Gulf Coast Community College

Learning Activity Guide Cooperative Education Clinical Internship

Basic Perioperative Nursing

Initiated July, 2003 Revised July, 2006 Clinical Log Added Aug, 2006

Libby McNaron, RN, CNOR, CST, BSN, MS

Gulf Coast Community College NUR 2949 Clinical Internship Basic Perioperative Nursing Learning Activity Guide

Clinical Internship in Perioperative Nursing

Syllabus.3 Topical Outline.5 Course Objectives.7 Requirements.4 Course Calendar....8 Theory Learning Units.9 Perioperative Nursing Roles Recommended A-V Viewing List11 Clinical Performance Evaluations and Guidelines...12 Lab Skills Checklist..9 14 Clinical Orientation Forms...15 -24 Evaluation Circulator Role...25 Evaluation- Scrub Role26

Clinical Internship in Perioperative Nursing

Gulf Coast Community College Basic Perioperative Nursing Cooperative Education 2949 COURSE TITLE AND NUMBER: Nur 2949 Clinical Internship in Perioperative Nursing PLACEMENT IN PROGRAM OF LEARNING: Elective Third Term through Fourth Term for Current Nursing Students; Open enrollment to any Florida Licensed Registered Nurse. COURSE DESCRIPTION: This course is designed to introduce the individual to Perioperative Surgical Nursing with a focus on Intraoperative Nursing. This course includes a study of the Patients Perioperative Experience, Roles and Responsibilities of the Registered Nurse; Principles and Practice of Sterile Technique; Sterilization and Disinfection; Operating Room Hazards; and an Introduction to Surgical Technique. CREDITS: 3 Semester Credits Clinical Internship. Student may register and attend the classroom session. Clinical hours can be completed over a period of two semesters. Student can exit at anytime once the course objectives are completed. It is expected that course completion will be achieved within two semesters. CLOCK HOURS: Voluntary Students: Student must complete 150 voluntary work hours to complete the course. Additional Lab practice and skills check-off hours can be scheduled according to the needs of the student. Scheduled practice and skills check-off hours will count toward the total 150 hours required. Clinical hours and clinical site must be scheduled with the instructor Libby McNaron, (873-3551). Potential local clinical sites to complete hours include Bay Medical Center and Gulf Coast Medical Center. Other alternatives can be established for distance education students located outside of Bay County. Site preference will be taken into consideration, but final clinical site assignment will be made by the instructor in conjunction with the clinical site. PRE-REQUISITE: Current pre-requisites for Third term nursing (Course NUR1211C, NUR 1260C); or current proof of licensure as a Registered Nurse in the State of Florida. CO-REQUISITE: Current enrollment or previously completed lifelong learning course Basic Perioperative Nursing Theory and Lab. METHODS OF INSTRUCTION: Lecture, group discussion and activities, audio-visuals, selfpaced modules, computer-assisted instruction, observation, skill demonstration, and return demonstration. METHODS OF EVALUATION: Clinical and Skills Lab Performance Written Examination
2 Exams: 1 at Midterm 1 Final Exam

GCCC GRADING SCALE

A (90-100) B (80-89) C (70-79) D (60-69) F (0-59)

Clinical Internship in Perioperative Nursing

TO MEET THE REQUIREMENTS FOR GRADE: See attached current course syllabus for CO-OP Course 2949 for the current semester. ABSENTISM: As per GCC Nursing attendance policy. Not to exceed 1/8th of classroom hours to complete the course or 2 classes. All practical/clinical hours must be completed. COMPLETION OF COURSE: Please note that completion of this course does not guarantee employment or a specific position at the Hospital. RECOMMENDED TEXTBOOK:
Pocket Guide to the Operating Room (1996); 2nd Ed., Goldman, F.A. Davis.

POLICIES IN THE CLINICAL SETTING: A copy of the current applicable health science student handbook will be provided. Students must follow all policies regarding clinical policies currently outlined in the applicable health science student handbook provided. ACCIDENTAL INJURY LIABILITY AND (MAL-PRACTICE) INSURANCE:
Each student must have liability and accidental injury insurance while enrolled in the program. When you pay fees for courses with clinical labs, the insurance fee is also paid. Since fees are subject to change, please consult the current Gulf Coast Community College catalog. Liability limits to coverage are $1,000,000 per incident for an individual student and $3,000,000 aggregate per incident for a group of students. The basic plan for Accidental Injury Coverage provides the following:
Coverage Accidental Medical Insurance Includes treatment as a result of exposure to a contagious and/or infectious disease including, but not limited to hepatitis, HIV, Meningococcal meningitis, TB. The policy would not include influenza, pneumonia or common colds. Dental - resulting from an accident Deductible Travel with a group under the direct supervision of insured. Accidental Death or Dismemberment (AD&D) $15,000 $1,000 None Yes $25,000

This coverage is designed to cover the students injured as a direct result of working in the clinical setting. It is not designed to cover accidents while walking/traveling to class or sitting in a classroom. It would extend to slips or falls in clinical settings or injury due to lifting patients or equipment but most importantly, it would cover treatment for exposure to disease as stated above.

ACCIDENTAL INJURY COVERAGE (HOW TO IMPLEMENT):

Should an accident occur during a clinical affiliation, the student must report this to the instructor immediately and complete the GCCC FCC Accident-Incident Form that is available in division secretary's office in HS 202 within 24 hours of occurrence. Claim forms may also be obtained from the Health Sciences Division secretary in Room 202.

Clinical Internship in Perioperative Nursing

Gulf Coast Community College Clinical Internship Perioperative Nursing

TOPICAL OUTLINE

PSYCHOMOTOR SKILLS 1. 2. 3. 4. 5. 6. Positioning of Surgical Patients Surgical Skin Preparation Scrubbing Gowning and Gloving Establishment & Maintenance of a Sterile Field Scrub Role Evaluation Surgical Case Responsibilities Circulator Role Evaluation Surgical Case Responsibilities

Clinical Internship in Perioperative Nursing

CLINICAL INTERNSHIP PERIOPERATIVE NURSING COURSE OBJECTIVES

Upon completion of the course, the student will be able to: ROLE AS A CIRCULATOR WITHIN THE DISCIPLINE OF NURSING: 1. Describe the basic role and responsibilities of the Registered Nurse during the preoperative, intraoperative, and postoperative phase of the patients surgical experience. Identifies the role and responsibilities of the circulator as a member of the OR Team. 2. Identifies the basic principles of surgical Aseptic Technique including the Association of Operating Room Nurses Standards of Care and the methods of sterilization and disinfection. 3. Establishes a client outcome and plan of care that focuses on prevention of problems. Identifies potential surgical hazards and safety measures to prevent injury including patient and occupational related hazards. 4. Demonstrate ability to position and perform surgical skin preparation for the surgical patient in the practice lab and clinical settings. 5. Demonstrate ability to establish and maintain the sterile field as a nonsterile member of the team.

ROLE AS A SCRUB WITHIN THE DISCIPLINE OF NURSING: 1. Identifies the role and responsibilities of the surgical scrub as a member of the OR team. 2. Demonstrate ability to perform the surgical scrub, gown, and glove technique correctly. 3. Demonstrate ability to establish and maintain the sterile field as a sterile member of the team. 4. Identifies key basic surgical instruments necessary for all surgical procedures. 5. Identifies basic surgical technique principles regarding tissue handling, wound closure, and hemostasis.

