CLINICAL INTEGRATION ASSESSMENT SKILLS

Hygiene
Skin, Eye, Ear, Oral, Back Care
• Assess patient’s bathing preferences (frequency, time of day,
time of hygiene products)
ASSESSMENTS • Assess physical activity limitations
• Assess patient’s ability to bathe him or herself
• Assess skin for dryness, redness, or areas of breakdown
• Bathing self-care deficit
DIAGNOSES • Impaired skin integrity
• Risk for impaired skin integrity
BATH
• Provide privacy, adjust the temperature of the room for comfort,
lay a towel across the patient’s chest, put on a bath blanket
• Eyes: inner canthus to outer part (rinse cloth before washing
other eye, no cleanser)
• Head: Face, Neck, Ears
• Arms: far arm, near arm (hand, arm, axilla)
• Chest: lower blanket to umbilical area then clean
INTERVENTION • Abdomen: lower blanket to perineal area then clean
• Legs: return bath blanket to original position, clean far leg
(ankle, knee, groin), foot (clean and dry), near leg
• Assists the patient to move to a prone or side lying position
• Clean back and buttocks
• Clean perineal area
• Help patient put on a clean gown
• Groom patient’s hair

• Patient is clean, verbalize improve body image, verbalize importance

EVALUATION
of cleanliness, no skin breakdown, dryness, redness
• Record any significant observation and communication
• Document condition of patient’s skin
DOCUMENTATION
• Amount of assistance given and patient participation
• Document application of skin products such as barrier cream
Wash basin, warm water, personal hygiene supplies, towels (2), washcloths (2),
SUPPLIES NEEDED
bedpan or urinal, non-sterile gloves
Oral Medication Administration
• Assess for allergy
• Assess the patient’s ability to swallow
• Assess the patient’s knowledge of the medication, if patient
ASSESSMENTS
has knowledge deficit about the medication, begin education
• If medication will affect vital signs, assess pre-administration
• For pain medications, assess pain for benchmark values
• Assist the patient to an upright or lateral (side-lying position) or
fowler’s position
• Offer water or other permitted fluids with pills, capsules, tablets, and
some liquid medication
INTERVENTION
• Ask whether the patient prefers to take the medications by hand
or in a cup
• Remain with the patient until each medication is swallowed
• Never leave medication at the patient’s bedside
 • Assess any adverse reaction specific to the medication
• For pain medications, assess pain to evaluate effectiveness of drug,
pain level should be lower than preassessment value after onset
EVALUATION
• Assess signs and symptoms of allergic reaction
• If medication will affect vital signs, assess pre-administration

KEY TEACHING Purpose, action, and possible adverse reactions of medication

MAR, PRN Effectiveness, reason for refusal or omission, pain assessment
DOCUMENTATION
findings, vital signs, any difficulty swallowing (dysphagia)
SUPPLIES NEEDED Medications, MAR, water or pudding, tray
Topical Medication Administration Skin

• Assess the skin at the location where the patch will be applied (no
lumps, bumps, masses, tenderness, scar)
• Site should be clean, dry and free of hair (do not place patch on
irritated or broken skin)
• Assess the patient for any old patches (do not place a new patch
ASSESSMENTS
until old patch has been removed)
• Assess the patient’s knowledge of the medication, if patient
has knowledge deficit about the medication, begin education
• For pain medications, assess pain for benchmark values
• Assess allergy to adhesives
TRANSDERMAL PATCHES/ TOPICAL CREAMS
• Put on gloves
• Cleaning the site with alcohol swab or wash cloth before
application
• Rotate application sites
• Remove any old transdermal patches
INTERVENTION • Remove covering on the patch without touching the
medication
• In application, use the palm of your hand to press firmly for
about 10 seconds
• Do not massage
• For creams, wipe off excess medication before applying a new
dose

