Transcript CCU Core Clinical Business

CCU Core Clinical Business
2013 Competency Module 2
What’s in Store for this Module
• This module will focus on CCU’s core clinical
business. This includes:
• Our key patient populations (HF, ACS, and A Fib)
• Our key skills (12 lead ECG, Cardiac Monitoring, Risk
Factor Counseling, and HF Self Care Education)
• The content will either briefly review or build on what
has already been covered in competency.
• The primary purpose of this module is for you to
highlight examples of excellence in practice as it
relates to our core clinical business
Heart Failure Self Care was covered in 2011 and Heart Failure
Disease Management was covered in 2012.
If you would like to review any prior competency modules you can
access them at
2011 https://www.dropbox.com/sh/gjcb7mdhubdv2gc/yAPV_Ew15E
2012 https://www.dropbox.com/sh/e4vycc013r1bndb/epaLDxXgZm
BUILDING ON HEART FAILURE SELF
CARE EDUCATION
Teach-Back . . . What Is It and What Does
The Evidence Say?
“Asking that patient’s recall and restate what they have
been told” is one of the 11 top patient safety practices
based on the strength of scientific evidence.”
•
- AHRQ, 2001 Report, Making Health Care Safer
• The “Teach-Back” method is one way to assess if the patient
understands the instructions
• “Teach-Back” is asking patients to repeat in their own words what
they need to know or do
• “Teach-Back” is NOT a test of the patient, but of how well you
explained a concept.
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Why is “Teach-Back” important?.....
Telling is not Teaching
• We Remember:
× 10% of what we read
× 20% of what we hear
× 30% of what we see
× 50% of what we see/hear
× 80% of what we say
× 90% of what we say and apply
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Using “Teach-Back”
•
The teach-back technique should replace the more common practice of simply asking a
patient, “Do you understand?”
•
Here are examples to get you started:
 “I have shared a lot of information with you. So I can see how well I did in explaining
things to you, will you tell me a couple of things you remember?”
 “Can you tell me what you will do when you get home?”
 “Show me what you would do…”
If you use, “Do you
have any questions?”
- you are not using
“Teach-Back”
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For Your Portfolio
• Reflective statements are an opportunity to step away from the
closeness of the day and evaluate our practice.
• Nurses are often overwhelmed with the busyness of practice, and do
not routinely build in opportunities to reflect on the outcomes of
practice interventions.
• Reflective statements are an opportunity to formally build reflection into
practice. Reflection is a strategy for clinical and professional
development and an important component of ongoing competency.
• Please submit two self reflective statements indicating how you used
teach back in providing education to a patient with heart failure. A
worksheet is provided for you in your “2013 Competency Packets” or
electronically at
https://www.dropbox.com/sh/ez02n2v0ueryodw/SNuyZEG
Zhb
Content of Self Reflective Statements:
• Patient initials, room number, and date & shift on which you provided education.
• Describe the specific question(s) you used to ask the patient teach back content to
you.
• Since the teach back strategy is a new skill, please discuss the barriers you
experienced in using this approach.
• Based on the patient response, what did you learn about the effectiveness of the
education provided.
• Summarize how the education you provided to the patient has the potential to impact
outcomes of care.
• According to the Synergy Model, patients have unique characteristics. What patient
characteristics influenced outcomes of the patient education session?
• According to the Synergy Model, one nurse competency is facilitator of learning.
What would you like to work on to improve your competency in this area of practice?
Accurate and evidence based cardiac monitoring were focus areas for both
2011 and 2012 CCU Competency.
If you would like to review any prior competency modules you can access
them at
2011 https://www.dropbox.com/sh/gjcb7mdhubdv2gc/yAPV_Ew15E
2012 https://www.dropbox.com/sh/e4vycc013r1bndb/epaLDxXgZm
BUILDING ON CARDIAC
MONITORING KNOWLEDGE AND
SKILL.
Lead placement is the foundation for
accurate cardiac monitoring
V1
• When V1 lead placement is
incorrect it is most frequently
because it is placed above
the 4th ICS.
• To palpate the 4th ICS start at
the patient’s sternal angle.