Clinical Internship in Perioperative Nursing

Gulf Coast Community College Clinical Performance & Skills Lab Evaluation Rationale: A. Clarification of the role of faculty: In competency-based education, faculty members assume the role of transfer agents-creating conditions when expertise is transferred to novices. The responsibility of the transfer agent is to: 1. Describe what it means to be expert. 2. Create and maintain an instructional environment which students are prepared to perform competently. 3. Design evaluative exercises to determine when students are, in fact, capable of competent performance. B. Facilitation of instructional accountability: We can anticipate certain results form a program of learning utilizing competency based performance criteria. The participant in such a program should demonstrate: 1. Increased levels of competency. 2. Increased awareness of what the instruction is to provide. 3. Increased awareness of their performance levels. 4. Increased accuracy of self-evaluation. Implementation: Specific clinical performance evaluation experiences have been identified for the Perioperative Class. The performance test items varies with each testing experience and reflect the content/skills the student should have mastered during that particular portion of the term. (Please refer to the LAG) Role of Instructor/Evaluator During Testing Experience: A. The primary role of the evaluator is objective observation. B. No assistance may be provided to the student performer. Show and tell, coaching, excusing, and helping are all strictly forbidden. C. The evaluator will remain silent during the performance situation. The evaluator will not give non-verbal cues such as facial expressions, and body movement. D. For process evaluation, the evaluator will remain with the student and observe all behaviors. Role of the Student/Performer During Testing Experience: A. Attendance for clinical performance is mandatory. The student must arrive at the designated time. B. The student should perform as though the evaluator were not present. C. The student should not attempt to introduce the evaluator in conversation or regard her/him as an assistant. D. All critical elements must be performed as specified. E. The student may be requested to supply a lab partner for the testing experience to assume a role as indicated including patient, circulator, or scrub. F. The student should be prepared to self-evaluate his/her performance. Role of Individual Assuming the Designated Role as Indicated:
7

Clinical Internship in Perioperative Nursing

A. The individual should perform as though the evaluator were not present. B. The individual should not attempt to introduce the evaluator in conversation or regard her/him as an assistant. C. No information regarding the task performance may be provided to the student/performer. This includes verbal information and non-verbal cues such as facial expressions and body movements. Critical Elements Criteria: Performance criteria identify the critical elements of the tasks. Critical elements are those aspects of care essential to protect and promote the patients well being. They are subdivided into three overriding areas of concern. A. Physical Jeopardy any act or inaction on the part of the student, which threatens the patients physical well being. B. Emotional Jeopardy any act or inaction on the part of the student, which threatens the patients emotional well being. C. Asepsis the prevention of the introduction and/or transfer of organisms. The elements are identified as critical because the omission or unsatisfactory performance of any one of them indicates the students failure to administer safe and effective care to that patient. By using only the prescribed critical elements of care, success on the exam is based on 100percent accuracy in performance. 1
1

The New York Regent External Degrees in Nursing Historical Developments and Program Study Guides for the Associate Degree Monograph I., 1976, pp. 89-90.

Accommodation for Individual Differences: Allowances are made, with certain time limitations, for a student to progress to a satisfactory competency level at their own rate. If a student fails to perform satisfactorily on an initial testing experience, they will be provided with additional supervised lab practice and an opportunity to repeat the test. All skill objectives must be mastered and validated by successful performance testing in the simulated lab before completion of the course.

Clinical Internship in Perioperative Nursing

Skills Experience
Course Description: Provides a setting in which the student is oriented to the Operating Room Environment. Skills are demonstrated and the student practices skills necessary for basic case preparation including instrumentation, supplies, sutures and stapling devices, electrocautery equipment, scrubbing and gowning, patient positioning and draping, creation and maintenance of the sterile field. Practice stations will be set up to allow sufficient skills practice for all students. Lab practice and skills check-off hours will be scheduled according to the needs of the student. Scheduled practice and skills check-off hours will count toward the total 180 hours required. See posted schedule when lab is available for assisted, and self-instruction practice.

Objectives: Course is designed as an introductory course to the operating room environment. Upon completion of the Lab Finals the student will be able: 1. 2. 3. 4. 5. 6. 7. 8. Demonstrate satisfactory proficiency in required skills as a Registered Nurse in the Operating Room. Identifies safety hazards and interventions appropriate for patient and environmental safety such as counts, electrical, laser, Infection Control measures, and Personal protection requirements. Demonstrate patient assessment skills such as vital signs. Demonstrates and applies the principles of surgical fundamentals such as aseptic technique, storage and handling of sterile supplies as the individual assigned the task. Demonstrates case preparation skills to ensure an organized and efficient case setup especially in regards to tourniquets, electrosurgical units, and laser equipment. Identifies appropriate action to take when confronted with an equipment-related malfunction or emergency. Demonstrates patient care procedures correctly and safely such as skin preparation, positioning, and draping. Demonstrate competencies as outlined on the specified evaluation sheets with a minimum level of 4. A level of 3 indicates a need for more experience in that area.

Methods of Evaluation: Performance evaluations in the skills experiences according to established criteria. Student will be notified via this module at the beginning of the course of the key competency skills and given the evaluation tools for each, which must be mastered. The student completes each skill and is evaluated on each skill. Student must submit one evaluation completed to the level 4-5 competency.

Clinical Internship in Perioperative Nursing

SKILLS EVALUATION & COMPETENCY FORM - SKIN PREP

Name_________________________Date______________Evaluator_____________________
* Items are critical items must have a 4-5 level.
MEETS STANDARDS/EXCEEDS GOALS..5 MEETS STANDARDS/ MEETS GOALS..............4 MEETS STANDARDS/MET REQUIREMENTS/NEEDS TO IMPROVE.3 STATES STANDARDS / NEEDS PRACTICE.2 INSERVICED ON STANDARDS/ GOALS NOT MET........................1 Points Points 1 2 Standards are defined as the basic principles of aseptic and operating room care as defined by AORN standards. Standard Operating Room Technique

1. Washes Hands. 2. Assembles supplies: Prep Tray, garbage can, positioning supplies for patient. 3. Positions patient supine with arms on armboards (does not extend arms greater than 90degrees, safety strap 2" above knees, pillow under upper thigh, foam pads under heels, arms palms up) 4. Exposes area needed only. Maintains patient warmth above and below site. 5. Places nonsterile towels to prevent pooling. 6. Opens prep tray (away from self first) with no contamination. 7. Dons sterile gloves open technique without contamination. 8. Applies sterile drapes to catch drips without contamination. 9. Open solutions - position setup to prevent spills. 10. Begin prep with cotton swabs in umbilicus as a separate prep. States that the umbilicus is a contaminated area. 11. Utilize scrub sponges begin prep Begins at the incision line and proceeds outward Utilizes circular motion to cleanse Does not return to incision site from periphery 12. Blots dry - does not contaminate - Peels back in a manner that does not allow contaminated edges to pass over the site. 13. Paints from incision site outward without contamination. 14. Preps sufficient area. (incision line is approximately 68" paints table to table, 2" above xiphoid process to symphysis pubis) 15. Prevents pooling under patient. (Controls amount of solution utilized) 16. Removes towels without contaminating prep.
Skills Lab Grade : 94100% (A) 86-93%(B) 75-85% (C) - Satisfactory [ 65-74% (D) 0-64% (F) ] Unacceptable Grade: _____ % ____ (Divide Student Total by Possible 320 at Level 4/Satisfactory) COMMENTS(Use Back of Form PRN: Strengths identified:

