0 pts
Skill is either done or not done
Skill is either done or not done. Must make sure to state to check pain level to get the point.
Requires nurse to use appropriate technique for handwashing and donning of clean gloves. Examiner will monitor for proper handwashing and gloving skills.
Skill is either completed or not completed. Rationale: Provides for privacy and ensures patient is not cold during the procedure.
Skill is either completed or not completed.
Requires psychomotor skills and critical thinking skills on the part of then nurse. Judgment by the nurse is indicated in observation of the wound for drainage, color, odor, etc. Nurse must remove soiled dressings in layers.
Skill is either done or not done. Dressings and gloves must both be removed.
Nurse must be able to discern "normal" from "abnormal" wound healing. Nurse must state that color, odor, and drainage will be inspected.
Nurse must be able to use appropriate technique to measure wound width, length, and depth.
Skill is either done or not done.
Requires nurse to open a sterile field. Requires dexterity and critical thought processes to ensure that items are placed on the sterile field without breaking sterile technique.
Must open bottle and check expiration date. Nurse must make sure to empty some solution into trash can if solution bottle is open.
Nurse must make sure to empty some solution into trash can if bottle is open. Nurse must ensure that the nonsterile bottle does not touch sterile field.
Requires dexterity and skill on the part of the nurse. Nurse must make sure that the outside part of the sterile glove package does not touch the sterile field.
Nurse must ensure that wound is cleaned from area of cleanest to area of dirtiest to prevent infectious agents on the skin from entering the wound. Requires psychomotor skills, dexterity, and critical thinking skills on the part of the nurse. Nurse must use appropriate psychomotor skills to pack wound and not break sterile technique. Nurse must be able to pack any tunnels with NuGauze or other packing as ordered.
Nurse must use sterile 4 x 4s to cover wet dressing. Sterile 4 x 4s are covered with an abdominal pad and secured with tape. Requires dexterity to manipulate dressings and tape.
Nurse must remove gloves without touching nurse's skin with soiled gloves.
Ask about pain level, place bed low position, place call light within reach.
Nurse must write nurse's note that addresses all interventions taken. Record wound appearance, client’s response, and characteristics of drainage. Nurse must state three findings that would prompt the nurse to call the doctor. This exercise would indicate the nurse's abilitiy to document appropriately and to make clinical judgments regarding the wound.