Transcript Initial Patient Assessment

Northside Hospital
Student Orientation
Welcome!!
We are so happy to have you as part of our
team!
We hope that your experience at Northside
Hospital will be a valuable stepping stone in
your career!
Purpose Of This Presentation
• Introduce Northside Hospital services
• Ensure accurate completion of required
paperwork
• Provide information regarding key policy &
procedural issues
About
Northside Hospital
• Sandy Springs location opened in 1970, presently
a 444 bed full service hospital
• Forsyth location in Cumming, GA acquired 2002,
presently a 78 bed hospital & growing
• Cherokee location in Canton, GA licensed for 84
beds
• All are not-for profit community hospitals
• Named Atlanta’s “Most Preferred Hospital” since
1997 by the National Research Corporation
Proud To Serve...
• Women’s Services--Obstetrics & GYN
• Oncology Programs--Bone Marrow, Leukemia,
Breast & GYN cancers
• Surgical Services
• Radiology Services
• Emergency Services
• Cardiology
• Medical/Surgical
• Critical Care
• Pharmacy
Core Values At Northside
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Dignity
Respect
Pride
Warmth
Caring
Forms
• The forms on this website must be
completed at the time of Orientation,
signed, dated & returned to instructor before
your arrival at any Northside Hospital
campus
– Acknowledgement and Release Form
– Health History
• All questions must be answered in #6 (TB skin test)
& #7 (Rubella)
Name Badge
• Our policy requires that you wear your
name badge AT ALL TIMES while you are
on the Northside Hospital Campus
• Name badge--school issued, photo ID
• You will also be issued a Northside Hospital
name badge, identifying the unit/
department in which you will be doing your
clinical experience
Dining At Northside
• Two food services on main campus
– McDonald’s
– Morrison’s
• 30% discount with your name badge
– Morrison’s: when open (6:30 AM - 7 PM)
– McDonald’s: only when Morrison’s is closed
• Northside Forsyth & Northside Cherokee
cafeterias offer students a 20% discount
Parking At Northside Facilities
• Parking at the main hospital is available in the
Women’s Center Deck on Hollis Cobb Drive
directly opposite the Women’s Center
• Enter the deck using a code (provided to your
faculty member) or by taking parking ticket;
show your student ID at attendant exit or use
code at keypad exits for free parking
• At Forsyth & Cherokee, use designated
employee parking areas--no code required
Confidentiality
• Critical to maintain because:
– Protect the trust patients have in their health
care providers
– Requirement of Code of Ethics of various
professions
– Required by regulatory & accrediting
organizations
Health Insurance Portability and
Accountability Act…... HIPAA
Enacted to ensure that personal medical
information (shared with doctors, hospitals and
others who provide and pay for healthcare) is
protected.
Establishes restrictions on uses and disclosures of
personal health information.
Allows patients enhanced protection and greater
access to their medical records.
Protected Health Information
(PHI)
• Any patient’s health or personal information
transmitted through oral, recorded, paper, or
electronic means.
Such as:
– Patient name and address.
– Social Security Number.
– Medical records.
– Billing information
Minimum Reporting Necessary
• PHI is to only be used or disclosed when it
is necessary to carry out a specific function.
• This standard does not apply when PHI is
used or disclosed for treatment purposes
Our Role for Privacy Notice
• We are required to inform patients of how
we, as a facility, use and disclose their PHI.
• Patients must receive this notice on the date
the first service is rendered.
• The right to access and control the PHI of
minors is left to the parents - except when
state law overrides parental control.
Patients Have Rights To:
• Restrict use and disclosure. (Although the provider, NSH, is
not required to agree).
• Designate an alternate means for communication with the
patient (i.e. work number vs home number)
• Inspect and amend their medical record or “state their part
of the story”.
• Request a history of non-routine disclosures for as far back
as 6 years.
• Contact the designated NSH privacy official with questions
and breech of privacy complaints.
