VUMC Perioperative Services HR/PACU RN Competency …

VUMC Perioperative Services HR/PACU RN Competency Assessment 1

VUMC Perioperative Services + Evaluation/Validation Methodologies: D = Return Demonstration V = Verbal O = Direct Observation 0820

Airway

Management Interpretation Rational

A. Identify

changes in

normal

breathing

patterns.

1. Rate -observe a full inspiration and expiration when counting rate.

2. Rhythm - in normal breathing, a regular interval occurs after each respiratory cycle.

3. Depth-observe the degree of excursion or movement in the chest wall.

4. Symmetry -comparison in size or form on opposite sides of the chest wall.

5. Body positioning- may be restrictive to optimal breathing.

1. Patient safety.

B. Recognize

patient changes:

color, nail beds

and mucus membranes.

1. Dusky skin.

2. Cyanosis -bluish discoloration of the skin particularly around the mouth. 3. Pale mucosa and nail beds.

1. Signs of

respiratory

distress.

C. Identify the minimum

oxygen

saturation

(Sp02).

1. Normal oxygen saturation (Sp02) values are 97-99 percent at sea level. 2. The clinically acceptable Sp02 value >94% but may vary with each patient and their

condition.

1. Patient safety.

D. Identify at

least five signs

and symptoms

of respiratory

distress or

airway

obstruction.

1. A decreased rate (bradypnea) or increased rate (tachypnea).

2. Increased effort may include:

a. Use of accessory muscles:

i. Neck

ii. Abdominal

iii. Intercostals.

b. Nasal flaring. c. Retractions of the suprasternal notch.

3. Noises such as:

a. Snoring.

b. Crowing.

c. Wheezing.

4. Restlessness.

1. Signs of

respiratory

distress.

2. Increased

respiratory effort

is a warning sign.

3. Indicators of

airway. obstruction.

4. Sign of decreased

oxygenation.

E. Demonstrate

two measures

used to correct

airway obstruction.

1. The head tilt/chin lift or jaw lift.

2. The nasopharyngeal airway.

1. Methods to correct

airway obstruction by

displacing the tongue.

2. Flexible piece of rubber or silicone

placed in the nose.

F. Demonstrate

appropriate

application of

various types of

oxygen delivery

apparatus.

1. Nasal Cannula.

2. Aerosol Face Mask.

3. Face Tent.

4. Blow By or T-piece.

5. Tracheostomy Collar (Trach Collar).

1. Patient safety.



Catheters &

Drains Interpretation Rational

A. Demonstrate

maintenance of

urinary

catheters.

1. Avoid tension or kinking of drainage tubing.

2. Attach drainage bag to bed frame not bed rail.

3. Keep drainage bag below patient's bladder at all times. 4. Verify catheter is attached with Foley securement device (STAT Lock) to patient's

thigh.

5. Check for leaking:

a. Around catheter.

b. Drainage bag.

6. Clean around Foley insertion site with clean soapy water and rinse:

a. Daily.

b. As needed.

1. Patient safety.

B. Demonstrate

sterile technique

when emptying of drainage bag.

4. Use universal precautions.

5. Avoid touching drainage port. 6. Do not permit port to touch measuring container.

7. Use clean graduated cylinder for each patient.

2. Patient safety.

C. Demonstrate

measurement, documentation,

and description

of urine as

ordered.

1. Do not spill contents when emptying drainage bag. 2. Document amount.

3. Document amount from the right or left side or kidney, as indicated.

4. Describe color, clarity and odor.

5. Observe for obvious blood or clots.

6. Strain urine if indicated.

1. Patient safety.

D. Demonstrate

maintenance of

surgical drains.

1. Avoid tension or kinking of drain tubing.

2. Fasten tubing to patient's gown.

3. Empty drain when half full.

4. Document amount.

5. Observe for any leakage of fluid around the drain. 6. Verify drain maintains suction.

5. Patient safety.

E. Demonstrate emptying of

Jackson-Pratt

and hemovac

drain

maintaining

sterility and

suction.

1. Use universal precautions when emptying surgical drains. 2. Avoid touching drainage port or letting it touch the measuring container.

3. Use clean graduated cylinder for each patient.

4. Compress bulb or cylinder after emptying and close port.

1. Patient safety.

F. Demonstrate

accurate

measurement

and description

of surgical

drainage as

ordered.

1. Avoid spilling drainage. 2. Document amount. 3. Describe color/consistency:

a. Bright red.

b. Fresh. c. Bloody. d. Pink. e. Clear. f. Yellow. g. Thin. h. Odorous. i. Yellow.

j. Blue-green.

1. Patient safety.



Central Venous

Catheter Line

Management

Interpretation Rational

A. Demonstrates Aseptic technique in accessing CVCs.

1. Wipe access cap with alcohol pad. (If IV fluids are continuous, may remove access cap). 2. Aspirate blood return. 3. Flush with normal saline. 4. Connect IV line or medication syringe.

1. Uses aseptic technique to reduce infection.

B. Demonstrates capping of CVC.

1. Clamp lumen. 2. Disconnect infusion line, medication syringe, or access cap. 3. Apply new needle free valve port-flush if necessary.

1. Maintain sterility.

C.

Demonstrates flushing of CVC.

1. May check of blood return. 2. Flush with normal saline

3. Flush with 2.5-3.0 ml heparinized saline, clamping on last ½ ml. (May omit heparin and clamping for Groshong).

1. Prevents clotting of

line and maintains aseptic technique.

D. Demonstrates CVC dressing

change.

1. Wash hands. 2. Explain the procedure to the patient, instructing patient to turn head in the direction opposite

of CVC insertion site. 3. Don clean non-sterile gloves.

4. Open CVC dressing tray onto clean surface and apply mask. 5. Remove dressing with non-sterile gloves, inspect site for redness or drainage. 6. Re-wash hands. 7. Establish sterile field. 8. Don sterile gloves. 9. Use alcohol swab x 1 to remove visible debris. 10. Clean site with 2% chlorhexidine and 70% isopropyl alcohol swab for 30 seconds (start at exit

site and move outward in a spiral motion to cover an area of 3 inches in diameter.

11. Apply skin prep and allow to dry. 12. Apply transparent dressing. 13. Anchor catheter and edge of dressing with tape. 14. Label with date and initials. 15. Document appearance of site, time, location, type of catheter, and patient’s tolerance of

procedure.