• Assess any adverse reaction specific to the medication

• Assess the patient for any old patches (do not place a new patch
until old patch has been removed)
• Assess the patient’s knowledge of the medication, if patient has
EVALUATION knowledge deficit about the medication, begin education
• For pain medications, assess pain to evaluate effectiveness of drug,
pain level should be lower than preassessment value after onset
• Assess signs and symptoms of allergic reaction

Purpose, action, and possible adverse reactions of medication, do not

KEY TEACHING remove patches, do not let family member touch medication side of the
patch
Skin assessment findings, time and position where the patch/ topical cream
DOCUMENTATIO was applied, any adverse reactions, allergic reactions, teaching provided
N and patient feedback
Medication (transdermal patch/cream), med cards, gloves, medical tape,
SUPPLIES NEEDED
tongue depressor
G-Tube Medication Administration
 • Assess for allergy
• Assess the patient’s knowledge of the medication, if patient
has knowledge deficit about the medication, begin education
• If medication will affect vital signs, assess pre-administration
ASSESSMENTS
• For pain medications, assess pain for benchmark values
• Auscultate the abdomen for evidence of bowel sounds
• Palpate the abdomen for tenderness and distention
• Assess bowel movement frequency and amount
• Using a pill crusher, crush each pill one at a time
• Dissolve the powder with water or other recommended liquid in a
liquid medication cup
• Keep the package label with the medication cup, for future
comparison of information
• Assist the patient to the high-Fowler’s position, unless
contraindicated
INTERVENTION
• If patient is receiving continuous tube feedings, pause the tube
feeding pump
• Check tube placement, depending on type of tube
(aspirating contents)
• Note the amount of residuals
• Liquids should be within room temperature
• Clean syringe tip before inserting
Irrigation set (60 mL syringe and irrigation container), medications, tap
SUPPLIES NEEDED water or sterile water (or normal saline), for irrigation, depending on facility
policy, gloves, additional PPE
Dressings: Clean Technique
• Skin redness around the tube
ASSESSMENTS • Drainage or leaking
• Discomfort or pain around the tube
CHANGING THE DRESSING
• Prepare supplies
• Wash hands
IMPLEMENTATION
• Put on gloves
• Take off the old dressing gently
• Assess any drainage on the dressing (color, amount, smell)

• Discard old dressing

• Remove gloves then wash hands
• Put on new gloves
• With soap and water clean the site using a washcloth, flip sides as
needed, use Q-Tips to reach skin under the tubing
• Assess the skin for any drainage (color, amount, smell), redness,
irritation, signs and symptoms of infection, pain
• If rashes are found apply barrier cream to protect the skin
around the site
• Apply a T-Drain sponge gauze over the G-Tube
• Tape the gauze to secure placement
• Label the new gauze
DRESSING TYPE: G-TUBE
DATE: JUNE 19, 2019
INITIALS: Sbelmes SPN
 • Skin redness around the tube
EVALUATION • Drainage or leaking
• Discomfort or pain around the tube
2 pair of gloves, wash basin with warm water, wash cloth, towel to dry, Q-
tips, T-Drain gauze pad, tape, pen for labelling

SUPPLIES NEEDED

Hypodermoclysis (Hydration)
SOLUTION BAG: any drainage, holes, punctures, moisture, appropriate
volume of liquid according to label, color, expiration dates, amount the
patient already absorbed
ASSESSMENTS
TUBING: any kinks, bubbles, sediments, if connected to the right patient, if
label is correct, verify drop rate according to doctor’s order
SKIN ON SITE: any redness, swelling, drainage, check label if correct
CHANGING THE SOLUTION BAG
IMPLEMENTATION
• Wash hands
 • Wear gloves
• Check the old bag for any drainage, holes, punctures, moisture
(might affect how much the patient already has absorbed)
• Record the amount of hydration the patient has absorbed in the
input/output sheet as input
• Grab a new bag
• Assess the new bag for any drainage, holes, punctures,
moisture, appropriate volume of liquid according to label,
color, expiration dates
• Clamp the tubing
• If the roller clamp has already been set to the drop rate
required, do not touch
• Un-puncture old bag, discard
• Puncture new bag using a twisting and pushing motion
• Change label on tubing
• Unclamp the tubing
• Change the label on the skin site
TIME DATE: 14 00 | 23 JUN 2019
SOLUTION: NaCl 0.9%
INITIALS: S. BELMES SPN