Tips On Confidentiality
• Avoid using waiting areas to interview or
brief patients or family members
• Be mindful that there are often patients &
family members on employee elevators, in
hallways & in the cafeteria
Confidentiality & Technology
• Prior to sending a fax, check with the charge nurse
in the department to which you are assigned
• When using a copier, don’t leave material
unattended
• Don’t use someone else’s username to access a
system for any reason
• Don’t leave computer displays showing
confidential information--log-off when finished
Questions About
Confidentiality Practices
• Ask your preceptor or the charge nurse of
the unit to which you are assigned
• If you see or suspect a possible HIPAA
Security or Privacy violation, call
Northside’s HIPAA hotline:
– (404) 845-5534
Respect and Courtesy At
Northside Hospital
• Knock before entering
• Introduce yourself before observing or
initiating care in any setting
PATIENT’S RIGHTS AND
RESPONSIBILITIES
PARTNERING WITH OUR
PATIENTS AND FAMILIES
Patient Rights
• Patients have the right to privacy, confidentiality,
ethics consultation, refusal of treatment, safety,
interpretation when needed, assessment &
management of pain and more
• Patients have the right to speak to a Patient
Representative to have complaints and or suggestions
for improvement heard and the right for assistance
with special needs, including interpretation services
• For a complete listing of patients rights, see “Your
Rights and Responsibilities as a Patient” fact sheet
Patient Responsibilities
• Patient responsibilities include asking
questions, providing accurate information,
following treatment plans and more
• Listed on the reverse side of “Your Rights
and Responsibilities as a Patient” fact sheet
Patient Rights & Responsibilities
• Northside encourages patients and families
to be active members of their healthcare
team in order to provide the highest quality
of care
• In keeping with this “partnership”
philosophy, every patient that is admitted to
Northside Hospital receives a written copy
of their rights and responsibilities along
with ways to help prevent medical errors
(available in English and Spanish)
Patient Rights & Responsibilities
• Other patients rights reference materials:
– Patient/Family/Visitors Guides located in all
patient rooms and patient access areas
– Mosby’s Multicultural Reference Guide
• Located on patient care units and in Health Resource
Library
– Multi-Faith Informational Manual
• Located on patient care units and in Health Resource
Library
• Information regarding Northside’s Ethical
Code of Conduct can be found in policy A-018
Other Supportive
Services Available
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Patient Relations
Interpretation Services
Pastoral Care
Check with the charge nurse for more
information on utilization or how to access
DIVERSITY
DIVERSITY
• Defined as “any collective mixture
characterized by similarities and
differences”
• NSH is committed to creating an
environment in which our patients’ cultural
differences, beliefs and practices are
respected
CULTURE
• Defined as the dynamic pattern of learned
behavior, values, beliefs and world view exhibited
by groups that share history and geographic
proximity
• Transmitted through institutions of society
(family, religion, educational systems, political
systems, media)
• Beliefs about the cause, prevention and treatment
of illness vary among cultures
CULTURAL DIFFERENCES
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Age
Gender
Educational background
Experience
Lifestyle
Nationality
Physical ability
Race
Religion
CULTURAL ASSESSMENT
• Listen with sympathy & understanding to the
patient’s perception of the problem
• Explain your perceptions of the problem & your
strategy for treatment
• Acknowledge & discuss the differences &
similarities between these perceptions
• Recommend treatment while remembering the
patient’s cultural parameters
• Negotiate agreement
Avoid
• Stereotyping: making broad statements/
assumptions based on membership in a group
(“All _____ think this way”)
• Ethnocentrism: belief in supremacy of one’s own
ethnic group