N/A Wt. 5 5 5

Possible Student *20 20 *20

Comment

5 5 5 5 5 5 5

20 20 *20 *20 *20 20 *20

*20

*20

5 5

*20 20

5 5

*20 *20 Total

Possible Total 320

Suggestions for improvement:

Check One: Student Practice _______ Instructor Practice_______ Skills Lab Testing/Competency Demonstration_____ Reviewed with Student: Date______________________ Student Signature_________________________________ Comments on back__ Instructor Signature_______________________________ ____1st Attempt ______2nd Attempt_____3rd Attempt

10

Clinical Internship in Perioperative Nursing

SKILLS LAB EVALUATION & COMPETENCY FORM - POSITIONING

Name______________________________Date___________Evaluator___________________
* Items are critical items must have a 4-5 level.
MEETS STANDARDS/EXCEEDS GOALS.........5 MEETS STANDARDS/ MEETS GOALS.....................4 MEETS STANDARDS/MET REQUIREMENTS/NEEDS TO IMPROVE ...3 STATES STANDARDS / NEEDS PRACTICE.....2 INSERVICED ON STANDARDS/ GOALS NOT MET...........................1 1 2 Standards are defined as the basic principles of Aseptic and Operating Room Care As defined by AORN Standards. Standard Operating Room Technique. Points Points 5 N/A Wt. Possible Student Comment 5 *20 5 20

1. 2.

3.

4. 5.

6.

7.

8.

9.

Washes Hands Assembles supplies needed for each position prior to need. Designates number of personnel needed to assist for each positioning event. Positions patient ensuring head is maintained in alignment at all times ( communicates with anesthesia & team). Turns patient as a complete unit on three. Privacy maintained as much as possible Monitors limbs - ensures limbs are under control and safely moved in normal ROM (range of motion). Supine Position: Arms on armboards not greater than 90 degrees. Arm secured to prevent falling with safety straps (2 finger check). Pillow under upper thigh (prevents back strain). Safety strap 2" above knees. Foam pads heels (elbows & wrists PRN) Prone position with arms on armboards: Chest rolls support iliac crest to shoulder/breasts free. Pillow roll under upper thigh (states checks scrotum on males) Shins supported on pillowtoes free from table. Arms rotated down and then onto armboards. Knees checked - foam pads applied if pressure detected. Labels stretcher "patient prone- do not remove"Security either safety strap or tape Lateral with upper arm on pillows: Two chest rolls with kerlix utilized and axillary roll. Two pillows between legs; bottom leg bent, top leg slightly bent. Two pillows between arms and secured. 3" tape to secure hips to table. Foam pads for bottom ankle Lithotomy in candy cane stirrups: Arms are to be tucked (uses foam pads and monitors fingers while foot of bed is lowered) Buttocks do not extend below table edge. Ankles padded with towels. Legs lowered & raised simultaneously, knees together until 45 degree bend then rolled outward with lower calf supported at all times. Identifies the positioning modifications possible for each basic position: Supine(trendelenburg, reverse trendelenburg, ENT, frog legged, Fowler's); Prone (knee chest, Jackknife, Kraske, Andrews table); Lateral (Bean bag, Arm suspension, Kidney position); Lithotomy ( Modified low/allen stirrups)

*20

5 5

*20 *20

*20

*20

*20

20

Skills Lab Grade : 93100% (A) 86-92%(B) 80-85% (C) - Satisfactory [ 70-80% (D) Less than 70 (F) ] Unacceptable Grade: _____ % ____ (Divide Student Total by Possible 180 at Level 4/Satisfactory) COMMENTS (Use Back of Form PRN): Strengths identified:

Possible Total 180

Total

Suggestions for improvement:

Check One: Student Practice _______ Instructor Practice_______ Skills Lab Testing/Competency Demonstration_____ Reviewed with Student: Date______________________ Student Signature_________________________________ Comments on back__ ____1st Attempt ______2nd Attempt_____3rd Attempt Instructor Signature_______________________________

11

Clinical Internship in Perioperative Nursing

SKILLS LAB EVALUATION & COMPETENCY FORM - ELECTROCAUTERY

Name________________________________Date___________Evaluator_________________
* Items are critical items must have a 4-5 level.
MEETS STANDARDS/EXCEEDS GOALS.........5 MEETS STANDARDS/ MEETS GOALS.....................4 MEETS STANDARDS/MET REQUIREMENTS/NEEDS TO IMPROVE ...3 STATES STANDARDS / NEEDS PRACTICE.....2 INSERVICED ON STANDARDS/ GOALS NOT MET...........................1 1 2 3 Standards are defined as the basic principles of aseptic and operating room care as defined by AORN Standards. Standard Operating Room Technique. Points Points N/A Wt. Possible Student Comment 5 20 5 5 20 *20

1. Moves and Positions Unit correctly. 2. Assembles all necessary supplies. 3. Obtains correct bovie grounding pad and applies correctly. (correct site for surgical procedure & protected from pooling of solutions) 4. Checks all cords and plugs in correctly 5. Places foot pedal appropriately. 6. Set unit controls within safe range for case. Coagulation , cutting, and blending. 7. States settings for each when connecting bovie unit or changing settings. 8. Demonstrates safe handling of tips (needle tip, reg. Tip, and extender) 9. Demonstrates correct utilization of the bovie suction attachment and identifies the correct adapter. 10. Given the scenario, Identifies the correct utilization of the bipolar Vs the monopolar unit. 11. Demonstrates the control of the surgical plume. Identifies the reason for controlling the surgical plume. 12. Demonstrates correct technique for "Buzzing a hemostat". 13. Identifies troubleshooting techniques in response to surgeon's request for increased cautery. (ineffective coagulation) 14. Inspects the bovie grounding pad site after removal and documents the skin condition. 15. Identifies the items to be documented and Documents electrocautery settings; unit number; pad site and skin condition. 16. Stores unit correctly.
Skills Lab Grade : 94100% (A) 86-93%(B) 75-85% (C) - Satisfactory [ 65-74% (D) 0-64% (F) ] Unacceptable Grade: _____ % ____ (Divide Student Total by Possible 320 at Level 4/Satisfactory) COMMENTS(Use Back of Form PRN: Strengths identified:

5 5 5 5 5 5 5 5 5 5

*20 20 *20 *20 *20 20 20 20 20 20

5 5

*20 *20

5 Possible Total 320

20

Total

Suggestions for improvement:

Reviewed with Student: Date______________________ ____1st Attempt ______2nd Attempt_____3rd Attempt

Student Signature_________________________________ Comments on back__ Instructor Signature_______________________________

12

Clinical Internship in Perioperative Nursing

SKILLS LAB EVALUATION COMPETENCY - CIRCULATOR

Name______________________________Date___________Evaluator___________________
* Items are critical items must have a 4-5 level.
MEETS STANDARDS/EXCEEDS GOALS.........5 MEETS STANDARDS/ MEETS GOALS.....................4 MEETS STANDARDS/MET REQUIREMENTS/NEEDS TO IMPROVE ...3 STATES STANDARDS / NEEDS PRACTICE.....2 INSERVICED ON STANDARDS/ GOALS NOT MET...........................1 1 2 Standards are defined as the basic principles of aseptic and operating room care as defined by AORN Standards. Standard Operating Room Technique. Points Points Possible Student *20 20

1. Washes hand. 2. Sterile room pre-setup. Assembles Supplies and equipment. (drape pack, basin kit, instrument set, surgical scrub
setup); Places items correctly to be opened.

