initially should be in the syringe.)
14. If a filter needle or VAD was used, draws air into syringe to clear medication from needle and proceeds according to Technique 23-4 in Volume 2.
15. Removes needle from vial and recaps needle, using needle capping device or approved one-handed scoop method.
16. Places a new sterile needle on the syringe to be used to give the injection.
17. Next holds syringe vertically and re-checks the dosage
at eye level.
PROCEDURE CHECKLIST
Preparing and Drawing Up Medications from Ampules
1. Prepares and administers medications according to “Medication Guidelines: Steps to Follow for All Medications.”
2. Recaps needles throughout, using a needle capping device or approved one-handed technique that has a low risk of contaminating the sterile needle (see Procedure Checklist Chapter 23: Recapping Needles Using One-Handed Technique).
3. Flicks or taps the top of the ampule to remove medication trapped in the top of the ampule. Alternatively, shakes the ampule by quickly turning and “snapping” the wrist.
4. Uses ampule snapper, or wraps 2×2 gauze pad or unwrapped alcohol wipe around neck of the ampule; using dominant hand, snaps off the top.
5. Breaks ampule top away from the body.
6. Attaches filter needle (or filter straw) to a syringe. If syringe has a needle in place, removes both the needle and the cap and places on a sterile surface (e.g., a newly unwrapped alcohol pad still in the open wrapper), then attaches filter needle.
7. Does not touch the neck of the ampule with the needle while withdrawing medication.
8. Uses one of the following techniques to withdraw medication:
a. Inverts ampule, places needle tip in liquid, and withdraws all of medication. Does not insert needle through the medication into the air at the top of the inverted ampule.
b. Alternatively, tips ampule, places needle in liquid, and withdraws all medication. Repositions ampule so that needle tip remains in the liquid.
9. Draws up exact amount of medication.
10. If necessary to eject medication after ejecting air, tips the syringe horizontal to do so.
11. Holds syringe vertically and draws 0.2 mL of air into the syringe. Measures exact medication dose (draws back plunger to the “dose + 0.2 mL” line).
12. Removes filter needle and reattaches the “saved” (or other sterile) needle for administration.
13. Ejects the 0.2 mL of air, and checks the dose again.
(If giving an irritating medication such as parenteral iron, omit this step.)
14. Disposes of top and bottom of ampule and filter needle in a sharps container.
INITIATING INTRAVENOUS FLUIDS INTO AN EXISTING IV SITE
1. *Verify order and gather equipment: IV solution, IV tubing (micro tubing if hourly rate 50ml/hr. or less), alcohol wipes, clean gloves, saline flush, 3ml syringe, blunt cannula, tape and watch with second hand.
2. *Wash hands.
3. *Correctly interpret IV math for ml/hour and gtts./min.
4. *Using three checks and the five rights to compare solution with the physician’s order on the MAR
5. Remove outer wrapper from IV bag and assess the expiration date and check for any leaks or impurities in the bag.
6. Label the bag with client’s name, solution type, date, time and your initials. Label IV tubing with date and time. Place time strip on side of bag with hourly rate.
7. Prepare the IV tubing for spiking into bag by sliding roller clamp to the top of the tubing and closing it completely.
8. Invert IV bag and remove outer cap. Remove cap off IV tubing spike and insert spike into the IV bag while keeping tips sterile.
9. Place bag on IV pole and squeeze drip chamber to fill half full.
10. Remove IV tubing cap, place adapter on IV tubing end and while holding IV tubing at waist level slowly open roller clamp to prime IV tubing until all air is removed. Recap tubing and hang on IV pole while you prepare IV flush.
11. To prepare IV flush cleanse saline vial with alcohol. Draw up 2 ml of air into 3ml syringe and inject into saline vial. Invert vial and draw up 2 ml of saline flush. Recap and label syringe.
12.*If you have prepared IV in the medication room then gather your supplies and at client’s bedside use two identifiers to validate the correct patient against the MAR.
13.Apply clean gloves. Assess site for signs of infiltration and phlebitis.
14. After cleansing IV site with alcohol slowly inject saline flush. Set syringe aside and connect IV tubing to site.
15. Open roller clamp slowly and assess patency of IV flow rate.
16. Secure IV tubing with tape. Lower bed and using second hand timer set IV to ordered rate.
17. *Wash hands and document.
ADMINISTERING IVP MEDICATIONS VIA INT/PRN ADAPTER/LOCK DEVICE
1. Gather supplies: MAR, vial or ampule of ordered medication, watch with second hand, clean gloves, alcohol swabs, saline flush, 2-3ml syringes with blunt cannulas and appropriate size syringe to withdraw medication.
2. *Check for any allergies. Calculate the correct amount of drug to be given. Wash hands.
3. *Using the five rights check medication against MAR. Complete three checks of medication, as you retrieve medication, after preparing medication and prior to medication administration.
4. Prepare a pre and post flush of saline by withdrawing 2 ml of saline in each syringe. Label syringes.
5. Prepare medication according to dosage and administration section of drug reference. Label medication.
6. *Identify client by using two identifiers found on MAR and ID bracelet. Recheck five rights.
7. *Apply clean gloves and assess IV site patency by observing for any redness or swelling at site. (Note: Some institution’s policy requires aspirating on syringe and assessing for a blood return to ensure IV patency.)
8. Cleanse INT with alcohol swab and slowly flush with normal saline solution. Assess INT patency by noting if any discomfort or resistance while flushing.