• Prejudice: biased or hostile attitudes or
perceptions toward a person who belongs to a
group simply because he/she belongs to that group
Culturally Sensitive Care
• Become familiar with socioeconomic &
demographic characteristics, belief systems
& health behaviors of other culture
• Apply cultural knowledge, behaviors &
interpersonal & clinical skills that enhance
your effectiveness in managing patient care
2005 NATIONAL PATIENT
SAFETY GOALS
2005 NATIONAL PATIENT
SAFETY GOALS
• Goal I: Improve the accuracy of patient
identification
 Taking of Blood Samples or Other Specimens for
Clinical Testing
 Administration of Medications
 Administration of Blood Products
 Any Treatment or Procedure
 NSH uses 2 identifiers--check with clinical
resource to determine appropriate identifiers for
procedure
2005 NATIONAL PATIENT
SAFETY GOALS
• Goal II: Improve the effectiveness of
communication among caregivers
– Do Not Use Abbreviations--refer to list on all
charts & throughout departments
– Verbal/Telephone Orders
– Timeliness of reporting and receipt of critical test
results and values
2005 NATIONAL PATIENT
SAFETY GOALS
• Goal III: Improve the safety of high-alert
medications
 Drug Concentration standardization
 Removal of concentrated electrolytes from patient
care areas
 Annual review of look-alike/sound-alike drugs
2005 NATIONAL PATIENT
SAFETY GOALS
• Goal IV: Eliminate wrong site, wrong patient,
wrong procedure surgery
– Pre-operative Verification Process
– Marking of site
– Conduct a “time-out” immediately before starting
the procedure
• Goal V: Improve the safety of using infusion
pumps
 Ensure Free-flow protection
2005 NATIONAL PATIENT
SAFETY GOALS
• Goal VI: Improve the effectiveness of clinical
alarm systems
 Regular testing and maintenance is performed
 Alarms are audible with respect to competing
noises in unit
• Goal VII: Reduce the risk of health careassociated infections
– Comply with current CDC hand hygiene guidelines
2005 NATIONAL PATIENT
SAFETY GOALS
• Goal VIII: Accurately and completely
reconcile medications across the continuum
of care
– Obtain and document complete list of patient’s
medication upon admission
– Communicate complete list of patient’s
medications to next provider of service whether
within or outside the organization
2005 NATIONAL PATIENT
SAFETY GOALS
• Goal IX: Reduce the risk of patient harm
from falls
– Assess and periodically reassess each patient’s
risk for Falling, including the potential risk
associated with Patient’s medication regimen
RISK MANAGEMENT
PURPOSE OF RISK
MANAGEMENT
• Identify, evaluate & reduce the risk of injury
or loss to patients, staff members & the
organization
• Injury can be actual physical injury to a
person or loss or damage to property,
reputation or income
• Early identification of injury or loss can
prevent similar recurrences in the future
INCIDENT REPORTING
• In your everyday contact with patients, you
are in the best position to identify patient
safety issues, unusual outcomes or injures
• These are recorded on incident reports
– Not to assign blame to to evaluate process
involved
– An opportunity to improve practice & quality
of care
INCIDENT REPORTS
• Factual statement
• Gives account of what actually happened to
a particular patient in a particular situation
– Does not give opinions of what happened or
why happened
– Does not point fingers or assign blame
– Is not part of Medical Record
– Does not take the place of documentation in the
Medical Record
IF YOU DISCOVER AN
UNUSUAL OCCURRENCE
• Report to charge nurse
• Follow instructions for completion of
Incident Report
• Document incident in Medical Record in
factual, concise way
IMPAIRED PROVIDERS
WHAT IS AN IMPAIRED
PROVIDER?
• A Physician or Affiliated Practitioner (CRNA, CNM,
etc) whose ability or clinical judgment may be
adversely altered because of
 psychiatric or other medical conditions or
 the use of alcohol or illegal drugs or
 the use or abuse of prescribed drugs or OTC drugs
 resulting in the inability to provide appropriate patient
care, an immediate threat to the safety and welfare of
patients and staff, or an inability to fulfill other duties
or responsibilities.
