Required Areas of Care - Vital Signs

Vital Signs

1. Complies with established guidelines
2. Obtains accurate vital signs by:
• Reading the instrument within a stated range of
• +/- 2 degrees for temperature
• Counting within a stated range of
• +/- 5 beats for apical or radial pulse (+/- 10 beats/minute for apical pulse for a child under 2 years)
• +/- 2 respirations/minute for adults (+/- 6 respirations for a child under 2 years)
• Reading the instrument within a stated range of
• +/-6 millimeters for blood presure
• Obtaining an accurate weight, when assigned by:
• balancing the scale
• undressing the patient as neccessary
• maintaining cleanliness of the scale
• weighing within one percent (1%) of the correct weight
• Obtaining oxygen saturation when assigned
• Assessing the level of pain, when assigned, by:
• Asking an adult patient to rate level of pain using a 0-10 scale or visual analog scale or
• Asking a child 3 or older to rate level of pain using a 0-5 faces scale or age appropriate visula analog scale or
• Using the FLACC pain assessment tool to rate level of pain for a child ranging in age 2 months to 3 years of age or
• Observing behaviors indicative or pain in a patient unable to rate his or her pain (e.g. moaning, grimacing, clutching, restlessness)
3. Records each of the assigned vital signs on PCS Recording  Form

Required Areas of Care - Fluid Management

Fluid Management

1. Assesses the hydration status of the patient by one of the following methods:
• Checking skin turgor or
• Inspecting the mucous membranes or
• Palpating the anterior fontanel of a child less than 1 year of age
2. For enteral fluids
• Determines the kind(s) of fluid to be ingested
• Administers or restricts fluids as designated
3. For parenteral fluids:
• Within 20 minutes after beginning the Implementation Phase:
• Verifies the accuracy of flow rate by either
• Counting the drops per minute currently flowing or
• Documenting that the flow rate of the infusion control device is set at the exact number required to deliver the prescribed volume by writing the correct setting on the PCS Recording Form
• Assesses the insertion site of peripheral, central, or implanted venous access devices for dislocation, infiltration, or other complications by using one of the following methods:
• Feeling the surrounding skin for changes in temperature OR
• Palpating the surrounding tissue for edema
• Regulates the flow rate when required by either:
• Adjusting flow to within +/- 5 drops per minute (regular or microdrops) of the calculated number of drops per minute OR
• Adjusting the flow rate of the infusion control device to the exact number required to deliver the prescridbed volume
• Records the prescribed fluid infusing on the PCS Recording Form
• Throughout the Implementation Phase:
• Administered the prescribed fluids
• Administers the designated amount of fluid per hour within the following ranges (as long as this amount of error does not place the patient in physical jeopardy):
• +/- 25 ml per hour for a patient over 2 years of age
• +/- 10 ml per hour for a patient under 2 years of age
• Recalculates the fow rate or adjusts the ICD settting if the physician's order changes
• When the next prescribed primary IV fluid is required:
• Selects the designated fluid
• Calcuates the amont of fluid to infuse per specified period of time
• Identifies the patient immediately before administering the IV solution by verifying two of the following peices of patient information
• Patient name
• Date of birth
• Medical record number
• Assesses the insertion site of peripheral, central, or implanted venous access devices for dislocation, infiltration, or other complications by using on of the following methods:
• feeling the surrounding skin for changes in temperature OR
• Palpating the surrounding tissue for edema
• Clears IV tubing of air before initiating flow
• Regulates the flow rate by either:
• Adjusting the flow to within +/- 5 drops per minute (regular or microdrop) of the calculated number of drops per minute or
• Adjusting the flow rate of the infusion control device to the exact number required to deliver the prescribed volume
• Records on the PCS Recording Form the new fluid being administered
• When maintenance of an intermittent venous access device is required:
• Assesses the insertion site of peripheral, central or implanted venous access device for dislocation, infiltration, or other complications by:
• Feeling the surrounding skin for changes in temperature OR
• Palpating the surrounding tissue for edema
• Aspirates for blood return unless cotraindicated
• Flushes the intermittent access device with the designated flush solution
• Records the flush solution on the PCS Recording Form
• When a peripheral device is discontinued:
• Assesses the condition of the IV site
• Removes the cannula
• Applies pressure to the venipuncture site
• Applies a protective covering
4. When enteral and/or parenteral intake is assigned:
• Measures the amount of fluid ingested/infused
• Records fluid intake within +/- 10% of the actual intake
• Records kind(s) of fluid ingested/infused
• Recouds hourly intake on PCS Recording Form within +/- 10 minutes of the designated time, when hourly intake is assigned
5. When output is assigned:
• Collects output
• Measures output during the entire PCS
• Records amount of output within +/- 10% of actual output for the PCS on the PCS Recording Foum (output from urinary retention catheters or other drainage apparatus is not measured during the PCS unless otherwise designated)
• Records amount of hourly output on the PCS Recording form within +/- 10 minutes of the designated time, when hourly output is assigned
6. Records data related to:
• Hydration status
• Condition of insertion site for peripheral, central, or implanted venous access devices