1. Maintains aseptic technique.

E. Demonstrates ability to draw blood from CVC.

1. Stop and clamp all infusion for a least one minute before drawing blood. 2. Aspirate waste (Use red top tube for waste). 3. Aspirate desired sample. 4. Flush with 3ml normal saline. 5. Resume any infusions or lock with heparinized saline as indicated.

1. Ensure appropriate blood sample and accurate results.



Circulatory

Assessment Interpretation Rational

A. Demonstrates Circulatory assessment.

1. Circulatory Assessment Includes: a. Heart rate (EKG leads changed q 24 hours). b. Cardiac rhythm (Evaluates rhythm strip for rate, rhythm, PRI, QRS width, QTI,

patient’s name, date, and time- with initial assessment and with rhythm changes or ectopy).

c. Heart sounds. Auscultate for bruits along the aorta. d. Capillary refill time (in seconds). e. Pulses bilaterally (radial, dorsalis pedis, posterior tibialis, ulnar on extremity with

radial arterial line). Use Doppler if necessary. Check for upper and lower differential.

f. Blood pressure. Doppler BP if unobtainable with noninvasive cuff or ausculatory methods.

g. Skin temperature and color.

h. Presence of jugular vein distention.

1. Patient safety.

B. Demonstrates accurate documentation of circulatory status and assessment.

3. Assessment/Documentation should occur:

1. On admission.

2. As indicated per standard of care/ physician orders. 3. With changes in hemodynamic status.

1. Patient safety.

C. Demonstrates Arterial Line Management.

1. Arterial line pressure transducers will be zero referenced with the closest port to the catheter insertion site (i.e. preferably held at the level of the phlebostatic axis). 2. Arterial line blood pressures recorded in HED q hour. If receiving titrated vasoactive drugs,

record arterial pressure every hour and with change. 3. Record pulse in HED q 2 hours (ulnar for radial line, dorsalis pedis for femoral line). 4. Manual BP q shift when BP within 5-20mm Hg of arterial line.

5. Recheck manual BP if arterial line pressure changes by 20 mm Hg or more, obtained from same arm as arterial line if possible and recorded in HED.

1. Patient safety 2. CL 30-18.06

Policy: Arterial Line, Management of.

D. Demonstrates Implementation of Circulatory Standing Orders.

1. Responds to acute changes in status (i.e. hypotension, rhythm changes) and performs complete circulatory assessment to include hemodynamic readings. 2. Call Rapid Response Team. (Surgical Transition Unit). 3. HR/PACU Notifies attending physician or his designee, and while initiating the emergency

page, the nurse may: a. Defibrillate for V- fib or pulseless V-Tach with the defibrillator AED function on

the emergency cart. 4. Vital signs documented q 15 minutes in response to change in condition until crisis has

resolved and /or patient’s acuity level has returned to level of care needed.

6. Patient safety.



Consciousness

Assessment


A. Demonstrates

Neurological assessment.

2. Neurological Assessment Includes:

a. Pupils- note size and reactivity to light; note abnormalities in eye movement/ corneal reflexes.

b. Level of Consciousness- based on the Glasgow Coma Scale (GCS), documenting total score and what each individual number means (motor, verbal, eye-opening).

c. Motor response. d. Sensory response- dermatome. e. Affect and behavior. f. Speech: clarity, difficulty with expression or understanding.

g. Memory- difficulty with immediate recall, recent or remote memory. h. Sedated patients will be assessed, using Richmond Agitation Sedation Scale

(RASS).

1. Patient safety.

B. Demonstrates accurate documentation of

Neurological status and assessment.


1. On admission.

2. With changes in neurological status.

3. On-going throughout patient stay.

6. Patient safety.

Glasgow Coma Scale

Eye Opening Verbal Response Motor Response Strength of Movement*

4 = Spontaneously 5 = Oriented x 3 6 = Obeys commands 5 = Normal power

3 = To speech 4 = Confused 5 = Localizes pain 4 = Minimal weakness

2 = To pain 3 = Inappropriate words 4 = Withdrawal 3 = Moves against resistance

1 = None 2 = Incomprehensible

sounds 3 = Flexion to pain 2 = Antigravity

T = ET tube or Trach

(assess level of

responsiveness)

1 = None 2 = Extension to pain 1 = No antigravity

T = ET tube or Trach

(assess level of

responsiveness)

1 = None 0 = None

NT = Not tested *Note that a patient must have voluntary movement to assess strength. Strength cannot be assessed in a

patient who is “posturing.”

Richmond Agitation Sedation Scale (RASS)

+4 Combative Combative, violent, immediate danger to staff

+3 Very Agitated Pulls or removes tube(s) or catheter(s); aggressive

+2 Agitated Frequent non-purposeful movement, fights ventilator

+1 Restless Anxious, apprehensive but movements are not aggressive or vigorous

0 Alert and calm

-1 Drowsy Not fully alert but has sustained awakening to voice (eye opening & contact greater than 10

seconds)

-2 Light Sedation Briefly awakens to voice (eye opening & contact less than 10 seconds)

-3 Moderate sedation Movement or eye opening to voice (but no eye contact)

-4 Deep sedation No response to voice but movement or eye opening to physical stimulation

-5 Unarousable No response to voice or physical stimulation



Adverse

Complication

of Electroconvulsive Therapy (ECT)

Status Epilepticus

Interpretation

Rational

A. Demonstrates

ability to identify

and provide

appropriate care for

Status Epilepticus.

1. Supports the Anesthesia provider and psychiatrist by:

a. Securing requested medication and equipment.

b. Supports Anesthesia during intubation.

c. Processes Stat Labs such as ABG’s and Chemistries.

2. If seizures continues: 1. Assesses safety of environment- padded side rails,

availability of various bite blocks, suction

set up, IV accessibility.

2. Assists in securing additional Anesthesia and nursing

support staff, needed medications and equipment.

3. Contacts Neurology Consult STAT.

4. If indicated, initiates ACLS principles.

1. Seizures lasting longer than three

minutes or Status Epilepticus

following ECT procedure confirmed

by either motor or EEG.

2. Anticipates and prepares for nursing

interventions.

B. Verbalize how

to initiate and

record proper

documentation.

