Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

Ministry of Health ‫وزارة الصحة‬

Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

Hind zakaria barnawi

Name:_______________________________ 2522955
Computer No:_______________ ICU
Department:______________
Initial Assessment: New Hired Cross Training Redeployed ✔ Reassessment

Scale Level:
Independent (I): Proficient/Confident/Expedient (No supporting cues required)
Supervision Required (SR): Proficient/Confident/Reasonably Expedient (Requires occasional supportive cues)
Dependent (D): Unskilled/Unable to demonstrate behavior/procedure (Required continuous verbal and
continuous physical directive cues)

No. Skills Methodology Scale Assessor Name Assessor Date

Level Computer No. Signature
VE DO WE RD

1. Assessment of Critically Ill Patient ✔ ✔ ✔ I 11/4/1443

Surumi Salim, 115203

2. Monitoring Critically Ill Patient ✔ ✔ ✔ I 11/4/1443

Surumi Salim, 115203

Recognizing Basic Cardiac ✔ ✔ ✔

3. I Surumi Salim, 115203 11/4/1443
Arrhythmias
Understanding Arterial Blood Gases ✔ ✔
4. I Surumi Salim, 115203 11/4/1443
Interpretation

5. Trauma Care ✔ ✔ ✔ I Surumi Salim, 115203 11/4/1443

6. Use of Glasgow Coma Scale ✔ ✔ ✔ I Surumi Salim, 115203 11/4/1443

Management of Increased Intracranial
7. ✔ ✔ ✔ I Surumi Salim, 115203 11/4/1443
Pressure

Care of Patient with External

8. Ventricular Drainage ✔ ✔ ✔ I Surumi Salim, 115203 11/4/1443

9. Assisting Lumbar Puncture

✔ ✔ ✔ I Surumi Salim, 115203 11/4/1443

10. Care of Comatose Patient ✔ ✔ ✔ I Surumi Salim, 115203 12/4/1443

Intercostal Tube
11. (assisting/care/removal) ✔ ✔ ✔ I Surumi Salim, 115203 12/4/1443

12. Use of Defibrillator ✔ ✔ ✔ I Surumi Salim, 115203 12/4/1443

Assisting, Measuring , and Care of ✔ ✔ ✔ I Surumi Salim, 115203 12/4/1443

13.
Central Venous Catheter

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 1 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023
No Skills Methodology Scale Assessor Name Assessor Date
VE DO WE RD Level Computer No. Signature

14. Assisting and Care of Arterial Line ✔ ✔ ✔ I Surumi Salim, 115203 12/4/1443
Peripherally Inserted Central Catheter
15. ✔ ✔ ✔ I Surumi Salim, 115203 12/4/1443
(PICC)
Care of Patient on Non-Invasive
16.
Ventilation
✔ ✔ ✔ I Surumi Salim, 115203 12/4/1443
Care of Patient on Mechanical
17.
Ventilator ✔ ✔ ✔ I Surumi Salim, 115203 12/4/1443

18. Care of Patient with Tracheostomy ✔ ✔ ✔ I Surumi Salim, 115203 12/4/1443

19. Care of Patient with Endotracheal Tube ✔ ✔ ✔ I Surumi Salim, 115203 13/4/1443
20. Pre-operative Care ✔ ✔ ✔ I Surumi Salim, 115203 13/4/1443

21. Post-operative Care ✔ ✔ ✔ I Surumi Salim, 115203 13/4/1443

22. Mechanical VTE Prophylaxis ✔ ✔ ✔ I Surumi Salim, 115203 13/4/1443

23. Knowledge on High Risk Medications ✔ ✔ ✔ I Surumi Salim, 115203 13/4/1443

24. Nurses Roles in Moderate Sedation ✔ ✔ ✔ I Surumi Salim, 115203 13/4/1443

25. Pronation Therapy ✔ ✔ ✔ I Surumi Salim, 115203 13/4/1443

26. Intra Abdominal Pressure Monitoring ✔ ✔ ✔ I Surumi Salim, 115203 13/4/1443

Care of Patient on High Flow Nasal
27. ✔ ✔ ✔ I Surumi Salim, 115203 13/4/1443
Cannula
I _________________________________aware
Hind zakaria barnawi of and understand my responsibilities in regards to above items and I will be allowed to
perform only for those within my skill level/scope of practice and only after I successfully demonstrated competency_____________________
(Signature)
Approved by:
Amal alshreef
Head Nurse Signature Date

CND-NED/Nurse Educator Signature Date

Nursing Director Signature Date

Methodology: VE: Verbal Examination DO: Direct Observation WE: Written Examination RD: Return Demonstration

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 2 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

1 - Assessment of Critically Ill Patient history, last meal consumed,

Performance Criteria/Evidence Scale Methodology and events)
 Most common cause of cardiac
VE DO WE RD
arrest 5 H's (hypovolemia,
I ✔ ✔
Identified the systematic approach I ✔ ✔ ✔ hypoxia, hydrogen ion,
hypo/hyperkalemia, and
 Conscious patient I ✔ ✔ ✔
hypothermia)
 Unconscious patient I ✔ ✔ ✔
 Most common cause of cardiac
Demonstrated basic life support I ✔ ✔ ✔ arrest 5 T's (tension
(BLS) assessment. I ✔ ✔
pneumothorax, tamponade in
Demonstrated knowledge and cardiac, toxins, thrombosis in
ability to perform primary I ✔ ✔
pulmonary, and thrombosis in
assessment coronary)
 A = Airway: airway patency,
Assessor Name:
advanced airway, placement of I ✔ ✔ ✔ Surumi Salim, 115203
airway device, and tube Date: 11/4/1443
serucement
2 – Monitoring Critically Ill Patient
 B = Breathing: assess
breathing, oxygen supplement, Performance Criteria/Evidence Scale Methodology
monitor adequacy of I ✔ ✔ ✔
VE DO WE RD
ventilation and oxygenation,
Demonstrated knowledge and ✔ ✔
and avoid excessive ventilation I
ability to monitor basic vital signs
 C = Circulation: CPR quality,
Demonstrated knowledge and
cardiac rhythm, use of ✔ ✔
ability to measure hemoglobin I
defibrillation or cardioversion, I ✔ ✔ ✔ saturation using pulse oximeters
IV/IO access, BP and HR,
glucose and temperature, Demonstrated knowledge and
perfusion issues ability to measure core temperature:
 D = Disability: neurologic  Rectal ✔ ✔ ✔
I
function, level of  Bladder
consciousness, pupil dilation, I ✔ ✔ ✔  Tympanic
AVPU (alert, voice, painful,  Esophageal
and unresponsive Identified indications for
 E = Exposure: physical continuous invasive pressure I ✔ ✔
examination, look for obvious recording
I ✔ ✔ ✔ Demonstrated knowledge and
signs of trauma, bleeding,
burns, unusual markings, or ability to record invasive BP
I ✔ ✔ ✔
medical alert bracelets measurement:
Demonstrated knowledge and  BP measurement thru intra-
ability to perform secondary I ✔ ✔ ✔ arterial catheter
assessment  Allen test
 Gathering focused history Demonstrated ability to perform
I ✔ ✔
using the memory aid the discharge planning
SAMPLE (signs and I ✔ ✔ Demonstrated knowledge and
symptoms, allergies, ability to measure central venous I ✔ ✔
medications, past medical pressure:

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 3 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

 Normal CVP range level I ✔ ✔ Demonstrated knowledge and

 Factors affecting CVP readings ability to identify and respond to I ✔ ✔
Demonstrated knowledge and asystole
I ✔ ✔
ability to measure end-tidal PCO2 Stated serious or significant signs
Demonstrated knowledge and and symptoms of unstable I ✔ ✔
ability to recognize and monitor I ✔ ✔ tachycardia
cardiac rhythm and heart rate. Demonstrated knowledge and
Demonstrated knowledge and I ✔ ✔
ability to identify and respond to
ability to monitor neurological tachyarrhythmias
status: ✔ ✔
I Demonstrated ability to identify and
 Pupil (PERLA) respond to bradyarrhythmias
I ✔ ✔
 Level of Consciousness
(Glasgow Coma Scale) Assessor Name:
Surumi Salim, 115203
Demonstrated knowledge and Date:
ability to measure urine output: 11/4/1443
✔ ✔
 Normal urine output and its
I

significants 4– Understanding Arterial Blood Gases Interpretation

Demonstrated knowledge and Performance Criteria/Evidence Scale Methodology
ability to measure level of sedation I ✔ ✔
VE DO WE RD
 Ramsay Sedation Score
Identified the purpose of arterial
Assessor Name: Surumi Salim, 115203 I ✔ ✔
blood gases
Date: Demonstrated knowledge on
11/4/1443 relative contraindication for arterial ✔ ✔
I
puncture.
3 – Recognizing Basic Cardiac Arrhythmias Determined factors that may affect
I ✔ ✔
arterial blood gases result.
Performance Criteria/Evidence Scale Methodology
I ✔ ✔
VE DO WE RD Performed ABGs sampling safely.
Stated understanding of normal Demonstrated knowledge of the
cardiac conduction system regulatory systems that affect pH I ✔ ✔
 Sinoatrial (SA) node ✔ ✔
rises or falls
 Atrioventricular (AV) node
I
Demonstrated knowledge and
✔ ✔
 Safety mechanism ability to interpret arterial blood I

