NNA SKILLS CHECKLIST



STUDENT NURSE

PRECEPTORSHIP HEMODIALYSIS SKILLS CHECKLIST

Name: _________________________ Clinic: ___________________

Date Started Training: ________________ Date Completed Training: _____

Instructions for use:

• All hemodialysis procedure skills listed in the first column will be explained and/or demonstrated to the student nurse by the preceptor. After completion of the demonstration, the trainer will initial and date the second column.

• The student nurse will then explain and demonstrate the procedural skill to the preceptor while being corrected and re-instructed as needed. After completion, the third column will be initialed and dated by the preceptor.

• After sufficient guidance and practice of the procedure, the student nurse will be rated on the performance of the procedure by the preceptor. All procedures must receive a satisfactory rating or will be repeated until a satisfactory rating is obtained. After a satisfactory performance of the skill, the trainer will date and initial the fourth column.

• Skills determined by the _________ as not assigned to the student nurse by the clinic will be indicated by a "N/A" (not authorized) placed by the procedure in column 2 and initialed and dated by the Facility Manager and a representative of the school of nursing.

• Upon satisfactory completion of the preceptor program, the student nurse will be eligible to work as a dialysis technician.

Preceptor Name: ____________________________ Preceptor Initials: _________

|INFECTION CONTROL |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

|UNIVERSAL PRECAUTIONS | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |1. Demonstrates appropriate use of barrier precautions | | | | | | |

| |2. Recalls and demonstrates sharp | | | | | | |

| |instrument and needle precautions | | | | | | |

| |3. Recalls high risk procedure precautions | | | | | | |

| |4. Recalls appropriate use of respiratory resuscitation | | | | | | |

| |equipment during cardiac and respiratory arrests | | | | | | |

| |5. Properly demonstrates appropriate cleaning and disinfecting | | | | | | |

| |of surfaces and equipment | | | | | | |

| |6. Properly performs body fluids spill disinfection procedure | | | | | | |

| |7. Properly disposes of contaminated or infectious waste | | | | | | |

| |8. Recalls isolation procedure | | | | | | |

| |9. Properly demonstrates appropriate hand washing technique | | | | | | |

| |10. Properly performs isolation procedure for patient care | | | | | | |

| |during dialysis | | | | | | |

| |11. Properly obtains and handles isolation blood specimens | | | | | | |

| |12. Properly performs and/or verbalizes airborne precautions | | | | | | |

| |13. Properly performs and/or verbalizes contact precautions | | | | | | |

| |14. Properly performs and/or verbalizes general infection | | | | | | |

| |control measures | | | | | | |

| |15. Demonstrates aseptic technique | | | | | | |

| |16. Verbalizes understanding of Post exposure follow up policy | | | | | | |

| |17. Verbalizes understanding TB Exposure Control Plan | | | | | | |

|Operation of Delivery System |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |1. Properly performs system start up procedure | | | | | | |

| |2. Properly performs alarm systems function test | | | | | | |

| |3. Properly performs manual conductivity test | | | | | | |

| |4. Properly performs manual | | | | | | |

| |temperature test | | | | | | |

| |5. Properly performs manual pH test | | | | | | |

| |6. Properly performs manual pressure holding test (IF | | | | | | |

| |APPLICABLE) | | | | | | |

| |7. Properly performs basic operator troubleshooting | | | | | | |

|Operation of Delivery System Cont’d |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |8. Properly cleans and disinfects exterior of machine | | | | | | |

| |9. Properly initiates chemical disinfect procedure and labels | | | | | | |

| |machine with RTK sign (Right to Know label for chemical) | | | | | | |

| |10. Properly tests for residual disinfectant after disinfectant| | | | | | |

| |dwell | | | | | | |

| |11. Properly initiates heat disinfect procedure | | | | | | |

| |12. Properly initiates standard rinse procedure | | | | | | |

| |13. Properly initiates acetic acid rinse procedure | | | | | | |

| |14. Properly initiates bleach rinse procedure | | | | | | |

| |15. Documents procedures performed and results | | | | | | |

| |16. Properly demonstrates using the Sodium Variation system | | | | | | |

| |17. Properly demonstrates using the Ultrafiltration Profiling | | | | | | |

| |System | | | | | | |

|DIALYSIS DELIVERY SYSTEM |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |Properly operates the Fresenius 2008 H | | | | | | |