1. Continuously monitors patient’s vital signs, oxygenation,

ventilation and circulation during and immediately after

seizures at a level consistent with the potential additional

effects from the ECT and Status Epilepticus.

2. Discharge criteria to the next level of care.

1. To record medical monitoring and

interventions initiated to resolve

Status Epilepticus.

2. Completes all necessary. Paper

work for discharge process.



Care of the patient with

an Epidural Pump Interpretation Rational

A. Demonstrates ability to start and change epidural bag medication.

5. Check physician orders. 6. Check MAR. 7. Check label on epidural bag.

8. Right patient. 9. Right time/frequency. 10. Right dose. 11. Right route. 12. Right drug. 13. Order refill when medication has 50ml left to count. 10. Connect tubing ends aseptically.

1. Patient safety for medication administration.

2. Allow 2 hours to receive new

medication from pharmacy. 3. If medication runs out, call acute pain

service to administer a loading dose to ensure adequate pain relief.

4. Prevent patient infection.

B. Demonstrates initial hook up of pump.

1. Verify pump settings are as ordered. 2. If pump is set in milligrams instead of milliliters, patient will receive wrong dose.

3. If the lock out is set at 1 hour instead of 4 hours, patient will receive wrong dose.

C. Demonstrates ability to change batteries.

1. Have 2 AA batteries available. 1. Energy source for pump to function.

D. Demonstrates changing the epidural demand rate and settings.

1. Knowledge of pump functionality. 2. Knowledge of unlocking and locking pump using keypad.

2. Ensures correct dose.

E. Verbalizes appropriate use of demand button

1. Teach family and patient when to use the demand button. 1. Reduce patient pain.

F. Demonstrates patient transport that has an epidural in place with a pump.

1. Do not let patient stand or walk until strength in legs is verified. 2. Ambulate with assistance only.

1 Legs may be weak or numb, high risk for patient fall.

G. Demonstrates alarm troubleshooting.

1. Cartridge alarm: a. Verify cartridge is correctly placed.

2. Distal occlusion alarm: a. Check for “kinking”.

3. Check battery power. 4. Failure to find correctable problem.

1. If cartridge is place correctly, sensor may be too sensitive. Call service center for replacement and tag unit for biomed.

2. Kinking could prevent flow. 3. Dead batteries will interrupt infusion.

4. Proceed to all acute pain service.

G. Verify patient pain status.

1. Patients with epidural pain medication should have pain no higher than “3” on a 10-point scale.

1. Patient comfort.



Implanted

Venous Ports


A. Demonstrates ability in accessing or

changing needle from an implanted venous port.

14. Perform hand hygiene and don non-sterile gloves. 15. Palpate port and/or remove old dressing and infusion set. 16. Remove non-sterile gloves and perform hand hygiene.

17. Open dressing kit, don mask, and prepare flushing supplies and prime infusion set, maintaining sterility of Huber infusion set.

18. Don sterile gloves. 19. May use alcohol swab X 1 to remove visible debris if present. 20. Clean site with 2% chlorhexidine and 70% isopropyl alcohol swab for 30 seconds (start at

center of port site and move outward in a spiral motion to cover an area of 3 inches in diameter.

21. Insert needle into port (Needle must hit back of well for security).

22. Apply skin prep. Support Huber needle with folded 2x2 gauze, if needed. 23. Aspirate blood return. 24. Flush with 10ml normal saline. 25. Dress (See below). 26. Proceed with infusion, medication administration, blood draw or heparin flush. 14. Label with date, Huber needle size, length and initials.

1. Maintains aseptic technique, verifies placement, and maintains

patency.

B. Demonstrates capping of

implanted venous port.

1. Clamp Huber needle infusion set. 2. Disconnect infusion line, medication syringe, or needle free valve port.

3. Apply new needle free valve port -flush if necessary.

1. Maintain aseptic technique and patency of

port.

C. Demonstrates flushing of implanted venous port.

4. May check of blood return. 5. Flush with 10 ml normal saline using a 10ml size syringe. 6. Flush with 4.5-5.0 ml heparinized saline, clamping on last ½ ml.

1. Maintains patency of port.

D. Demonstrates

implanted venous port dressing change.

16. Perform hand hygiene and put on non-sterile gloves.

17. Remove old dressing being careful to secure and maintain sterility of Huber Needle. 18. Remove non-sterile gloves and perform hand hygiene. 19. Open dressing change kit/establish sterile field. 20. Don sterile gloves and mask. 21. May use alcohol swab x 1 to remove visible debris if necessary. 22. Clean site with 2% chlorhexidine and 70% isopropyl alcohol swab for 30 seconds (start at exit

site and move outward in a spiral motion to cover an area of 3 inches in diameter. 23. Apply skin prep (as needed at adhesive site) and allow to dry.

24. Apply skin prep. Support Huber needle with folded 2x2 gauze if needed, leaving entry site visible.

25. Apply transparent dressing. 26. Anchor catheter and edge of dressing with tape. 27. Label with date and initials, date of Huber needle access, size and length of needle. 28. Document appearance of site, time, location, type of catheter, and patient’s tolerance of

procedure.

1. Maintains aseptic

technique and patency of port.

E. Demonstrates

ability to draw blood from an implanted venous port.

5. Stop and clamp all infusion for a least one minute before drawing blood.

6. Aspirate waste (may use red top tube for waste). 7. Aspirate desired sample from HUB of Huber needle, not “smart site” adaptor. 8. Flush with 10ml normal saline. 5. Resume any infusions or lock with heparinized saline as indicated.

1. Maintains aseptic

technique and patency of port.

F. Demonstrate ability to discontinue a Huber Needles.

5. Don non-sterile gloves. 6. Flush catheter and clamp infusion set. 7. Remove dressing. 8. Stabilize port with non-dominant hand.

9. Pull needle straight upward or per needle removal instructions. 6. Apply gauze or band-aid as necessary.

1. Maintains aseptic technique and patency of port.



Intravenous

Therapy Interpretation Rational

A. Demonstrates Access and Maintenance of IV.

3. Demonstrates use of Alaris Pump, medication library, and guard rails for IVF’s and vasoactive drips.

4. Documents vasoactive drips in HED noting the concentration, IV line used, and infusion rates.

5. Documents intake amounts q 1-2 hours in HED and as orders are modified for MIVF and

IVPB. 6. Assesses and documents IV sites (central and peripheral) in HED q 2 hours. 7. Discontinues any field inserted peripheral IV’s upon admission. 8. Changes IV fluid, solutions, tubing, and additives q 96 hours, except for TPN and Lipids (q

24 hours as directed by WIZ orders). 9. Rotates peripheral IV’s q 72 hours. 10. Flushes peripheral IV q8 hours and after each access. Start date, gauge, and RN initials must

be verified q shift.