INSERTING THE BUTTERFLY

• Hold wings together between thumb and index finger
• Insert at 450, bevel up
• Needle should lie in subcutaneous tissue
• Release wings, lay flat and secure butterfly with occlusive
transparent dressing over insertion site & some of the tubing

SIGNS OF FLUID RETENTION: edema, crackles in lungs, bladder distension

SIGNS OF DEHYDRATION: increased thirst, dry mouth, decreased
EVALUATION
urine output, poor skin turgor

Catheter Care
CATHETER TUBING: any kinks, obstruction, leakage
PERINEAL AREA: redness, swelling, drainage, signs and symptoms of infection
ASSESSMENTS URINE: color, consistency, smell, amount, any sediments, any blood in the
urine

EMPTYING CATHETER BAG

• Provide privacy
• Wash hands
• Wear gloves
• Grab a graduated cylinder to measure urine output
• Place a napkin below the graduated cylinder
• Unclamp the Foley bag tip
INTERVENTION
• Empty the bag
• Swab the tip of the Foley bag
• Check tubing for any kinks, leakage, obstruction
• Record urine output amount
• Assess urine for color, consistency, smell, amount (30 mL / hour, any
sediments, any blood in the urine
• Empty into the bathroom
 • Clean the graduated cylinder
• Catheter should be hanging in a permanent fixture

CLEANING THE CATETHER TUBE

• Only expose the area being cleaned, not the whole body
• Provide privacy and maintain professionalism
• Ask for permission (consent)
• Wear gloves
• Do required assessments
• FEMALE: meatus – catheter – vaginal folds
• MALE: meatus – catheter – penis – scrotum
• Stabilize the catheter with non-dominant hand while cleaning to
avoid pulling it out accidentally
CATHETER TUBING: any kinks, obstruction, leakage
PERINEAL AREA: redness, swelling, drainage, signs and symptoms of infection
EVALUATION URINE: color, consistency, smell, amount, any sediments, any blood in the
urine

Parenteral Medication Administration

Subcutaneous Injections
SITES FOR INJECTION
• Outer aspect of the upper arm
• Abdomen
• Anterior aspects of the thigh
• Upper back
• Upper ventral or dorsal-gluteal area

THEORY

Heparin Subcutaneous Injections

LAB VALUE: PTT (if within normal range)
ASSESSMENTS Assess for any bruising, bleeding, fever, swelling, nosebleed
 ANTICOAGULANT IS A HIGH ALERT MEDICATION: Need a cosigner
when drawing medication
• Check the site where the last dose was given, rotate sites
• Select a 1 ml syringe
• Do not aspirate when injecting subcutaneous medications

DRAWING HEPARIN
• Wash hands
• Wear gloves
• Swab the cap of the vial
• Prepare syringe (1 mL) and needles (BLUNT 18G, 25 G 3/8 5/8)
needed
INTERVENTION
• Attach 18G needle into 1 ml Leur lock syringe
• Draw air into syringe while still capped (same amount as
medication to be drawn from vial)
• Uncap needle using rainbow technique
• Inject air into vial and draw ordered amount of heparin
needed from vial
• Check and get rid of bubbles then draw back air for changing
needles
• Change 18G needle to 25G needle. Do not take out of the
wrapper
• Attach the label to the tip of the syringe