 Abnormal impulses gases:

✔ ✔
Demonstrated knowledge and
I ✔ ✔  Indication of pH rise or fall I

ability to monitor cardiac rhythms  PaCO2 correspond with change ✔ ✔

 Applying cardiac monitor in pH
I

 Recognizing normal sinus rhythm  Bicarb correspond with change

I ✔ ✔
Demonstrated knowledge and in pH
ability to identify and respond to: I ✔ ✔
 Compensation I ✔ ✔
 Ventricular fibrillation
 Pulseless ventricular tachycardia  Indication of PaO2 rise or fall I ✔ ✔

Demonstrated knowledge and  Indication of SaO2 rise or fall I ✔ ✔

ability to identify and respond to I ✔ ✔
pulseless electrical activity (PEA)

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 4 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

Demonstrated knowledge and  Assess tracheal deviation, use

ability to intervene abnormal blood of accessory muscle, chest wall I ✔ ✔
I ✔
gases following interpretation: movement
 Presences of dullness or
 Respiratory Acidosis I ✔
hyperresonance during chest I ✔ ✔
✔ percussion
 Respiratory Alkalosis I
 Assess breath sound and heart
✔ ✔ I ✔
 Metabolic Acidosis I tones
 Presence of muffled heart tones ✔
 Metabolic Alkalosis ✔ ✔
I I

Documented relevant finding and ✔ ✔  Needle decompression I ✔

I
interventions provided in the
 Chest tube I ✔
patient's file.
Assessor Name: Surumi Salim, 115203  Open sealed dressing I ✔
Date:
11/4/1443  Pericardiocentesis I ✔

5– Trauma Care  Circulation and Hemorrhage

 Assess heart rate and regularity, I ✔ ✔
Performance Criteria/Evidence Scale Methodology BP
VE DO WE RD  Asses skin color, temperature,
moisture I ✔ ✔
Demonstrated ability to assess and
recognize priority treatment for  Assess peripheral pulses I ✔ ✔
patient base on their injuries, vital I ✔ ✔
signs, and the mechanisms of their  Maintain fluid and electrolytes I ✔ ✔
injuries  Identify and management of ✔ ✔
Identified the correct sequence of I ✔ ✔ external hemorrhage
I

priorities for assessment of a  Identify and management of I ✔ ✔

multiply injured patient internal hemorrhage
Demonstrated knowledge and  Identify and management of
ability to apply primary surveys I ✔ ✔ I ✔ ✔
pelvic fracture
 Airway with C-spine control  Disability
 Assess airway patency I ✔ ✔
 Assess Glasgow Coma Scale I ✔ ✔
 Asses obvious injury and/or I ✔ ✔  Assess pupil for size, equality,
obstruction on the airway I ✔ ✔
and reaction (PEARL)
 Use of airway adjunct I ✔ ✔  Check glucose level I ✔ ✔

 Use of definitive airway I ✔ ✔  Exposure/Environment

Control
 Manual in-line C-spine I ✔ ✔
stabilization  Log rolling I ✔ ✔

 Applying C-collar I ✔ ✔  Assess spinal column I ✔ ✔

 Breathing and Oxygenation  Assess rectal and bladder ✔ ✔
 Assess respiratory rate, depth, I ✔ ✔ ✔ overriding
I

quality
 Prevent hypothermia I ✔ ✔

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 5 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023
Identified adjuncts to Primary  Maintain effective ✔ ✔
I ✔ ✔ I
Survey immobilization
Demonstrated knowledge and ability ✔ ✔ ✔ ✔

I I
to apply secondary survey Transfer and positioning
 ✔ ✔
✔ ✔ 
I
Use AMPLE to obtain history I Skin care
 Perform head-to toe physical ✔ ✔
 Complication
I
I ✔ ✔
examination
Identified adjuncts to Secondary Assessor Name: Surumi Salim, 115203
I ✔ ✔
Survey Date:
Demonstrated knowledge and ability 11/4/1443
I ✔ ✔
to assess for spinal injury and
complications. 6– Use of Glasgow Coma Scale
Demonstrated knowledge and ability Performance Criteria/Evidence Scale Methodology
to apply and maintain spinal I ✔ ✔
precautions such as: VE DO WE RD
 Ensure spinal precautions as Identified the purpose of GCS
✔ ✔ ✔
I ✔ ✔ scoring tool
I
ordered by physician
Identified the frequency of GCS
 Proper spinal alignment I ✔ I ✔ ✔ ✔
assessment
 Spinal collars, application, and I ✔ Demonstrated knowledge and
removal I ✔ ✔ ✔
ability to assess eye opening:
 Assist to stabilize the spine with  Correct method of assessment
I ✔ ✔ ✔ ✔ ✔
manual and / or mechanical of eye opening to voice and
I
traction
painful stimulus
 Log rolling techniques I ✔ ✔  Correct type of painful
Demonstrated knowledge and ability stimulus to assess for eye ✔ ✔ ✔
I
to provide nursing care and I ✔ ✔ opening
interventions specific to the client Demonstrated knowledge and ✔ ✔ ✔
I
with spinal injury such as: ability to assess verbal response:
✔ ✔  Correct methods of assessing
 Assess motor power I
orientation and verbal response
I ✔ ✔ ✔

 Assess neurovascular status I ✔ ✔  Focal verbal deficit such as I ✔ ✔ ✔

 Assess skin care and institute aphasia, receptive and
I ✔ ✔ expressive dysphagia
protective measures
 Care of drainage tubes and ✔ ✔
Demonstrated knowledge and
I ✔ ✔ ✔
I
equipment ability to assess motor response:
 Safety precautions with casts, ✔ ✔  Identify the ability to obey
I I ✔ ✔ ✔
clam shells, halo traction commands.
✔ ✔  Correct methods of pain
 Provide wound care I
stimulus when assessing limb I ✔ ✔ ✔
 Elimination I ✔ ✔ response (fingertip pressure,
Demonstrated knowledge and ability trapezius pinch, supraorbital
to apply and care of patient with I ✔ ✔ notch).
cervical collar ✔ ✔ ✔
 Identify abnormal flexion
I

✔ ✔

I
Size and fit
 Identify abnormal extension I ✔ ✔ ✔

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 6 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023
Identified limitations of GCS as an I ✔ ✔  Change in level of I ✔ ✔ ✔
assessment tool: consciousness, behavior, and
 Pre-existing factors: language, GCS
cultural differences, intellectual, ✔ ✔
✔ ✔

I
neurological deficit, hearing Changes in vital signs I

loss, speech impediment. ✔ ✔

 Pupillary changes I
 Effects of current treatment:
✔ ✔
physical (intubation or
I
✔ ✔  Extraocular movements I

tracheostomized),  Other changes (headache,

pharmacological (sedation or vomiting, papilledema, motor
paralysis) and sensory dysfunctions, I ✔ ✔
 Effect of other injuries or ✔ ✔ speech impairment, seizures,
lesions: orbital/cranial fracture, I
decreased brain stem function,
dysphasia, hemiplegia, spinal and pathologic reflexes)
cord damage Demonstrated knowledge and
Demonstrated knowledge and ability to intervene increased ICP: I ✔ ✔
✔ ✔
 Established ABC (airway,
I
ability to avoid loss of information
I ✔ ✔
✔ ✔ breathing, and circulation)
 Communication barrier I
✔ ✔