| |Properly operates the Fresenius 2008 K | | | | | | |

| |Properly operates the Cobe C 3 | | | | | | |

| |Properly operates the Baxter 1550 | | | | | | |

| |Properly operates the Baxter SPS 550 | | | | | | |

| |Properly operates the Althin “Tina” | | | | | | |

| |Other: | | | | | | |

| |Other: | | | | | | |

|VASCULAR ACCESS PROCEDURES |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |Properly assesses access for function and lack of pathology | | | | | | |

| |Properly cleans needle site with appropriate disinfectant | | | | | | |

| |Properly cannulates fistula at 25( angle | | | | | | |

| |Properly cannulates an AV graft at 45( angle | | | | | | |

| |Properly performs pre-dialysis CVC care (as allowed by state | | | | | | |

| |nursing practice) | | | | | | |

| |Properly changes CVC dressing (as allowed by state nurse | | | | | | |

| |practice act) | | | | | | |

| |Properly performs post dialysis vascular access care | | | | | | |

|VASCULAR ACCESS PROCEDURES Cont’d |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |Properly uses safety guard provided on needles | | | | | | |

| |Properly demonstrates butterfly taping | | | | | | |

| |Properly discontinues dialysis with CVC (as allowed by state | | | | | | |

| |nurse practice act) | | | | | | |

| |Properly initiates treatment with internal vascular access | | | | | | |

| |Properly discontinues treatment with internal vascular access | | | | | | |

| |Properly initiates treatment with CVC (as allowed by state | | | | | | |

| |nurse practice act) | | | | | | |

| |Properly assesses access for function and cessation of bleeding| | | | | | |

| |from needle sites | | | | | | |

|ADMINISTRATION OF MEDICATIONS |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

|(AS ALLOWED BY STATE NURSE PRACTICE ACT) |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

|PREPARATION AND ADMINISTRATION OF MEDICATIONS |

| |Properly verifies the medication prescription and patient | | | | | | |

| |Obtains appropriate supplies/correct needle and syringe | | | | | | |

| |Properly reads and checks medication label three times | | | | | | |

|ADMINISTRATION OF MEDICATIONS |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

|(AS ALLOWED BY STATE NURSE PRACTICE ACT) |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |Properly recalls the five rights of administering medications | | | | | | |

| |Properly documents the administration of medications on flow | | | | | | |

| |sheet | | | | | | |

| |Demonstrates proper aseptic technique preparing and | | | | | | |

| |administering medications | | | | | | |

|ADMINISTRATION OF LIDOCAINE |

| |Recalls signs and symptoms of adverse reactions | | | | | | |

| |Properly administers ID xylocaine | | | | | | |

| |Proper angle of needle insertion 15( | | | | | | |

| |Aspirates prior to injection | | | | | | |

|ADMINISTRATION OF HEPARIN |

| |Recalls signs and symptoms of adverse reactions | | | | | | |

| |Recalls methods of heparin administration | | | | | | |

| |Recalls types of heparin protocols | | | | | | |

|ADMINISTRATION OF HEPARIN |

| |Properly administers heparin bolus | | | | | | |

| |through venous line | | | | | | |

| |Waits 3 minutes after bolus administration prior to treatment | | | | | | |

| |initiation | | | | | | |

|ADMINISTRATION OF MEDICATIONS |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

|(AS ALLOWED BY STATE NURSE PRACTICE ACT) |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

|ADMINISTRATION OF NORMAL SALINE |

| |Recalls indications for use during | | | | | | |

| |hemodialysis | | | | | | |

| |Properly administers normal saline per | | | | | | |

| |procedure | | | | | | |

| |Properly follows precautions during | | | | | | |

| |normal saline administration | | | | | | |

| |Recalls the signs and symptoms of fluid volume overload | | | | | | |

| |Properly recalls the systemic effects of normal saline | | | | | | |

|RISKS AND HAZARDS OF HEMODIALYSIS |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

|COMMON OCCURENCES | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |Recalls and/or responds properly to hypotension | | | | | | |