TYPES OF HEALTH ISSUES THAT
MAY RESULT IN IMPAIRMENT
 Any disease that might impact manual dexterity, such
as arthritis in a physician or other practitioner who
performs procedures
 Any situation that could slow response times or cloud
decision making
 Lack of sleep
 Depression
 Stress from divorce, problems with children, or
family illness
 Substance dependency or abuse
RECOGNIZING AN IMPAIRED
PROVIDER--JOB PERFORMANCE
 Agitation with questions regarding activities or care
 Complaints from patients or families regarding care provided or
unreasonable behavior during visits
 Memory lapses or generalized forgetfulness, including forgotten
verbal orders
Alteration in clinical judgment (treatments/orders don’t fit the
patient’s clinical situation)
 Inappropriate medication orders or over prescribing medications
 Decreased quality of medical record documentation
 Delays in returning pages/calls or inappropriate response to
calling
 Making rounds in “off hours”
RECOGNIZING AN IMPAIRED
PROVIDER--PHYSICAL
APPEARANCE/BEHAVIOR
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Personality changes, especially increased irritability
Changes in personal grooming or mode of dress
Slurred speech, tremors
Reddened eyes, dilated or pinpoint pupils
Frequent accidents with evidence of abrasions,
hematoma, sprains or fractures
 Alcohol on breath
 Needle marks
PROTECTING PATIENTS
• NSH requires that hospital staff report any
“reasonable suspicion” of impairment
• Anyone may report suspected impairment,
including family, patients, staff or students
• May be reported to:
 Any manager, director, or VP
 Any House Coordinator or designated House
Coordinator/Supervisor
 Medical staff leadership such as Chief of Staff, Vice Chief of
Staff, Department Chairs, etc
IMMEDIATELY REPORT:
• An immediate report of reasonable
suspicion of impairment should be made
to your supervisor if any of the following
occur  The impaired provider is attempting to care for a patient
 The impairment could contribute to a potential adverse
outcome for a patient
 Impairment has contributed to an accident or incident
SUMMARY OF APPROACH TO
IMPAIRED PROVIDERS
 The primary goal of reporting impairment is to
offer assistance to the impaired provider and
at the same time protect patients and hospital
staff from harm
• Northside Hospital and Medical Staff
recognize that impaired providers are
individuals who are dedicated to helping
others, and are now in need of help
themselves.
ENVIRONMENT OF CARE
Seven Elements of the
Environment of Care
• Safety Management
• Utilities Management
• Fire Safety
• Medical Equipment
• Security
• Hazardous Materials
• Emergency
Management
Safety Management
• Safety Officer for NSH System
– (404) 851-8784
• Use the location- specific emergency number to
report all Code Blue, Safety, Security and Medical
Emergencies.
SAFETY CODES
• Code Red--fire
• Code Blue--medical
emergency
• Code Gray--tornado
• Code Orange--bomb
threat
• Code Brown--evacuation
• Code Pink--missing
infant/child
• Code Dry--Water system
failure
• Code White--snow/ice
• Code Triage-Stand-by-incident command
Admin.
• Code Triage--incident
command section leaders
• Code Green--mass
casualty event
• Code Yellow--HazMat
Decontamination
• Code One--immediate
security assistance
required
Safety Management
• Report all Needle Sticks and Injuries to
your Supervisor.
• Use Standard Precautions when dealing
with patient’s bodily secretions.
• Personal Protective Equipment (PPE) will
be provided at no cost.
Security Management
• There is 24 hour Security on-site
• Escorts are available by calling Security
• Emergency Phones, Intercoms and Stairwell
Alarms are available in Parking Decks
• Report all Suspicious Persons to Security
Fire Safety
• Code Red is the Code for Fire or Smoke.
• Use R-A-C-E if you discover a fire or
smoke condition.
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Rescue:
Alarm:
Contain:
Extinguish:
Your Patient and Yourself
Pull the nearest Alarm
Close all Doors.
Use a Fire Extinguisher
Fire Safety
• Report all Smells of Smoke to emergency
number & Alert your Charge Person.
• Use P-A-S-S with Fire Extinguishers.
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Pull the pin.
