bsc (hons) nursing (adult)

W.Yorkshire Ongoing Record of Achievement and Skills Log for Pre-Registration Nursing (Leeds) 2017/18

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BSc (Hons) Nursing

(Adult)

Ongoing Achievement Record

and Skills Log

STUDENT NAME:

UNIVERSITY LECTURER:

STUDENT ID NUMBER

UNIVERSITY EMAIL:

UNIVERSITY EMAIL:

TELEPHONE CONTACT:

TELEPHONE CONTACT:

COURSE START DATE:

EXPECTED COMPLETION DATE:

This document is ESSENTIAL for the Student Nurse to evidence learning & achievement

If found please return to: University of Leeds Leeds LS2 9JT


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This Ongoing Achievement Record and Skills Log document has been developed to facilitate the requirements of the NMC from September 2007. These Standards have outcomes for mentors, practice teachers and teachers who are supporting you, with mandatory requirements for each part of the register: This record is a sister document to the Practice Assessment Document, where your practice learning experiences are jointly documented. Summary of main points of the Standards to support learning and assessment in practice (NMC 2008)

Students on NMC approved pre-registration nursing education programmes, leading to registration on the nurses’ part of the register, must be supported and assessed by and appropriately qualified professional. From September 2007 for the year 3 final placement a sign-off mentor, who has met additional criteria (paragraph 2.1.3), must make the final assessment of practice and confirm that the required proficiencies for entry to the register have been achieved (paragraph 3.2.6). From September 2007 students on NMC approved specialist practice programmes leading to a recordable qualification on the nurses’ part of the register must be supported and assessed by sign-off mentors who have met additional criteria (paragraph 2.1.3), or practice teachers where this is a requirement by commissioners. The sign-off mentor must make the final assessment of practice and confirm that the required proficiencies for recording a specialist practice qualification have been achieved (paragraph 3.2.6).

YOU MUST:

[1] Maintain and keep up to date the content of this ongoing ‘Ongoing achievement record and skills log’

[2] Share this document with your mentor at all your initial interviews.

[3] Use this document to record each final interview with your mentor and record achievement of skills within the skills log section

[4] Meet with your personal lecturer after each placement to discuss your progress (practice and theory). Personal Lecturers must participate and sign this document to say that they have met with you.

[5] Present this completed document to your final placement mentor (the ‘Sign off’ mentor) at the beginning of the placement so that an informed decision can be made as to whether they will ‘Sign off’ or not ‘Sign off’ your practice

[6] Submit this document along with the Assessment in Practice Document.

[7] REMEMBER: it is your responsibility to keep this document safe. Your sign off mentor will need it to enable them to be satisfied that you are competent to practice. If it is lost, your registration may be delayed


3

PLACEMENT 1 STAGE 1


4

Placement 1 - Stage 1 Professional Behaviour in Practice Final interview stage

Your mentor must complete this page fully in all aspects before undertaking the Final Interview, completing the final interview mentor feedback page. NB Failure on ANY element of these behaviours at this interview stage will result in a failure of placement

Stage 1, Placement 1 Satisfactory

Unsatisfactory

Professional Attitude in a Practice Setting - Final

Interview

Practice consistently

reflects professional

values & attitudes

Practice mainly reflects

professional values &

attitudes

(development plan must

be agreed and recorded)

Practice consistently reflects

unprofessional values &

attitudes

Mentor to sign their full signature in the box corresponding to their assessment of the student’s professional attitude

1. Make the care of people their first concern, treating them as individuals and respecting their dignity

The following activities reflect this principle of care and my assessment of the student’s professional attitudes and values in relation to these is:

communication with people (patients, their

carers/family and colleagues) including listening.

maintaining people’s privacy and dignity

being respectful and courteous and non-

judgmental

using their skills of empathy and is sensitive to the

needs of others

2. Work with others to protect and promote the health and wellbeing of those in their care, their families, carers and the wider community


maintaining confidentiality

maintaining records

using problems solving skills

recognising their own limitations and seeking

support when unsure of what to do

maintaining professional boundaries

3. Be open and honest, act with integrity and uphold the reputation of your profession


working alongside other members of the health

care team

taking responsibility for making the most out of

their learning opportunities

managing feedback about their learning

using reflection as a means of identifying their

own learning needs and limitations

timekeeping is satisfactory and they communicate

appropriately is unable to attend placement

complying with hygiene, uniform and dress codes.