5 N/A Wt. 5 5

Comment

3. Ensures mannequin is positioned supine with "prepped area " (Breast Biopsy) exposed. 4. Opens sterile supplies maintaining sterile technique. 5. Preps patient - Utilize scrub sponges begin prep Begins at the incision line and proceeds outward Utilizes circular motion to cleanse Does not return to incision site from periphery 6. Assists Scrub: Ties up Scrub Correctly, Checks instrument tray and verifies dry. Verifies counts of raytex, laps, instruments, and suture Utilizes count sheet. 7. Assists with local Pours solutions correctly. Ensures meds are transferred from labeled container to labeled container. 8. Assists with draping and establishment of sterile field. Assists with back table. 9. Connects suction - ensures working. 10. Connects bovie electrocautery and notifies surgeon of settings. 11. Pours saline correctly and sterile water for instrumentation. 12. Conserves energy-time-motion: Utilizes step stools, etc as indicated. 13. Maintains sterile technique - if breaks in technique identifies per self or responds correctly. 14. Monitors surgical field and anticipates needs appropriately such as suture; specimen; counts; etc. 15. Secures Dressing Ensures all prep solution clean. Checks and documents bovie site and skin condition postop 16. Completes documentation correctly and records all required information including assessment; care plan; positioning; bovie unit; prep; postop dressing and disposition. No blank lines.
Skills Lab Grade : 94100% (A) 86-93%(B) 74-85% (C) - Satisfactory [ 65-74% (D) 0-64% (F) ] Unacceptable Grade: _____ % ____ (Divide Student Total by Possible 320 at Level 4/Satisfactory) COMMENTS(Use Back of Form PRN: Strengths identified: Suggestions for improvement:

5 5 5

20 *20 20

*20

*20

5 5 5 5 5 5 5 5 5

*20 *20 *20 20 20 *20 20 20 20

Possible Total 320

Total

Reviewed with Student: Date______________________ ____1st Attempt ______2nd Attempt_____3rd Attempt

Student Signature_________________________________ Comments on back__ Instructor Signature_______________________________

13

Clinical Internship in Perioperative Nursing

SKILLS LAB EVALUATION COMPETENCY - UNIVERSAL CASE SETUP

Name___________________________Date___________Evaluator________________
* For Satisfactory completion must have a 4-5 level Meets Standards/Exceeds Goals........5 Standards Are Defined as the Basic Principles Meets Standards/ Meets Goals......................4 Of Aseptic And Operating Room Care as Meets Standards/Met Requirements/Needs To Improve ..............3 Defined By AORN Standards. Standard States Standards / Needs Practice.....2 Operating Room Technique. Inserviced On Standards/ Goals Not Met............................................1 Points Points 1 2 3 4 5 N/A Wt. Possible Student 5 *20 1. Washes hand.

Comment

2.

Sterile room pre-setup. Assembles all required Supplies & equipment. (Opens in correct sequence: drape pack, basin kit, instrument set, surgical scrub setup); Wraps/packages appropriately; Places items correctly to be opened. Ensures mannekin is positioned supine with "prepped area " exposed. Opens sterile supplies maintaining sterile technique.
(Inspects package; opens away from self first; unsterile arm does not reach over; No unsecured edges)

20

3. 4. 5. 6. 7.

5 5

20 *20

Performs Surgical Hand Scrub Correctly. Dons sterile gown and gloves using closed glove technique. (pinches in middle/no drips/front watched) Prepares the instrument Area to receive tray with a blue towel without contaminating. Lifts out the inner
instrument tray. Waits for circulator to check the inside of container and verify sterility. Places tray on top of blue towel. Prepares the mayo stand: Drapes mayo stand, places ties on mayo cover, towel, towel rolls. Places items without looking at diagrams given previously to receive a 4 or 5.

5 5 5

*20 *20 20

8. 9.

20

Sets up basin. Places items out of basin in place on back table, mayo correctly, etc. 10. Initiates counts of raytex, laps, instruments, & suture. 11. Prepares draping supplies (towel with bovie/suction/light
handles/two laps); drape, towels, clips, surgeon's gown/gloves.

5 5 5 5 5 5 5

20 *20 *20 20 20 20 20

12. Completes Back table setup. 13. Completes Mayo stand Setup. (5 hemostats, 2-4 kell's, allis's,
kocker's, right angles, needle holders, retractors, pickups, etc.)

14. Conserves energy-time-motion: does not move an item over 3 times before it is in its setup/final place. 15. Completes setup within correct time: Completes setup
within correct time: STS0155 & 120- 10 minutes (number 6 to finish ); STS0121- 5 minutes; STS122 - 10 minutes from number 4 to finish including opening supplies (3 min scrub). Maintains sterile technique-if breaks in technique identifies per self or responds correctly (IDs how to correct).

16.

5 5 5 5 5

*20 20 *20 *20 *20

17. Correctly identifies all instruments on setup. 18. Labels all Medication containers (from labeled
container to labeled container). Correctly prepares syringe.

19. Handles Sharps appropriately positions needle box in limited traffic area (hand does not pass over) 20. Hands: Keeps hands at table level only. Maintains hands
in sight, not above shoulder height or lower than table or waist level. 21. Faces Sterile Field at all times. Does not walk between two sterile fields. Maintains 12 distance between sterile and unsterile areas.

*20

22. Guards Sterile Field Assertively.

Maintains field within sight and grouped closely together. Instructs others to maintain proper distance. Skills Lab Grade : 90100% (A) 80-89%(B) 70-79% (C) - Satisfactory[ 60 -69% (D) Less than 60 (F) ] Unacceptable Grade: _____ % ____ (Divide Student Total by Possible 440)

20

Possible Total 440

Total

14

Clinical Internship in Perioperative Nursing COMMENTS:

Strengths identified:

Suggestions for improvement:

Plan to correct any deficiencies:

Checklist for LAB: All supplies put away All instruments reassembled & put away Manikin/linens clean (NO tape) Furniture/ equipment returned to normal location/storage Scrub sink clean Lab Clean Yes______ No_______ Extenuating
Circumstance:

Not Clean (5 point Deduction)_______________ Instructor signature _____________________

Reviewed with Student: Date______________________ ____1st Attempt ______2nd Attempt_____3rd Attempt

Student Signature_________________________________ Comments on back__ Instructor Signature_______________________________

Completed Satisfactorily _______Must Redo______

15

Clinical Internship in Perioperative Nursing

SKILLS LAB EVALUATION & COMPETENCY FORM - BREAST BIOPSY

Name____________________________Date___________Evaluator_____________________
* For Satisfactory completion must have a 4-5 level Meets Standards/Exceeds Goals........5 Standards Are Defined as the Basic Principles Meets Standards/ Meets Goals......................4 Of Aseptic And Operating Room Care as Meets Standards/Met Requirements/Needs To Improve ..............3 Defined By AORN Standards. Standard States Standards / Needs Practice.....2 Operating Room Technique. Inserviced On Standards/ Goals Not Met............................................1 Points 1 2 3 4 5 N/A Wt. Possible 5 20 1. Washes hand.

Points Student

Comment

2. Sterile room pre-setup. Assembles Supplies and equipment.

pack, basin kit, instrument set, surgical scrub setup); Places items correctly to be opened. Assembles additional items required.