Aim at the base of the fire.
Squeeze the handle.
Sweep the fire.
Medical Equipment
• Notify Charge Person if Medical Equipment
does not seem to be working correctly
• All Electrical Patient Equipment MUST
have a three prong plug and an up to date
Safety Inspection Sticker.
Emergency Management
• Code Orange is for Bomb Threats. Report
suspicious items to Security. Do Not Touch
or Move Suspicious Items.
• Code Grey is for Tornadoes. Close & Latch
all Windows. Relocate patients to Inner
Hallways if able. If not, protect patients by
moving them away from windows.
Emergency Management
• Code Green is for External Mass Casualty.
Continue in your present role and follow the
instructions of your Charge Person.
• Bio-Terrorism: Use Standard Precautions
for all patients. smallpox patients will be
placed on Air Control & Contact
Precautions. Plague patients will be placed
on Droplet Precautions.
Hazardous Materials
• Material Safety Data Sheets (info on all
chemicals used on unit/department)--ask the
department supervisor on how to retrieve
• Report all Chemical Spills to your Charge
person.
• Use Personal Protective Equipment
Utilities Management
• Utility Systems include Elevators, Water,
Electricity, Heating,Ventilation and Air
Conditioning.
• Report any problems with Utility Systems
to your Charge Person or the Hospital
Safety Officer.
Environment of Care Key
Numbers
• Emergency Number
– Atlanta: 8911
– Cherokee: 250
– Forsyth: 54321
• Security Control Center number
– Atlanta:(404) 851-8797
– Cherokee: (770) 720-5199
– Forsyth :(678) 776-7869
INFECTION CONTROL
PRESENTS
ISOLATION
BIOTERRORISM
CLEAN/STERILE TECHNIIQUE
The Isolation Guidelines
Has Two Major Parts
• Standard Precautions
– Precautions for care of all patients regardless
of diagnosis
• Transmission Based Precautions
– Precautions designed for care of specified
patients
Unconfirmed Infectious Process
• Isolate pending confirmation of diagnosis
• Based on experience
• “Educated guess”
Standard Precautions
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Used for all patients at all times
Replaces Universal Precautions
Barrier precautions the same
Use common sense
Standard Precautions
Barriers
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Handwashing
Gloves
Gowns/Aprons
Masks
Goggles
Sharps containers
Ventilation Devices
Standard Precautions Procedures
• Handwashing (Most important prevention)
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Consider waterless when no sinks
before patient care
after removing PPE
between tasks
after patient care completed
Standard Precautions
• Gloves
– for venipuncture, vascular access, when
touching contaminated items
– clean gloves for mucous membranes & change
often
• Gowns
– to prevent soiling of uniform and skin
contamination when pt. care requires contact
with blood, body fluids or nonintact skin
Standard Precautions
• Mask & Goggles
– to protect mucous membranes of the eyes, nose
and mouth from droplets of blood or body
fluids
– use anytime there is a potential risk
• THIS MEANS SUCTIONING!!!
