Professional Documents
Culture Documents
for
Registered Nurses
Caring for
July 2009
Version 3
1. Bedside Safety
5. Documentation
Observation chart
Fluid balance chart
Care plan
9. Nutritional Care
Enteral nutrition
Glycaemic control
CCaNNI 1
ICU Nursing Skills
July 2009
Version 3
Introduction
The following skills document has been developed by the Education Sub
Group of the Critical Care Network (NI)
The following is based upon the assumption that level 3 care (Intensive Care)
will be at least doubled within each Trust and that the normal standards of
care and staff ratios will be altered during a pandemic escalation.
The remit was to identify additional skills that are needed by non ICU staff at
the same time recognising the skills that are already available. In this light we
assume staff will have up-to-date core skills such as; administration of IV
drugs, blood administration, safe handling etc and have therefore not included
these in our recommendations.
Signatures are used to signify that the skills have been demonstrated
/discussed with a member of staff and NOT as an assessment of competence.
This process can be delivered in own work place by an appropriate member of
staff (nurse, doctor, technician)
CCaNNI 2
ICU Nursing Skills
July 2009
Version 3
Checks Suction ♦ Ensure suction assembled, attached to
patient and working effectively
♦ Ensure various sizes of closed/open suction
catheters available
Intubation Tray / ♦ Aware of location, contents and purpose of
Trolley equipment.
Cardiac Arrest trolley ♦ Aware of location, contents and purpose of
equipment.
Alarms ♦ Check monitor, pump and ventilator alarms
are activated and responded.
Lines & ♦ Check all lines/infusions labelled & dated
Infusions according to local policy
♦ Check all infusions
rate/volume/dose/additives/expiratory
date/connections
Pressure ♦ Check and change pressure bags/systems as
bag/transducer per local policy
Planning & Co- Effective ♦ Ensure all electrical equipment plugged in,
ordination Bedside switched on and leads secured.
of Care management ♦ In the event of equipment failure calls for
help.
♦ Aware of need to maintain a clean
uncluttered bedside/unit environment
♦ Remove equipment for decontamination
when no longer required
♦ Aware of need to maintain bedside stock
♦ Ensure vacant bed spaces ready for new
admissions at all times.
♦ Do not leave patient unobserved
CCaNNI 6
ICU Nursing Skills
July 2009
Version 3
Care of arterial ♦ NEVER INJECT VIA THIS ROUTE
line ♦ Dressing & site check (as per unit policy)
♦ Blood sampling
♦ Keep site exposed
♦ Correctly labelling
Arterial Line Positioning / ♦ Correct position transducer
Monitoring Patency ♦ Recognise normal trace / accuracy of
waveform
♦ Recognise when to call for help to
troubleshoot waveform, line problems
♦ Know how to flush line
♦ Understand importance of No air in line
♦ Check pressure bag
Check for:
♦ Thrombosis
♦ Peripheral ischaemia
♦ Haemorrhage
♦ Infection
♦ Call for help – if any of above present
Removal of ♦ Removal as per unit guidelines
Arterial line ♦ Aware of post line removal observations
Central Insertion Assist with insertion of catheter
venous procedure
Catheters Care of central ♦ Check line sutured in and secured
line ♦ Ensure lines labelled and dated and
documented accurately
♦ Perform dressing change and site check as
per unit protocol
Central Positioning / ♦ 4th intercostal space mid axilla line
Venous patency ♦ Recognise trace / accuracy of wave-form
Pressure ♦ Recognise when to call for help to
Monitoring troubleshoot wave-form / line problems
Flushing / no air in line
CCaNNI 7
ICU Nursing Skills
July 2009
Version 3
Fluid Fluid replacement ♦ record fluid replacement
Management ♦ Recognise early signs of deteriorating renal
function and report same
CCaNNI 8
ICU Nursing Skills
July 2009
Version 3
Nursing Practice Skill 10 Psychosocial / Spiritual Care
CCaNNI 9
ICU Nursing Skills
July 2009