(drape

20

3. Ensures manikin is positioned supine with "prepped area exposed for Breast Biopsy. 4. Opens sterile supplies maintaining sterile technique. 5. Performs Surgical Hand Scrub Correctly. 6. Dons sterile gown and gloves using closed glove technique. (pinches in middle/no drips/front watched) 7. Prepares the instrument Area to receive tray with a blue towel without contaminating. Lifts out the inner instrument tray.
Waits for circulator to check the inside of container and verify sterility. Places tray on top of blue towel

5 5 5 5 5

*20 *20 *20 *20 *20

8. Prepares the mayo stand: Drapes mayo stand, places ties on mayo cover, towel, towel rolls. Places items without looking
at diagrams given previously to receive a 4 or 5.

20

9. Sets up basin. Places items out of basin in place on back table, mayo, etc. Basin is placed appropriately after opening/
wrapper edges monitored.

20

10. Initiates counts of raytex, laps, suture, instruments. Counts initial,

closure of peritoneum, closure of skin. Starts at field, mayo, back table, kick bucket. 11. Prepares draping supplies (towel with bovie/suction/light handles/two laps); drape, towels, clips, surgeon's gown/gloves.

*20

5 5 5 5 5

*20 20 20 20 20

12. Completes Back table setup. 13. Completes Mayo stand Setup. ( 5 hemostats, 2-4 kelly's, allis's ,
kocker's, right angles, needle holders, retractors, pickups, etc.)

14. Conserves energy-time-motion: does not move an item over 3 times before it is in the final setup place. 15. Completes setup within correct time: Completes setup
within correct time: STS0155 & 120- 10 minutes (number 6 to finish ); STS0121- 5 minutes; STS122 - 10 minutes from number 4 to finish including opening supplies (3 min scrub).

16.

Drapes appropriately for procedure. (Passed correctly, cuffs hand to protect) "surgeon/instructor".

5 5 5 5 5 5 5 5

*20 20 *20 20 *20 *20 20 20

17. Passes instruments correctly as requested by 18. Maintains sterile technique - if breaks in technique identifies per self or responds correctly. 19. Correctly identifies all instruments on setup. 20. Labels all Medications. Ids med as passed 21. Handles Sharps appropriately positions needle box in limited traffic area (hand does not pass over) 22. Guards Sterile Field Assertively. Maintains field within sight
and grouped closely together. Instructs others to maintain proper distance. 23. Anticipation. Correctly anticipates sequence: incision (sponge/local/ knife/cautery) Vessel (clamp/clamp/cut/tie) Closing (irrigation/suture/ pickups/counts) Skills Lab Grade : 90100% (A) 80-89%(B) 70-79% (C) - Satisfactory[ 60 -69% (D) Less than 60 (F) ] Unacceptable Grade: _____ % ____ (Divide Student Total by Possible 420)

Possible Total 420

Total

16

Clinical Internship in Perioperative Nursing COMMENTS:

Strengths identified:

Suggestions for improvement:

Plan to correct any deficiencies:

Checklist for LAB: All supplies put away All instruments reassembled & put away Manikin/linens clean (NO tape) Furniture/ equipment returned to normal location/storage Scrub sink clean Lab Clean Yes______ No_______ Extenuating
Circumstance:

Not Clean (5 point Deduction)_______________ Instructor signature _____________________

Reviewed with Student: Date______________________ ____1st Attempt ______2nd Attempt_____3rd Attempt

Student Signature_________________________________ Comments on back__ Instructor Signature_______________________________

Completed Satisfactorily _______Must Redo______

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Clinical Internship in Perioperative Nursing

SKILLS LAB EVALUATION & COMPETENCY FORM SCRUB ROLE

Name______________________________Date___________Evaluator___________________
* Items are critical items must have a 4-5 level.
MEETS STANDARDS/EXCEEDS GOALS.........5 MEETS STANDARDS/ MEETS GOALS.....................4 MEETS STANDARDS/MET REQUIREMENTS/NEEDS TO IMPROVE ...3 STATES STANDARDS / NEEDS PRACTICE.....2 INSERVICED ON STANDARDS/ GOALS NOT MET...........................1 1 2 3 Standards are defined as the basic principles of Aseptic And Operating Room Care as defined by AORN Standards. Standard Operating Room Technique. Points Possible *20 *20 Points Student

1. Washes hand. 2. Sterile room pre-setup. Assembles Supplies and equipment. (drape pack, basin kit, instrument set, surgical
scrub setup); Places items correctly to be opened. Assembles additional items required.

N/A Wt. 5 5

Comment

3. Ensures mannequin is positioned supine with "prepped area " exposed for Breast Biopsy. 4. Opens sterile supplies maintaining sterile technique. 5. Performs Surgical Hand Scrub Correctly. 6. Dons sterile gown and gloves using closed glove technique. 7. Prepares the instrument Area to receive tray with a blue towel without contaminating.
Lifts out the inner instrument tray. Waits for circulator to check the inside of container and verify sterility. Places tray on top of blue towel

5 5 5 5 5

*20 *20 *20 *20 *20

8. Pepares the mayo stand: Drapes mayo stand, places ties on mayo cover, towel, towel rolls. Places items without
looking at diagrams given previously to receive a 4 or 5.

*20

9. Sets up basin. Places items out of basin in place on back table, mayo, etc. 10. Initiates counts of raytex, laps, instruments, and suture. 11. Prepares draping supplies (towel with bovie/suction/light
handles/two laps); drape, towels, clips, surgeon's gown/gloves.

5 5 5 5 5

*20 *20 *20 *20 *20

12. Completes Back table setup. 13. Completes Mayo stand Setup. ( 5 hemostats, 2-4 kelly's, allis's , kocker's, right angles, needle holders, retractors, pickups, etc.) 14. Conserves energy-time-motion: does not move an item over 3 times before it is in it's setup place. 15. Completes setup in a timely fashion. 16. Drapes appropriately for procedure. Drapes with assistance from instructor(surgeon). (stands well back from table edge; cuffs drape over hand and steadies sheet with other hand; watches hand in motion) 17. Passes instruments correctly as requested by "surgeon/instructor". 18. Maintains sterile technique - if breaks in technique identifies per self or responds correctly.
Skills Lab Grade : 94100% (A) 86-93%(B) 75-85% (C) - Satisfactory [ 65-74% (D) 0-64 (F) ] Unacceptable Grade: _____ % ____ (Divide Student Total by Possible 360 at Level 4/Satisfactory) COMMENTS(Use Back of Form PRN: Strengths identified: Suggestions for improvement:

5 5 5

*20 *20 *20

5 5

*20 *20

Possible Total 360

Total

Reviewed with Student: Date______________________ ____1st Attempt ______2nd Attempt_____3rd Attempt

Student Signature_________________________________ Comments on back__ Instructor Signature_______________________________

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Clinical Internship in Perioperative Nursing

NAME_____________________ DATE____________________
ALLEN STIRRUPS BASIN KIT BLUE FOAM PADS elbow/heel protectors BMC QUICK RESPONSE CARDS CO2 GAS TANKS SPARE DOPPLER GEL/PROBE EEA SIZERS ETHER SCREEN FRAZIER SUCTION HEMOSTATS - PEEL PACK ICE COOLER IMPRA GRAFTS LAHEYS MICROSCOPE (S) MICROSCOPE STERILE EYE PIECES OSULLIVAN OCONNER PILLING LARYNGOSCOPE PLEUREVAC PORT-A-CATH AND SENSOR PREFERENCE CARDS RINGS SMOKE EVACUATOR SPARE SCREWS FOR SETS SPINAL TABLE STERILE WEBRIL 3 STERION FILTER for instrument cases STERIS MACHINE or Sterrad Machine STERNOTOMY TRAY Emergency Chest tray STRYKER COMPARTMENTAL MEASURING KIT FOR COMPARTMENTAL SYNDROME SUTURE BOOTS SUTURE CART PROLENE TONSIL SNARES TRAY CHEST TRAY ENT TRAY GI TRAY LAP CHOLE VIDEO MONITORS -LAPAROSCOPIC WARMING LIGHTS FOR KIDS #16 FOLEY CATH KIT #8 SHILEY TRACH TUBE 10 CC SYRINGE SLIP TIP ARMY NAVY RETRACTOR ARTHROSCOPY MACHINE AVITENE BEACH CHAIR POSITIONER