I
✔ ✔ Promote normal PCO2
 Treatment influences
I

✔ ✔
✔ ✔  Avoid hypoxia I
 Other injuries I
 Maintain cerebral perfusion
Demonstrated knowledge and ✔ ✔
✔ ✔ pressure (CPP) I
ability to assess GCS for children I
 Administer osmotic diuretic
Assessor Name: Surumi Salim, 115203 and hypertonic saline I ✔ ✔
Date:
11/4/1443  Insert indwelling catheter I ✔ ✔

7 – Management of Increased Intracranial Pressure  Administer corticosteroids I ✔ ✔

Performance Criteria/Evidence Scale Methodology  Maintain balanced fluids and I ✔ ✔

electrolytes
VE DO WE RD
✔ ✔

I
Demonstrated knowledge of the Monitor effects of sedation
pathophysiology and etiology of ✔ ✔ ✔ ✔

I I
increased ICP: Maintain normothermia
 3 components and volume ratio  Avoid positions or activities
I ✔ ✔
compromised during increased I ✔ ✔ that may increase ICP
ICP
 Maintain normal blood glucose I ✔ ✔
✔ ✔
 Monroe-Kellie doctrine I Demonstrated knowledge and
✔ ✔
I
ability to monitor ICP
 Compensation of increased ICP I ✔ ✔
Assessor Name: Surumi Salim, 115203
 Etiologies of increased ICP I ✔ ✔ Date:
11/4/1443
Demonstrated knowledge and
I ✔ ✔
ability to recognize signs and 8 – Care of Patient with External Ventricular Drainage
symptoms of increased ICP:

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 7 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

Performance Criteria/Evidence Scale Methodology Positioned the patient correctly on

VE DO WE RD
the bed, ensuring that the patient is I ✔ ✔
protected from potential risk of
Demonstrated knowledge and I ✔ ✔ ✔ falling or injury
ability for EVD care includes: Demonstrated appropriate
 Leveling of EVD to patient I ✔
I ✔ ✔ ✔ preparation and cleaning of the
tragus site
Demonstrated safe administration
 Dressing I ✔
of local anesthetic I ✔

 Oscillating CSF I ✔ ✔ Demonstrated the safe insertion of I ✔ ✔

the lumbar puncture needle
✔ ✔
 Volume drained I Obtained the necessary CSF
samples and label the containers I ✔ ✔
Demonstrated collection of CSF I ✔ ✔
specimen using sterile technique. appropriately
Demonstrated knowledge and Demonstrated the safe removal of
I ✔ ✔ the lumbar puncture needle and
ability in the event:
manages the puncture wound I ✔ ✔
✔ ✔
 EVD disconnected I appropriately
 EVD pulled out of the Disposed of equipment used
I ✔ ✔ according to the Infection Control ✔ ✔
patient's head I

Verbalized the procedure required policy

when transporting a patient with an I ✔ ✔ Performed post-procedure
EVD. observations and record as I ✔ ✔
Identified reasons why a patient appropriate
I ✔ ✔
may require ICP monitoring. Discuss signs and symptoms of
Demonstrated knowledge and ✔ ✔
post-dural puncture headache ✔ ✔
I
ability to measure ICP using an I (PDPH) and management
EVD. Demonstrated ability to accurately
Demonstrated ability to zero records the procedure in the
✔ ✔
monitor with ICP transducer. I ✔ ✔ patient’s records I

Demonstrated ability to document Assessor Name: Surumi Salim, 115203

I ✔ ✔
the procedure done and relevant
findings to patient's file. Date: 11/4/1443
Assessor Name:
Surumi Salim, 115203
Date: 11/4/1443 10 – Care of Comatose Patient
Performance Criteria/Evidence Scale Methodology
9 – Assisting Lumbar Puncture VE DO WE RD
Demonstrated knowledge and
Performance Criteria/Evidence Scale Methodology
ability to assess level of ✔ ✔
I
VE DO WE RD consciousness
Identified rationale for the Demonstrated knowledge to
procedure I ✔ ✔
recognize impaired neurological
Explained related anatomy and I ✔ ✔
I ✔ ✔ status, and assist patient's family to
physiology discuss concerns.
Described nursing responsibility in I ✔ ✔ Demonstrated ability to offer
obtaining informed consent emotional support to patient and I ✔ ✔
family

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 8 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

 Demonstrated caring and I ✔ ✔ Asssiting ICT insertion

concern Verified physician order for ✔ ✔
 Used of effective insertion of ICT, and the location
I

I ✔ ✔
communication techniques Described nursing responsibility in
Demonstrated knowledge and I ✔ ✔ ✔
obtaining informed consent
ability to manage unconscious I ✔ ✔
Obtained need equipment, lab
patient reports, and imaging studies I ✔ ✔ ✔

 Maintaining patent airway I ✔ ✔ Described and demonstrated TIME-

✔ ✔ ✔
I
OUT
 Maintain monitoring and
I ✔ ✔ Identified indications of chest tube I ✔ ✔
observing significant
alterations in vital signs insertion
 Pain assessment and Described the function of the 3 I ✔ ✔
I ✔ ✔ chamber of chest drainage system
management
 Protecting the patient from fall Demonstrated the correct assembly
I ✔ ✔ I ✔ ✔
and self harm of all equipments needed for chest
 Maintaining fluid balance and tube drainage
I ✔ ✔
managing nutritional needs Described nursing responsibilities I ✔ ✔
 Prevent from appearance of during assisting chest tube insertion
I ✔ ✔ Care of ICT
physical deformations
Demonstrated securement of the
 Preventing urinary retention I ✔ ✔
ICT and dressing of the insertion ✔ ✔
I

 Providing sensory stimulation I ✔ ✔ site

Demonstrated preparation and
 Family needs I ✔ ✔ assembly of equipment for suction
I ✔ ✔
if required
 Potential complications I ✔ ✔ Outlined the correct procedure for
I ✔ ✔
Demonstrated the knowledge and measuring chest drainage
ability to refer to appropriate I ✔ ✔ Described nursing responsibilities
support services such as: and care of the patient post ICT I ✔ ✔
includes insertion site, dressing, and
 Religious support I ✔ ✔
tubings
 Physiotherapy I ✔ ✔ Described management for chest I ✔ ✔
drainage losses
 Social worker I ✔ ✔
Performed pain assessment and I ✔ ✔
✔ ✔ management
 Nutritionist I
Described tidaling of the fluid level
I ✔ ✔
 Home care I ✔ ✔ in the drainage system
Demonstrated knowledge and
Assessor Name: Surumi Salim, 115203 I ✔ ✔
ability for milking of the chest tube
Determined if the patient has
Date: 12/4/1443 ✔ ✔
ongoing air leak I

Described the precautions required

11 – Intercostal Tube (assisting/care/removal) for transporting a patient with an I ✔ ✔
ICT
Performance Criteria/Evidence Scale Methodology
Removal of ICT
VE DO WE RD

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 9 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023
Verified physician oder for removal I ✔ ✔ Demonstrated knowledge and
of ICT ability to use defibrillator machine I ✔ ✔
Discussed procedure for removal of as a monitoring device:
I ✔ ✔
ICT
Assessor Name:  Monitoring ECG I
✔ ✔
Surumi Salim, 115203
Date: 12/4/1443  Monitoring SpO2 I ✔ ✔

 Monitoring EtCO2 I ✔ ✔
12 – Use of Defibrillator
Demonstrated knowledge and
✔ ✔
Performance Criteria/Evidence Scale Methodology ability to place paddles on patient I

VE DO WE RD safely and effectively

Demonstrated knowledge on  Standard paddle placement for I ✔ ✔ ✔
general warnings and cautions in I ✔ ✔ adult
using defibrillator:  Standard paddle placement for
I ✔ ✔ ✔
✔ ✔ pediatric
 Shock hazard and fire hazard I

 Special placement (obese, thin,

 Possible fire or explosion I ✔ ✔ implanted pacemaker, I ✔ ✔
 Possible electrical interference implanted defibrillator)
with device performance I ✔ ✔
Demonstrated knowledge and I ✔ ✔
 Possible defrillator shutdown I ✔ ✔ ability to use automated external
defrillation (AED) mode:
 Possible device failure I ✔ ✔
 AED Warnings (Possible
 Possible improper defibrillator misinterpretation of data, I ✔ ✔
I ✔ ✔
performance Pediatric patient safety risk
 Possible failure to detect an out I ✔ ✔  AED Setup and procedure
of range condition (Monitor ON, placement of
I ✔ ✔
 Safety risk and possible I ✔ ✔
paddles or electrodes, analyze,
equipment damage shock advised or no shock
advised)
 Possible skin burns and
ineffective energy delivery I ✔ ✔  Troubleshooting for AED I ✔ ✔
mode
 Possible interference with
I ✔ ✔  Switching AED to Manual
implanted electrical device I ✔ ✔
Defibrillation
Defined symbols of defibrillator I ✔ ✔ ✔
machine Demonstrated knowledge and
ability to use manual debifrillation I ✔ ✔
Demonstrated knowledge and
mode:
ability to describe and apply I ✔ ✔ ✔
controls, indicators, and connectors  Monophasic defibrillator I ✔ ✔
of defibrillator.
 Biphasic defibrillator I ✔ ✔