1. 1. Patient safety. 2. 2. CL 30-06.04 IV

Medication Administration.

3. 3. CL 30-06.07 Total

Parental Nutrition. 4. 4. CL 30-07.01 IV

Therapy: Peripheral Vascular Access.

B. Demonstrates tubing and dressing changes.

5. Changes q 24 hours lipids and Propofol tubing. 6. Changes q 24 hours gauze dressings used after initial line insertion. 7. Changes q 72 hours all IV tubing including TPN. 8. Changes q 96 hours pressure lines. 9. Changes q 5 days transparent dressings.

7. Patient safety.

C. Demonstrates Management of Central Venous and Pulmonary Artery Catheters.

1. Utilizes CVC blue (medial) ports for TPN administration. 2. Utilizes CVC red/brown (distal) ports for CVP administration or blood products. 3. Utilizes CVC white (proximal0 ports for IV fluids and medications. 4. Sterile technique will be instituted when changing a CVC dressing and when a TPN is used. 5. Tapes all lines securely to prevent excessive motion. 6. Flushes CVC ports daily, after medication infusion, and after drawing blood specimens. 7. Flushes IV drug therapy lines with 3ml’s of normal saline. 8. Aspirates and irrigates CVC with no less than a 3ml syringe if a clot is suspected 9. Discontinues (MD or RN) CVCs and cordis when ordered.

1. Patient safety. 2. CL 30-07.02

Percutaneous and Tunneled CVC’s: Care and Maintenance.

D. Demonstrates management of PICC Lines.

1. Administer all IVFs through Alaris pumps. 2. Provides new tubing and fluids with new PICC line insertion. 3. Flushes lumen (size 21 or greater) with 10ml’s preservative free normal saline after use. 4. Flushes line q 6 hours or connects continuous fluids if gauge is less than 21.

7. Patient safety. 8. CL 30-07.04 PICC

and ML, Care and Maintenance.



Isolation

Protocols Interpretation Rational

A. Verbalizes appropriate use of standard precautions when caring for all patients in the perioperative

setting.

1. Standard precautions apply to exposure or potential for exposure to the following: a. Blood and all body fluids, secretions, and excretions (except perspiration). b. Non-intact skin. c. Mucous membranes.

2. Risk of exposure to potentially infectious agents is minimized by using personal protective equipment (PPE), work practices, and engineering controls.

3. Uses proper technique for:

a. Handling linen. b. Safety devices (IV cannulas/needles, transfer devices). c. Disposing of sharps. d. Disposal of infectious and regulated medical waste. e. Storing clean and sterile supplies. f. Collecting and transporting lab specimens. g. Managing blood spills.

4. Describes procedures for managing a needle stick or blood borne pathogen exposure per

Exposure Control Plan- Standard Precautions, IC 10-10.10. 5. Demonstrates proper cleaning and decontamination of medical equipment using appropriate

cleaning agents.

Prevents transmission of diseases to patients and/or staff.

B. Demonstrates appropriate methods of

performing hand hygiene.

1. Hand hygiene should be performed at the following times: a. Beginning of shift. b. Before and after patient contact.

c. After removing gloves. d. Before and after eating. e. Before and after using the restroom. f. Any time there is a possibility that there has been contact with blood or other

potentially infections materials. g. Any time when the practitioner knows or believes his or her hands may have been

soiled.

Prevents transmission of diseases to patients and/or staff.

C. Verbalizes appropriate use of protective barriers to reduce risk of skin and mucous membrane exposure to potentially

infections materials.

1. 1. Gloves should be worn when touching blood or body fluids or when handling items contaminated 2. with blood of body fluids. 3. 3. Change gloves between patients and/or procedures. 4. 4. Masks and eye protection or a face shield should be worn to protect mucous membranes of the 5. eyes, nose, and mouth from splashes and sprays. 6. 5. Gowns should be worn to protect skin and/or prevent soiling of clothing during patient care 7. activities when contact with blood or body fluid is likely. 8. 6. Gowns should be worn for direct patient contact if the patient has uncontained secretions or

9. excretions. 10. 7. Do not reuse gowns, even for repeated contact with the same patient.

Minimizes risk of cross contamination among staff, patients, and their environment.

D. Verbalizes work practices that help to

minimize risk of exposure to pathogens.

1. The following activities are prohibited in the patient care area: a. Eating. b. Drinking. c. Smoking.

d. Applying cosmetics or lip balm. e. Handling contact lenses. 2. Food and drink should not be stored where potential exposure to blood or other infections materials could occur. 3. All equipment and environmental surfaces should be cleaned and decontaminated between patients.

Minimizes risk of cross contamination among staff, patients,

and their environment.

E. Verbalizes appropriate measures to implement for patients on Airborne Precautions.

1. Airborne Precautions apply to diseases spread long distances via air currents. Diseases in this category include but are not limited to:

29. Pulmonary tuberculosis (TB). 30. Measles. 31. Varicella (chicken pox). 32. Bioterrorism agents (e.g. SARS, smallpox).

2. Post the blue “Airborne Precautions” sign and the red “No Traffic” sign on the isolation room door.

Reduces risk of exposure to potentially infections materials.



3. All staff must wear N-95 respirators when entering the isolation room. 4. Remove the N-95 respirator upon exiting the isolation room and perform hand hygiene. 5. All staff must undergo N-95 fit testing on an annual basis.

F Verbalizes appropriate

measures to implement for patients on Droplet Precautions.

1. Droplet precautions apply to diseases spread via close contact with respiratory secretions. Diseases in this category include but are not limited to:

a. Influenza. b. Pertussis. c. Mumps. d. Meningitis. e. Fifth disease.

2. Post the green “Droplet Precautions” sign and the red “No Traffic” sign on the isolation door. 3. Wear a surgical mask when entering the isolation room. 4. Wear gloves when handling items contaminated with respiratory secretions.

a. Perform hand hygiene upon exiting the isolation room.

