CC2433 Skill Performance Checklist Lab 2 2009

PERFORMANCE CHECKLIST

Blood Pressure ( 8th Kozier- index find blood pressure- Skill)

Procedure Yes No Comments
• Check all the equipment is
functioning properly
• Explain to the client
• Wash hand and don gloves if
necessary. Pay attention to the
infection control procedure
• Place the client in the
appropriate position
• Wrap the deflated cuff evenly
around the upper arm
Remember to count the brachial
1. Locate the brachial artery pulse!
2. Centre of the bladder
apply over the artery
• The lower border of the cuff
should be 2.5 cm or 1 inch
above the antecubital space
• Initial examination-  Palpate the brachial pulse
preliminary palpatory  Inflate the cuff until you cannot feel
the brachial pulse
determination of systolic
 Remember the reading
pressure  Deflate the cuff
• Position of the stethoscope
• Pump up the cuff until
30mmHg above the point
where the branchial pulse
disappeared palpatory
• Release the valve at the rate of
2 to 3 mmHg per second
• Identify the Korotkoff phase How many different phases?
• Deflate the cuff rapidly and
completely
• Wait 1-2 minutes if
remeasurement is required
• Remove the cuff
• Documentation Please document both pulse and BP!

Students should pay attention to your: 1

 Thorough assessment of the client
 Accuracy with usage of the equipments
 Knowledge accuracy
 Communication and patient’s comfort
 General organization, learning attitude
 Fluency of the skills
CC2433 Skill Performance Checklist Lab 2 2009

PERFORMANCE CHECKLIST

Nasogastric tube insertion

(8th Kozier- Index find Nasogastric tube- Skill: insertion of nasogastric tube))

Yes No Comment
1. Assessment*
 Nares: patency and skin intact
 History of surgery
 Presence of gag reflex + swallowing
 Mental status
2. Collect adequate equipment *Check expiry date and size
3. Explanation to the client
4. Positioning of the client and provide privacy
5. Hand hygiene
6. Assess the client’s nares
7. Prepare the tube
8. Determine how far to insert the tube *Correct measurement
 Tip of the nose- tip of the earlobe- xiphoid
process (two fingers width below the base of the
sternum)
9. Insert the tube
 Don gloves
 Lubrication of the tube (tip 8-10cm)
 Tilt head forward
 Encourage the client to swallow
1 Ascertain correct placement of the tube
0.  Open the mouth to check any coiling of the
tube
 Aspirate the stomach content and check pH
 Auscultate air insufflation
 Correct placement of the stethoscope
 X- ray ( if necessary)
1 Secure the tube by taping it to the bridge of the
1. client’s nose
1 Attach the tube to a suction source or feeding
2. apparatus, or clamp the end of the tubing
1 Secure the tube to the client’s face
3.
1 Document relevant information
4.

Students should pay attention to your: 2

 Thorough assessment of the client
 Accuracy with usage of the equipments
 Knowledge accuracy
 Communication and patient’s comfort
 General organization, learning attitude
 Fluency of the skills
CC2433 Skill Performance Checklist Lab 2 2009

PERFORMANCE CHECKLIST

Removing a nasogastric tube

(8th Kozier- Index find Nasogastric tube- Skill: removal of nasogastric tube))

Yes No Comment
1. Collect adequate equipments
Preparation
2.  Confirm the physician’s prescription
3.  Positioning of the client and provide privacy
4.  Place the disposable pad
 Provide tissue
5. Explain to the client
6. Hand hygiene
7. Detach the tube
Remove the nasogastric tube
8.  Don gloves
 (optional) Instill 50ml of air into the tube
9.  Ask client to take a deep breath and to hold it
10.  Pinch the tube
11.  Quickly and smoothly to withdraw the tube
12.  Observe the intactness of the tube
13.  Place the tube in the bag
14. Ensure client comfort
15. Dispose of the equipment appropriately
16. Document all relevant information

17.

Students should pay attention to your: 3

 Thorough assessment of the client
 Accuracy with usage of the equipments
 Knowledge accuracy
 Communication and patient’s comfort
 General organization, learning attitude
 Fluency of the skills
CC2433 Skill Performance Checklist Lab 2 2009

PERFORMANCE CHECKLIST
Nasogastric Tube Feeding
(8th Kozier- Index find Nasogastric tube- See also Enteral nutrition-Skill: administering a tube feeding)

Students should pay attention to your: 4

 Thorough assessment of the client
 Accuracy with usage of the equipments
 Knowledge accuracy
 Communication and patient’s comfort
 General organization, learning attitude
 Fluency of the skills
CC2433 Skill Performance Checklist Lab 2 2009

Yes No Comment
1. Assess client’s need for enteral tube feeding.
2. Auscultate for bowel sounds before feeding
3. Obtain baseline weight and laboratory values. Refer to text book and notes!
Thorough assessment to the client’s condition
4. Verify physician’s order for formula, rate, route, and
frequency.
5. Explain procedure to client
6. Hand hygiene
7. Prepare feeding container to administer
formula continuously
8. Check expiration date on formula and integrity of can
or bottle.
9. Have tube feeding at room temperature Do not use microwave!
1 Connect tubing to container
0.
11 Shake formula container well, and fill container with
. formula. Open stopcock on tubing, and fill tubing with
formula to remove air. Hang on intravenous
(IV) pole.
1 Positioning of the client and provide privacy. Place
2. client in high-Fowler’s position or elevate head of bed
at least 30 degrees.
1 Determine tube placement. How?
3.
1 Check for gastric residual. Document the amount of
4. a. Connect syringe to end of feeding tube, and pull aspiration and refeed!
back evenly to aspirate gastric contents.
b. Return aspirated contents to stomach
(check agency policy).
1 Flush tubing with 30 ml water.
5.
1 Initiate feeding:
6.  Feeding bag: attach gavage tubing to end of feeding
tube. Set rate by adjusting roller clamp on tubing.
 Allow bag to empty gradually over 30
to 60 minutes. Label bag with tubefeeding type,
strength, and amount. Include date, time, and initials.
1 Following intermittent infusion or at end of continuous
7. infusion, flush nasoenteral tubing with 30 ml of water,
using irrigating syringe. Repeat every 4 to 6 hours as
prescribed .
1 Monitor patient’s fluid and electrolyte balance and
8. limitation
1 When tube feedings are not being administered, cap or
9. clamp the proximal end of the feeding tube.
2 Monitor intake and output every feeding
0.
2 Record amount of feeding on Intake and Output Chart
1.
2 Record client’s response to tube feeding, patency of
2. tube, and any side effects.
2 Record and report type of feeding, status of feeding
3. tube, client’s tolerance, and adverse reaction
2 Observe the latest laboratory values
4.
Students should pay attention to your: 5
2 Hand hygiene
Thorough assessment of the client
5. Accuracy with usage of the equipments
 Knowledge accuracy
 Communication and patient’s comfort
 General organization, learning attitude
 Fluency of the skills