SCAVENGER HUNT Circle Site: BMC GCMC Eye77

AESOP ROBOTIC ARM AUTOCLAVE BEAN BAG BONE HOOK BOTTLE OF SKIN DEGREASER BRONCHOSCOPE CAST CART CHOLEODOCOSCOPE COLD SALINE CRASH CART AND DEFIBRILLATOR CUSA CYSTO TUBING ELECTRIC RAZOR FORMALDEHYDE AND GAS MASK FRACTURE TABLE HALL DRILL HAND DRAPE HARMONIC SCALPEL HOFFMAN EXTERNAL FIXATOR HOLMAN RETRACTOR ICE MACHINE ICP MONITOR KNEE INSTRUMENTS MSDS SHEET FOR STERIS SOL NEZHAT DORSEY MACHINE PNEUMATIC TUBE SYSTEM PORTABLE CYSTO TABLE RONGEUR PULSEVAC IRRIGATION/ASPIRATION MACHINE STAMEY NEEDLE SURE CLOSURE SKIN DEVICE SYNTHES LARGE FRAGMENT TRAY - PLASTIC - DR NUNNERYS TRAY - LARGE BONE VAN BURENS ZIMMER HIP INSTRUMENTS

BIOHAZARDOUS BOXES CORRUGATED/TAPE BLANKET WARMER CAMERA CANDY CANE STIRRUPS C-ARM DRAPE CELL SAVER MACHINE AND SUPPLY BOX DOPPLER GELPI GIA 55 (TLC55) STAPLES GREEN RETRACTOR GUT ALLIS PEEL PACK HAMBURGER RETRACTOR IOBAN DRAPE LAP PACK LASER LIGACLIP APPLIERS PADGET DERMATONE/BLADE PHYSICIANS LOUPES & OPTIVISOR PROCTO SET UP/PLUG IN TOO PYXIS MACHINE RAYTEX RICHARDSON RETRACTOR SHROUD KIT for postmortem care SLUSH MACHINE SMOKE EVACUATOR FILTERS SPARE EQUIP LIGHT BULBS TOURNIQUET TRACE CART - LAP CHOLE Drape pack TRAY LACRIMAL DUCT TRAY T&A UNSTERILE RAZORS

Must be completed and submitted for a grade for this course.

Find The Item and Write In Where You Found It. Instructor.

If You Have Any Problem, See

19

Clinical Internship in Perioperative Nursing

20

Clinical Internship in Perioperative Nursing

CASE PULLING ASSIGNMENT (8-10 Cases) Day 1

Clinical Adjunct Designee or Preceptor assigns student to case preparation area to pull cases, and instructs student regarding the techniques to prepare for a case. Student will receive instruction regarding preference cards utilized including storage of sterile supplies, handling techniques to follow, supply assembly, positioning tools, and general case cart setup for specific procedures. Student is assigned to gain experience with case cart preparation and sterile supply room organization to with the preference cards, location of supplies, and case preparation. Student is to determine a plan of action for case preparation in the operating room and then assess for variances in the plan with the actual experience. A. Assignment a. Checks case cart with preference card. b. Adds any items not pulled including positioning tools. c. Make sure next case for each room has been pulled. Makes sure any add-on cases are pulled. d. When assigned by case pulling personnel, pushes case cart outside assigned room (outer hall) for each case after verification for completeness Paperwork to be Submitted for this assignment: a. Complete the case pulling assignment on the first time assigned to the supply room. b. Evaluation: During one of your experiences (after you are comfortable pulling cases) give preceptor that you are working with the student case preparation skills check off evaluation to complete. Please note: anytime that you are not assigned to a clinical case due to downtime (case canceled; delay in case, etc), you are expected to report to case pulling or the instrument room to gain further experience in these areas.

21

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22

Clinical Internship in Perioperative Nursing

Case Pulling Learning Activity

Utilize preference card and schedule. Pull cases when not assigned to a case or room. Need to pull at least 8-10 cases. Choose three cases to pull the first time assigned and complete the following information on each one. Submit as documentation of activity.

1. Case #1 a. Case______________________________Surgeon____________Age of Pt__________ b. Basics: Drape______________________________________________________________ Instruments_________________________________________________________ Suture______________________________________________________________ Other Supplies______________________________________________________ Dressing____________________________________________________________ Prep_______________________________________________________________ Positioning/items_____________________________________________________

Case #2 a. Case______________________________Surgeon____________Age of Pt__________ b. Basics: Drape______________________________________________________________ Instruments_________________________________________________________ Suture______________________________________________________________ Other Supplies_______________________________________________________ Dressing___________________________________________________________ Prep_______________________________________________________________ Positioning/items____________________________________________________ Case #3 a. Case______________________________Surgeon____________Age of Pt__________ b. Basics: Drape______________________________________________________________ Instruments_________________________________________________________ Suture_____________________________________________________________ Other Supplies______________________________________________________ Dressing____________________________________________________________ Prep_______________________________________________________________ Positioning/items_____________________________________________________

4. Make a copy of the three other preference cards.

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Clinical Internship in Perioperative Nursing

CASE PULLING EVALUATION Submitted after pulling cases. Filled out by preceptor.

NAME____________________________DATE___________EVALUATOR________________ __
MEETS STANDARDS, SHOWS INITIATIVE..................................5 MEETS STANDARDS, MEETS EXPECTATIONS..........................4 UNDERSTANDS STANDARDS, NEEDS MORE PRACTICE.......3 STATES STANDARDS, UNACCEPTABLE PRACTICE................2 INSERVICED ON STANDARD, UNACCEPTABLE PRACTICE..1 STANDARDS ARE DEFINED AS THE BASIC PRINCIPLES OF ASEPTIC AND OPERATING ROOM CARE AS DEFINED BY AORN STANDARDS. STANDARD OPERATING ROOM TECHNIQUE.

1 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Arrives on time Utilizes preference card correctly to ensure case complete (positioning items also) for room turnover Informs appropriate personnel when items are not available ASAP. Utilizes correct body mechanics, work simplification techniques to reduce strain. ex. lifting trays Case pulled and ready on time. ( no room delay) Keeps work area neat, clean and organized. Returns items to sterile supply storage correctly. Correctly identifies supplies, instruments and trays Checks with front desk frequently for add ons; set up next case outside the assigned room. Pulls add on emergency cases in a speedy and timely manner. Handles packages and supplies appropriately and stores correctly. (Does not put sterile supplies on floor/wet areas, etc) Identifies breaks potential event related contamination that may occur and corrects same. Handles/packages sharp items correctly Shows interest/ asks questions appropriately Keeps coworker/team members informed. Shares info quietly and plans ahead Follows directions within a timely fashion. On time returning from lunch and breaks.