PATIENT’S NAME: Tall, Pete

MEDICATION: Heparin
DOSE: 10 000 UNITS

INJECTING INTO PATIENT

• Clean the site using an alcohol swab for 30 seconds and dry for
30 seconds
• Inform patient that they will feel a slight burning sensation but it is
normal for anticoagulants
• Pinch the skin lightly
• Inject needle at a 45 to 90 degrees angle
• Hold the pinch and the needle while administering and 10
seconds after
• Do not massage site after administration
LAB VALUE: PTT (if within normal range)
EVALUATION
Assess for any bruising, bleeding, fever, swelling, nosebleed
KEY TEACHING • Use soft bristle brush for brushing teeth
Parenteral Medication Administration
Intramuscular Injections
• Review allergies and laboratory data that may influence drug
administration.
• Assess the injection site. Avoid site that is bruised, tender,
ASSESSMENTS
swollen, hard, inflamed, scarred.
• Vital signs (baseline)
• Pain assessment if medication is for pain
• Deficient knowledge
DIAGNOSES • Risk for injury
• Risk for infection
THEORY LANDMARKING
 DELTOID: Three fingers down the acromion process and injection site is in the
middle of an inverted triangle
VENTROGLUTEAL: place palm on greater trochanter and index finger toward
the anterosuperior iliac spine
VASTUS LATERALIS: divide the thigh into thirds horizontally and vertically
(outer middle third)

Image from Taylor’s Clinical Nursing Skills

PATIENT POSITIONING
DELTOID: Patient may sit or stand. (adolescents, adults) VENTROGLUTEAL:
patient may stand, sit, lie laterally and lie supine. (adults only)
VASTUS LATERALIS: patient may sit or lie supine (infants, toddlers, adolescents)

NEEDLE LENGTH
VASTUS LATERALIS: 5/8” to 1¼ “
DELTOID (CHILDREN): 5/8” to 1¼ “
DELTOID (ADULTS): 1” to 1 ½ “
VENTROGLUTEAL: 1 ½ “

LIQUID VOLUME
DELTOID: 1-2 mL
VENTROGLUTEAL: 1-5 mL
VASTUS LATERALIS: 1-5 Ml

Z-TRACK
Pull the skin and underlying tissue down or to one side about 1 inches with
your nondominant hand and hold the skin and tissue in this
position.

INTRAMUSCULAR INJECTION
• Always Keep medication in sight
• Put on gloves
• Select an appropriate administration site
IMPLEMENTATION • Expose only the site being used
• Cleanse the area with antimicrobial swab for 30 seconds. Use firm,
circular motion while moving outward from the injection site.
• Dry for 30 seconds
 • Remove the needle cap using rainbow motion
• Hold the syringe in your dominant hand between the thumb and
forefinger
• Displace the skin in a Z-track manner
• Quickly dart the needle into the tissue so that the needle is
perpendicular to the patient’s body (72-90 ° angle)
• Use the thumb and forefinger of nondominant hand to hold the
lower end of the syringe, taking care to maintain the
displacement of skin and tissue
• Slide dominant hand to the end of the plunger. Inject solution
slowly (10 sec/mL)
• Once medication is instilled, wait 10 seconds before
withdrawing needle
• Withdraw the needle smoothly and steadily at the same angle at
which it was inserted
• Remove the hand holding the displaced skin and tissue only after
removal of the needle
• Do not recap the used needle
• Apply gentle pressure at the site using dry gauze (Do not
massage)
• Assist patient to a position of comfort
• Discard the needle to sharps bin
• Assess for any adverse reactions/ allergic reactions
• Assess the injection site. No swelling, redness, discharge.
EVALUATION • Assess signs of infection
• Vital signs (post-assessment)
• Pain post-assessment if medication is for pain
• Medication’s purpose, action, adverse reactions
KEY TEACHING • Do not massage site
• Rotate injection sites
• Document medication administration on MAR
• Skin assessment and pain assessment results
DOCUMENTATION
• If patient refuse medication, record reason for refusal
• Interventions done
Gloves, medication, sterile syringe and needle of appropriate size and
SUPPLIES NEEDED
gauge, antimicrobial swab, small gauze square, MAR
Medication Administration
Narcotics
ADMINISTRATION • Need a cosigner for narcotic count and wasting
Oxygenation
Nasal Cannula
FOCUS: Respiratory (monitor oxygen saturation to provide baseline for
evaluating effectiveness of medication, lung sounds, respiratory rate and
ASSESSMENTS
rhythm, accessory muscle use, tripod position, cyanosis, patency
of nares)
• Impaired gas exchange
DIAGNOSES • Ineffective breathing pattern
• Risk for activity intolerance
• Raise bed to Fowler’s position
• Assess kinks on oxygen tubing
INTERVENTIONS • Assess if oxygen is connected to oxygen tree and not medical air
• Deep breathing exercises