* Reference to NMC Code (2015) may assist your decision making about what is regarded as ‘satisfactory professional conduct’ from a student. NB Any professional behaviour or attitude assessed by your mentor as failing to reflect appropriate professional standards, may be subject to further investigation by the University and/or relevant Trust/Clinical Placement as well as requiring an action plan

Date completed ……………… Mentor signature………………………....Student signature………………………….


5

Placement 1 - Stage 1

Final Interview

This interview gives you and your mentor an opportunity to reflect on the experience and for a progress assessment to be completed. There should be no ‘surprises’ at this time so you should be aware of your progress. It should be completed within the last week of the placement by the mentor.

NB - Should there be an expectation that the student is going to fail to progress, a member of the students’ academic team must be present at this interview.

STUDENT self evaluation

You may wish to consider the following areas: how you have made links between theory and practice, multidisciplinary/interagency working, communication skills, nursing skills

Strengths of my practice

Aspects of my practice I need to develop and how I intend to improve these


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Mentor’s Feedback; Is the student working at the level expected for this stage of training? Yes / No For the University of Bradford and Huddersfield students only: have you graded their practice? Yes / No

Strengths of the students practice

Aspects of practice the student needs to develop

Ongoing Achievement Record and Skills Log reviewed? Yes / No

Practice Standards elements reviewed? Yes / No

Professional Behaviours completed? Yes / No

Testimonies / Service user feedback reviewed? Yes / No / Not applicable

Have any concerns or potential concerns been raised at this point? Yes / No

If yes, has the academic tutor/ link lecturer been informed? Yes / No

Student Signature

Date

Mentor Signature

Date

Practice Evaluation completed (www.healthcareplacements.co.uk) certificate date


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Placement 1- Stage 1

STATEMENT OF PLACEMENT ACHIEVEMENT (mentors please note this is a duplicate of the statement in the practice assessment document

and must be completed here as well)

NAME OF STUDENT (please print): ………………………………………….………….. NAME OF PLACEMENT …….…………………………………………………….………… ORGANISATION (e.g. name of NHS Trust) ……………………………………………... NAME OF MENTOR (please print): ………………………………………………………..

PASS (the practice standards for the stage have been achieved) Based on the evidence documented during this placement and summarised on the final interview comment sheet, I confirm that the student has PASSED the placement and is ready to progress to the next stage.

Signature of Mentor:

Date:

Signature of Student:

Date:

FAIL (some of the practice elements haven’t been achieved'. N.B. practice elements decided in this way should be addressed as a priority in the next placement) Based on the evidence documented on this student’s performance during this placement and summarised on the final interview sheet, I confirm that the student has FAILED on the placement. If the student has attempted but been unsuccessful in achieving any practice standard or skill then they CANNOT be deemed to have passed the placement. The student’s progress has been discussed and an ACTION PLAN will be developed with the appropriate lecturer and used in the next placement.

Signature of Mentor: Date:

Signature of Student: Date:


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PLACEMENT 1

STAGE 2


9

Professional Behaviour in Practice Final interview stage


Stage 2, Placement 1 Satisfactory

Unsatisfactory


Interview



values & attitudes



attitudes





attitudes


2. Make the care of people their first concern, treating them as individuals and respecting their dignity






judgmental


needs of others




maintaining records





4. Be open and honest, act with integrity and uphold the reputation of your profession The following activities reflect this principle of care and my assessment of the student’s professional attitudes and values in relation to these is:


care team












10


Final Interview








11











Student Signature

Date

Mentor Signature

Date



12


STATEMENT OF PLACEMENT ACHIEVEMENT

(mentors please note this is a duplicate of the statement in the practice assessment document and must be completed here as well)


PASS (the practice standards are being achieved)

Based on the evidence documented during this placement and summarised on the final interview comment sheet, I confirm that the student has PASSED the placement.


Date:


Date:

FAIL (some of the practice elements haven’t been achieved'. N.B. practice elements decided in this

way should be addressed as a priority in the next placement)

Based on the evidence documented on this student’s performance during this placement and summarised on the final interview sheet, I confirm that the student has FAILED on the placement. If the student has attempted but been unsuccessful in achieving any practice standard or skill then they CANNOT be deemed to have passed the placement. The student’s progress has been discussed and an ACTION PLAN will be developed with the appropriate lecturer and used in the next placement.




