internship program clinical skills achievement logbook · nebulizer . page 6 of 41 kingdom of saudi...

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Kingdom of Saudi Arabia Ministry of Education

Prince Sattam Bin Abdulaziz University College of Applied Medical Sciences

Nursing Department

المملكة العربية السعودية

وزارة الــتــعـــلـــيـــم

جامعة األمير سطام بن عبد العزيز

كلية العلوم الطبية التطبيقية

سم التمريضق

Internship Program

Clinical Skills Achievement Logbook

Name of Intern: ___________________________

Graduation Year: ___________________________

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Nursing Department





قسم التمريض

Contents Introduction ......................................................................................................................... 3

Internship Program Goals ................................................................................................... 3 Internship Program Objectives ........................................................................................... 3 Purpose of the Logbook ...................................................................................................... 3

Clinical Checklist Category: Medical Unit Rotation .......................................................... 4 Clinical Checklist Category: Dialysis Unit Rotation .......................................................... 7 Clinical Checklist Category: Surgical Unit Rotation .......................................................... 8

Clinical Checklist Category: Operating Room Rotation .................................................. 11 Clinical Checklist Category: Maternal and Obstetrics Unit Rotation ............................... 13

Clinical Checklist Category: Gynecology Unit Rotation.................................................. 15

Clinical Checklist Category: Labour and Delivery Room Rotation – Part 1 .................... 17

Clinical Checklist Category: Labour and Delivery Room Rotation – Part 2 .................... 20 Clinical Checklist Category: Pediatric Medical Unit Rotation ......................................... 22

Clinical Checklist Category: Pediatric Surgical Unit Rotation......................................... 26 Clinical Checklist Category: Neonatal/Pediatric Intensive Care Unit Rotation ............... 29 Clinical Checklist Category: Public Health Clinic Rotation............................................. 33

Clinical Checklist Category: Emergency Room Rotation ................................................ 34 Clinical Checklist Category: Intensive Care Unit Rotation .............................................. 37

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Nursing Department


ـــلـــيـــموزارة الــتــع




Introduction The internship program (also called internship year) consists of 48 weeks of clinical

training. It starts after the student's completion of his/her academic courses.

Internship program is considered as a complementary part of student's academic

program at the College of Applied Medical Sciences. The student shall not be eligible

to practice the profession until he/she completes the internship year.

Interns are assigned to different clinical units after the completion of the 4-year

nursing program.

The logbook includes a list of major clinical skills to ensure their achievement at each

specific training unit. It is designed to provide a guideline for nurse students during

the internship program.

The logbook is kept with the intern.

After completion of task, it is the responsibility of the intern to check and to

take the signature from immediate staff nurse trainer.

Upon the completion of the internship: The logbook should be submitted to the

Nursing Department at College of Applied Medical Sciences.

Internship Program Goals 1. To provide nursing students with an opportunity to strengthen nursing skills, apply

their knowledge in various clinical practices and demonstrate competency in practical

skill and procedure.

2. To facilitate the transition to professional role.

3. To develop an attitude of nursing caring.

Internship Program Objectives Upon completion of internship program, the professional nurse intern will:

1. Be acquainted with hospital policies and procedures.

2. Apply theoretical knowledge into various clinical setting.

3. Enhance effective communication skill.

4. Improve the ability to act independently and implement appropriate nursing

intervention.

5. Utilize appropriate available resources in patient care.

6. Ensure safe environment for patients, families and health care personnel.

7. Provide organized and quality patient care.

Purpose of the Logbook To emphasize major clinical skills in each unit rotation.

To assist in the follow up / progress of nurse intern throughout internship program.

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Nursing Department






Clinical Checklist Category: Medical Unit Rotation

Started From: ______/____/______ To _____/_____/_____

For each skill demonstrated by the intern, the preceptor/staff nurse trainer will sign in the

appropriate column. The nurse intern is able to discuss the policy and demonstrate the

following skills.