• Assess if nasal cannula is connected properly

 NASAL CANNULA
• Review medical order to verify the use of nasal cannula, flow rate,
and administration parameters
• Assemble equipment on overbed table
• Explain what you are going to do to patient
• Review safety precautions (fire hazards)
• Place cannula in the patient’s nares
IMPLEMENTATION
• Place tubing behind ear
• Place adjuster under chin
• Gauze pad can be placed under the tubing in the ears
• Adjust fit of cannula: tubing should be snug but not tight
against the skin
• Encourage patient to breathe through the nose with the
mouth closed
• Reassess patient’s respiratory status
• Oxygen saturation within normal range
EVALUATION
• Assess nares at least every 8 hours for evidence of irritation or
bleeding
KEY TEACHING • Deep breathing exercises
Oxygen via nasal cannula applied at 2 L/min. Humidification in place.
Pulse oximeter before placing oxygen 92%; after oxygen at 2 L/min 98%.
DOCUMENTATION Respirations even and unlabored. Chest rises
symmetrically. No nasal flaring or retractions noted. Lung sounds clear and
equal in all lobes.
SUPPLIES NEEDED Gloves, nasal cannula, oxygen tree, humidification
Oxygenation Metered
Dose Inhaler
FOCUS: Respiratory (monitor oxygen saturation to provide baseline for
evaluating effectiveness of medication, lung sounds, respiratory rate and
ASSESSMENTS
rhythm, accessory muscle use, tripod position, cyanosis, patency
of nares)
• Impaired gas exchange
DIAGNOSES • Deficient knowledge
• Risk for activity intolerance
METERED DOSE INHALER
• Shake the inhaler well
• Attach MDI to the spacer, remove the mouthpiece
• Have patient place the spacer’s mouthpiece into mouth
(grasp with teeth and sealed lips) Have patient breathe
normally through spacer
• Patient should breathe out completely
• Depress cannister once, releasing one puff into the spacer, then
INTERVENTION inhale slowly and deeply through the mouth
• Instruct patient to hold his or her breath for 5 to 10 seconds, or as
long as possible, and then to exhale slowly through pursed lips
• Wait 1 to 5 minutes between each puff
• After administration, remove the MDI from spacer and recap both
• Have patient gargle and rinse with tap water to avoid
infection