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FINAL PLACEMENT

STAGE 2


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Final Placement - Stage 2 Professional Behaviour in Practice Final interview stage


Stage 2, Final Placement Satisfactory

Unsatisfactory


Interview



values & attitudes



attitudes





attitudes


1Make the care of people their first concern, treating them as individuals and respecting their dignity






judgmental


needs of others

2.Work with others to protect and promote the health and wellbeing of those in their care, their families, carers and the wider community



maintaining records





3.Be open and honest, act with integrity and uphold the reputation of your profession The following activities reflect this principle of care and my assessment of the student’s professional attitudes and values in relation to these is:


care team











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Date completed ……………… Mentor signature………………………....Student signature…………………………. Final Placement - Stage 2

Final Interview This interview gives you and your mentor an opportunity to reflect on the experience and for a progress assessment to be completed. There should be no ‘surprises’ at this time so you should be aware of your progress. It should be completed within the last week of the placement by the mentor.







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Final Placement - Stage 2










Student Signature

Date

Mentor Signature

Date



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STATEMENT OF PLACEMENT ACHIEVEMENT (mentors please note this is a duplicate of the statement in the practice assessment document

and must be completed here as well)


PASS (the practice standards for the stage have been achieved) Based on the evidence documented during this placement and summarised on the final interview comment sheet, I confirm that the student has PASSED the placement and is ready to progress to the next stage.


Date:


Date:

FAIL (some of the practice elements haven’t been achieved'. N.B. practice elements decided in this way should be addressed as a priority in the next placement) Based on the evidence documented on this student’s performance during this placement and summarised on the final interview sheet, I confirm that the student has FAILED on the placement. If the student has attempted but been unsuccessful in achieving any practice standard or skill then they CANNOT be deemed to have passed the placement. The student’s progress has been discussed and an ACTION PLAN will be developed with the appropriate lecturer and used in the next placement.




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PLACEMENT 1 STAGE 3


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Placement 1 - Stage 3 Professional Behaviour in Practice Final interview stage


Satisfactory

Unsatisfactory


Interview


professional values & attitudes

Practice consistently reflects unprofessional

values & attitudes (development plan must

be agreed & recorded)


1 Make the care of people their first concern, treating them as individuals and respecting their dignity The following activities reflect this principle of care and my assessment of the student’s professional attitudes and values in relation to these is:





judgmental


needs of others




maintaining records







care team












20

Placement 1 - Stage 3 Final Interview








21











Student Signature

Date

Mentor Signature

Date



22








Date:


Date:







23

FINAL PLACEMENT

STAGE 3


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Record of Weekly Review Meetings.

Date Record of Key Issues – may also form on-going development plan Your Initials

Sign off Mentor Initials


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Final Placement - Stage 3 Professional Behaviour in Practice Final interview stage


Satisfactory

Unsatisfactory

Professional Attitude in a Practice Setting -

Final Interview




values & attitudes (development plan must be

agreed & recorded)




carers/family and colleagues) including

listening.



judgmental

using their skills of empathy and is sensitive to

the needs of others




maintaining records







care team






timekeeping is satisfactory and they

communicate appropriately is unable to attend

placement

complying with hygiene, uniform and dress

codes.




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Final Placement - Stage 3 Final Interview








27











Student Signature

Date

Mentor Signature

Date



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PASS (the practice standards have been achieved) Based on the evidence documented during this placement and summarised on the final interview comment sheet, I confirm that the student has PASSED the placement and is ready to progress to registration.


Date:


Date:







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Statement of overall practice achievement for Programme Declaration of achievement of NMC requirements for eligibility to apply for registration on Part 1 of the NMC register, Registered Nurse

Student’s FULL Name: Intake:

Field/Pathway: Month & Year of Completion:

/20

Declaration by Sign off Mentor/Practice Teacher

I have reviewed the Student’s Ongoing Record of Achievement and Skills Workbook and the current practice placement evidence (final placement document) and can confirm that I am on the same Part and Branch of the NMC register as the student and have:

worked with the student for 40% of time on placement.

had time to reflect, give feedback and also kept a record of the student’s achievement,

assessed the student on his/her final placement and I sign to confirm that to the best of my knowledge this student is a capable, safe and effective practitioner, who has attained the practice elements for eligibility to apply for registration with the NMC.

