State the importance of colour coding and important aspects of EWS recoding? Yes/No Patient is assessed using minimum observation levels? Yes/No What accurate measurements are required as a normal part of nursing observation? Yes/No Observations performed accurately? Yes/No Calculate an early warning score? Yes/No Score is calculated accurately? Yes/No Explain what to do if the trigger score is reached? Yes/No Assesses pain score accurately? Yes/No Identify the two main factors required to improve the outcome of the patient’s early warning score? Yes/No Checks whether it is necessary to contact medical staff or not? Yes/No Explain minimum observation levels? Yes/No Assess and identify clinical concerns regarding patients’ conditions? Yes/No State what they would do if a patient had no urine output? Yes/No Observations are recorded on Sunrise? Yes/No States how to assess pain? Yes/No States what should be done whilst waiting for medical staff to review the patient? Yes/No States what should be done if they are concerned about a patient and they have not triggered? Yes/No Explain who and why we alter the EWS parameters? Yes/No
Explain the importance of target saturations? Yes/No Explain how to assess the conscious level of a patient? Yes/No Print Name of Assessor: Print Name of Student: Assessor Signature: Student Signature: Date: Pulse Oximetry Assessment of Competency Date of Assessment Name of Student Undertaking Assessment Assessors’ Name Year/Semester Band/Designation Ward/Unit Can state 3 reasons for using pulse oximetry? Yes/No The procedure is explained fully to the patient and consent is obtained? Yes/No Can describe how a pulse oximetry works? Yes/No Equipment is checked and is in working order? Yes/No
Can discuss the correct sites for attaching the probe? Yes/No Suitable site is selected for attaching the probe, ensures that the site is clean and free from nail varnish? Yes/No Can describe how they would know when a pulse has been detected? Yes/No Records the result and documents accurately in the patient record, also recording if the patient is receiving oxygen therapy? Yes/No Can state what they would do if an abnormal reading was observed? Yes/No Reports any abnormal readings to the appropriate nursing/medical staff and documents action taken? Yes/No Is able to state what a normal reading would be? Yes/No When procedure is complete, ensures that the patient is left comfortable again? Yes/No Print Name of Assessor: Print Name of Student: Assessor Signature: Student Signature: Date: Pulse Assessment of Competency Date of Assessment Name of Student Assessors Name Year/Semester Band/Designation Ward/Unit Can define what a pulse is? Yes/No Consent is gained and the procedure explained fully to the patient? Yes/No Can state why we record the pulse rate? Yes/No Patient remains warm and comfortable? Yes/No
Can identify any five of the nine sites on the body where the pulse can be recorded? Yes/No Suitable site is selected (preferably the same site as previously). Yes/No Is able to state what a normal adult pulse rate is? Yes/No Gently press over chosen artery site with second or third finger? Yes/No Is able to state the meaning of Tachycardia and Bradycardia? Yes/No Pulse rate is counted for period of sixty seconds? Yes/No Can describe what is meant by sinus rhythum and fibrillation? Yes/No Pulse rate is recorded and documented? Yes/No Was the rhythm recorded e.g. regular, irregular? Yes/No Print Name of Assessor: Print Name of Student: Assessor Signature: Student Signature: Date: Respiration Assessment of Competency Date of Assessment Name of Student Assessors Name Year/Semester Band/Designation Ward/Unit Explain the term respiration? Yes/No Patient approached confidently and consent gained? Yes/No State what the average range of a Yes/No Patients’ chest can be easily observed? Yes/No
Can state two reasons why blood pressure is recorded Yes/No Consent is obtained Yes/No Is able to define Systolic blood Pressure Yes/No Procedure is explained Yes/No Is able to define Diastolic blood pressure Yes/No The patient is advised to rest for 3 minutes if supine or seated and for 1 minute if standing. Yes/No Describe how Systolic blood pressure is recorded Yes/No The equipment is checked to make sure is in working order. Yes/No Describe how Diastolic blood pressure is recorded Yes/No Clothing is removed positioned cuff that covers 80% of the circumference of upper arm. Yes/No Define Hyper and Hypotension When should blood pressure cuff be cleaned? Yes/No Yes/No The upper left arm is supported and positioned at heart level with the palm of the hand facing upwards Inflates the cuff until the radial pulse can no longer be felt. Yes/No Yes/No When should disposable cuffs be used? Yes/No The diaphragm of the stethoscope is placed over the pulse point of the brachial artery. Yes/No Deflates the cuff at 2mmHg per second per heartbeat Obtains and removes cuff correctly. Yes/No Yes/No
ICP – Intracranial Pressure AVM – Arterio-venous Malformation LP – Lumbar Puncture MR – Magnetic Resonance scan MRI – Magnetic Resonance Imaging Scan CT – Computerised Tamography USS – Ultra Sound Scan NAD – Nothing Abnormal Detected ROS – Removal of Sutures IVI – Intra Venous Infusion NBM – Nil by Mouth ABX – Antibiotics DN – District Nurse TTO – Tablet to Take Home HOB – Head of Bed MS – Multiple Sclerosis MND – Motor Neurone Disease Dress Code Guidelines regarding uniforms You are expected to wear the complete official uniform whilst you are attending clinical placements and during clinical skills sessions within the university. Uniforms must be clean and neat at all times. Cardigans if worn must be removed when in the clinical area.