COMMENTS

12. 13. 14. 15. 16. 17.

COMMENTS:

STRENGTHS:

AREAS TO WORK ON:

Reviewed with Student: Date_______________Instructor Signature__________________Student Signature_____________________ Comments attached____Yes____No 24

Clinical Internship in Perioperative Nursing

INSTRUMENT ROOM ASSIGNMENT ROTATION (Instrument Decontamination, Identification, Preparation)

Day 2-3 (8 Hours) Student receives instruction and experience regarding the techniques in instrument decontamination, identification, preparation, and sterilization techniques. Student is to determine a plan of action for instrument decontamination and sterilization in the operating room for flash sterilization and routine sterilization and then assess for variances in the plan with the actual experience. Assigned to assist with instrument preparation to gain experience with the instrument handling, decontamination, flash autoclave utilization, wrapping and packaging procedures, instrument count sheets, and instrument identification. 1. Assignment Areas of training: A. Manual Decontamination aa. PPE bb. techniques cc. solutions/Safety precautions B. Operation Washer/Sterilizer C. Assembly of trays aa. inspection bb. testing cc. cleaning dd. lubrication D. Sterilization/Disinfection
aa. bb. cc. dd. ee. flash Sterilizer operation*** steris operation**** cidex biological and dart preparation tests for gas (ETO)

E. F.

Transportation to CSR Wrapping/Tray Assembly

aa. bb. cc. dd. ee. Peel pack Wrappers Trays Vac-pac Indicators

2.

Paperwork to be Submitted: A. Evaluation: During one of your experiences (after you are comfortable in the instrument room) give preceptor that you are working with the student case preparation skills check off evaluation to complete. Gives staff preceptor the student evaluation sheet to complete. Please note: anytime that you are not assigned to a clinical case due to downtime (case canceled; delay in case, etc), you are expected to report to case pulling or the instrument room to gain further experience in these areas.

3.

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Clinical Internship in Perioperative Nursing

26

Clinical Internship in Perioperative Nursing

INSTRUMENT ROOM EVALUATION

Submitted during orientation to clinical site.

NAME____________________________DATE___________EVALUATOR______________
Meets Standards, Exceeds Expectations, Exceeds Goals................5 Meets Standards, Meets Expectations, Meets Goals.......................4 Meets Standards, Met Requirements, Needs to Improve ..3 Standard States Standards, Expectation not met, Needs Practice.2 Inserviced on Standard, Expectations not met...1 Standards Are Defined As The Basic Principles Of Aseptic And Operating Room Care As Defined by AORN Standards. Operating Room Technique.

1 1. Arrives on time 2. Duties of Instrument Technician explained 3. Utilizes Personal Protection Equipment in care of instruments. 4.Cares for and handles/cleans/inspects/tests: a. surgical instruments correctly b. powered equipment (drills/saws) c. laparoscopic equipment d. micro instruments 5. Utilizes correct body mechanics, work simplification techniques to reduce strain. Ex: lifting trays 6. Manually decontaminates instrumentation per procedure. Dons appropriate PPE. 7. Utilizes Washer/Sterilizer correctly(loading; use) 8. Utilizes instrument list to complete tray correctly. 9. Correctly identify instrument trays and contents. 10. Prepares instruments for gas sterilization correctly 11. Prepares instruments for steam sterilizing correctly 12. Secures instruments/prepares packaging correctly a. peel packs (double; indicator; appropriate) b. wrapper (folded for correct presentation) c. containers (secures correctly) 13. Labels all items correctly with process date; item; OR; external indicator and initials. 14. Transports instruments CSR correctly 15.Handles/packages sharp items correctly 16. Informs appropriate personnel of missing or defective items from trays/instrument. 17. Shows interest/ asks questions appropriately 18. Follows directions within a timely fashion. 19. On time returning from lunch and breaks. 20. Keep coworker/team members informed. Shares info quietly and plans ahead 21. Operates Steris (BMC) or Sterrad (GCMC) Sterilizer correctly per instructions. 22. Operates flash Sterilizer correctly per instructions 23. Correctly utilizes/checks cidex correctly. 24. Keeps work area neat, clean, and organized.
COMMENTS: STRENGTHS:

COMMENTS

AREAS TO WORK ON:

Reviewed with Student: Date______________________

Student Signature_________________________________ Instructor Signature_______________________________

27

Clinical Internship in Perioperative Nursing

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Clinical Internship in Perioperative Nursing

ASSIGNMENTS SKILLS TO BE COMPLETED SUBMIT FORM Circulator Role Skill Date Completed
Completes Scavenger Hunt Position Supine Position Prone Position Lateral Position Lithotomy using candy canes Position Lithotomy using Allen Stirrups Skin Prep Abdominal Prep Skin Prep Vaginal Prep Skin Prep Extremity ESU Application and operation of Electrocautery Unit Laparoscopic Case Setup with Monitors/Camera Power Instrument Nitrogen Connection X-Ray Specimen Care Documentation OR record completed correctly without assistance

Scrub Role Skill

Pulls case Open case Sterile Supplies using Preference Card Gown and Glove Observe Case Scrubbed in Sterile Scrub in and setup a minor case Assists Surgeon to gown Assists with Laparotomy Draping Loads and passes suture correctly Assembles Balfour Disassembles case and transports instruments to processing

Date Completed

29

Clinical Internship in Perioperative Nursing

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Clinical Internship in Perioperative Nursing

CLINICAL INTERNSHIP - NURSE (CIRCULATOR) SKILLS EVALUATION

Name________________________________ Date____________________Evaluator_______________________ Lowest Possible score 104 with maximum score of 130 to meet all goals (* items require 4-5 level).
MEETS STANDARDS/EXCEEDS GOALS...........5 MEETS STANDARDS/ MEETS GOALS......................4 MEETS STANDARDS/MET REQUIREMENTS/NEEDS TO IMPROVE...3 STATES STANDARDS / NEEDS PRACTICE.....2 INSERVICED ON STANDARDS/ GOALS NOT MET.......................1 Standards are defined as the basic principles of aseptic and operating room care as defined by AORN standards. Standard operating room technique

1 2 3 1. Arrives on time for report or to prepare for case 2.Checks with front desk for instructions. Prepares for case. Researches
assignment PRN. Communicates changes such as closing; added procedures during case

4 5
*

Comments

3.Checks Case Supplies. Supplements set up correctly. Utilizes preference cards correctly prior to case start. 4.Opens sterile supplies with out contaminating. Check exp. Dates indicators/event
related package indications to verify sterility. Takes action PRN.

* * * * *

5. Greets & transfers patient to OR table correctly verifies consent; chart preop checklist; site; physician; Obtains lab/x-rays/blood in a timely manner 6. Completes Surgical Prep according to policy. 7. Positions patient according to policy. Protects from injury; utilizes positioning tools correctly. Modifies for age as appropriate. 8.Gloves using open technique correctly 9.Maintains room clean and orderly during case. 10. Assists with Mayo and Back Table Setup/draping: standard for type case.
Connects equip & pulls up.

11. Initiate/ Completes counts (sponges/needles/instruments) 12. Keeps attention on the surgical procedure. Shows interest. Anticipates next step
in procedure & establishes priorities. Reacts smoothly & quickly to surgeon/scrub requests.