Name of Sign Off Mentor/ Practice Teacher (Please print)

Date: / / Signature of Sign Off Mentor/ Practice Teacher

Declaration by Designated Academic Representative:

I have reviewed the student’s:-

Ongoing Record of Achievement and Skills Workbook;

Self Declaration of Good Health and Character and can confirm to the best of my knowledge that:-

the NMC practice elements have been signed off by a Sign-off Mentor/Practice Teacher

all NMC theory and practice requirements have been successfully completed

Name of Designated University Representative:

Date: / /

Signature of University Lecturer:

Declaration by Lead-Pre Registration Nursing:

I confirm that to the best of my knowledge, all NMC requirements for registration have been successfully met

Name of Lead-Pre Registration Nursing:

Date: / /

Signature of Lead-Pre Registration Nursing:


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Patient and Service User Feedback


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Patient/Service User Feedback Form

Mentors should obtain consent from patients/service users who should feel able to decline to participate.

We would like to hear your views about the way the student nurse has looked after you.

Your feedback will help the student nurse’s learning

The feedback you give will not change the way you are looked after

Tick if you are: The Patient/Service User Carer/Relative

How happy were you with the way the student nurse:

Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?

Listened to your needs?

Understood the way you felt?

Talked to you?

Showed you respect?

What did the student nurse do well?

What could the student nurse have done differently?

Mentor signature: Date: Student signature: Date:

Thank you for your help

This form has been designed by Service Users, and with thanks from the Pan London PAD group.

http://www.iconarchive.com/show/ios7v2-icons-by-visualpharm/Emoticons-Lol-icon.html

http://www.iconarchive.com/show/ios7v2-icons-by-visualpharm/Emoticons-Happy-icon.html

http://www.iconarchive.com/show/ios7v2-icons-by-visualpharm/Emoticons-Question-icon.html

http://www.iconarchive.com/show/ios7v2-icons-by-visualpharm/Emoticons-Sad-icon.html

http://www.iconarchive.com/show/ios7v2-icons-by-visualpharm/Emoticons-Cry-icon.html


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Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












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Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












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Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












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Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












36








Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












37








Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












38








Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












39








Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












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Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












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Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












42








Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












43








Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












44








Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












45








Very Happy

Happy

I’m not sure

Unhappy

Very Unhappy

Cared for you?



Talked to you?

Showed you respect?












46

Testimony

These pages provide an opportunity for any person (including service users and carers, other professional) who you have worked with to comment on your practice. Permission MUST be sought from mentor/ qualified member of staff before seeking testimony from any service user or carer. Service users and carers should NOT sign their entries (for reasons of confidentiality) Mentors should countersign these entries. Entries may be dictated if appropriate. You might want to consider the professionalism of the student, their communication skills, were you treated with dignity & respect, their ability to carry out your cares etc.

Date Stage/ placement in programme (e.g. stage 1, placement 2)

Print Name, Sign & give your role

Student to identify which practice standards these comments can be mapped to.


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Testimony






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Testimony






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Testimony






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Testimony

These pages provide an opportunity for any person (including service users and carers, your peers, another professional) who you have worked with to comment on your practice. Permission MUST be sought from mentor/ qualified member of staff before seeking testimony from any service user or carer. Service users and carers should NOT sign their entries (for reasons of confidentiality) Mentors should countersign these entries. Entries may be dictated if appropriate. You might want to consider the professionalism of the student, their communication skills, were you treated with dignity & respect, their ability to carry out your cares etc.





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Testimony






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Testimony






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Testimony






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Testimony






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Testimony






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Testimony






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Testimony






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Testimony






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Testimony






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Testimony






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Testimony






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Testimony






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Testimony






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SKILLS LOG


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Skills Log

Introduction Attainment of the professional skills outlined in this Skills Log (SL) are essential for the development of your nursing competence and the assessment of your progress in practice. Each skill in this SL has been identified as important by both clinical practitioners and lecturers, and will help you demonstrate that you have achieved the NMC (2010) Standards of Competency for entry to the Register. You should however remember at all times when you have been deemed to have achieved safe performance of a skill you will still always work under the supervision of a First level Nurse/Mentor. KNOWLEDGE OF COMMON MEDICATIONS HAS BEEN INCLUDED IN THE SL.

How to Use This Log book 1. It is a requirement of all nursing programmes that the Essential Skills in this logbook must be met

by the end of your programme in order to Register.

2. You may observe and practice with guidance the skills in this SL as many times as you wish. Remember - repetition and practising of skills with formative feedback is a useful aid to developing competence.

