ARELLANO UNIVERSITY LEGARDA, MANILA College of Nursing

Station 5: Critical Care Management OBTAINING AN ECG Evaluation Tool Rating: ____________________ Students Name: ______________________________ Date: ______________________ Section & Group: _____________________________ Adviser: ___________________ Instructions: Check corresponding box if performed. Mark corresponding box with X if not performed. One check mark equals one point. X mark equals zero points. Add scores to get students raw score. Compute for students rating as shown below.

Station 5 Critical Care Management: Evaluation Tool. M.C. Agra, J.M. Garcia, F. Mercado Page 37

Criterion Measure

Weight

Score

Remarks

1. Places the electrocardiogram 1 (ECG) machine close to the patients bed and plug the power ON. 2. Performs hand washing. 2 Checks the patients identification 3. Sets up the machine to record a 1 12 lead ECG, explain the procedure to the client. Explain that the test records the hearts electrical activity and it may be repeated at a certain intervals. Also tell the patient that the test basically takes at least five (5) minutes 4. 5 Places patient in a supine position in the centre of the bed with his arms at his sides. Adjust the head of the bed if necessary to promote comfort. Exposes the patients arms and legs and drape appropriately. Encourages the patient to relax the arms and legs. If the bed is to narrow, place the patients hands under his buttocks to prevent muscles tension. Also, use this technique if the patient is shivering or trembling. Make sure the feet are not touching the bed board 5. Chooses flat fleshy areas to 1 place the electrodes. 6. Cleans excess oil or other 1 substances from the skin. If an area is excessively hairy, clip it. 7. Applies the electrode paste, gel, 1 or the disposable electrodes to the patients wrist and to the medial aspects of his ankles. If using or gel, rub it into Station 5 paste Critical Care Management: Evaluation Tool. M.C. Agra, J.M. Garcia, F. Mercado 38 the skin. If using disposable electrodes, peel of the contact paper and apply the electrodes

Page

Computation for Student Rating:

Raw Score Perfect Score

X 55 + 45

Students Signature and Date: ______________________________

Signature of Preceptor and Date: _____________________ ARELLANO UNIVERSITY LEGARDA, MANILA College of Nursing

Station 5: Critical Care Management PERFORMING CARDIOPULMONARY RESUSCITATION Evaluation Tool Rating: ____________________ Students Name: ______________________________ Date: ______________________ Section & Group: _____________________________ Adviser: ___________________ Instructions: Check corresponding box if performed. Mark corresponding box with X if not performed. One check mark equals one point. X mark equals zero points. Add scores to get students raw score. Compute for students rating as shown below.

Station 5 Critical Care Management: Evaluation Tool. M.C. Agra, J.M. Garcia, F. Mercado Page 39

Criterion Measure 1. Determines if the scene is safe. Assess for responsiveness then calls for help 2. Maintains in - line stabilization of the cervical spine 3. Asks questions by letting state his/her name or ask if his ok 4. If the patient is unresponsive, opens the airway using a head tilt / chin lift maneuver. If trauma is suspected, use the jaw thrust without head tilt maneuver 5. Looks, Listens, and Feels if breathing is absent deliver two (2) breaths. Each breaths should be deliver in one(1) second 6. Checks for the presence of pulse and other signs of circulation up to ten (10) seconds 7. Performs CPR until an AED monitor is available, if there is no pulse 8. For adults the ratio of chest compressions to ventilations is 30 2 for both one rescuer and two rescuer CPR. An adult should be given 10 to 12 ventilations per minute (1 ventilation every 5 to 6 seconds) 9. If two or more rescuers are present, the rescuers giving chest compression should switch roles with the rescuers giving ventilations about every 2 minutes. Try to accomplish the switch in less than 5 seconds. 10. Reassess breathing of patient until the medical help arrives 11. Records the time and document the unresponsiveness of the client. Total Perfect Score = 15

Weight 1 1 1 2

Score

Remarks

1 1 1

1 1 Students Raw Score =

Station 5 Critical Care Management: Evaluation Tool. M.C. Agra, J.M. Garcia, F. Mercado Page 40

Computation for Student Rating:

Raw Score Perfect Score

X 55 + 45

Students Signature and Date: ______________________________

Signature of Preceptor and Date: ____________________________

ARELLANO UNIVERSITY LEGARDA, MANILA College of Nursing

Station 5: Critical Care Management APPLYING A CARDIAC MONITOR Evaluation Tool Rating: ____________________ Students Name: ______________________________ Date: ______________________ Section & Group: _____________________________ Adviser: ___________________ Instructions: Check corresponding box if performed. Mark corresponding box with X if not performed. One check mark equals one point. X mark equals zero points. Add scores to get students raw score. Compute for students rating as shown below.