9. Remove flush, cleanse site with alcohol and connect medication syringe. Using second hand on watch administer medication at recommended rate.
10. Remove medication syringe, cleanse site with alcohol and administer post-saline flush at the same rate at which medication was administered.
11. Dispose of syringe in sharps and container and remove gloves.
12. *Wash hands and document medication administration.
Algorithm of students’ communication with patients with pathology in subject (communication skills)
During examination of the patient students have to use such communicative algorithm.
Complaints and anamnesis taking in patients.
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Take complaints and anamnesis in a patient.
5. Explain to the patient results of his/her lab tests correctly and accessibly.
6. Explain to the patient your actions concerning him/her (the necessity of hospitalization, certain examinations and manipulations), which are planned in future.
7. Conversation accomplishment.
Objective examination:
Physical methods of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient, what examinations will be carried out and get his/her informed consent.
5. Find a contact with the patient and make an attempt to gain his/her trust.
6. Inform about the possibility of appearing of unpleasant feelings during the examination.
7. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope, etc.).
8. Examination (demonstration of clinical skill).
9. Explain to the patient results of his/her lab tests correctly and accessibly.
10. Conversation accomplishment.
Estimation of laboratory and instrumental investigations
Informing about the results of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient results of his/her lab tests correctly and clearly.
5. Involve the patient into the conversation (compare present examination results with previous ones, clarify whether your explanations are clearly understood).
Planning and prognosis the results of the conservative treatment
Friendly facial expression and smile.
1. Gentle tone of speech.
2. Greeting and introducing.
3. Correct and clear explanation of necessary treatment directions.
4. Discuss with a patient the peculiarities of taking medicines, duration of their usage, possible side effects; find out whether your explanations are clear for him/her or not.
5. Conversation accomplishment.
ADMINISTER MEDICATIONS BY IV PIGGYBACK
Standards: Prepared the IV piggyback unit without contamination and administered it to the patient without complications.
Performance Steps
1. Identify the patient, explain the procedure, and ask about allergies.
2. Check the medication sheet (DA Form 4678) against the physician’s orders.
a. Name of the medication.
b. Amount (dose) of medication.
c. Route of administration.
d. Time to be administered.
3. Select the medication.
a. Check the medication label three times to ensure that the correct medication is being prepared for administration.
b. Check the expiration date of the medication.
c. Handle only one medication at a time.
NOTE: If unfamiliar with a medication, look it up to determine contraindications, precautions, and side effects.
4. Prepare the medication.
a. Calculate the amount of medication required to equal the prescribed dose.
NOTE: If the medication is in powdered form, prepare it for use by adding the diluent specified on the drug information instructions.
b. Draw the prescribed amount of the prepared medication into a syringe.
c. Check the medication and calculations again to ensure that the correct medication and correct dose have been prepared.
5. Prepare the piggyback unit.
NOTE: Refer to the drug manufacturer’s instructions to determine the type and amount of solution to be used as the piggyback unit.
a. Use an alcohol prep pad to swab the injection port on the container of IV solution to be used as the piggyback unit.
b. Inject the prepared medication into the container of IV solution.
c. Mix the solution and medication into the container of IV solution.
d. Label the piggyback unit with the name of the medication, the amount added, the time added, the date added, and the initials of the person who prepared the piggyback unit.
e. Dispose of the needle and syringe IAW local SOP.
6. Prime the piggyback infusion tubing.
a. Close the clamp on the piggyback tubing.
b. Aseptically insert the spike on the piggyback tubing into the solution port on the piggyback unit.
c. Squeeze the drip chamber to fill it half full.
d. Open the clamp on the piggyback tubing, allowing the solution to prime the tubing.
e. Close the clamp on the piggyback tubing when the solution reaches the end of the tubing.
NOTE: Attach a sterile needle to the end of the piggyback tubing if one is not provided by the manufacturer.
CAUTION: Take care not to waste any medicated IV solution while priming the tubing.
7. Connect the piggyback unit to the primary tubing.
a. Swab the injection port on the primary tubing with an alcohol prep pad.
b. Insert the needle into the injection port of the primary tubing.
c. Secure the connection with tape.
NOTE: Attach the piggyback tubing to the primary tubing below the level of the roller clamp. This will allow the piggyback unit to flow at its set rate without adjusting the flow rate of the primary solution.
8. Hang the piggyback unit on the IV pole, ensuring that the piggyback unit is at least 6 inches higher than the primary container.
9. Ensure patency of the primary IV.
10. Begin the secondary (piggyback) infusion.
a. Calculate the flow rate in accordance with the physician’s orders.
NOTE: If the physician does not specify a flow rate, set the flow rate IAW the drug manufacturer’s instructions.
b. Adjust the roller clamp on the piggyback tubing to regulate the flow rate of the piggyback solution.
CAUTION: Do not adjust the flow rate of the primary container.
NOTE: When fluid from the secondary line enters the primary tubing, the primary infusion is automatically interrupted. When all the solution in the piggyback unit has been delivered, the primary infusion will resume flow at the set rate.
11. Label the piggyback infusion tubing with the time and date the medication was initiated.
12. Observe the patient for signs of infusion complications or reaction to the medicine. (
13. Document the procedure and significant nursing observations on the appropriate forms IAW local SOP.
Evaluation Guidance: Score each soldier according to the performance measures in the evaluation guide. Unless otherwise stated in the task summary, the soldier must pass all performance measures to be scored GO. If the soldier fails any step, show what was done wrong and how to do it correctly.