# List of Essential Skills Observed

(add Date of Achievement) Mastered

(add Date of Achievement) Remarks 1st 2nd 3rd 1st 2nd 3rd

1 Receiving and

endorsing of patients

(at end of shift)

2 Caring of patient

hygiene

3 Performing admission

procedures

4 Performing discharge

procedures

5 Measuring and

documentation of

vital signs

6 Performing physical

health assessment

7 Measuring and

recording weight and

height

8 Testing blood sugar

using glucometer

9 Medication - Performing

calculation of dosage

- Preparation and

administration of:

Oral Medication

- Preparation and

administration of:

Subcutaneous

Medication

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Nursing Department









- Preparation and

administration of:

Intravenous

Medication

- Preparation and

administration of:

Intramuscular

Medication

10 Performing CPR 11 Following aseptic

techniques in each

procedure

12 Documentation - Reviewing physician

orders on a regular

basis

- Documenting

accurately on hospital

forms

13 Assisting with safe

preparation and post

procedure care for

the following

procedures (as

applicable):

X-ray procedure

CT Scan

Endoscope

Ultrasound

ESWL procedures

Nuclear medicine

Insertion/Removal

of central lines

Caring of central

lines

CVP monitoring

14 Administration of

nebulizer

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Nursing Department










chemotherapy


thrombolytic therapy

17 Administration of anti-

hypertensive

18 Nursing care and

management of:

Unstable Angina and

Ischemic Heart Disease

19 Nursing care and

management of:

Diabetes / DKA

20 Nursing care and

management of:

Cerebral Vascular

Accident

21 Cardiac management - Cardiac monitoring - ECG recording/

interpretation

- Recognizing basic and

life threatening

dysrhythmias

- Recognizing and

interpreting of unstable/

deteriorating patients

signs and symptoms

- Recognizing and

interpreting of laboratory

findings

- Performing focused

assessment on presenting

complications

Head Nurse / Clinical Instructor Hospital Training Coordinator

Name: Name:

Signature and Date: Signature and Date:

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Nursing Department






Clinical Checklist Category: Dialysis Unit Rotation

Started From: ______/____/______ To _____/_____/_____



following skills.




1 Machine priming 2 Preparing of patient

for hemodialysis

3 Performing pre- and

post- dialysis care of

vascular access

(AVF, SC catheter)

4 Performing

predialysis patient

assessment

5 Performing patient

monitoring during

dialysis

6 Assisting in

peritoneal dialysis

7 Caring and

maintaining of exit

sites for peritoneal

dialysis

8 Infection controlling 9 Patient teaching 10 Obtaining blood

sample


Name: Name:


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Nursing Department






Clinical Checklist Category: Surgical Unit Rotation

Started From: ______/____/______ To _____/_____/_____



following skills.




1 Receiving and


(at end of shift)

2 Caring of patient

hygiene


procedures


procedures

5 Measuring and

documentation of

vital signs


health assessment

7 Measuring and

recording weight,

height


using glucometer



- Preparation and

administration of:

Oral Medication

- Preparation and

administration of:

Subcutaneous

Medication

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Nursing Department









- Preparation and

administration of:

Intravenous

Medication

- Preparation and

administration of:

Intramuscular

Medication


techniques in each

procedure


orders on a regular

basis

- Documenting


forms

13 Preoperative

Management

- Organizing a pre-

chest x-rays, ECG

- Preoperative forms

and preparations

- Deep breathing and

coughing exercises

- Leg exercises 14 Pre-procedural

preparations

- Colonoscopy - OGD - CT

15 Post-operative

Management

- Immediate post-

operative care

- Positioning - Ambulation

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Nursing Department









- Neurovascular

observation

- Measuring intake and

output

16 Surgical Dressing - Setup/of surgical field - Assessing of wound - Wound irrigation - Changing dressing

aseptically

- Packing a wound - Removal of sutures - Removal of staples - Drain monitoring - Drain removal

17 Renal/Urologic

Management

- Inserting an

indwelling catheter

- Continuous caring of

an indwelling catheter

- Maintaining of

continuous bladder

irrigation

- Caring of

nephrostomy tube

18 Orthopedic and care

of tractions

- Maintaining and

caring of traction

- Caring of Plaster cast - Applying of bandages


Name: Name:


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Nursing Department






Clinical Checklist Category: Operating Room Rotation

Started From: ______/____/______ To _____/_____/_____



following skills.