Transmission Based Precautions
• Designed for patients known or suspected to
be infected or colonized with transmissible
or epidemiologically important organisms
Transmission Based Precautions,
con’t:
• Three Types:
– Airborne Precautions
– Droplet Precautions
– Contact Precautions
• New precautions called STANDARD PLUS
– Use Gloves to enter room & for all patient
contact
Airborne Precautions Used For:
• Airborne spread, tiny
droplets
• TB - Suspect or
confirmed
• Chicken Pox (Varicella)
– or disseminated Zoster
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Measles - (Rubeola)
Small Pox - (BT)
SARS
Hemorrhagic
Fevers - (BT)
– (Ebola, Lassa, Marburg
Airborne Precautions
• Mask
– use at all times
– N95 (must be fitted) for TB, SMALLPOX &
SARS
– surgical mask for CP & other
• Isolation room needed
– negative pressure
– keep door closed
AIRBORNE
• Add CONTACT PRECAUTIONS
– for Chicken Pox , disseminated Zoster &
Smallpox ( Use 2 signs) & SARS
– Teach patient to cover nose & mouth when
coughing
Droplet Precautions used for
• Large Droplets
• Acute respiratory infections
• N.meningitides, pneumonia caused by :
influenza, Mycoplasma,, parvovirus,
pertussis, Plague (BT), SARS
Droplet Precautions Con’t
• Mask
– Surgical Mask is the primary barrier unless
patient has large amounts of secretions or
drainage
– Wear mask when working within 3 feet of
patient
– Wear Mask when suctioning
– Wear mask on patient when transporting
Contact Precautions Used For:
• Drug Resistant Bacteria
– MRSA, VRE &, Others Identified by ICC
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C. Difficile
Major Drainage from wound infections
Diarrhea if patient is incontinent
Highly Contagious skin infections ie:
scabies, lice, impetigo
• SARS
Contact Precautions
• Wear gloves and gowns when entering the
room
• Remove all PPE before leaving the room
• Transmission by direct pt. contact or
contact with items in the environment
• Create a barrier ALL THE TIME
• May use empirically
Northside Isolation For
Resistance ( Orange Sign)
• Use With Contact Isolation Sign
• Important Points
– Wear all PPE when entering room
– Remove all PPE before leaving
– Don’t touch doorknobs and surfaces after
gloves are contaminated
New Precautions Called
Standard Plus
• Standard Precautions With Gloves
– Wear gloves to enter room and for all contact
with patient
– designed for patients who have a hx of MRSA,
VRE but who have no symptoms of infection,
drainage, or an invasive device in place
Standard Precautions:
Other Components
• Linen - Clean Cover Or Store In Closet
– Never toss on floor
– Never shake
– Consider used as contaminated
• CPR - Masks Available--check with
supervisor of unit for location
Standard Precautions:
Other Components
• All NSH facilities dispose of waste in strict
compliance with Georgia Regs
– Red Bagged
• Fluid filled containers
• Microbiological, pathological
– Tissue
• Blood Spills - clean up by using gloves,
paper towels and disinfect area
• Sharps - Empty 3/4 Full
Standard Precautions:
Other Components
• Exposures
– First aid
– Report ASAP to Employee Health in off hours
your supervisor / ER/ school
– Source testing
– PEP prophylaxis/vaccine
– Use safety devices
Standard Precautions
• Exposure Control Plan (ECP) In The
Infection Control Manual
– Tuberculosis Plan
– Vaccines
Bioterrorism
• What Is Bioterrorism?
– Bioterrorism is the intentional release of
pathogenic organisms , (bacteria, viruses, fungi)
or toxins into a community to cause disease
and inflict terror
– Primary Agents
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Anthrax
Botulism
Plague
Smallpox
Bioterrorism
• What Is Your Role?
– NSH has a bioterrorism plan
– Take directions from your
supervisor
– Apply appropriate isolation
• Standard precautions for all.
• Smallpox - place in airborne/contact precautions
• Plague - droplet precautions
Appropriate Use Of Clean and
Sterile Technique
• Basic Principles
– Microorganisms are capable of causing illness
in humans
– Microorganisms can be transmitted by direct or
indirect contact
– Illness can be prevented by interrupting
transmission
Definition Of ASEPSIS
• Clean technique - refers to practices that
reduce the numbers of microorganisms to
prevent or reduce transmission
• Surgical technique- refers to practices
designed to render and maintain objects and
areas maximally free from microorganisms
Clean Technique
• Reduce numbers of skin microorganisms by
handwashing or cleaning
– Use soap for routine care
– Apply friction to increase amount of soil
removed
– Clean from areas of clean to areas of less clean
Clean Technique (Cont.).