 Manual defibrillation setup I ✔ ✔

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 10 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

 Defibrillation procedure  Cleaning I ✔ ✔

(monitor ON, placement of ✔ ✔
paddles or electrodes, energy
I
 Function test (ecg, paddles,
I ✔ ✔
select, charge, shock) battery power, cables, printer)
Assessor Name:
 Abnormal energy delivery I ✔ ✔ Surumi Salim, 115203
Date: 12/4/1443
 CPR Metronome I ✔ ✔

 Troubleshooting for manual 13– Assisting, Measuring , and Care of Central Venous
I ✔ ✔ Catheter
defibrillation
Performance Criteria/Evidence Scale Methodology
Demonstrated knowledge and
I ✔ ✔ VE DO WE RD
ability to use synchronized
Assisting Insertion of CVC
cardioversion mode:
I ✔ ✔
 Synchronized cardioversion Stated indication for use of CVC
setup and procedure (monitor Reviewed accuracy and
✔ ✔ ✔ I ✔ ✔
ON, placement of paddles or I completeness of order and consent
electrodes, sync, energy select, for insertion of CVC
charge) Assessed patient's hydration status
I ✔ ✔
and allergies
 Troubleshooting for Identified the route and position of
✔ ✔ I ✔ ✔
Synchronized cardioversion I
CVC
Demosntrated knowledge and Demonstrated knowledge of I ✔ ✔
✔ ✔ different types of central lines
ability to use non-invasive pacing I
Demonstrated knowledge of risks
 Non-invasive pacing warning associated with central lines
I ✔ ✔
(possible inducement of VF, I ✔ ✔
Assessed for proper function of
interruption of therapy, I ✔ ✔
CVC before therapy
inability to pace, and patient Measuring CVC pressure
skin burns) Stated the purpose of measuring
✔ ✔ ✔
 Demand and nondemand I ✔ ✔ central venous pressure (CVP) I

pacing Identified patient's position in

I ✔ ✔ ✔
measuring CVP
 Noninvasive pacing setup and Demonstrated knowledge and
procedure (Monitor ON, ECG I ✔ ✔ ability to measure CVP using I ✔ ✔ ✔
cable, quik-combo electrodes, manometer
pacer, rate, current, pause) Demonstrated knowledge and
I ✔ ✔ ✔
 Troubleshooting for I ✔ ✔
ability to measure CVP using
noninvasive pacing transducer
Demonstrated interpreting
Demosntrated knowledge and measurements I ✔ ✔ ✔
ability to maintain the defibrillator ✔ ✔
I I ✔ ✔
machine: Stated potential complication
Care of CVC
 Daily auto test I ✔ ✔
Demonstrated ability to apply
I ✔ ✔ ✔
 User test I ✔ ✔
critical thinking and clinical

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 11 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023
judgment throughout the nursing 14 – Assisting and Care of Arterial Line
process when caring for patient with I ✔ ✔
CVC. Performance Criteria/Evidence Scale Methodology
Demonstrated knowledge of ✔ ✔
I VE DO WE RD
different types of central lines
Demonstrated knowledge of risks Assisting for Arterial Line
I ✔ ✔ Insertion
associated with central lines
Demonstrated knowledge and  Stated indication and
contraindication for use of I ✔ ✔ ✔
ability to provide basic care to a ✔ ✔ ✔
I arterial lines
patient with a central line as per
 Reviewed accuracy and
policy
completeness of order and I ✔ ✔ ✔
 Assessment consent for insertion of arterial
 Site care line
 Change of dressing  Assessed patient's coagulation I ✔ ✔ ✔
Demonstrated ability to monitor the status and lab studies
I ✔ ✔
central line infusion.  Identified anatomic landmarks:
Demonstrated knowledge and I ✔ ✔
radial and femoral
ability to provide additional care to  Demonstrated knowledge and
a patient with a central line as per I ✔ ✔
ability to facilitate proper
policy: cannulation
 Cap, injection hubs, tubing  Stated contraindications and ✔ ✔
change I ✔ ✔ complications arterial line I

 Flush  Assessed for proper function of

✔ ✔
 Heparin/saline locks arterial line before therapy
I

 Withdraw blood Care of Arterial Line

 Administration of fluids Demonstrated knowledge and
and medications as ability to measure blood pressure I ✔ ✔
appropriate using transducer
Demonstrated knowledge and Demonstrated knowledge and
ability to maintain central venous ✔ ✔ ability to provide basic care to a
I
pressure while providing care of the
patient with arterial line
central line.
Demonstrated knowledge and  Assessment I ✔ ✔
ability to recognize signs and I ✔ ✔  Site care
symptoms of CVC complications.  Change of dressing
Demonstrated knowledge and  Change of injection hubs and
✔ ✔
ability to perform troubleshooting
I cap
Demonstrated ability to remove Demonstrated knowledge and
I ✔ ✔ ability to provide additional care to
central line as per policy
Demonstrated proper a patient with an arterial line:
✔ ✔ ✔ ✔
 Measuring blood pressure
I I
documentation of care provided on
the patient's file  Zeroing transducer
Assessor Name: Surumi Salim, 115203  Pressure bag
 Flush bag
Date: 12/4/1443  Arterial line fluid

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 12 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

 Modified Allen test  Remove the stabilization

 Withdraw blood sample and or I ✔ ✔ device
arterial blood gases  Inspect the catheter exit site
Demonstrated knowledge and I ✔ ✔ for swelling, redness or
ability to perform troubleshooting exudate
Demonstrated ability to remove I ✔ ✔  Verify the external catheter
arterial lines as per policy length.
Demonstrated proper  Remove non-sterile gloves,
I ✔ ✔
documentation of assessment and apply sterile one
care provided on the patient's file  Perform skin antisepsis
Assessor Name: Surumi Salim, 115203  Apply a new manufactured
stabilization I ✔ ✔
Date: 12/4/1443  Apply a chlorhexidine
impregnated sponge
15 – Peripherally Inserted Central Catheter (PICC)  Apply a new Tegadirm over
the exit site and Catheter
Performance Criteria/Evidence Scale Methodology tubing.
VE DO WE RD  Discard used supplies
Verbalized the indication of PICC I ✔ ✔ ✔  Remove gloves and discard
line. them, then perform hand
Identified the different skin asepsis hygiene
✔ ✔
 Label the dressing
I
solutions, application techniques,
and dry times.  Document the procedure
Identified the different types of Identified the types of needleless
stabilization devices: I ✔ ✔
connectors
 Understand the reasons and Demonstrated understanding of the
frequency of changing proper technique for flushing,
StatLock and the frequency of I ✔ ✔ locking, drawing blood, and doing
it power injection:
 Demonstrate Application steps  Understand purpose of catheter
of StatLock flushing
 Demonstrate Removal steps of  Understand frequency of
StatLock flushing and locking
Demonstrated understanding of the  Demonstrate necessary supply I ✔ ✔ ✔
different types of dressings, for changing dressing
procedure for changing them, and  Perform hand hygiene
the frequency at which they should
 Using friction, scrub the Hup
be changed:
with available disinfectant
 Assess site of insertion
 Attach syringe of preservative-
 Demonstrate necessary supply I ✔ ✔ ✔
free 0.9% sodium chloride to
for changing dressing the needleless connector
 Perform hand hygiene, don a  Pull back on the syringe until
mask, and put on non-sterile you are able to aspirate blood
gloves
 Flush the catheter with a
 Carefully remove the old minimum of 10ml of saline,
dressing