1 Using electronic life

support equipment

2 Vital signs and

monitoring

3 Draping, scrubbing,

gloving and gowning

techniques

4 Hemodynamic

monitoring

5 Performing sponge,

sharp and instruments

counts

6 Maintaining sterile

aseptic technique

7 Receiving patient at

surgical unit

8 Positioning patients

for operative

procedures –standard

surgical

9 Providing psycho-

social support of

patients

10 Providing immediate

postoperative care

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Nursing Department









11 Providing full PACU

report (including

consciousness,

breathing, blood

pressure,

oxygenation, motor

function, etc.)


Name: Name:


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Nursing Department






Clinical Checklist Category: Maternal and Obstetrics Unit Rotation

Started From: ______/____/______ To _____/_____/_____



following skills.




Antenatal care 1 Performing

abdominal palpation

(abdominal

maneuver)

2 Measuring and

recording fetal heart

rate using Pinard and

Doppler

3 Performing urine test 4 Administering of

oxytocin at delivery

for control of PPH

continuous infusion

5 Performing CTG

care: Applying CTG

machine

6 Monitoring

contraction and fetal

heart rate

7 Interpreting CTG

reading and reporting

abnormalities and

providing care as

indicated

8 Caring of high risk

patients

9 Elective LSCS

Preparing for CS

10 Providing pre and

post-operative care

11 Collecting cord blood

sample

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Nursing Department









12 Observing vaginal

bleeding, and

changing of dressing

13 Caring of patients

with hyperemesis

gravidarum

14 Performing urine

dipstick for ketones

and proteins

15 Caring of patients

with diabetes in

pregnancy

16 Post-natal routine

care

- Monitoring vital signs - Checking uterus and

lochia

- Assessing lower legs - Providing breast care - Educating mothers on

breast care

17 Documentation of

nursing note


Name: Name:


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Nursing Department






Clinical Checklist Category: Gynecology Unit Rotation

Started From: ______/____/______ To _____/_____/_____



following skills.




1 Care of gynecology

oncology patient

- Caring of patient

undergoing radiation

- Caring of patient

undergoing

chemotherapy

2 Pre–operative care - Performing pre-

operative shaving

- Inserting

catheterization

3 Post-operative

OB/Gynae care

- Changing dressing - Removing of vaginal

pack

- Removing of urinary

catheter

- Providing nursing

care for:

Dilatation and

Curettage

- Providing nursing

care for:

Vaginal/ Abdominal

Hysterectomy

- Providing nursing

care for:

Anterior / Posterior

Repair

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Nursing Department









- Providing nursing

care for:

Tubal Ligation

(Abdominal and

Laparoscopic)

- Providing nursing

care for:

Fistula Repair

- Providing nursing

care for:

Bartholin's Cyst

- Providing nursing

care for:

Ovarian Cyst

- Providing nursing

care for:

Cervical Cerclage

- Providing nursing

care for:

Pelvic Inflammatory

Disease

- Providing nursing

care for:

Salpingectomy /

Oopherectomy


Name: Name:


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Nursing Department


لـــيـــموزارة الــتــعـــ




Clinical Checklist Category: Labour and Delivery Room Rotation – Part 1

Started From: ______/____/______ To _____/_____/_____



following skills.