• Barrier techniques reduce transmission from
patient to personnel
– Use no-touch dressing technique to avoid
contaminating sterile supplies
– Use sterile gloves for dressing application
– Wear clean gloves or apron or gown to protect
clothing
– Wear clean gloves to avoid contact with
infectious material
– Room placement important (ie: neg pressure)
Surgical Technique
• Provide maximum reduction of skin
microorganisms without damaging tissue
• Surgical Scrub
– Cleanse with soap to remove soil
– Use antimicrobial agent: may leave residue to
continue suppression
– Apply friction with scrub brush
Sterile Technique
Provide Maximum Reduction
• Patient Prep
– Use antiseptic agent
– Remove hair when necessary.
• Note: When hair removal is necessary, it should be
done with a depilatory or, less desirably , by
clipping, rather than by shaving with a razor. It
should be done immediately before the procedure,
Sterile Technique
• Use barrier techniques to decrease
transmission of microorganisms from
personnel to patient
– Maintain area of sterile field with sterile gloves,
gowns and drapes
– Wear appropriate attire as indicated by risk of
procedure and area of hospital where the
procedure is performed
Surgical Technique
– Environmental Controls To Reduce
Microorganisms During Surgical Procedures:
Use special treatment rooms
– Control activity to reduce airborne transmission
• Keep doors closed during procedures
• Exclude visitors and unnecessary personnel
• Avoid cleaning activities in the area during surgical
procedures
Reprocessing Equipment
Between Patients
– Discard disposables after each patient use.
– Use mechanical cleaning or change cover of surfaces not
in contact with abraded skin, mucous membranes, or
infectious secretions/excretion (e.g., exam. tables,
stretchers, wheelchairs.)
– Use mechanical cleaning and disinfection of noninvasive
equipment that may become contaminated with body
fluids (e.g., electrodes, ear speculums, stethoscopes, blood
pressure cuffs, outside surfaces of equipment such as
ventilators or intravenous pumps.)
CARING FOR PATIENTS
Assessment
• Each department has a specific scope of
assessment based on professional &
regulatory standards
• Consult with preceptor to determine
expectations & requirements appropriate to
your clinical assignment
Interdisciplinary Plan of Care
• Shows collaboration and coordination of patient
care among disciplines
• Interdisciplinary Plan of Care is supported by:
– Interdisciplinary Clinical Guidelines
– Standards of practice
– Protocols
• Each discipline documents consultation visit-promotes communication about care of patient
Interdisciplinary Plan of Care
Includes
• Admission date,
diagnosis
• Problem identification
and prioritization
• Consultation visits
• Nutrition
• Diagnostics
• Activity
• Treatments/
Interventions
• Psychosocial/Spiritual
• Patient/Family
Education
• Discharge Plan
• Goals/Outcomes
Patient Safety-Restraints
• Definition:
– Method of physically restricting a person's freedom of
movement, physical activity, or normal access to his or her
body, including medication.
• Goal:
– Limit use of restraints to situations where alternative
measures have failed & only when the possible benefits
clearly outweigh the risks
Patient Safety-Restraints
• Your role:
– Restraints always require an MD order prior to
implementation
• Restraints used as part of a procedure are not considered a restraint
– Communicate with patient’s nurse prior to any
treatment/procedure/interaction
– Communicate assessment findings relevant to patient’s
behavior to patient’s nurse
– If restraints are removed prior to treatment/procedure, have
patient’s nurse check re-application prior to leaving patient
unattended
Patient Safety-Falls
• DEFINITION: An uncontrolled or unintentional descent
from a higher elevation to a lower elevation
• CAUSE OF FALLS: Age; gait; impaired cognition,
vision and mobility; medications; failure to call for assistance;
elimination; environmental issues
• Falls occur in all Service Areas!
• Falls occur on all shifts!
• Restraints do not prevent falls!