Station 5 Critical Care Management: Evaluation Tool. M.C. Agra, J.M. Garcia, F. Mercado Page 41

Criterion Measure 1. Introduces self. 2. Completes all the equipment needed close to the client bed. Turns ON the machine. Secure all the cables. Explain the procedure to the patient and provide privacy. 3. Performs hand washing 4. Exposes chest and determines electrode positions on the patients chest, based on which system and lead being used. Clean the area with an alcohol pad and dry it completely. 5. Removes the backing from the pre gelled electrode. Checks the gel for moistness. If the gel is dry, discard it and replace it with a fresh electrode. 6. When all the electrodes are in place, checks waveform clarity, position and size. 7. Sets the upper and lower limits of the heart rate alarm, based on unit policy. Turn alarm ON 8. Labels the strip with the patients name and room number, date, time, and rhythm identification. 9. Records the date and time that monitoring lead used in the medical record. Documents a rhythm strip at least every eight (8) hours. Total Perfect Score = 13

Weight 1 4

Score

Remarks

1 2

Students Raw Score =

Computation for Student Rating:

Station 5 Critical Care Management: Evaluation Tool. M.C. Agra, J.M. Garcia, F. Mercado Page 42

Raw Score Perfect Score

X 55 + 45

Students Signature and Date: ______________________________

Signature of Preceptor and Date: ____________________________

ARELLANO UNIVERSITY LEGARDA, MANILA College of Nursing

Station 5: Critical Care Management USE OF MANUAL DEFIBRILLATOR Evaluation Tool Rating: ____________________ Students Name: ______________________________ Date: ______________________ Section & Group: _____________________________ Adviser: ___________________ Instructions: Check corresponding box if performed. Mark corresponding box with X if not performed. One check mark equals one point. X mark equals zero points. Add scores to get students raw score. Compute for students rating as shown below.

Station 5 Critical Care Management: Evaluation Tool. M.C. Agra, J.M. Garcia, F. Mercado Page 43

Criterion Measure A. PREPARATORY PHASE: 1. Analyzes rhythm on cardiac monitor is an indication for defibrillation Identifies VT o VF Checks for pulse 2. Readies the defibrillator Switches on the main power Turns the synchronize switch off 3. Lubricates the paddles with conductive gel and rubs them together. 4. Charges the defibrillator and announces the correct energy requirement based on clinical judgement and manufacturers recommendation.

Weight 2

Score

Remarks

B. PERFORMANCE PHASE: 3 5. Ensures correct delivery of electrical current Places paddles on proper anatomical location Sternal 2nd intercostals space right sternal border Apical 5th intercostals space midaxillary line Applies firm pressure on paddles against the chest to overcome transthoracic impedance 6. Confirms ECG rhythm and 2 checks for pulse to ensure that defibrillation is indicated Identifies VT or VF Asks colleague to check for pulse 7. Clears the area to check that 4 there is no one touching the patient by shouting the following directives: I am going to shock the patient on three! Im clear Are you clear? Is everybody clear? 8. Just before firing the 2 defibrillator, announces Station 5 Critical Care Management: Evaluation Tool. M.C. Agra, J.M. Garcia, F. Mercado 44Delivering shock! 9. Announces Shock delivered! after delivery of shocks

Page

Computation for Student Rating:

Raw Score Perfect Score

X 55 + 45

Students Signature and Date: ______________________________

Signature of Preceptor and Date: ____________________________

Station 5 Critical Care Management: Evaluation Tool. M.C. Agra, J.M. Garcia, F. Mercado Page 45

ARELLANO UNIVERSITY LEGARDA, MANILA College of Nursing

Station 5: Critical Care Management PERFORMING BASIC CODE MANAGEMENT Evaluation Tool Rating: ____________________ Students Name: ______________________________ Date: ______________________ Section & Group: _____________________________ Adviser: ___________________ Instructions: Check corresponding box if performed. Mark corresponding box with X if not performed. One check mark equals one point. X mark equals zero points. Add scores to get students raw score. Compute for students rating as shown below. Criterion Measure 1. Identifies client introduces self. Weight 1 1 Score Remarks

and

2. Remains in the area to offer information related to the patients prior to the code. 3. Reviews order for specific intervention instruction 4. Prepares crash cart. 5. The code teams consist of recorder, for documentation, physician who gives the order and runs the code, nurse who prepares medication. Anesthesiologists and respiratory therapist for airway management. 6. Removes other client and

1 1 1

Station 5 Critical Care Management: Evaluation Tool. M.C. Agra, J.M. Garcia, F. Mercado Page 46

extraneous health care team members from the room. 7. Checks the laryngoscope. 8. Gathers proper equipment from the crash cart and establish a suction set- up. 9. Assesses client patent airway breathing and circulation. 10. Provides privacy for the client. 1 1

1 1 1

11. Explains the purpose and describes detail for basic code management. 12. Performs hand hygiene.

Total Perfect Score = 12

Students Raw Score =

Computation for Student Rating:

Raw Score Perfect Score

X 55 + 45

Students Signature and Date: ______________________________

Signature of Preceptor and Date: ____________________________

Station 5 Critical Care Management: Evaluation Tool. M.C. Agra, J.M. Garcia, F. Mercado Page 47