Medical Surgical Nursing Skills List - Prince Edward Island

Medical – Surgical Nursing Skills ListRead each of the required clinical skills for a Registered Nurse working on a typical acutemedical-surgical unit. Write the number that corresponds to the level of experience youhave had with the specific skill. For example, under I. Assessment - A. Measurepatient’s vital signs, if you had taken a patient’s vital signs on your own (independently)in your previous nursing job then you would put a 4 beside this skill and all the otherskills you had performed on your own.Performance Code: 1 I have no experience with this skill2 I have performed this skill with assistance3 I have performed this skill under supervision4 I have performed this skill independentlyCompetency Self-Assessment1. ASSESSMENT:Measure patient’s vitalsigns:PerformanceCodeTPRBlood pressure- manual and machineNeurological checks (orientation to time, place,person; response todirections and painful stimuli, pupillary reaction,extremity te initial plan of care – nursingdiagnosis/need/focus/dischargeplanning and patient teaching needs.Establish goals with patient/family/SO.Write nursing interventions.3. IMPLEMENTATION:a. Maintain RespiratoryFunction:PerformanceCode1. Administration of oxygen- set up,initiate and administer:Nasal cannulaFace maskVenti maskNonrebreathing maskTrach collar1

T-piece2. Incentive spirometry- demonstrate use of3. Coughing and deep breathing - demonstrate andwork with patient.4. Suctioning - lubricate catheter if applicable,insert, suction, al5. Tracheotomy care - perform tube care, cleanwound, change dressing,document.6. Closed chest drainage - observe for leaks,maintain, measure output, assess and documentrespiratory status, assess dressing:GravitySuction7. Pulse oximeter - set up, apply sensor, setalarms, reassure, interpret,record.8. Suction equipment - set up and maintain:Portable suction9. Respiratory assist devices - set up and maintain:CPAP for sleep apneaBIPAP10. Ventilator management – identify FIO2, rate,TV mode. Respond, reset, and interpret alarms.Check humidification source and venttemperature. Empty excess water from tubing andadminister nebulized medication.2

3. IMPLEMENTATION:PerformanceCodeb. Maintain CardiovascularFunction:1. Code management:Verbalize emergency number to call.Initiate and administer BCLS.Bring code cart and EKG machineAttach oxygen to Bag-Valve-Maskresuscitator.Prepare code medications2. Code cart and equipment maintenance - checkcart, check oxygen tank, check suction, and EKGmachine3. Blood products:Check, administer, and document bloodproduct administrationMonitor patient during administrationState policy/procedure to use withtransfusion reactionc. Support and MaintainNutritional Requirements:1.TPN, PPN, intra-lipids – administer anddocument2. Tube feeding - check for placement, administerfeedings, check and record residual:NasogastricGastrostomyJejunostomy3. Intravenous therapy (peripheral, intermittentinfusion devices):Verify orderInsert line/device and label dressingLabel bag and tubingCalculate and regulate rateFlush intermittent infusion deviceAssess and document site condition4. Central line/Peripherally inserted central line(PICC) catheter care:Assess, change dressing, document sitecondition3. IMPLEMENTATION:c. Support and MaintainNutritional Requirements:(cont’d)PerformanceCodeAccess central venous access catheterwith subcutaneous reservoirFlush/heparinize as per policy/procedureor as ordered by MD3

d. Administer ntramuscularIntravenous via peripheral line, intermittentinfusion device, central line6. Rectal7. Vaginal8. Ophthalmi9. Otic10. Topical11. Patient Controlled Analgesia (PCA)12. Nebulization13. Metered Dose Inhaler (MDI) with inhalere. Care for the Patient withLimited Mobility:1. Pressure ulcer management - assess riskfactors, document stage/observation, initiate andmaintain skin care protocol2. Range of motion exercises - initiate andmaintain skin care protocol3. Preventive positioning and turning4. Transfer to chair5. Transfer to stretcher6. Ambulation:With assistanceCaneCrutchesWalker7. Care of patient with immobilizing device:CastTractionSling3. IMPLEMENTATION:f. Maintain EliminationFunction of GI and GUSystems:PerformanceCode1. Care of the patient with naso-gastric tube check for placement and patency, maintainsuction, check bowel sounds, perform nasal care,and document2. Enemas:FleetsRetention3.Ostomy Care:4