1 Receiving and


(at end of shift)

2 Caring of patient

hygiene


procedures


health assessment

5 Measuring and


height


using glucometer



- Preparation and

administration of:

Oral Medication

- Preparation and

administration of:

Subcutaneous

Medication

- Preparation and

administration of:

Intravenous

Medication

- Preparation and

administration of:

Intramuscular

Medication

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Nursing Department










techniques in each

procedure


orders on a regular

basis

- Documenting


forms

11 Admission of patient

in labour

- Measuring and

recording of vital

signs

- Palpating the

abdomen

- Assessing

contractions

- Testing urine - Administering fleet

enema as indicated

- Establishing an IV/

collection of blood

works

12 Management of

patient in labour

- Applying CTG

machine

- Monitoring

contraction and fetal

heart rate

- Interpreting CTG

reading and reporting

abnormalities and

providing care as

indicated

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Nursing Department









- Filling in Partogram - Administering

analgesia

- Administering

inhalational analgesia

- Administering

narcotics

- Preparing trolley for

delivery

- Preparing trolley for

suturing

- Performing vaginal

examination (under

supervision)

- Inserting urinary

catheter

- Assisting with normal

vaginal delivery

- Inspecting of the

placenta and collection

of cord blood

- Preparing patient for

emergency caesarian

section

13 Performance of

physical health

assessment and

nursing

management

- Pre-eclampsia - Hemorrhage (ante-

and post-partum)

- Fetal distress


Name: Name:


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Nursing Department






Clinical Checklist Category: Labour and Delivery Room Rotation – Part 2

Started From: ______/____/______ To _____/_____/_____



following skills.




1 Immediate newborn

care:

- Checking and

preparing newborn

resuscitation

- Suctioning of the

baby

- Providing eye care - Administering of

oxygen as indicated

- Participating in

advanced

resuscitation

- Assessing Apgar

score

2 Examining the

newborn

- Measuring the baby’s

head circumference


weight


height

- Inspecting umbilical

cord

- Applying

identification of

newborn

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Nursing Department









3 Caring of Mother - Providing perineal –

Episiotomy care

- Checking uterus and

lochia

4 Documentation - Filling in the birth

register

- Filling in the

obstetrical booklet

- Filling in the proper

documentation


Name: Name:


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Nursing Department






Clinical Checklist Category: Pediatric Medical Unit Rotation

Started From: ______/____/______ To _____/_____/_____



following skills.




1 Receiving and


(at end of shift)

2 Caring of patient

hygiene


procedures


procedures

5 Measuring and

documentation of

vital signs


using glucometer



- Preparation and

administration of:

Oral Medication

- Preparation and

administration of:

Subcutaneous

Medication

- Preparation and

administration of:

Intravenous

Medication

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Nursing Department









- Preparation and

administration of:

Intramuscular

Medication

- Preparation and

administration of:

Intradermal

Medication

- Preparation and

administration of:

Eye Drops

- Preparation and

administration of:

Ear Drops

- Preparation and

administration of:

Nasal Drops

- Preparation and

administration of:

Eye Ointments

- Preparation and

administration of:

Enema


techniques in each

procedure


orders on a regular

basis

- Documenting


forms

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Nursing Department









11 Measuring and

recording of:

- Abdominal Girth - Weight - Length - Head circumference - Chest circumference - Arm circumference

12 Collecting

laboratory

specimens

- Urine - Stool - Blood - Nasal secretions - Sputum - Throat swabs

13 Performance of

physical health

assessment and

nursing

management

- Cardiovascular - Respiratory - Gastrointestinal - Musculoskeletal - Integumentary - Neurological - Metabolic - Hematology and

Oncology

- Endocrine - Genitourinary

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Nursing Department









14 Patient safety - Using bedrails

appropriately

- Using restraints when

required

- Performing education

of mother

15 IV therapy - Care of IV Heplock/

cannula and cannula

flushing

16 Oxygen

administration/

respiratory therapy

- Using simple face

mask

- Using nasal cannula - Using tracheostomy

mask

- Using incentive

spirometry

- Using Ambu -

bagging (pediatric

and neonate

- Inserting oral airway


Name: Name:


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Nursing Department

العربية السعوديةالمملكة





Clinical Checklist Category: Pediatric Surgical Unit Rotation

Started From: ______/____/______ To _____/_____/_____



following skills.