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 13 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023
using a pulse or stop-start Demonstrated knowledge and
technique ability to document all relevant I ✔ ✔
 Disconnect the syringe using activities to the patient's file.
I ✔ ✔
the appropriate clamping Assessor Name:
sequence for the connector Surumi Salim, 115203
described below Date: 12/4/1443
 Lock with heparin
Demonstrated knowledge and 16– Care of Patient on Non-Invasive Ventilation
ability to withdraw blood for
sampling from the PICC line: Performance Criteria/Evidence Scale Methodology
 Stop any IV fluids infusing VE DO WE RD
through all lumens Identified indications and
✔ ✔
 Using friction, scrub the hub contraindications for non-invasive I

using available disinfectant ventilation

 Gently aspirate blood Identified advantage of non- I ✔ ✔
invasive over invasive ventilation
 Pull back the syringe plunger,
Demonstrated knowledge and ✔ ✔
pausing for 2 seconds to I
ability to set-up and monitor
allow blood to come into patient for NIV
catheter I ✔ ✔
 Physician order: FIO2, tidal
 Slowly continue to aspirate volume, rate, mode, PEEP, and I ✔ ✔
blood inspiratory pressure, I:E, target
 Disconnect the syringe and SPO2
discard it  Additional settings according I ✔ ✔
 Attach an appropriately sized to physician orders
empty syringe to withdraw ✔ ✔
the amount of blood needed  Patient's position I

for testing  Apply face mask or nasal, ✔ ✔

I
 Disconnect the syringe and tubing, and filters
attach the saline filled syringe ✔ ✔
 Hygiene and nutritional needs I

 Flush the catheter with a  Initial and monitoring ABGs I ✔ ✔

minimum of 20 ml of normal result
saline, using the stop-start”  Oxygen saturation and ECG I ✔ ✔
technique monitoring
 Dispose of used supplies in a Observed and recorded additional I ✔ ✔
biohazard container monitoring:
 Remove gloves and perform  Respiratory rate and heart rate I ✔ ✔
hand hygiene
 Document the procedure per  Conscious level I ✔ ✔
facility protocol
Demonstrated understanding of the  Comfort, chest wall movement I ✔ ✔
I ✔ ✔
use of PICC line for power injection  Ventilator synchrony ✔ ✔
I
of contrast.
Demonstrated understanding the  Mask fit/leak I ✔ ✔
procedures for PICC catheter I ✔ ✔
Demonstrated knowledge and ✔ ✔
clearance, repair, and removal. ability to optimize NIV
I

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 14 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

 ABGs improved ✔ ✔  Introduce laryngoscope and

I I ✔ ✔
visualize glottis opening
 No change, failing to respond
I ✔ ✔  Place the endotracheal tube
adequately or deteriorating I ✔ ✔
and inflate the balloon
Discussed appropriate note writing ✔ ✔
with reference to the use of NIV
I
 Confirm placement with
Demonstrated knowledge and auscultation (5 points),
I ✔ ✔ radiological imaging, I ✔ ✔
ability to handle troubleshooting for
NIV quantitative waveform
Demonstrated knowledge and capnography, CO2 detector,
ability to handle patient on weaning I ✔ ✔ etc.
from NIV:  Hemodynamically stable I ✔ ✔
 Order for weaning from NIV I ✔ ✔
Care of Mechanical Ventilation
 Assess weaning tolerance and Identified the indications for
controlled oxygen therapy with I ✔ ✔ ✔ ✔
mechanical ventilation. I
target saturation Determined the patient’s ventilator
Assessor Name: Surumi Salim, 115203 settings on a given ventilator and I ✔ ✔
verifies against the physician’s
Date: 12/4/1443
orders:
 FIO2, tidal volume, rate,
17 – Care of Patient on Mechanical Ventilator mode, PEEP, pressure support, ✔ ✔
I
and flow rate.
Performance Criteria/Evidence Scale Methodology
 Identifies additional settings ✔ ✔
I
VE DO WE RD according to physician orders.
Assisting Intubation Described the various modes of
Demonstrated knowledge and I ✔ ✔
ventilation and their implication.
I ✔ ✔
ability to prepare patient for Described at least two
intubation. complications associated with
 Prepare intubation equipment ✔ ✔
patient’s response to mechanical I ✔ ✔
I
and laryngoscope ventilation and their signs and
 Prepare pretreatment symptoms.
medications (sedative agents I ✔ ✔ Described the causes of given
and neuromuscular blocking ventilator alarms and nursing I ✔ ✔
agents measures taken to trouble shoot
 Assess for a difficult airway, given alarm.
use LEMON (look, evaluate 3- I ✔ ✔  Peak pressure I ✔ ✔
3-2, Mallampati score,
obstruction, and neck  Minute ventilation I ✔ ✔
mobility)
 Respiratory rate ✔ ✔
 Pre-oxygenate by 100% using I

✔ ✔
non-rebreather mask or bag- I
 Spontaneous tidal volume I ✔ ✔
valve-mask without bagging
 Patient position (cervical  Apnea ventilation I ✔ ✔
injury or suspected cervical I ✔ ✔
Demonstrated knowledge and
injury) I ✔ ✔
ability to document relevant

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 15 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023
finding and intervention provided
✔ ✔
 Removal of ET tube I ✔ ✔
I
on the patient's file.
Weaning Off  Establish regular breathing I ✔ ✔
Defined weaning from mechanical
✔ ✔  Obtain ABG I ✔ ✔
ventilation I

Demonstrated knowledge and Demonstrated knowledge and

ability to handle patient for I ✔ ✔ ability to provide post-extubation I ✔ ✔
weaning from mechanical care
ventilation  Oxygen supplement I ✔ ✔
 Verify Physician's order to I ✔ ✔
wean off  Non-invasive ventilation I ✔ ✔
 Hemodynamic status I ✔ ✔  Extubation failure I ✔ ✔
 Oxygenation status ✔ ✔
I VAP Prevention
 Mode of mechanical I ✔ ✔
Demonstrated knowledge and I ✔ ✔
ventilation ability to implement VAP bundle:
 Spontaneous breathing (SBT) ✔ ✔
I ✔ ✔  Sedation I

 Glucocorticoids ✔ ✔  Head elevation I ✔ ✔

I

 T-piece  Administer anticoagulant ✔ ✔

I ✔ ✔ I
agent or pneumatic cuff
 Patient position during ✔ ✔
weaning I ✔ ✔  Mouth care I

 Leak test I ✔ ✔  Peptic ulcer prophylaxis I ✔ ✔

Demonstrated knowledge and Demonstrated knowledge to avoid ✔ ✔

I ✔ ✔ I
ability to manage weaning failure gastric over distension
 Signs of weaning failure Discussed prevention of
I ✔ ✔ I ✔ ✔
unplanned and re-intubation
 Increase muscle strength and Discussed orotracheal over
✔ ✔ nasotracheal intubation I ✔ ✔
decrease muscle demand I

Extubation (Endotracheal) Described and demonstrated

Demonstrated knowledge and ability to prevent and handle I ✔ ✔
ability to handle patient during I ✔ ✔ condensate formation in the
extubation ventilator
 Prepare equipment needed Described and demonstrated ✔ ✔
I ✔ ✔ I
additional care to prevent VAP:
 Timing of extubation ✔ ✔  Standard precautions and hand
I I ✔ ✔
hygiene
 Monitoring vital signs, cardiac ✔ ✔  Change of heat-moisture
I
rhythm, and SpO2 I ✔ ✔
exchanger and bacterial filters
 Patient position during ✔ ✔
extubation
I
 Chest x-rays I ✔ ✔
 Pre-oxygenation by 100% I ✔ ✔  Heated humidification
I ✔ ✔
FiO2 systems, nebulizer

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 16 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

 Change of ventilator saline. Rinsed cannula thoroughly I ✔ ✔

I ✔ ✔ with saline
circuits/tubing
 Suction catheters and closed- ✔ ✔
Placed clean tube on sterile 4 × 4
I ✔ ✔
suction systems
I gauze pad and dried tube
thoroughly
 Artificial airways I ✔ ✔ Replaced inner cannula carefully,
stabilizing outer flange of the ✔ ✔
 Immobility I ✔ ✔
cannula, with your other hand.
I