13.Observes sterile field at all times. Guards sterile field assertively. Initiates action for
breaks

14. Completes documentation completely and accurately.

a. b. c. d. Patient Assessment completed and documented Documents patient identification, surgical site verification, and ensures consent/preop checklist is present and accurate. Initiates Care Plan (Anxiety, Safety, Hypothermia Prevention) Modifies care plan and interventions appropriately for age 1. Neonate/Infant (Birth to 18 months) 2. Pediatric (19 months to 11Yrs) 3. Adolescent ( 12 17 Yrs) 4. Adult (18-64 Yrs) 5. Geriatric (65 plusYrs) 6. Modifies appropriately for handicaps, mental and physical conditions. *

15. Handles, tape correctly.

passes, and stores sharps safely. 16. Assists with dressing/drain. Cleans all prep materials from patients skin. Secures 17. Removes and cares for items after the case correctly (Specimens). 18. Assists with equipment removal and room turnover. Ensures all equip. &
supplies are returned to the appropriate storage place. Meets room turnover goals.

19. On time returning from lunch and breaks. 20. Asks appropriate questions pertinent to the case. Maintains a quiet professional
room. (limits noise)

21. Keep coworker/team members informed.

premedicates; RR bed

Shares info quietly and plans ahead. ex

22. Demonstrates Patient Centered Care. Functions as Patient Advocate while meeting patients needs.
Comments (Use Back PRN) To Obtain Grade Divide Total Score Achieved By The Total Number Possible (4x22 = 88points) : Strengths: Areas To Work On:

Reviewed with Student: Date______________________

Student Signature_________________________________ Comments on back__ Preceptor Signature_______________________________ Need to have preceptor complete at weekly intervals to provide you with feedback during the 150 hours of experience. One should be completed by your preceptor on the last day of your clinical experiences and submitted for grade.

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Clinical Internship in Perioperative Nursing

CLINICAL INTERNSHIP EVALUATION SCRUB ROLE

Name______________________________Date___________Evaluator___________________
* Items are critical items must have a 4-5 level.
MEETS STANDARDS/EXCEEDS GOALS.........5 Standards are defined as the basic principles MEETS STANDARDS/ MEETS GOALS.....................4 of Aseptic And Operating Room Care as MEETS STANDARDS/MET REQUIREMENTS/NEEDS TO IMPROVE ...3 defined by AORN Standards. Standard STATES STANDARDS / NEEDS PRACTICE.....2 Operating Room Technique. INSERVICED ON STANDARDS/ GOALS NOT MET...........................1 Points Points 1 2 3 4 5 N/A Wt. Possible Student 5 20 1. Washes hand.

Comment

2. 3. 4. 5. 6. 7.

Sterile room pre-setup. Assembles all required Supplies & equipment. (Opens in correct sequence: drape pack, basin kit, instrument set, surgical scrub setup); Placed correctly to be opened. Opens sterile supplies maintaining sterile technique. (Inspects package; opens away from self first; unsterile arm does not reach over; No unsecured edges) Dons appropriate protective personal equipment. (eyewear, mask, X-ray gown prn) Performs Surgical Hand Scrub Correctly. Dons sterile gown and gloves using closed glove technique. Prepares the instrument Area to receive tray with a blue towel without contaminating. Lifts out the inner instrument tray.
Waits for circulator to check the inside of container and verify sterility. Places tray on top of blue towel

20

*20

5 5 5 5

*20 *20 *20 20

8. 9. 10. 11.

Prepares the mayo stand: Drapes mayo stand, places ties on mayo cover, towel, towel rolls Sets up basin. Places items out of basin in place on back table, mayo, etc.
Initiates counts of raytex, laps, suture, instruments. Counts initial, closure of peritoneum, closure of skin. Starts at field, mayo, back table, kick bucket. Prepares draping supplies (towel with bovie/suction/light handles/two laps); drape, towels, clips, surgeon's gown/gloves.

5 5 5

20 20 *20

5 5 5 5 5 5

20 20 20 20 20 20

12. Completes Back table setup. 13. Completes Mayo stand Setup for case. ( 5-6 hemostats, 2-4
kelly's, allis's , right angles, needle holders, pickups, etc.)

14. Conserves energy-time-motion: does not move an item over 3 times before it is in final setup place. 15. Completes setup in a timely fashion. (10-15 min) 16. Drapes appropriately for procedure. Drapes with assistance from instructor(surgeon). (stands well back from table edge; cuffs drape over hand and steadies sheet with other hand; watches hand in motion) 17. Passes instruments correctly as requested by surgeon. 18. Maintains sterile technique - if breaks in technique identifies per self or responds correctly. 19. Hands: Keeps hands at table level only. Maintains hands in
sight, not above shoulder height or lower than table or waist level. 20. Faces Sterile Field at all times. Does not walk between two sterile fields. Maintains 12 distance between sterile and unsterile areas.

5 5

20 *20

21. Guards Sterile Field Assertively.

Maintains field within sight and grouped closely together. Instructs others to maintain proper distance. Skills Lab Grade : 94100% (A) 86-93%(B) 75-85% (C) - Satisfactory [ 65-74% (D) 0-64 (F) ] Unacceptable Grade: _____ % ____ (Divide Student Total by Possible 360 at Level 4/Satisfactory) Possible Total 360 COMMENTS(Use Back of Form PRN: Strengths identified: Suggestions for improvement:

Total

Reviewed with Student: Date______________________ Student Signature_________________________________ Comments on back__ Preceptor Signature_______________________________ Need to complet at ____1st Attempt ______2nd Attempt_____3rd Attempt least 3 experiences. Submit one form for grade. Scrub cases should be simple minor cases such as breast biopsy, hernia repair, excision of 32 mass, etc.

Clinical Internship in Perioperative Nursing

NUR2949 Perioperative Nursing COOP Class Course Completion Documentation Checklist and Clinical Log
I LAB Components
1) Positioning of Surgical Patients Instruction/video observation Lab Skills Checkoff Completed 2) Surgical Skin Preparation Instruction/video observation Lab Skills Checkoff Completed 3) Electrosurgery Instruction/video observation Lab Skills Checkoff Completed 4) Scrubbing Gowning and Gloving Instruction/video observation Lab Skills Checkoff Completed 5) Establishment and Maintenance of Sterile Field (Universal Case Setup) Instruction/video observation Lab Skills Checkoff Completed 6) Circulator Evaluation 1st Mock Breast Biopsy Lab Skills Checkoff Completed 7) Scrub Role Evaluation 2nd Mock Breast Biopsy Lab Skills Checkoff Completed 1) Scavenger Hunt Completed and Form submitted 2) Case Pulling Assignment Case Pulling Learning Activity Form submitted Case Pulling Evaluation Submitted 3) Instrument Room Rotation Instrument Room Evaluation submitted 4) Skills List Skills List Form completed and submitted 5) Circulator Evaluation Evaluation Form #1 submitted for Grade 6) Scrub Evaluation Evaluation Form #1 submitted for Grade 7) Log of Hours Log of Hours completed and submitted 150 volunteer hours (includes Lab time)

II Clinical Components Completed

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Clinical Internship in Perioperative Nursing

Log of 150 Voluntary Hours

Date Time In Time Out Assignment Total # of Hours Preceptor Signature

TOTAL HOURS 34

Clinical Internship in Perioperative Nursing Time Time In Out Beginning Total from Previous Page Date Assignment Total # of Hours Preceptor Signature

TOTAL 35

Clinical Internship in Perioperative Nursing Time Time In Out Beginning Total from Previous Page Date Assignment Total # of Hours Preceptor Signature

TOTAL

36

Clinical Internship in Perioperative Nursing

37