| |Recalls and/or responds properly to patient complaints of chest| | | | | | |

| |pain | | | | | | |

| |Recalls and/or responds properly to patient cramps | | | | | | |

| |Recalls and/or responds properly to patient complaints of | | | | | | |

| |nausea and vomiting | | | | | | |

| |Recalls and/or responds properly to pruritis | | | | | | |

|RISKS AND HAZARDS OF HEMODIALYSIS |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| UNUSUAL OCCURENCES |

| |Recalls and/or responds properly to an air embolism | | | | | | |

| |Recalls and/or responds properly to anaphylactic reactions | | | | | | |

| |Recalls and/or responds properly to cardiac/resp. arrest | | | | | | |

| |Recalls and/or responds properly to hemolysis | | | | | | |

| |Recalls and/or properly performs infected access care | | | | | | |

| |Recalls and/or responds properly to an allergic reaction due to| | | | | | |

| |a medication | | | | | | |

| |Recalls and/or properly performs identifying fever source | | | | | | |

| |Recalls and/or responds properly to a pyrogen reaction | | | | | | |

| |Recalls and/or responds properly to angina | | | | | | |

| |Recalls and/or responds properly to arrhythmias | | | | | | |

| |Recalls and/or responds properly to back pain | | | | | | |

| |Recalls and/or responds properly to a blood loss | | | | | | |

| |Recalls and/or responds properly to crenation | | | | | | |

|RISKS AND HAZARDS OF HEMODIALYSIS |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| UNUSUAL OCCURENCES – Cont’d |

| |Recalls and/or responds properly to difficulty with needle | | | | | | |

| |insertion | | | | | | |

| |Recalls and/or responds properly to disequilibrium syndrome | | | | | | |

| |Recalls and/or responds properly to hypertension | | | | | | |

| |Recalls and/or responds properly to hypoglycemia | | | | | | |

| |Recalls and/or responds properly to a reaction of undetermined | | | | | | |

| |cause | | | | | | |

| |Recalls and/or responds properly to a rising venous pressure | | | | | | |

| |Recalls and/or responds properly to shortness of breath | | | | | | |

| |Recalls and/or responds properly to a dialyzer reaction | | | | | | |

| |Recalls and/or responds properly to transfusion reaction | | | | | | |

| |Recalls and/or responds properly to a seizure | | | | | | |

|TECHNICAL PROBLEMS |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |1. Recalls and/or properly evaluates a clotted dialyzer | | | | | | |

| |2. Recalls and/or properly evaluates a dialyzer blood leak | | | | | | |

| |3. Recalls and/or properly changes an arterial blood line | | | | | | |

| |4. Recalls and/or properly changes a venous blood line | | | | | | |

| |5. Recalls and/or properly replaces a dialyzer | | | | | | |

| |6. Recalls and/or responds properly to hematoma formation or | | | | | | |

| |infiltration | | | | | | |

| |7. Recalls and/or responds properly to blood flow problems | | | | | | |

| |8. Recalls and/or properly performs the emergency termination | | | | | | |

| |of dialysis | | | | | | |

| |9. Recalls and/or properly performs the hand crank during a | | | | | | |

| |power failure | | | | | | |

| |10. Knows the contents of the emergency evacuation kit | | | | | | |

|Emergency Procedures |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of Satisfactory|Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Performance by |Initials |

| | | |Trainee | |Trainee | |

| |Recalls and/or responds properly to a bomb threat | | | | | | |

| |Recalls and/or responds properly to a disaster | | | | | | |

| |Recalls and/or responds properly to patient evacuation procedure| | | | | | |

| |Recalls and/or responds properly to the fire drill procedure | | | | | | |

| |Demonstrates proper use of the fire extinguisher | | | | | | |

| |Recalls and/or responds properly to a facility fire | | | | | | |

| |Recalls and/or responds properly to emergency transfer of | | | | | | |

| |patients to the hospital from the clinic | | | | | | |

|LABORATORY PROCEDURES |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |Properly obtains blood specimens per procedure | | | | | | |

| |Properly obtains blood specimens for URR and KT/V | | | | | | |

| |determinations | | | | | | |

|LABORATORY PROCEDURES |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |Demonstrates proper basic laboratory skills: | | | | | | |

| |A. Demonstrates acceptable aseptic and isolation technique | | | | | | |

| |B. Properly labels specimens | | | | | | |

| |C. Properly fills out forms | | | | | | |

| |D. Demonstrates good technique collecting specimen | | | | | | |

| |E. Properly obtains specimen from arterial blood line port | | | | | | |

| |F. Properly obtains specimen from venous bloodline port | | | | | | |

| | G. Properly obtains specimen from vascular access port | | | | | | |

| |H. Properly obtains specimen for blood cultures (as allowed by | | | | | | |

| |state nurse practice act) | | | | | | |

| |I. Properly obtains blood specimen for transfusion | | | | | | |

| |J. Properly packs and prepares specimens for transport | | | | | | |

| |Blood glucose monitoring | | | | | | |

| |A. Properly performs blood glucose QC calibration | | | | | | |

| |B. Properly performs blood glucose monitoring | | | | | | |

|LABORATORY PROCEDURES |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |C. Properly performs operator maintenance procedures | | | | | | |