Reduces risk of exposure to potentially

infections materials.

G. Verbalizes appropriate measures to implement for patients on

Contact Precautions.

1. Contact precautions apply to diseases transmitted by direct contact with the patient’s skin and/or infections substances, as well as through indirect contact with the patient’s environment. Diseases in this category include but are not limited to:

a. Methicillin Resistant Staphylococcus aureus (MRSA). b. Vancomycin Resistant Enterococcus (VRE).

c. Clostridium difficle. d. Congenital rubella. e. Lice. f. Scabies. g. Resistant organisms such as Acinetobacter baumannii. h. All patients with burns and/or large wounds.

2. Wear gown and gloves upon entry into the isolation room, even if not in direct contact with the patient.

3. Remove PPEs and perform hand hygiene upon exiting the isolation room if not involved in patient transport.

Reduces risk of exposure to potentially infections materials.



Mechanical

Ventilation Interpretation Rational

A. Verbalizes common

indications for mechanical ventilation.

1. Ineffective ventilation (decreased O2/CO2 exchange) as evidenced by inability

to maintain open airway or breathe adequately, inadequate chest movement, diminished or absent breath sounds with or without respiratory effort.

2. Bradypnea, tachypnea or apnea. 3. Labored or shallow respiration. 4. Inability to maintain adequate O2 saturation and effective respiration as

evidenced by pulse oximetry measurements and/or arterial blood gases indicating severe hypoxia.

5. Work of breathing is greater than patient can maintain.

1. Mechanical ventilation

supports the patient in maintaining optimal ventilation and oxygenation. 2. Hypothermia and shivering, common side effects of general anesthesia, may contribute to ineffective ventilation in the PACU.

B. Verbalizes understanding of Synchronized Intermittent Mechanical Ventilation (SIMV)

mode of mechanical ventilation.

1. The ventilator delivers a preset number of breaths at a specific tidal volume. 2. The patient may supplement these mechanical ventilations with his own

breaths, in which case the tidal volume and rate are determined by his own inspiratory ability.

3. Provides automatic apnea backup.

1. Supports patient respiratory status.

C. Verbalizes understanding of

Pressure Support (PS) mode of mechanical ventilation.

1. All breaths are patient-initiated. 2. Assists patient’s spontaneous tidal volumes with a “boost” of positive pressure.

3. Patient’s inspiratory flow determines ends of breath. 4. No guaranteed tidal volume is delivered to the patient. 5. Patient MUST have spontaneous respirations to be placed on this setting.

1. Supports patient respitory status.

D. Verbalizes understanding of

Continuous Positive Airway Pressure (CPAP).

1. Patient breathes independently through ventilator circuit or with CPAP mask. 2. Does not deliver a preset tidal volume.

3. Only FiO2 and gas pressure are set. 4. Does not provide apnea protection! 5. May be used to evaluate spontaneous ventilation prior to extubation. 6. May be used via mask for sleep apnea.

1. CPAP delivers positive airway pressure that keeps the

patient’s upper airways open, making ventilation easier.

E. Verbalizes understanding of positive end-expiratory pressure (PEEP).

1. Adds positive airway pressure to mechanically assisted breaths. 2. PEEP keeps the patient’s airway open at the end of expiration and increases

functional residual capacity (FRC). 3. PEEP prevents collapse of small airways, thereby maximizing the number of

alveoli available for ventilation and results in increased oxygenation. 4. Range for PEEP is 5-20 cm H2O.

1. PEEP is frequently used to decrease the FiO2 needed for optimal oxygenation. 2. A PEEP of 20 must be weaned slowly! 3. The recommended method of weaning PEEP >5 is to decrease

PEEP by 5 every 30 minutes as tolerated.

F. Verbalizes understanding of who can make ventilator setting changes.

1. The attending physician or respiratory therapist can make changes to FiO2 ONLY.

2. All other settings must be adjusted by respiratory therapist or physician.

1. Patient safety. 2. If ventilator alarms and no immediate cause can be found, remove patient from vent and

start manual ventilation with AMBU and 100% FiO2. Call Respiratory Therapy to troubleshoot vent.



G. Verbalizes appropriate troubleshooting methods.

1. Low pressure alarm could indicate: 2. Vent tubing disconnect. 3. Leak in system. 4. High pressure alarm could indicate:

a. Secretions in airway. b. Patient may be biting ET tube. c. Tracheal tube displacement.

1. Patient safety. 2. If ventilator alarms and no immediate cause can be found, remove patient from vent and start manual ventilation with AMBU and 100% FiO2. Call Respiratory Therapy to

troubleshoot vent.

H. Verbalizes the nurse’s role in preparing to wean a patient from the ventilator.

1. Assess clinical parameters for weaning and extubation:

a. Spontaneous respiratory rate >8 and <24 and Breaths per minute. b. Tidal volume 5-10ml/kg. c. Stable vital signs. d. Minute ventilation 5-10L/minute. e. Vital capacity of a minimum of 10-15ml/kg. f. Maintains adequate respiratory effort on blow-by. g. Negative inspiratory pressure of -25 to -30cm H2O. h. Moving all extremities (if applicable).

i. Protective reflexes present. j. ABGs within normal range or comparable to baseline.

2. Monitor heart rate, blood pressure, cardiac rhythm, pulse oximetry and respiratory rate, depth and use of accessory muscles.

3. Monitor anxiety and reassure patient. 4. Position patient to facilitate good diaphragm position (if not on spine

precautions). 5. Suction as needed.

6. Assess patient’s strength prior to extubation! Must be able to hold head off of pillow for 5 seconds. If in c-collar, assess strength of extremities.

1. Patient safety.

2. Most patients requiring mechanical ventilation in the PACU setting do so because of slow recovery from deep levels of anesthesia or long acting anesthetic agents, narcotics, sedatives, and/or neuromuscular blocking agents.

3. Remain with the patient during the entire weaning period.

I Verbalizes the nurse’s role in extubation.

1. Assemble equipment for extubation: a. 10 ml syringe to deflate balloon. b. Resuscitation bag/mask/100% FiO2. c. Oral/Nasotracheal suction.

d. Face Tent with blue tubing connected to O2 supply of at least 5-10%. FiO2 > FiO2 on ventilator to keep SpO2 >92%.