EVALUATION • Reassess patient’s respiratory status

 • Oxygen saturation within normal range
• Any adverse reactions
• Always rinse the mouth after using inhalers
KEY TEACHING
• Medication’s adverse effects, interaction, purpose
Wheezes noted in all lobes of lungs before albuterol MDI, O2 saturation
92%, respiratory rate 24 breaths per minute. After albuterol treatment, lung
sounds are clear and equal, in all lobes, 02 saturation 97%, respiratory rate
18 breaths per minute. Patient able to demonstrate accurately the use of an
MDI and spacer and verbalizes understanding of medication purpose and
action.
DOCUMENTATION
 Assessment information
 Interventions done
 Teachings provided
 Client feedback
 Safety precautions done
Stethoscope, medication in an MDI, spacer or holding chamber,
SUPPLIES NEEDED
MAR, doctor’s order
Oxygenation
Nebulizer
FOCUS: Respiratory (monitor oxygen saturation to provide baseline for
evaluating effectiveness of medication, lung sounds, respiratory rate and
ASSESSMENTS
rhythm, accessory muscle use, tripod position, cyanosis, patency
of nares)
• Impaired gas exchange
DIAGNOSES • Ineffective airway clearance
• Ineffective breathing pattern
NEBULIZERS
• Remove the nebulizer cup from the device and open it. Place pre-
measured medication into the bottom section of the cup
• Screw the top portion of the nebulizer back in place and
attach cup to the nebulizer.
• Attach one end of tubing to the stem on the bottom of the
nebulizer cuff and the other end to the air compressor or oxygen
source
• Turn on the oxygen. Check that a fine medication mist is
produced by opening the valve.
INTERVENTION • Have the patient place the mouthpiece into the mouth and
grasp securely with teeth and lips
• Instruct patient to inhale slowly and deeply through the mouth. Hold
each breath for a slight pause, before exhaling
• Continue this inhalation technique until all medication in the
nebulizer cup has been aerosolized (usually about 15 minutes)
• Once the fine mist decreases in amount, gently flick the sides of
the nebulizer cup
• Once empty, have the patient remove the nebulizer from the
mouth and gargle and rinse with tap water, as indicated.
• Clean and store nebulizer according to facility policy.
• Reassess patient’s respiratory status
EVALUATION • Oxygen saturation within normal range
• Any adverse reactions
• Always rinse the mouth after using inhalers
KEY TEACHING
• Medication’s adverse effects, interaction, purpose
 Wheezes noted in all lobes of lungs before albuterol MDI, O2 saturation
92%, respiratory rate 24 breaths per minute. Patient reports “feeling like I
can’t get my breath.” Patient reassessed 20 minutes after albuterol
nebulizer treatment; lung sounds are clear and equal, in all les, 02 saturation
97%, respiratory rate 18 breaths per minute unlabored. Patient verbalizes
relief of shortness of breath and an understanding of medication purpose
DOCUMENTATION and action.

 Assessment information
 Interventions done
 Teachings provided
 Client feedback
 Safety precautions done
Stethoscope, medication, nebulizer tubing and chamber, oxygen hookup,
SUPPLIES NEEDED
MAR
TED (Thrombo-Embolic-Deterrent) STOCKINGS
• Assess feet and legs for any bruises, swelling, redness
ASSESSMENTS
• Assess feet size if appropriate for stocking size
DONNING COMPRESSION SOCKS
• Get stockings that are the correct size for the patient
• Legs should be dry of any water or lotion
• Applying baby powder/cornstarch on legs can help stockings
IMPLEMENTATION move up on legs
• Reach into the stocking and grab the toe of the sock
• Pull upper half of the sock inside out to the heel
• Slide foot into sock and get it in place on foot and heel
• Grab stocking and pull them up
EVALUATION • Assess feet and legs for any bruises, swelling, redness
BRIEF CHANGE
• Assess the perineal area for any redness, swelling, drainage, rashes,
ASSESSMENTS signs and symptoms of pressure ulcer
• Assess stool/urine
BRIEF CHANGE
• Provide privacy
• Wash hands
• Wear gloves
• Put soaker pad under the patient
• Open the used briefs
• Clean the genitalia (FEMALE: least contaminated to most
contaminated/ away to near, creases and folds) (MALE:
meatus, glans, shaft, scrotum, creases and folds)
IMPLEMENTATION • Ask the patient to reposition their self laterally away from the
nurse
• Clean the anal area and the back parts of genitalia
• Roll and discard old diaper
• Wash hands and change gloves
• Put fresh diaper to where the patient will land when they lay back
• Assess the skin
• Ask the patient to lay down
• Secure the briefs and provide privacy