3. A Registered Practitioner (RP)/Mentor must sign you have been TAUGHT THE SKILL.

4. You should take every opportunity to practice the skill as many times as you feel necessary before you and the RP/Mentor agree you are ready to assess the skill as being achieved.

5. RP / Mentors who teach and assess skills must complete the table on page 44.

6. ‘Skill Achieved’ is defined as consistently undertaking a skill in a safe and smooth practice based activity with no need for RP/Mentor intervention. You must also ensure patient/client comfort and should be able to articulate the rationale for the skill.

7. You must be proactive in seeking learning opportunities in order to reach the ‘skill-achieved’ level in each essential skill, working in partnership with practitioners in practice placement areas. The desirable skills [i.e. those in italics] should be attained at the ‘skill achieved’ level if the opportunity is available. In each category there is a space for additional skills that you have observed, practised and/or achieved.

8. REMEMBER - you must never work beyond your competence. A RP/Mentor should guide you on your practice placement as to the appropriateness of observing and practicing a clinical skill.

9. If you experience difficulty in attaining the 'skill achieved' level in an essential skill you should liaise with your RP/Mentor and where appropriate with your named university lecturer/link lecturer, in order to give you every opportunity to attain ALL essential skills by the end of the specified stage and no later than the end of the programme

10. During your placement you must retain this SL and make it available to your RP/Mentors and when required by your programme to your named university lecturer/link lecturer. Successful completion of the Programme can only be ratified when the essential skills (together with the assessment in practice documentation) have been successfully attained at the 'skill achieved' level.

11. You MUST submit your SL on the dates specified by your university programme. The SL will be retained by the University; you may photocopy sections for you Personal Development Profile PRIOR to submission.

12. REMEMBER; once a skill has been achieved, the expectation is that you will continue to perform that skill to a competent standard.


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Flow Chart

Skill Taught either in University OR in Practice. 'Teacher' Dates and Signs SW

Skill Observed

Skill Practiced

Student/Mentor Identifies Student Ready To Be Assessed

Registered Practitioner/Mentor Assesses Student's Performance/Knowledge/Understanding of Skill.

If Student ‘Achieves Skill’ – RP/Mentor Dates and Signs SW

All skills must be completed by the end of the programme.

Skills Logbook MUST be submitted as per specific university programme requirements


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Record of RP/Mentor’s Signature/Initials who have taught and/or assessed the student.

Registered Practitioner / Mentor [ Full Name]

Signature Initials Dates Placement


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70





71





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SKILLS In Order to have the following skills signed off as ‘skill achieved’ you must

Identify that the skill is appropriate for that stage of the programme (identified by the non shaded boxes)

Have been taught, observed and practiced the skill whilst ensuring the individual’s comfort, safety, dignity and privacy is maintained throughout the procedure, respecting individuality, culture, age and choice.

Perform the skill as a safe and smooth practice based activity with no need for RP/Mentor intervention whilst articulating the rationale for the skill.

Demonstrate effective communication skills throughout the performance of the skill Complete all record keeping for the identified skill. At all times adhere to the relevant local Organisational policies and procedures and NMC Guidelines Once a skill has been achieved, the expectation is that you will continue to perform that skill to a competent standard in all other placement areas PLEASE DO NOT SIGN THE SHADED SKILLS as the shading indicates the stage at which students are deemed to have the underpinning knowledge needed to complete the whole skill, rather than perform the task. They should be working towards all skills whenever possible

Mandatory training

You will undertake training and updates in Moving and handling (M&H), BLS and managing conflict sessions in order for you to undertake your role as a student nurse and for no other purpose. Your attendance at these sessions will be recorded via registers. These sessions are mandatory and failure to attend your allocated session will mean you are not able to access your placement. In addition you will need to undertake the on line Information Governance package on an annual basis. You need to print off two copies of your certificate of completion, one for your records and one to be submitted to PPU.