2. Perform endotracheal suctioning prior to extubation if indicated. 3. Perform oral suction prior to extubation and keep suction ready for oral

suction post extubation.

1. Patient safety. 2. Make certain you have mask attached to resuscitation bag and O2 supply turned on

and ready for emergency use. 3. Make certain you can get Intubation Tackle Box to the bedside quickly if needed.

J. Verbalizes proper procedure for transporting ventilator patients from PACU to ICU/SD.

1. Patient must be accompanied by RN and Respiratory. Therapist or MD, MDA or CRNA.

2. Notify Respiratory Therapy Transport if MD, MDA or CRNA not assisting with transport.

3. Provide appropriate monitoring – same parameters are to be monitored during transport.

4. Make certain ETT/Trach is secure to avoid airway irritation or dislodgement of tube during transport.

5. Administer sedation per orders. Request order if necessary.

6. CO2 monitor if requested by MD, MDA or CRNA in attendance.

1. Gathering appropriate equipment and personnel prior to transfer ensures patient safety and minimizes the time they are off the ventilator. 2. It is best to have 2 people to push stretcher/bed and a third person to ventilate patient during transport.



Neurological

Assessment Interpretation Rationale

A. Demonstrates accurate neurological assessment.

11. Neurological Assessment Includes: a. Pupils- note size and reactivity to light; note abnormalities in eye movement/

corneal reflexes. b. Level of Consciousness through verbal, tactile, and pain stimuli. c. Assesses baseline vital signs.

d. Orientation to Person, Place, & Time; Compared to baseline and developmental age

e. Assesses facial muscle movement and strength of upper and lower extremities. f. Speech: clarity, difficulty with expression or understanding. g. Sedation & Mental Status will be assessed, using Richmond Agitation Sedation

Scale (RASS) and Delirium CAM-ICU. h. Neurological patients: Performs a postop drift check; Babinski reflex; cranial

nerve functions when appropriate; evaluates and monitors for signs of increased

intracranial pressure; performs correct positioning when appropriate. i. Assesses involuntary movements. j. Identifies and describes seizure activity. k. Assessment of any suspicious drainage (otorrhea and rhinorrhea) for presence of

CSF. l. Communicates all pertinent information per institution and unit specific

policy/protocols/standards.

1. Patient safety.

B. Demonstrates accurate documentation of neurological status and assessment.


1. On admission, and in each phase of postop care.

2. With changes in neurological status. 3. With changes in condition.

8. Patient safety.

Modified Aldrete Score

Parameter Description of Patient Score

Activity Level Moves all extremities voluntarily/on command 2

Moves 2 extremities voluntarily/on command 1

Unable to move extremities voluntarily/on command 0

Respirations Breathes deeply and coughs freely 2

Dyspneic, shallow or limited breathing 1

Apneic 0

Circulation (blood pressure) BP +/- 20 mm Hg preanesthestic level 2

BP +/- 20 - 50 mm Hg>preanesthetic level 1

BP +/- 50 mm Hg> preanesthestic level 0

Consciousness Fully awake 2

Arousable on calling 1

Not responding 0

Oxygen saturation as

determined by pulse oximetry

SpO2>92% on room air 2

Supplemental oxygen required to maintain level >90% 1

SpO2<<90% with oxygen supplementation 0



Neurological

Assessment Interpretation Rationale

Richmond Agitation Sedation Scale (RASS)

+4 Combative Combative, violent, immediate danger to staff

+3 Very Agitated Pulls or removes tube(s) or catheter(s); aggressive

+2 Agitated Frequent non-purposeful movement, fights ventilator

+1 Restless Anxious, apprehensive but movements are not aggressive or vigorous

0 Alert and calm

-1 Drowsy Not fully alert but has sustained awakening to voice (eye opening & contact greater than 10

seconds)

-2 Light Sedation Briefly awakens to voice (eye opening & contact less than 10 seconds)

-3 Moderate sedation Movement or eye opening to voice (but no eye contact)

-4 Deep sedation No response to voice but movement or eye opening to physical stimulation

-5 Unarousable No response to voice or physical stimulation

CAM-ICU

Feature 1: Acute onset of mental status changes or a fluctuating course

All patients in the PACU are feature 1 positive if exposed to anesthesia.

Feature 2: Sedation Assessment (RASS):

Start by assessing patient’s RASS score.

If RASS is -4 or -5, then STOP & Reassess patient at later time.

If RASS is -3 or higher proceed.

Inattention:

Have patient squeeze your hand on “A”

SAVEAHAART

If greater than 2 errors=positive for inattention

Continue only if >2 errors

Feature 3: Altered LOC:

If RASS is anything other than a “)” patient is positive for altered LOC and is CAM-ICU positive/delirious.

Continue only if RASS “0”

Feature 4: Disorganized Thinking:

Ask these yes/no questions (worth 1 point each).

Will a stone float on water?

Are there fish in the sea?

Does one-pound weigh more than two pounds?

Can you use a hammer to pound a nail?

Two-part command (worth 1 point):

Ask the patient “Hold up this many finger”.

Then “Now do the same thing with your other hand”.

If greater than 1 question/command is wrong, feature 4 is positive and patient is CAM_ICU positive/delirious.

Must have Features 1 and 2 AND either 3 or 4 to be positive for delirium.



Normothermia Interpretation Rational

A. Verbalizes

potential negative outcomes related to perioperative hypothermia.

1. Hypothermia increases the patient’s risk of the following:

a. Adverse cardiac events. b. Surgical site infection. c. Surgical bleeding. d. Patient discomfort.

e. Longer hospital stays.

1. Patient safety.

2. Surgical Care Improvement Project Guideline.

B. Verbalizes

factors that contribute to perioperative hypothermia.

6. Factors include but are not limited to the following:

a. Low ambient room temperature. b. Patient exposure including cavities. c. Use of room temperature irrigation fluids. d. Wet linens and surgical drapes.

a. Anesthetized patients lose

the ability to generate heat through increased muscle activity or shivering.

C. Pre-Operative

Management.

1. Measure tympanic temperature.

2. Bair Paws gown provided, and warm air turned on to maintain temperature to 36.5°C.

3. Identify risk factures: a. Age.

b. Weight. c. Overall health. 4. Determine patient’s thermal comfort level. 5. Observe for symptoms of hypothermia:

a. Shivering. b. Piloerection (goose bumps). c. Cold extremities.