Locked the inner cannula

 Sputum c/s and gram stain I ✔ ✔
Cleansed around tracheostomy site
 Endotracheal tube cuff I ✔ ✔
I ✔ ✔ with applicator soaked in normal
pressure saline. Cleansed outer cannula with
 Endotracheal cuffed with I ✔ ✔ separate applicator
subglottic suctioning Applied precut, nonraveling trach
 Cleaning and disinfection of dressing around insertion site (flaps I ✔ ✔
I ✔ ✔ pointing up), and changed tracheal
respiratory-care devices
ties if needed
Documented interventions
I ✔ ✔ Discarded soiled dressings, tapes,
provided in the VAP bundle form ✔ ✔
cleaning equipment, and gloves. I
Assessor Name: Surumi Salim, 115203 Performed hand hygiene
Documented care provided in the I ✔ ✔
Date: 12/4/1443
patient's file
Suctioning
18 – Care of Patient with Tracheostomy Identified the patient correctly by I ✔ ✔
using two identifiers
Performance Criteria/Evidence Scale Methodology
Identified rationale for the
VE DO WE RD procedure I ✔ ✔
Tracheostomy Care Demonstrated knowledge and
Demonstrated an understanding of ✔ ✔ ability to assess and perform I ✔ ✔
I
the anatomy and physiology of the suctioning as per hospital policy
respiratory system Demonstrated knowledge and I ✔ ✔
Described indications for ability to use suction equipment:
I ✔ ✔
tracheostomy Appropriate size and lumen of
Obtained all necessary equipments. I ✔ ✔
✔ ✔
suction catheters
I
Performed hand hygiene
Appropriate suction pressure I ✔ ✔
Demonstrated ability to open trach
tray and put on one sterile glove. I ✔ ✔
I ✔ ✔ Portable suction
With gloved hand separate basins;
with ungloved hand, pour saline I ✔ ✔
into basin. Donned second sterile In-wall suction
glove. Demonstrated ability to perform
Demonstrated ability to remove suctioning considering the need for I ✔ ✔
I ✔ ✔ deep and shallow suction
inner cannula properly
Soaked nondisposable cannula in Bagging I ✔ ✔
I ✔ ✔
sterile basin with saline to remove
dried secretions Closed suctioning I ✔ ✔
Cleansed the lumen and outer
surface of the cannula with pipe Endotracheal suctioning I ✔ ✔
I ✔ ✔
cleaners or brush moistened with

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 17 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

I ✔ ✔ Demonstrated knowledge and

Tracheostomy tube suctioning ability to prevent and manage I ✔ ✔
Identified adverse effects of airway complications of ETT
suction I ✔ ✔ Medical device pressure related to I ✔ ✔
Demonstrated proper disposal of the mouth
used items according to Infection I ✔ ✔
Control policy Damage to teeth I ✔ ✔

Assessor Name: Surumi Salim, 115203 ✔ ✔

Tongue numbness I

Date: 12/4/1443 I ✔ ✔
Aspiration into the lungs
19 – Care of Patient with Endotracheal Tube
Implacemnt and blockage of ETT I ✔ ✔
Performance Criteria/Evidence Scale Methodology
I ✔ ✔
VE DO WE RD Sore throat
ETT Care Inadvertent extubation I ✔ ✔
Identified indications ad ✔ ✔
I
I ✔ ✔
contraindication of ETT intubation Stridir/laryngeal edema
Demonstrated knowledge and I ✔ ✔
ability to manage patient with ETT Vocal cord palsy I ✔ ✔

✔ ✔ I ✔ ✔
Respiratory status I Premature ventricular contraction
✔ ✔
Documented all relevant ✔ ✔
I I
Securement of ETT information on the patient's file
I ✔ ✔ Suctioning
Patient's position Identified the patient correctly by
I ✔ ✔
I ✔ ✔ using two identifiers
Placement of ETT
Identified rationale for the I ✔ ✔
I ✔ ✔
Cuff pressure procedure
Demonstrated knowledge and I ✔ ✔
Oral airway or bite block I ✔ ✔ ability to assess and perform
I ✔ ✔ suctioning as per hospital policy
Air leak Demonstrated knowledge and I ✔ ✔
✔ ✔
ability to use suction equipment:
Oral care I
 Appropriate size and lumen of I ✔ ✔
Suctioning (open and closed suction catheters
system) I ✔ ✔
✔ ✔

I
I ✔ ✔ Appropriate suction pressure
Standard precautions
Demonstrated knowledge and  Portable suction I ✔ ✔
ability to protect and prevent self- I ✔ ✔
I ✔
extubation  In-wall suction
Patient and family education ✔ ✔ Demonstrated ability to perform
I I
✔ ✔
regarding presence of ETT suctioning considering the need for
Prevent pulling and jarring of ✔ ✔
deep and shallow suction
I
ventilator ✔ ✔
 Bagging I

Physical restraint I ✔ ✔
 Closed suctioning I ✔ ✔
I ✔ ✔
Sedation ✔ ✔
 Endotracheal suctioning I

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 18 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

✔  ✔ ✔
 Tracheostomy tube suctioning I
Skin preparation as necessary I

Identified adverse effects of airway

I ✔ ✔  Deep breathing and coughing
suction exercises I ✔
Demonstrated proper disposal of
used items according to Infection I ✔ ✔ ✔  Assist and apply surgical gown I ✔ ✔
Control policy ✔ ✔
Assessor Name: Surumi Salim, 115203  Discharge teaching I

✔ ✔
Date: 13/4/1443  Personal hygiene care I

Observation of changes in patient's I ✔ ✔

condition and reporting of same
20– Pre-operative Care
I ✔ ✔
Completed pre-operative checklist
Performance Criteria/Evidence Scale Methodology
Demonstrated knowledge and
VE DO WE RD
ability to prepare and transfer
Demonstrate knowledge and ability I ✔ ✔
I ✔ ✔ patient to the operating room (OR)
to perform pre-operative care: as policy.
 Pre-operative database I ✔ ✔ Documented necessary procedures
assessment in the patient's file I ✔ ✔
✔ ✔
 Type of surgery I Assessor Name: Surumi Salim, 115203
 Pre-existing medical conditions I ✔ ✔ Date: 13/4/1443
and allergies
 Administer pre-operative I ✔ ✔ 21– Post-operative Care
medications
Performance Criteria/Evidence Scale Methodology
 Catheterization I ✔ ✔
VE DO WE RD
 Bowel preparation I ✔ ✔ Identified the patient correctly by
I ✔ ✔
 Frequent monitoring of vital two identifiers
I ✔ ✔
signs as required Performed handwashing before and ✔ ✔
I
after contact with the patient
 Confirm oral intake restrictions I ✔ ✔ Discussed and demonstrated correct
patient monitoring I ✔ ✔
 Ensure consent is signed I ✔ ✔
Demonstrated accurate patient
I ✔ ✔
✔ ✔ assessment

I
Family contact information
Airway
 Check laboratory investigation
I ✔ ✔ ✔ ✔

I
and ECG Described airway assessment
✔ ✔  Described techniques for
 Marking of the site I
airway support under I ✔ ✔
 Remove nail anesthesia.
polish/dentures/eyeglasses/cont I ✔ ✔  Recalled indications for use of
act lens an airway support and
 Secure valuables and personal I ✔ ✔ demonstrates correct size I ✔ ✔
property selection and insertion
technique.

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 19 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

 Identified sign and symptoms I ✔ ✔  Demonstrated the use of non- ✔ ✔

I
of airway obstruction. pharmacological methods of
Breathing pain control.
 Described respiratory Demonstrated postoperative
I ✔ ✔ ✔ ✔
assessment. exercise I

 Identified indication for

I ✔ ✔  Purse-Lip Exercise I ✔ ✔ ✔
oxygen administration.
✔ ✔
Circulation  Coughing Exercise I

 Identified sign and symptoms

✔ ✔  Leg Exercises I ✔
of impaired cardiovascular I

status.  Range of Motion (ROM) I ✔ ✔

 Identified early signs of shock I ✔ ✔ Exercises
or hemorrhage. Discussed preventive measures and I ✔ ✔
Disability nursing intervention of common
 Demonstrated assessment of I ✔ ✔
postoperative discomfort
pupil size and reaction.  Postoperative Nausea and
I ✔ ✔
 Demonstrated assessment of I ✔ ✔
Vomiting (PONV)
level of consciousness.
 Thirst I ✔ ✔
 Discussed indication of glucose
I ✔ ✔ ✔ ✔
monitoring.  Constipation and Gas Cramps I

Exposure Discussed postoperative

 Described and demonstrate I ✔ ✔
complications and management
techniques to improve and / or I ✔ ✔
 Shock I ✔ ✔
maintain temperature that is
within normal limits. ✔ ✔