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SKILLS Essential skills in BOLD Desirable skills in italic’s. Do not sign in shaded

boxes All essential skills must be

completed by end of stage 3

University or Practice

Registered Nurse:

Registered Nurse:

Registered Nurse:

Skill Taught Skill Achieved Stage 1

Skill Achieved Stage 2


Date Signed Date Signed

Date Signed

Date Signed

On the Bed

Bed to Chair/Chair to bed

Trolley to Bed/Bed to Trolley

Use of equipment Specify x2:

1]

2]

After a Fall or From Floor

Postural management

BASIC LIFE SUPPORT

Emergency Equipment Checks (Stage 1) O2 & Suction



First aid

Oral/nasal suctioning

Participates in BLS

Participates in complex life support

Participates & supports individuals in emergency first aid situation

Participate in Basic Airway Support Management

Attends managing conflict sessions/updates as per HEI Specify stage

APPLYING INFECTION CONTROL PROCEDURES USING PERSONAL PROTECTIVE EQUIPMENT (PPE)

Hand washing

Uses PPE appropriately

Food hygiene/handling

Sterilising feeding equipment

Bed making – vacant

Bed making - Occupied

Cleans commode as per Trust policy


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SKILLS Essential skills in BOLD Desirable skills in italic’s.

Do not sign in shaded area. All essential skills must be



Registered Nurse:

Registered Nurse:

Registered Nurse:




Date Signed Date

Signed Date

Signed

Date

Signed

Aseptic technique: surgical wounds

Aseptic technique: non-surgical wounds

Clean technique

Isolation barrier nursing

Handling & Disposal of:

Clinical Waste

Sharps

Body fluids: blood/vomit/faeces

Dealing with spillage

Bed Linen

Demonstrate effective communication skills; with service users and carers, families and members of multi-agency teams, using a Person-Centred approach and demonstrating self-awareness in challenging situations. To include

verbal, non-verbal and written forms of communication

Care of all patients

Demonstrates listening/attending skills

Client/Adult

Family/Carers

Relatives/Extended family

Patients/relatives who are unable to understand English

Refers to /uses translation service

Adapts to/responds to communication difficulties i.e. culture, language, hearing, speech

The multi-disciplinary team

Message taking & reporting

Manages electronic records as per policy

Hand- over information -single patient

Demonstrate self-awareness in challenging situations


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Registered Nurse:

Registered Nurse:

Registered Nurse:




Date Signed Date Signed Date Signed Date Signed

Care of patient with complex communication needs

Hand-over information a group of patients

Breaking bad news

PARTICIPATE IN THE PROCESS OF NURSING CARE

from first point of contact to transition or discharge


Emergency/acute admission

Arranged admission

Assessment of an adult and completion of appropriate documentation

Assessment Tools—Specify X2

Tool 1

Tool 2

Pain assessment: specify tool

Tool 1

Tool 2

Pain Control – Differentiates between appropriate Pharmacological intervention

Specify:

Pain Control - Non-pharmacological intervention

Specify:

UNDERTAKE ASPECTS OF PRACTICAL CARE FOR INDIVIDUALS respecting their individuality, age and developmental needs

Care of all patients - Vital signs. Recording and Reporting

Blood pressure: manual

Blood pressure –electronic

Pulse – radial

Pulse – Brachial

Pulse – Carotid


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Registered Nurse:

Registered Nurse:

Registered Nurse:




Date Signed Date

Signed Date

Signed

Date

Signed

Pulse - lower limb

Take Doppler

Temperature-orally

Temperature – Axilla

Temperature -Electronically - state type used:

Respiration recording

Blood Glucose Monitoring Tool x 1:

Maintain Fluid Balance Chart

Peak flow measurement

Measurements:

Weight

Body Mass Index

Assessment of capillary refill

Care of the Complex Patient

Assessment of respiratory distress i.e. nasal flaring, noise, effort, recession

Oxygen saturation monitoring

Neurological assessment

Glasgow coma scale

Care of central venous line

Nursing Process

Planning care for individual

Evaluating care for individual

Prioritising care for individual

Documents care accurately

Documents accidents according to Trust policy

Documents complaints according to Trust policy

Transfer of Information/Discharge planning


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Registered Nurse:

Registered Nurse:

Registered Nurse:




Date Signed Date

Signed Date

Signed

Date

Signed

HYGIENE AND TOILET NEEDS


Care of skin-hygiene

Eye care

Care of mouth and teeth

Bathing an adult in bed

Assisted hygiene

Shaving

Assisting with toilet needs:

Toilet

Bed pan/urinary bottle

Care of a Complex Patient

Pressure area care

Care of an adult with complex elimination needs: state example……………

Catheter care: indwelling urinary catheter

Catheter care: intermittent urinary catheter

Urethral catheterisation

Care of Stoma

HYDRATION / NUTRITIONAL NEEDS


Assess nutritional status State tool …………..