1. Maintain normothermia.

D. Verbalizes room temperature to maintain

normothermia.

1. Set thermostat at 24° C (75°F). 2. Document ambient room temperature in VPIMS on the Checklist tab. 3. The Celsius/Fahrenheit Conversion Calculator can be found in the electronic

VPIMS charting (Pre-Op, Intra-Op and Post Op).


E. Verbalizes methods for maintaining normothermia.

1. Apply warm blankets. 2. Patient may wear socks or surgical cap. 3. Monitor patient temperature.

1. Preventative measures protect the patient from heat loss due to radiation, conduction, and/or evaporation.

F. Post-Operative Management.

1. Measure tympanic temperature. 2. Warm IV fluids. 3. Humidify & warm gases on ventilator patient (38° C-40° C). 4. Assess temperature and patient’s thermal comfort level every 30 minutes until

normothermia is reached.




Nutrition and

Elimination

Assessment


A. Demonstrates Nutrition and

Elimination assessment.

12. Nutrition and Elimination Assessment completed and documented q shift: a. Completes bowel assessment, auscultating bowel sounds in all 4 quadrants.

b. Assesses abdomen for tone. c. Documents color, consistency and amount of all stool in HED. d. Implements Bowel Management System with MD order.

i. Must be inserted by a RN or MD. ii. Irrigate q shift with 60 mls room temperature water.

iii. Assess peripheral region q shift for leakage and/or skin breakdown. 13. Completes nutrition screening within 8 hours of admission. 14. Communicates with dietician if:

a. Nutritional screening indicates. b. Intolerance of tube feeding. c. Patient condition warrants (Coumadin, wired jaw, soft mechanical diets). d. Patient request. e. New onset difficulty eating (excessive nausea/vomiting, diarrhea,

chewing/swallowing). 15. Record amount (in percent) of food that patient consumes in HED.

5. 1. Patient safety. 6. 2. CL 30-14.03 Bowel

Management System (BMS) Fecal Tube Insertion and Management.

B. Demonstrates management of NG/OG tubes.

11. Document position and assess drainage q 4 hours (and appropriate suction). 12. Verifies placement prior to each irrigation and medication administration. 13. Irrigates NG and OG tubes q 4 hours with normal saline or water. 14. Changes tape daily to inspect skin (i.e. Tape tube to avoid pressure on nose or mouth).

9. Patient safety.

C. Demonstrates

Management of Feeding Tubes.

1. Records tube feeding (and fluid/water) intake.

2. Changes tubing q 24 hours (and container q 48 hours). 3. Infuses gravity feeding over 20-40 minutes. 4. Checks residuals q 4 hours (holds feedings for residuals greater than 500cc, recheck in two hours, if still greater than 50, notify MD)- exception: J-tube feedings (no need to check residuals. 15. Withholds tube feeding through small bore tube until placement is verified by X-ray. 16. Irrigates tube with 30 mls of NS or water q 8 hours. 17. Irrigates tube before and after medication administration.

1. Patient safety.

2. CL 30-14.01 Tube Feeding Care Administration Guidelines.

D. Demonstrates management of PEG tube.

1. Assesses site q shift noting the level of the tube at the skin (average adult size 3-4 cm and up), and record in HED. 10. Assesses site q 4 hours for possible leakage. 11. Cleans tube site with soap and water every shift. 12. Applies an abdominal binder to all patients with PEG tubes to deter or prevent dislodgement.

9. Patient safety.



Respiratory


A. Demonstrates respiratory assessment.

16. Respiratory Assessment Includes: a. Breath sounds. b. Respiratory pattern. c. Respiratory rate and depth. d. Depth of respirations.

e. Verification of FIO2 (if on ventilator or trached). f. SaO2 level. g. Sputum-character and quantity. h. Skin color.

1. Patient safety.

B. Demonstrates accurate

documentation of respiratory status.

18. Documentation should occur:

1. On admission.

2. At the beginning of each shift.

3. With changes in respiratory status.

13. Patient safety.

C. Demonstrates Tracheostomy Tube Care.

1. Extra trach tube plus obturator taped to bed. 2. Performance of trach care q shift and documented in HED. 3. Care will include:

a. Clean site with normal saline. b. Clean inner cannula with ½ strength H2O2 + ½ strength NS. c. Change drain sponge. d. Change disposable cannulas q 12 hours. e. Clean metal cannulas q 8 hours (using sterile technique). f. Keep adaptor for metal trachs at bedside for use with ambu bag.

1. Patient safety.

D. Demonstrates

Tracheostomy Suctioning.

1. Determines need for suctioning based on patient need (i.e. amount of secretions, respiratory

pattern/workload, SpO2, breath sounds). 14. Dons PPE. 15. Hyper-oxygenates with 100% O2 prior to suctioning. 16. Applies intermittent suction during withdrawal of suction catheter (Entire pass not to exceed

10 seconds). 17. Normal Saline used to clear the in-line catheter of secretions. 18. Sputum description should be documented in HED with each suctioning event. 19. Suction canister should be changed q 24 hours and when full (use isolizer).

10. Patient safety.

E. Demonstrates management of Chest Tubes.

1. Records CT levels and output in HED q 4 hours. 2. Assesses suction status: a. Observes closed drainage system for proper functioning. b. assesses that regulator is functioning by the gauge and drainage fluctuation in the tubing.

c. Assesses CT gauze dressings q shift, changes gauze q 24 hours and PRN.

1. Patient safety.



Sharps Injury

Prevention Interpretation

Rational

A. Verbalize

when to double glove.

1. Practices double gloving during all invasive surgical procedures.

Double gloving helps to reduce transfer

of bloodborne pathogens if sharps injury occurs.

B. Verbalize safe practice when using knife blades.

1. Uses safety knife handles when handling knife blades. 2. Activates blade sheath before passing knife handle. 3. Establish and uses neutral zone when passing exposed knife blades. 4. Uses a blade disarmer if removing blade from handle.

Using safe practices when handling knife blades helps prevent sharps injury.

C. Verbalizes safe practices when using suture needles.

1. Uses blunt suture when sewing muscle and fascia. 2. Establishes and uses a neutral zone when passing sharp suture. 3. Uses an instrument to separate needles in needle book when counting. 4. Removes needle from suture before tying.