I
Hemorrhage
 Identified signs and symptoms
I ✔ ✔
of malignant hypothermia.  Deep Vein Thrombosis I ✔ ✔
 Described and demonstrated ✔ ✔
techniques to promote optional I ✔ ✔  Pulmonary Complications I

nutritional status and return of

gastrointestinal function.  Pulmonary Embolism I ✔ ✔

 Demonstrated urinary catheter  Urinary Retention I ✔ ✔

I ✔ ✔
care.
 ✔ ✔
 Discussed and demonstrated Intestinal Obstruction I
I ✔ ✔
management of surgical
wounds and drains.  Wound Infection I ✔ ✔

 Described and demonstrate  Wound Dehiscence and I ✔ ✔

I ✔ ✔ Evisceration
techniques to maintain safety
Pain  Depression I ✔ ✔
 Discussed nursing assessment ✔ ✔
and management of pain. I ✔ ✔  Delirium I

 Discussed opioid agents Documented all relevant I ✔ ✔

I ✔ ✔ information on the patient's file
commonly used in your unit.
Assessor Name: Surumi Salim, 115203

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 20 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023
Date: 13/4/1443  Personal hygiene I ✔ ✔
 Wash/change
22 – Mechanical VTE Prophylaxis Demonstrated knowledge to ✔ ✔
I
discontinue use of AES/graduated
Performance Criteria/Evidence Scale Methodology compression stocking.
VE DO WE RD Demonstrated knowledge and
Antiembolism ability to educate patient for
stockings/Graduated dischargehome with antiembolism
Compression Stocking stocking:
Demonstrated knowledge and  Benefits and importance of I ✔ ✔
ability to assess patient at risk for I ✔ ✔ wearing antiembolism
DVT and need prophylaxis. stockings
Demonstrated ability to identify  Washing, removal and
indication of antiembolism ✔ ✔ replacing
I
stockings/graduated compression  Discontinuing and how to
stocking. contact healthcare provider if
Demonstrated ability to identify there is a problem or adverse
✔ ✔
contraindication of antiembolism I effects.
stockings/graduated compression Intermittent Pneumatic
stocking. Compression (IPC)
Demonstrated ability to assess Demonstrated knowledge and
patient colour, warmth and I ✔ ✔ ability to assess patient at risk for I ✔ ✔ ✔
sensation. DVT and need prophylaxis.
 Pedal pulse must be palpable Demonstrated ability to identify
prior to application. indication of intermittent ✔ ✔
I
Determined the size of pneumatic compression.
stockings required to meet the Demonstrated ability to identify
risk and contraindication of I ✔ ✔
needs of thepatient.
 Patient position during calf I ✔ ✔ intermittent pneumatic
measurement compression.
 Below knee Demonstrated ability to identify
I ✔ ✔
 Above knee different types of IPC.
Determined when to reassess and Demonstrated knowledge and
I ✔ ✔
re-measure patient size. ability to apply IPC on bare
Demonstrated proper application legs orover pyjama trousers or ✔ ✔
I
of antiembolism stockings.
✔ ✔
stockings/graduated compression
I
 Thigh/leg
stocking.  Pressure cuff
Demonstrated proper removal of  Duration
antiembolism stockings/graduated I ✔ ✔ Demonstrated ability to assess skin
Compression stocking. integrity, mobilization, and I ✔ ✔
Demonstrated proper care of sensation every shift.
patient with antiembolism Determined when to take off IPC:
stockings/graduated I ✔ ✔  Patient independently I ✔ ✔
compression stocking: mobile
 Skin assessment and care  Discharge from hospital

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 21 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023
Demonstrated knowledge and ✔ ✔
Differentiate between drug abuse ✔ ✔
I I
ability to remove IPC. and drug misuse.
Assessor Name: Differentiate between
Surumi Salim, 115203 physiological and psychological I ✔ ✔
Date: 13/4/1443 dependence.
Concentrated Electrolytes
23 – Knowledge on High Risk Medications Demonstrated knowledge of
different concentrated electrolytes
Performance Criteria/Evidence Scale Methodology indications, contraindications, side I ✔ ✔
VE DO WE RD effects, and complications.Ability
Defined high risk medications. I ✔ ✔ to prepare and administer safely
and effectively.
Stated how to identify, store, and
I ✔ ✔
 Potassium chloride 2 mEq/ml I ✔ ✔
label high risk medications.
Demonstrated ability to locate list I ✔ ✔  Potassium phosphate 2 mEq/ml I ✔ ✔
of high risk medications.
Demonstrated knowledge and  Potassium acetate 2 mEq/ml I ✔ ✔
ability to perform independent ✔ ✔
double checking in preparing high
I
 Magnesium sulfate 10% or
greater I ✔ ✔
alert medications.
Inotropes and Vasopressor  Calcium gluconate 10% I ✔ ✔
Demonstrate knowledge and ability  Sodium bicarbonate 8.4%
to handle and administerinotropes I ✔ ✔ I ✔ ✔
and vasopressors  Sodium phosphate 4 mEq/ml
✔ ✔
 Indication/ contraindication ✔ ✔
I
I
 Sodium chloride more than ✔ ✔
 Side effects/adverse
I
0.9%
I ✔ ✔
reaction/complications
Other High Risk Medications
 Therapeutic effects ✔ ✔
I Demonstrated knowledge of the
 Drug interactions drugs listed below, its indications,
I ✔ ✔ I ✔ ✔
contraindications, side effects.
 Formulas/calculation/dosage Ability to prepare and administer
I ✔ ✔ the drug safely and effectively.
range
Narcotic and Controlled  Beta blocker I ✔ ✔
Substances
Demonstrate knowledge and  Antiarrhythmic
I ✔ ✔
ability to handle and administer I ✔ ✔
 Serotonin-norepinephrine
narcotic and controlled medications I ✔ ✔
reuptake inhibitor (SNRI)
 Indication/ contraindication I ✔ ✔  Antithrombotic agents I ✔ ✔
 Side effects/adverse  Parenteral cytotoxic agent
I ✔ ✔
reaction/complications I ✔ ✔
 Therapeutic effects ✔ ✔  Oral cytotoxic agent
I I ✔ ✔
 Drug interactions ✔ ✔  Neuromuscular blockers
I I ✔ ✔
 Calculation/dosage range ✔ ✔  Hypoglycemic medication
I
I ✔ ✔

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 22 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

Assessor Name: Surumi Salim, 115203  Assess airway patency &

assurance of ventilation
Date: 13/4/1443 Identify indication and selection of I ✔ ✔
proper size: oral airway,
24– Nurses Roles in Moderate Sedation nasopharyngeal airway, LMA,
Performance Criteria/Evidence Scale Methodology endotracheal airway
Breathing
VE DO WE RD
I. Skills
 Assess respiration rate &
respiratory effort
Pre-procedure
● Obtains informed consent  Assess breath sound & chest
● Performs appropriate pre- expansion
sedation evaluation  Assess oxygen saturation using
I ✔ ✔
● Pre-medicates patient as pulse oximetry
✔ ✔
needed  Identify indication of oxygen I

● Assembles and checks therapy

equipment Identifies different types of oxygen
Intra-procedure delivery devices and its uses: nasal
 Ensures that appropriate prong, simple face mask, partial re-
breather mask, non-rebreather
devices are functioning
mask, bag valve mask.
 Orders appropriate sedative
Circulation
agent at correct times
 Proper placement of 5 ECG
 Monitors patient’s response to electrodes
sedation
 Identifies cardiac arrhythmias ✔ ✔
 Titrates sedation effectively to I
 Assess heart rate and BP
needs
 Assess central & peripheral
 Repositions patients head/jaw
pulses
when necessary
 Assess capillary refill, skin
 Promptly recognizes and temperature, and color
intervenes on respiratory I ✔ ✔
Disability
depression  Assess of level of
 Treats other complications consciousness ✔ ✔
I
appropriately that arise  Assess for pupil (PERLA)
 Discontinues sedation  Assess blood glucose
appropriately
 Administers reversal agents Assessor Name: Surumi Salim, 115203
when necessary Date: 13/4/1443
Post-procedure
 Assesses patient in recovery
phase 25– Pronation Therapy
 Discharge patient when Performance Criteria/Evidence Scale Methodology
appropriately recovered I ✔ ✔
VE DO WE RD
 Provides appropriate written
discharge instructions Pre-Procedure
II. Monitoring  Multidisciplinary discussion ✔ ✔
I
Airway regarding the potential risks and
I ✔ ✔
benefits of prone ventilation.