Drinking

Management of Enteral Feeding

Eg Naso gastric/PEG feeds

Insert a naso gastric tube

Records , report, fluid balance charts

Accurately Interprets fluid balance charts


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Registered Nurse:

Registered Nurse:

Registered Nurse:




Date Signed Date

Signed Date

Signed

Date

Signed

Care of complex patient

Oral feeding of an adult with complex needs. Specify .e. Gastrostomy/PEG feeds

1)

2)

Use of feed pump

Parenteral feeding

Assessment of hydration status (input/output)

Intravenous infusion: care of the infusion site

Care of peripheral line

Care of giving set

Use of volumetric pump

Use of syringe driver

Care of Blood transfusion

In liaison with a registered midwife provides essential advice and support to mothers who are breast feeding

SPECIMENS: COLLECTING, RECORDING, REPORTING


Urine collection: 2 methods

Method 1

Method 2

Faecal/stool collection

Throat swab

Wound swab

Accurately interprets results from specimens Specify 2:

1)

2)

Obtain a sputum specimen

Observation of Sputum


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SKILLS Essential skills in BOLD

Desirable skills in italic’s. Do not sign in shaded area.

All essential skills must be completed by end of stage 3


Registered Nurse:

Registered Nurse:

Registered Nurse:




Date Signed Date

Signed Date

Signed

Date

Signed

Care of patient: pre- procedure (diagnostic and/or surgical)

Routine pre procedure care

Preparation of an adult taking into account individual needs

Preparation of area/ equipment

Anti-embolic stockings - Application

Anti-embolic stockings – Patient advice and care

Emergency pre-procedure care (complex patient/admission)

Care of patient: post- procedure (diagnostic and/or surgical)

Care of and adult with altered levels of consciousness

Perform post operative observations: specify

Assessment of wound post operatively

Wound care: assess plan implement and evaluate wound/wound healing

Removal of drains

Removal of skin closures. specify

Safeguarding

Able to use a range of risk assessment tools eg

Other please specify

Falls

NEWS

Pressure area care


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Registered Nurse:

Registered Nurse:

Registered Nurse:




Date Signed Date

Signed Date

Signed

Date

Signed

EXPRESSING SEXUALITY

Respects dignity and privacy

Selects age appropriate clothing

Provides age appropriate care i.e. management of menstruation.

APPRECIATING DIVERSITY

Including:

Spirituality/Religion

Family dynamics

Culture

END OF LIFE/DYING/LOSS

Demonstrate the ability to support an adult and family at a time of loss

Perform last offices

Demonstrate an understanding of procedures following the death of an adult and complete relevant documentation

Provides ongoing support to the family that is sensitive to family, cultural and religious need.

MANAGEMENT SKILLS Prioritising care of individual patient

Prioritising care of a group of patients

Participates in Discharge planning


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Registered Nurse:

Registered Nurse:

Registered Nurse:




Date Signed Date

Signed Date

Signed

Date

Signed

Undertakes lead in co-ordinating care for group of adults (or caseload) for a shift On at least 4 occasions specify role ……….

1)

2)

3)

4)

Able to delegate workload appropriately

Manages change effectively

Identifies learning needs within team, plans & undertakes teaching activity to meet need (i.e. one-to-one, group)

Undertakes referrals to other professional/agencies as appropriate

HEALTH PROMOTION

Addresses health promotion Specify x 3 Issues:

1]

2]

3]

Additional Skills Undertaken In The Clinical Area/University – BUT NOT LISTED IN THE LOGBOOK - Please Specify


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Registered Nurse:

Registered Nurse:

Registered Nurse:




Date Signed Date

Signed Date

Signed

Date

Signed

Safely administer Medicines under the supervision of a Registered Nurse To include: calculating dose, actual giving, performing safety checks, preparation of drug for administration,

monitoring dosage & side effects, completing documentation & storage. Calculate Drug Dosage

Follows storage of medicines policy

Oral Medication

Sub-Cutaneous Injection

Intramuscular Injection

Inhaled Medication

Nebulised Medication

Enteral Medication

Transdermal Medication

Eye-Drops

Rectal Medication

Topical Medication

Undertakes Management of Medication for an individual patient for a shift (Stage 2)

Undertakes Management of Medications for a group of patients for a shift (Stage 3)