Using safe practices when handling suture needles help prevents sharps injury.

D. Verbalize safe

practices when handling hypodermic needles.

1. Uses neutral zone if passing exposed needle.

2. Places needle and syringe in sharps container immediately after use. 3. Use one hand method when recapping needle. 4. Uses mechanical device to cover exposed needle.

Using safe practices when handling

hypodermic needles help prevent sharps injury.

E. Verbalize additional safe practices when handling sharps.

1. Keep sharps pointed away from self and team members. 2. Give verbal notification when passing sharps. 3. Keep hands away from surgical site when sharps are in use. 4. Keep track of and account of all sharps. 5. Use neutral zone when passing sharp instruments.

Using safe practices when handling sharps help prevent sharps injury.



Skin and Wound


A. Demonstrates

skin/wound

assessment.

17. Neurovascular Assessment Includes (6 P’s):

a. Pulselessness.

b. Pallor.

c. Polar.

d. Pain.

e. Paresthesias.

f. Paralysis.

18. Motor function:

a. Upper extremity- grasp and release; spread fingers apart.

b. Lower extremity- flex ankle; flex and spread out toes.

19. Sensory function:

a. Touch lateral surface of great toe and medial surface of 2nd toe- does patient feel pain, numbness,

tingling?

b. Touch medial and lateral surfaces of hands/feet-does patient feel any pain, numbness or tingling?

1. Patient safety.

B. Demonstrates

accurate

documentation of

skin and wound

status.

19. Documentation should occur:

1. On admission.

2. Every shift (document Braden score in the WIZ order, check HED under Braden that it was

recorded in WIZ/HEO.

3. With changes in skin/wound status.

20. Patient safety.

C. Demonstrates

Skin Care.

1. Orders skin protection in WIZ under Nurse to Nurse orders.

2. Uses Transparent or Hydrocolloid for fragile skin around stage 1 ulcers.

3. Floats heels and elbows PRN.

4. Uses Skin Barrier and Hydrogel for stage two ulcers and skin tears.

5. Assesses skin under devices and braces q shift, noting additional care needed in WIZ.

6. Pressure ulcer care directed through WIZ Pressure Ulcer Order guidelines as wounds noted.

7. All wounds/incisions documented in HED q shift (standard or complex wound format).

8. Hair Care: provided daily with scalp assessment PRN.

1. Patient safety.

2. CL 30-09.01 Pressure

Ulcer Prevention and

Treatment.

3. CL 30-09.02

Specialty Dressings.

D. Demonstrates

Turning.

1. Turns patients q 2 hours unless physician’s order indicates otherwise.

2. Documents all turning and repositioning (with time noted) in HED.

3. Assesses boney prominences when turning.

4. Log rolls spinal precautions patients to maintain spine immobilization.

11. Patient safety.

E. Demonstrates

Ambulation.

1. Ambulates BID all patients with OOB to Chair or OOB to ambulate orders.

2. Assesses weight bearing status for patients with fractures.

3. Assists patient with ambulation (STU/HR/PACU or PT/OT staff).

4. Implements use of ordered equipment for assistance for patients with weight bearing/

neurological issues (Smooth Moves, walkers, crutches, etc.).

1. Patient safety.

F. Demonstrates

use of Therapeutic

Mattresses/ Beds.

1. Assesses patient needs for specialty beds (i.e. Low Air Loss, Low Air Loss with pulsation, Air

Fluidized Bed, Obesity Bed with First Step Overlay, and Kinetic beds).

12. Verifies MD order for bed and documents in HED q shift when in use. Reassesses needs daily.

1. 1. Patient safety.

2. 2. CL 30-08.18 Ordering

and Maintenance of

Beds.

H. Demonstrates

use of Sequential

Compression

devices.

1. Verifies physician order and removes from extremity for assessment and relief q shift. 3. 1. Patient safety.

G. Demonstrates

assessment of

therapeutic splints/

Multipodis boots.

1. Alternates use of splints (on 4 hours/ off 2 hours).

2. Assesses all areas under splints for signs of pressure.

3. Notifies OT for issues r/t splints/braces.


H. Demonstrates

Oral Care.

1. Assures presence of patient’s personal oral care supplies.

2. Mouth care/ teeth (dentures) brushed q shift, unless physician order states otherwise.

3. Performs hypopharyngeal suctioning q 4 hours.

4. Remove and clean oral airway PRN.


I. I. Demonstrates II. Pin Care.

1. 1. Cleans pin site with soap and water q 12 hours. 2. 2. Assures that all pins are covered with pin caps.




Specimens,

Labeling of Interpretation Rational

A. Verbalize correct process for labeling all patient biological products/items.

1. Verify all patient labels with: a. Full patient name. b. Medical record number. c. Account number. d. Electronic white board.

e. VUnetID (Universal ID of the specimen collector). f. Include collection date for specimens going to the Blood Bank. g. Specimen bags contain only one patient’s specimen per bag. h. Blood Bank specimen contains date. 2. After verification that the label contains information for the correct patient, label all biological products/patient items as necessary.

1. Ensures correct information/label is placed on all patient biological products and items.

2. Policy: Labeling of Laboratory

Specimens. CL 30-08.22

B. Verbalizes process for two-person phlebotomy procedures.

1. Two-person phlebotomy procedure: Two people are both present at the patient bedside and participate in specimen collection. The phlebotomist performs the venipuncture and the labeler labels the containers.

a. Non-Blood Bank Specimen: i. Patient’s full name (first and last).

ii. Patient’s medical record number. iii. VUnetID of labeler is required on label of all specimen

container(s) and on the requisition(s).

b. Blood Bank specimen: i. Patient’s full name (first and last).

ii. Patient’s Medical Record number. iii. VUnetID of labeler is required on the label of all

specimen containers and on the requisition(s). iv. Date (the date must be on the specimen label). v. Blood Bank specimens may not be relabeled.

1. Ensures correct patient label and information are placed on specimen.

C. Demonstrate labeling of specimen collected in a tube.

1. Place label lengthwise on the tube just below the cap. 2. The label does not overlap itself, protrude from the sides of the tube, or extend onto the tube stopper (cap).

1. Policy: Labeling of Laboratory Specimens. CL 30-08.22

VUMC Perioperative Services HR/PACU RN Competency …

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