| |Demonstrates use of the hemoccult slide (as allowed by state | | | | | | |

| |nurse practice act) | | | | | | |

|OPERATION AND USE OF ANCILLARY EQUIPMENT |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |Properly operates, maintains, and inspects EKG Machine | | | | | | |

| |Knows location and contents of crash cart | | | | | | |

| |Properly operates, standardizes and maintains conductivity | | | | | | |

| |meter | | | | | | |

| |Properly demonstrates use of the AED | | | | | | |

|MEDICAL RECORDS | | | | | | |

| |Verbalizes understanding of confidentiality of medical records | | | | | | |

| |Demonstrates proper documentation in the medical record | | | | | | |

| |Demonstrates proper completion of the Incident Reporting | | | | | | |

| |system | | | | | | |

| |Verbalizes understanding of release of information from patient| | | | | | |

| |medical record | | | | | | |

| |Properly uses ESRD lab system | | | | | | |

|DIALYSATE BATH PROCEDURES |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |Properly prepares bicarbonate concentrate with bicarbonate | | | | | | |

| |mixer | | | | | | |

| |Properly cleans and disinfects bicarbonate mixer and containers| | | | | | |

| |Familiar with storage and distribution of acid concentrate | | | | | | |

| |Properly performs manual conductivity test of dialysate | | | | | | |

| |Properly obtains manual temperature of dialysate | | | | | | |

| |Properly performs manual pH testing of dialysate | | | | | | |

| |Properly performs presence test for bleach | | | | | | |

| |Properly performs bacterial culturing of dialysis delivery | | | | | | |

| |system (if applicable) | | | | | | |

| |Properly performs bacterial culturing of bicarbonate mixer (if | | | | | | |

| |applicable) | | | | | | |

|WATER TREATMENT PROCEDURES |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |1. Properly performs RO System start up procedure | | | | | | |

| |2. Properly performs the water hardness test | | | | | | |

|WATER TREATMENT PROCEDURES |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |3. Properly performs the chlorine/chloramine test | | | | | | |

| |4. Properly reads the total dissolved solutes meter (TDS Test) | | | | | | |

| |5. Properly reads pressure drops | | | | | | |

| |6. Properly records RO rejection and product flow rates | | | | | | |

| |7. Properly documents performance and operating parameters | | | | | | |

| |8. Properly performs RO System shut down procedure | | | | | | |

| |9. Properly performs manual RO bypass procedure | | | | | | |

| |10. Properly performs bacterial culturing of water treatment | | | | | | |

| |system | | | | | | |

| |11. Properly performs water treatment system disinfect | | | | | | |

| |procedure | | | | | | |

| |12. Properly rinses water treatment system free of disinfectant| | | | | | |

| |13. Properly reports to the charge nurse/administrator and | | | | | | |

| |technical water treatment deviations and abnormal quality test | | | | | | |

| |results | | | | | | |

|OTHER PROCEDURES |Date of Demonstration |Preceptor |Date of Return |Preceptor |Date of |Preceptor |

| |by Preceptor |Initials |Demonstration by |Initials |Satisfactory |Initials |

| | | |Trainee | |Performance by | |

| | | | | |Trainee | |

| |Properly endorses over patient assignment before leaving the | | | | | | |

| |floor in a consistent manner. | | | | | | |

| |Completed extra assignments in a timely manner. | | | | | | |

| |Completed all inservices. | | | | | | |

| |Effectively communicates with patients, families, and | | | | | | |

| |multidisciplinary team members. | | | | | | |

| |Refers problems/issues to appropriate multidisciplinary team | | | | | | |

| |member. | | | | | | |

|The above individual has received training and has demonstrated competency at performing |Preceptor Signature: _______________________________________ |Date: ________________ |

|procedures listed above. | | |

___________________________________ has received training in the above procedures satisfactorily as indicated above by a check.

Signature of Employee: _____________________________ Date: ___________

Signature of Medical Director: _______________________ Date: ___________

Signature of Education Coordinator ___________________ Date: ___________

Signature of Clinic Manager: ________________________ Date: ___________

Copyright 2005, American Nephrology Nurses' Association (ANNA).

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