Administer Oxygen Therapy

Use Oxygen Humidification

Other: Specify

Controlled Medication

Please complete Common Medication Used in Practice Placement pages below. If you are in a placement where you do not administer medication, as an exception and with your programme managers agreement, you must identify a range of medications that the service users are taking and discuss with your mentor the action, effect, side effects and contra-indications of these medications as if you were administering them. If your mentor is happy with your answers, they can then be signed off as being achieved. NB: University of Huddersfield and Leeds Met students may use authentic world to complete the drug calculations


83

The ability to ensure safe medication means a nurse has to be competent with the whole process of medication management, not just the giving of medicines. Therefore whenever a nurse has an interaction with a patient/client they must be confident they understand all the sections below to ensure safe medication management even if the patient/client is self-medicating

Medication 1; Name of Medication …

Action

How does the medication work on the body

Effect / Indication

What effects does it have on the body? Why is the patient/client taking this medication?

Route

What routes can this medication be given? Has the most appropriate route been chosen? If a different route is chosen what will that mean for the patient/client?

Dose

Is the dosage correct for the patient/client, age/condition, route?, Does the patient/client have other conditions which need to be considered e.g. does the dose need adjusting if the client has liver or renal conditions?

Common Side effects (Please relate this to a

patient/service user you are caring for /involved with)

What are the common side effects? Do you need to give advice about these? E.g. advice about ‘not standing too quickly’, or ‘take with food’ and explain why to the patient/client If the patient/client experiences these side effects what have they to do about them? If the patient/client experiences these side effects what can we do about them? E.g. ask for anti-emetics to be prescribed if nausea is experienced, or change the route/time of day the medication is taken to reduce symptoms

Cautions

(Please relate this to a patient/service user you are caring for /involved with)

What other conditions or medication is the patient/client taking, both prescribed and over the counter, which may interact with this medication Does the patient/client know how to store the medication at home?

Drug Calculation (you must show workings

out

We must be accurate in our calculations to ensure the correct dose is administered by the medical/nursing staff or by the patient/client in the home So we need to check are they self medicating the right dose, the right number of times per day, with the correct time gap between doses?

Safely given drug to identified individual (indicate route used)

This section is where you record that you have given the medication safely. Where this is a medication self-administrated by the patient/client you can record the route as SA (self-administered). You can record up to 5 examples, within the programme, where you have demonstrated competence with SA medications Route ……………. Mentor Signature ……………………………….. Date …………………….


84

Medication 1; Name of Medication … Medication 2; Name of Medication … Action

Effect / Indication

Route

Dose

Common Side effects (Please relate

this to a patient/service user you are

caring for /involved with)

Cautions


Drug Calculation (you must

show workings out

Safely given drug to

identified individual (indicate

route used)

Route ……………. Mentor Signature ……………………………….. Date …………………….

Route ……………. Mentor Signature ……………………………….. Date …………………….…………………….


85


Effect / Indication

Route

Dose




Cautions (Please relate this to a patient/service user you are caring for /involved with)


show workings out



route used




86


Effect / Indication

Route

Dose




Cautions



show workings out



route used




87


Effect / Indication

Route

Dose




Cautions



show workings out



route used




88


Effect / Indication

Route

Dose




Cautions



show workings out



route used




89


Effect / Indication

Route

Dose




Cautions



show workings out



route used




90


Effect / Indication

Route

Dose




Cautions



show workings out



route used




91


Effect / Indication

Route

Dose




Cautions



show workings out



route used




92


Effect / Indication

Route

Dose




Cautions



show workings out



route used




93


Effect / Indication

Route

Dose




Cautions



show workings out



route used




94


Effect / Indication

Route

Dose




Cautions



show workings out



route used




95


Effect / Indication

Route

Dose




Cautions



show workings out



route used




96

Medication 25; Name of Medication … Action

Effect / Indication

Route

Dose




Cautions



show workings out



route used




97

CATCH UP PLACEMENT


98

Catch up Placement Professional Behaviour in Practice - Final interview stage


Satisfactory

Unsatisfactory


Interview




values & attitudes (development plan must

be agreed & recorded)







judgmental


needs of others




maintaining records







care team




using reflection as a means of identifying their own

learning needs and limitations







99

Catch up Placement Final Interview








100

Catch up Placement










Student Signature

Date

Mentor Signature

Date



Pg 101

Catch up Placement







Date:


Date:







Pg 102