1 Receiving and


(at end of shift)

2 Caring of patient

hygiene


procedures


procedures

5 Measuring and

documentation of

vital signs


health assessment

7 Measuring and


height


using Glucometer



- Preparation and

administration of:

Oral Medication

- Preparation and

administration of:

Subcutaneous

Medication

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Nursing Department









- Preparation and

administration of:

Intravenous

Medication

- Preparation and

administration of:

Intramuscular

Medication


techniques in each

procedure


orders on a regular

basis

- Documenting


forms

13 Surgical nursing

care

- Pre-operative care - Post-operative care - Positioning - Transporting of child - Care of wound - Caring of drains - Removal of sutures,

staples

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Nursing Department

ديةالمملكة العربية السعو








14 Performance of

physical health

assessment and

nursing

Management

- General surgery - Plastic surgery - Orthopedic - Renal - Neurological - Urinary surgery

15 Patient safety

- Using bedrails

appropriately

- Using restraints when

required


Name: Name:


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Nursing Department






Clinical Checklist Category: Neonatal/Pediatric Intensive Care Unit Rotation

Started From: ______/____/______ To _____/_____/_____



following skills.




1 Receiving and


(at end of shift)

2 Caring of patient

hygiene


procedures


procedures

5 Measuring and

documentation of

vital signs


health assessment

7 Measuring and


height


using glucometer



- Preparation and

administration of:

Oral Medication

- Preparation and

administration of:

Subcutaneous

Medication

- Preparation and

administration of:

Intravenous

medication

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Nursing Department




التطبيقية كلية العلوم الطبية





- Preparation and

administration of:

Intramuscular

medication


techniques in each

procedure


orders on a regular

basis

- Documenting


forms

13 Assessing newborn

reflexes

14 Measuring and

recording intake and

output

15 Feeding - Performing

nasogastric tube

feeding

- Performing

gastrostomy tube

feeding

- Performing

nasoduodenal tube

feeding

- Performing artificial

feeding for neonates

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Nursing Department









16 Performance of

physical health

assessment and

nursing

management

- Premature neonate

and low birth infant

- Term neonate - Congenital anomalies

(cardiac, respirator,

gastric, neurological,

urinary tract and

hydrocephalus)

- Down syndrome - Communicable

disease

- Respiratory disease

and nephritic

syndrome

- Seizures,

unconscious,

comatose

- Diabetic - Post-natal disorder - Jaundice - Infant of diabetic

mother

- Respiratory surfactant

disorder

- Care with sepsis 17 Patient safety and

oxygenation

- Using incubator and

phototherapy

- Using restraints –

when required

- Using radiant warmer - Applying daily and

terminal care of

incubators

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Nursing Department









- Providing incubator

oxygen therapy

- Performing postural

drainage

- Performing

tracheostomy

suctioning

- Performing oral

suctioning

- Performing nasal

suctioning

18 IV therapy - Caring of IV

(Heplock/cannula

dressing)

- Caring of IV

(Heplock/cannula

flushing)

- Blood transfusion


Name: Name:


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Nursing Department




طبيقيةكلية العلوم الطبية الت


Clinical Checklist Category: Public Health Clinic Rotation

Started From: ______/____/______ To _____/_____/_____



following skills.




1 Applying two nursing

processes for two

cases – mother with

her child

2 Working as care

provider in different

clinical areas

3 Implementing health

education about

chronic diseases

(such as diabetes,

hypertension)

4 Implementing health

education to women

regarding different

basic health concepts

and reproductive

health issues (such as

child care, breast

feeding, weaning,

immunization)


Name: Name:


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Nursing Department






Clinical Checklist Category: Emergency Room Rotation

Started From: ______/____/______ To _____/_____/_____



following skills.