This is the point where your
sternum is most anterior. Just
to the right and down slightly
from the sternal angle is the
2nd ICS. From this point you
can palpate down to the 4th
ICS.
V3
• V3 is a difficult to lead to place.
V3 is to be placed between V2
and V4. Since V2 and V4 are
not actually on the chest you
must visually place them in
order to have accurate V3 lead
placement. V2 is 4th ICS LSB
and V4 is 5th ICS mid clavicular
line.
Electrode Placement
Chest (Precordial) Leads
• Lead V1
• 4th ICS, RSB
• Lead V2
• 4th ICS, LSB
• Lead V3
• Midway Between V2 & V4
• Lead V4
• L midclavicular line, 5th ICS
• Lead V5
• L anterior axillary line, same
level as V4
• Lead V6
• L midaxillary line, same level
as V4
Limb Leads
• The most common errors for limb lead placement are:
• The left arm electrode is not pulled out toward the left arm but
rather is placed too close to the mid clavicular line.
REMEMBER: The left arm electrode is the “camera”
looking at the high lateral wall of the left ventricle and
therefore must be pulled out toward the left arm (clavicle)
so it can “see” the high lateral wall.
• The left leg electrode is not below the rib cage when using it
as a limb lead for lead 3. This is the same principle as above.
If you want the “camera” of the left leg electrode to see the
inferior wall, it must be below the patient’s rib cage and
toward the left hip.
Limb Lead
Electrode
Placement
For Your Portfolio
•
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Please review the lead placement for five different patients at the beginning of your
shift. Use the worksheet in your competency packet or download the competency packet at
https://www.dropbox.com/sh/ez02n2v0ueryodw/SNuyZEGZhb
This review needs to occur on at least two different calendar days.
For each patient reviewed please document the following:
• Patient initials, room number, and date & shift you reviewed.
• Indicate the leads being monitored via hardwire or telemetry.
• Answer the following questions:
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Was the patient on hardwire or telemetry?
Was the left arm electrode pulled out toward far enough to the left shoulder?
Was the right arm electrode pulled out toward far enough to the right shoulder?
Was the left leg electrode below the level of the rib cage and toward the left hip?
Was the V1 electrode precisely in the 4th ICS on the right of the sternal border?
• You must palpate to verify
• If on telemetry, was the V3 electrode in the position between V1 and the 5th ICS mid clavicular
line on the left?
• The 5th ICS mid clavicular line on the left is the location for V4.
Additional Examples of Accurate and Evidence
Based Monitoring
• Bundle branch blocks should be documented as right or left based on
their morphology in lead V1.
• ST segment alarms should be set at 0.6 mm above or below baseline in
the limb leads.
• Abnormal rhythms should be documented in the following ways:
• Strip posted in the chart with onset and offset of the arrhythmias.
• Rhythm interpretation should be documented in interactive flow sheet
in Cerner.
• Provider documentation should be documented for any clinically
significant arrhythmias.
• QTc intervals should be monitored. QTc intervals > 500 msec (0.5
seconds) should be reported and the MAR should be assessed for drug
therapy with the potential to increase the QTc.
For Your Portfolio
•
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Please submit two self reflective statements indicating how you demonstrated
accurate rhythm interpretation or evidence based monitoring practice. Use the
worksheet in your competency packet or download the competency packet at
https://www.dropbox.com/sh/ez02n2v0ueryodw/SNuyZEGZhb
The self reflective statements should include the following:
• Patient initials, room number, and date & shift during which your example occurred.
• The Synergy Model identifies clinical judgment and patient advocacy as two important
nursing competencies. Please identify how your cardiac monitoring example
demonstrates clinical judgment and advocacy.
• Please describe what happened as a result of your example of excellence in practice.
The purpose here is for you to connect your nursing care to patient outcomes. For
example if you identified a prolonged QTc, consulted with the pharmacist regarding
medications prolonging the QT, notified the provider, and as a result a medication was
discontinued; the result is the discontinuation of a potentially harmful medication, the
avoidance of Torsades de Pointes, and improved patient safety.
• What would you like to work on to improve your competency in the area of cardiac
monitoring?
Please see Rhonda Fleischman for any questions.