Skin careObservation of stoma.Application of appliance.Irrigation (with cone only), if applicable4. Catheterization - insert, maintain, recordoutput, provide perineal care, remove5. Suprapubic catheter care6. External catheter care (condom)7. Peritoneal dialysis:Initiate peritoneal dialysisAdd medicationsPerform solution exchangeObtain dialysate culture and cell countPerform catheter and exit site careTerminate peritoneal dialysisg. Collect Specimens:1. Stool for occult blood2. Urine for urinalysis3. Urine for culture and sensitivity:IndwellingClean catch4. 24-hour urine collection5. Urine for S & A6. Wound for C & S7. Sputum for C & S8. Sputum for AFB9. Blood glucose monitoring5

3. IMPLEMENTATION:PerformanceCodeh. Implement Principles ofInfection Control (routinepractices):1. Hand washing2. Isolation protocols3. Universal precautions4. Sterile dressing changes5. Gowning, gloving, masking6. Disposal of contaminated linen/trash7. Handling of reusable equipment8. Use of particulate respiratorsi. Maintain Patient, Visitor,Staff Safety, EnvironmentalSafety:1. Falls prevention - identify patient at risk,initiate and maintain patient safety alertprotocol.2. Restraints - identify need, assess, and providecomfort measures, renew order, document3. Fall safe device - initiate, maintain, andmonitorj Identify Patient Precautions(suicidal and non-suicidal) Initiate, Maintain, andDocument.k Miscellaneous:1. Applies:Abdominal binderElastic stockings, Ace bandages observe peripheral circulation, includingcolour, sensation, capillary refill, skintemperature, peripheral pulse2. Utilize equipment - set up, initiate, andmonitorHypo/hyperthermia blanketBedscale/chair scaleElectronic thermometerGlucometer equipmentTherapeutic bedInfusion pumpEnteral feeding pump3. IMPLEMENTATION:k Miscellaneous: (cont’d)PerformanceCodeContinuous Passive Motion (CPM)deviceHoyer lift6

Sequential Compression device (SCD)3. Maintain drains:Jackson PrattHemovacChannel4. Postmortem carePEI uses a combination of paper and electronic documentation presently. Please indicate familiarity ofusing either paper or electronic or both. Place P for Paper E for Electronic (or both) after Code numberl. Document Patient Care:1. Admission nursing assessment.2. Patient care plan/MPC.3. Activity flow record4. Nursing treatment kardex/MPC5. Fluid balance record6. Medication administration record (MAR)7. Integrated progress notes8. Pre-op checklist9. Pre-/postoperative teaching record10. Informed consent11. Transfer summary12. Restraint flow sheet13. Discharge nursing assessment14. Patient discharge instructions15. PCA administration record16. Peritoneal dialysis flow sheet17. Finger-stick accession quality control form18. Pressure ulcer risk assessment/flow sheet19. Patient classification system, if appliesOnce completed please return to your Clinical Educator/ Manager/ SupervisorIEN Signature: Date:Nurse Educator / Manager Signature: Date:Please ensure both parties have a copy of this documentation and maintain a copy for both your records.Adapted from Canadian Association of Schools of Nursing and Kwantlen University College. (2008) IENModule – Assessing Learner Needs7

medical-surgical unit. Write the number that corresponds to the level of experience you have had with the specific skill. For example, under I. Assessment - A. Measure patient’s vital signs, if you had taken a patient’s vital signs on your own (independently) in your previous nursing job then you would put a 4 beside this skill and all the .