Overriding Areas of Care - Physical Jeopardy

Physical Jeopardy

Any action or inaction on the part of the student which threatens the patient's physical well-being. Students are accountable for the patient's safety throughout the entire PCS. Any time the physical safety of the assigned patient is threatened through ommission, such as not reporting a deterioration in the patient's clinical condition, or by an imminent incorrect action by the student, the entire PCS will be terminated and failed. This area of care is to be invoked at the discretion of the Clinical Examiner and supported by data from the clinical situation.

Overriding Areas of Care - Mobility

Mobility

1. Assesses the patient for
• level of mobility
• use of assistive devices
• presence of balance abnormalities
2. Moves or positions the patient by
• supporting the weak or injured parts of the body
• supporting the patient's head, shoulders, and pelvis
• turning, lifting, or moving the patient to a different position
• using body parts or external devices to keep the patient in the desired position
• using positioning and/or devices to reduce pressure on vulnerable skin surfaces
• using measures to prevent shearing of skin
3. Assists with transfer or ambulation by
• stabilizing equipment
• using measures to maintain the patient's balance
4. Records
• data related to:
• level of mobility
• use of assistive devices
• presence of balance abnormalities
• positioning, transfer, or ambulation activities completed during the PCS
• patient's response to the psoition, transfer, and/or ambulations activities

Overriding Area of Care - Emotional Jeopardy

Emotional Jeopardy

 Any action or inaction on the part of the student which threatens the emotional well-being of the patient or significant other(s). This area is invoked at the discretion of the Clincal Examiner, validated with the patient, and supported by data from the clinical situation. The entire PCS will be terminated and failed any time the emotional well-being of the patient or significant other(s) is threatened.

Overriding Areas of Care - Caring

Caring

1. Establishes communication and a trusting relationship with the patient at the beginning of the Implementation Phase by:
• Introducing self and  identifying the patient by comparing two of the following pieces of patient information against the PCS form
• patient name
• date of birth
• medical record number
• explaining the purpose of the interaction or using touch with a patient who is a child or non-communicationg adult if culturally appropriate.
2. Uses therapueutic communication techniques consistent with the patient's level of understanding to interact with the patient and significant others by
• encouraging the patient's expression of needs
• responding to the patients's verbal expressions
• responding to the patients's non-verbal expressions
• facilitating goal-directed interactions by
• explainging the nursing actions to be taken
• asking questions to determine the patient's reponse to nursing care
• asking questions to determine the patient's comfort level
• focusing communication toward patient-oriented intersts
• eliciting the patient's choices/desires in the organization of care
3. Uses verbal expressions that are not overly familiar, patronizing, demeaning, abusive, or otherwise unacceptable
4. Uses physical expression that are not overly familiar, patronizing, demeaning, abusive, or otherwise unacceptable
5. Relates in a manner that respects the values, dignity, and culture of others

Overriding Areas of Care - Asepsis

Asepsis

1. Washes hands in the presence of the Clinical Examiner before beginning the Implementation Phase of each PCS.
2. Protects self, others, and the environment from contamination
3. Protects the patient from contamination
4. Disposes of contaminated material in designated container
5. Establishes a sterile field when required