1 Receiving and


(at end of shift)

2 Caring of patient

hygiene

3 Measuring and

documentation of

vital signs


health assessment

5 Measuring and


height


using glucometer



- Preparation and

administration of:

Oral Medication

- Preparation and

administration of:

Subcutaneous

Medication

- Preparation and

administration of:

Intravenous

Medication

- Preparation and

administration of:

Intramuscular

Medication

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Nursing Department










techniques in each

procedure


orders on a regular

basis

- Documenting


forms

11 Defibrillation /

Cardioversion




vasopressin

14 Performance of

physical health

assessment –

- Adult/Pediatric/

Neonate

- A,B,C,D,E for trauma

patient

15 Triage system - Demonstrating

criteria for

prioritizing patient

management

- Demonstrating

awareness of hospital

fire and disaster

protocol

16 Admissions

procedure

- ICU - In–patient - Direct to OR - Labor and delivery

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Nursing Department









17 Medicolegal cases - Aware of clinical

situations which should

be reported to the

police

18 Respiratory/oxygen

therapy

- Applying care for

airway

- Ambu – bagging - Inserting oral airway

19 Mother in labor - Assessing of

contraction

- Assessing of F.H.R. - Performing obstetric

examination

20 Multi-trauma patient - Caring of patient with

suspected cervical

fracture

- Stabilizing fractures

with splints

- Caring of head injury

patient

21 Burn patient - Fluid resuscitation - Dressings


procedures


Name: Name:


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Nursing Department






Clinical Checklist Category: Intensive Care Unit Rotation

Started From: ______/____/______ To _____/_____/_____



following skills.




1 Receiving and


(at end of shift)

2 Caring of patient

hygiene


procedures


procedures

5 Measuring and

documentation of

vital signs


health assessment

7 Measuring and


height


using glucometer



- Preparation and

administration of:

Oral Medication

- Preparation and

administration of:

Subcutaneous

Medication

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Nursing Department









- Preparation and

administration of:

Intravenous

Medication

- Preparation and

administration of:

Intramuscular

Medication


techniques in each

procedure


orders on a regular

basis

- Documenting


forms

13 Basic unit skills

- Defibrillation

/cardioversion

- Administration of


- Caring of temporary

pacemaker

transcutaneous

/transvenous

14 Airway and

ventilation

management

- Caring of mechanical

ventilator

- Assisting in initiating

invasive and

noninvasive

mechanical ventilator

- Providing care for

patient with

mechanical ventilator

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Nursing Department









- Assisting in weaning

from mechanical

ventilator

- Assisting in insertion

of airway tube

(endotracheal ,

tracheostomy,

nasopharyngeal )

- Providing care of

airway tube

- Suctioning of airway

passage

15 Central lines - Collecting of

equipment for

insertion of central

line

- Discussing the

normal parameters for

CVP measurement

- Determining and

records CVP using a

water

- Identifying chest

landmarks for CVP

measurement

- Flushing of a central

line

- Administering of

drugs and fluids

- Assisting in

aseptically changing

central IV lines

- Aseptically changing

central IV lines

dressing

- Setting up a

transducer systems

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Nursing Department









16 Pulmonary artery

catheters and

arterial lines

- Taking appropriate

action to prevent or

resolves

complications of PA

catheters and arterial

lines

- Sitting up a single

and multiple

transducer system

- Identifying a PA and

arterial trace on the

cardiac monitor

- preforming zeroing of

PA and arterial lines

- Preforming Allen's

test

17 Feeding

management

- Administering of

TPN

- Administering tube

feeding through

Tummy syringe

- Using feeding pump 18 Underwater seal - Assisting in

insertion/removal of

underwater seal

drainage

- Caring of underwater

seal drainage

19 Nursing care of

specific patients

- Post-operative

bleeding

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Nursing Department









- Unconscious (general

care to prevent of foot

drop and

contractures)

- Post PTCA - Post cardiac

catheterization

- Intracranial surgeries - Fractures and

osteoarthritis

- Biliary and pancreatic

disorder

- MI/unstable angina - Intestinal obstruction,

colonic surgery and

ostomies

- Intracranial surgeries - Fractures and

osteoarthritis


Name: Name:


internship program clinical skills achievement logbook · nebulizer . page 6 of 41 kingdom of saudi...

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