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 23 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

 Adequate equipment: 3-4  Prepare for post-proning

I ✔ ✔
pillows, Gel Mat. instability with preparation of I ✔ ✔
 Inform and counsel vasopressors/inotropes.
patient/relatives. I ✔ Neuro:
 Ensure adequate numbers of staff  Adequate sedated (RASS -5). I ✔ ✔
available to facilitate safe I ✔ ✔
procedure (at least 5).  Consider muscle relaxation
I ✔ ✔
 Consider any investigations, (Bolus dose may be required).
procedures and necessary ✔ ✔
Skin/Eyes:
I
transfers that would prove to be  Eyes cleaned, lubricated and
I ✔ ✔
difficult to perform once the taped
patient is prone. Tubes/Lines
Check for Contraindication  Nasogastric feed is stopped, and
the nasogastric tube aspirated ✔ ✔
 No Spinal instability I ✔ ✔
I

(ideally at least 1hr before

 No Hemodynamic instability. ✔ ✔
proning), document length.
I
 Chest drains is well secured and ✔ ✔
 No Head injury/Raised
I
I ✔ ✔ placed below the patient.
intracranial Pressure.
After positioning
 No Open chest Post-cardiac
surgery/trauma.
I ✔ ✔  Recheck hemodynamic and I ✔ ✔
oxygen saturation
 No Anterior burns, chest tubes,
and open wounds.
I ✔ ✔  ECG electrodes re-attached/ all I ✔ ✔
monitoring is re-established.
 Not < 24 hours post cardiac
surgery.
I ✔ ✔  Recheck ETT cuff pressure I ✔ ✔
 No Central cannulation for VA  Ensure the ETT is not kinked and
ECMO or BiVAD support. I ✔ ✔
that a CO2 trace is still present on I ✔ ✔
Airway/Breathing the capnography.
 Difficult airway trolley checked ✔ ✔  Note the length of the ETT and
I
I ✔ ✔
and available. review ventilator settings.
 Suction oropharynx and airway I ✔ ✔  Take arterial blood gas (ABG) I ✔ ✔
prior to procedure. after 20 minutes and compare
 Pre-oxygenated with 100% O2 with pre-proning ABG.
✔ ✔
and ensure appropriate ventilator I
 Reassess position and function of ✔
I
settings. all lines and tubes.
 Ensure closed circuit suctioning is I ✔ ✔  Reposition and recalibrate all
available I ✔ ✔
pressure transducers.
 Perform pre-proning arterial I ✔ ✔  Reassess the need for
blood gas and document results. sedation/analgesia. I ✔ ✔
Cardiovascular Lines  Assess patient’s tolerance to the
 All lines are sutured and secured. turning (respiratory rate and
I ✔ ✔
effort, heart rate or bloodpressure I ✔ ✔
 Non- essential infusions ✔ ✔ return to normal within 5
I
discontinued minutes.)
 Patient is hemodynamically I ✔ ✔  No extension, flexion or lateral I ✔ ✔
stable. rotation /flexion of the spine.

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 24 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

 All joints should be in a neutral  Sterile 0.9% sodium chloride ✔ ✔

✔ ✔ I
anatomical position. I
 Clamp
 Patient’s head is repositioned on Demonstrated knowledge and
a two hourly basis I ✔ ✔ ability to prepare the monitoring
Discontinuation of proning if: equipment:
 Duration of prone position (for  Perform hand hygiene
safety reasons, from 12 to 16 H). I ✔ ✔  Open procedure pack or tray
by using external corners
 The patient becomes
hemodynamically unstable. I ✔ ✔  Prepare patient and caregivers
– use gloves
 The patient has a worsening
respiratory status. I ✔ ✔  Using an aseptic non touch I ✔ ✔
technique, prime the
Assessor Name: Surumi Salim, 115203 transducer set and monitoring
Date: 13/4/1443 lines with sterile 0.9%
sodium chloride only
26–Intra-Abdominal Pressure (IAP) Monitoring  The tubing must be free of
kinks and air bubbles.
Performance Criteria/Evidence Scale Methodology  Connect drainage end of
VE DO WE RD urinary Foley catheter (tip is
Defined Intra Abdominal Pressure already inserted in patients
I ✔ ✔
monitoring bladder) to the urine drainage
Discussed the assessment of risk bag with connector and two,
factor for elevated Intra- 3-way taps.
Abdominal Pressure:  Attach pressure transducer to
 Diminished abdominal wall I ✔ ✔ 3-way tap closest to the
compliance urinary catheter connector.
 Increased intra-luminal  Ensure all connections are
contents securely luer locked.
 Increased abdominal contents  All transducer monitoring
 Capillary leak/fluid lines should be clearly
resuscitation labelled.
Determined ability to manage &
I ✔ ✔  Urine flow into the drainage
measure IAP direct or indirectly. bag should be unclamped and
Identified and collected all uninterrupted except during
equipment for procedure : IAP measurement.
 Foley© urine catheter of Demonstrated knowledge and
appropriate size(if the catheter ability to measure IAP:
has already been inserted)  Placed the patient in the
 Urine bag for drainage of I ✔ ✔ supine position
✔ ✔
urine  Adjust the height of the I

 2 x 3 way tap transducers so that the top of

 Connector (leur lock to the 3 way tap (atmospheric
catheter tip) port) is levelled at the cross
 Pressure transducer and tubing section of the mid-axillary line
 50ml leur lock syringe and the iliac crest and zero the
 10ml or 30ml leur lock syringe transducer.

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 25 of 26

 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Western 1 Cluster, Makkah ‫التجمع الصحي بمكة المكرمة‬
Al-Noor Specialist Hospital ‫مستشفى النور التخصصي‬

FORM
FM Intensive Care Unit Specific Competency
Issue Date 01/09/2020 Activation Date 01/11/2020 Revision Date 01/09/2023

 Clamp the drainage tube to the  Physician order: Flow rate,

urine bag FIO2, Humidified gasses. I ✔ ✔
 Fill the bladder with 1mL/kg  Additional settings according
(minimum of 3 mL and to physician orders
maximum 25mLs) of 0.9% Increased the flow rate
sterile sodium chloride using subsequently in 5 to 10L/min if:
the syringe. The volume of  Respiratory rate fails to
fluid in the bladder should be improve
constant for each I ✔ ✔  Oxygenation fails to I ✔ ✔
measurement. adequately improve
 Close the stopcock of the  Breathing remains labored
syringe and allow 30 to 60 Demonstrated knowledge and
I ✔ ✔
seconds for equilibrium to ability to monitor patient
occur. Obtain the mean  Oxygen saturation and ECG ✔ ✔
I
pressure reading upon end monitoring
expiration
✔ ✔
 The abdominal blood flow  Respiratory rate & heart rate I

should produce fluctuations in  Hygiene and nutritional needs I ✔ ✔

the waveform.
Stated the factors that affect
I ✔ ✔  Conscious level I ✔ ✔
measurements
Stated potential complication and  Comfort, chest wall movement I ✔ ✔
✔ ✔
the symptoms 
I
Complication (Abdominal
Discussed in discontinuing IAP distension, Aspiration, I ✔ ✔
I ✔ ✔
monitoring Barotrauma).
Documented all relevant Identified sign of failure in used of
I ✔ ✔ I ✔ ✔
information on the patient's file HFNC.
Assessor Name: Surumi Salim, 115203 Demonstrated knowledge and ✔ ✔
I
ability to handle patient on
Date: 13/4/1443 weaning from HFNC:
27– Care of Patient on High Flow Nasal Cannula  Order for weaning from NIV I ✔ ✔
(HFNC)

Assess weaning tolerance and
Performance Criteria/Evidence Scale Methodology
controlled oxygen therapy I ✔ ✔
VE DO WE RD with target saturation/FiO2
Defined the High Flow Nasal ✔ ✔ Documented all relevant
I I ✔ ✔
Cannula Therapy information on the patient's file
Identified indications and Assessor Name:
contraindications for HFNC I ✔ ✔ Surumi Salim, 115203

I ✔ ✔ Date: 13/4/1443
Identified the advantage of HFNC
Discussed the different between
HFNC therapy and:
✔ ✔
 Normal Nasal Cannula
I

 Non-Invasive Ventilation
Demonstrated knowledge and I ✔ ✔
ability to set-up patient for HFNC:

Code: NSD-DP-FM-029– 01 Issue No: 05 Page 26 of 26