Patient Safety-Falls
• Fall Prevention:
– All patients are assessed on admission and each shift
– “Risk to Fall” assigned to patients with the following
criteria:
• History of falls
and/or
• Combination of two or more factors: age>70, gait
problems, fatigue/weakness, disorientation/confusion,
medications affecting balance, judgement &/or level of
consciousness
Patient Safety-Falls
• ‘Risk to Fall Plan’
– Confidential ID with “Yellow Armband”
– Frequent monitoring: toileting & ADLs every 2 hours or
as indicated
– Pt & Family Ed Plan - teaching tool
– Environmental Safety precautions
• Keep pathways clear
• Provide assistance with mobility
– Communicate concerns to RN coordinating patient’s care
Patient Safety-Falls
• FALL EVENT
– Notify patient’s nurse immediately
– Assess patient for injury
– Complete an Incident Report
• Report is forwarded to unit manager and Risk Management
• Fall data included on monthly unit report card
• Unit leadership reviews fall data and addresses issues at staff
meetings
– Document factual details of event in medical record
• Do not refer to incident report in medical record
• Stick to observations & what the patient says
• Do not make assumptions or judgments
Patient Safety-Armband Alerts
• Yellow: Risk to Fall
– Educate patient / family on Safety Tips to prevent falls
– Check physical environment for safety measures
• Pink: Lymphedema Precautions
– Criteria applies to patients with history of Breast
Cancer surgery where axillary nodes removed; dialysis
arm shunt and upper extremity surgery
• Orange: Do Not Resuscitate
– Armband should list “No-Code” or “Limited
Code” with limitations listed
DOCUMENTATION
General Guidelines
• All medical record entries must be done in
black ink & dated & timed
• Times used are based on 24 hour clock
(military time); e.g., 7 AM = 0700 & 7 PM
= 1900
• Errors are corrected by crossing through the
error, writing “error” above the notation &
initialing the error; do not erase or use
correction fluid
General Guidelines (Cont.)
• Signature form is to be used by all members
of the interdisciplinary healthcare team to
sign on the chart initially;afterward, use
initials for any chart entry
• All categories of forms must be completed-do not leave blanks
General Guidelines (Cont.)
• Charting by exception:
– A checkmark will be placed in the appropriate
column if patient meets defined assessment
criteria
– If patient does not meet defined assessment
criteria, place an asterisk in the appropriate time
column & document abnormal findings using
bolded letter or narrative note
NON-NURSING STUDENTS:
STOP HERE!!
• Nursing Students must
continue to review this
program
Nursing Process
• “A” (assessment) documented by
observations & narrative notes; documented
by RN, LPN, PCT & other supportive
personnel
• RN analyzes data to identify problem &
develop plan
• “P” (plan) documented on Plan of Care; RN
function to prioritize problems & coordinate
care
Nursing Process (Cont.)
• “I” (intervention) documented on acuity
tool, flow sheets, through narrative notes or
checklists; completed by all who provide
care
• “E” (evaluation) documented at least once
per shift; evaluates progress to goals &
effectiveness of treatment; RN
responsibility
Initial Patient Assessment
•
•
•
•
Physical, psychological, and social status
Nutritional, functional, and educational needs
Department's specific content
Determines the need for care or treatment,
– H & P (done by MD)
• Inpatient: on chart within 24 hrs
• Outpatient: on chart prior to procedure
– Nursing Assessment completion:
• Inpatient: on chart within 24 hrs
• Outpatient: on chart prior to procedure
Patient Reassessment
• Done according to the department's specific
policies and procedures on reassessing
patients.
• Done when
– significant change in the patient's condition
– when a significant change occurs in the
patient's diagnosis.
– According to department specific, patient
specific guidelines
Plan of Care
• Initiated within 24 hours of admission
• Reviewed each shift to determine currency
& priority of problem list
Implementation
• Activities performed by all members of
nursing team documented to demonstrate
care provided to patient
Evaluation
• Nursing evaluation should reflect patients
progress toward goals/outcome criteria
(achievement or non achievement of the
goals/outcome criteria)
• If a patient does not meet outcome criteria
for identified problems prior to discharge,
they should be referenced in the discharge
education, follow-up, transfer note etc.
MEDICATION
ADMINISTRATION
Medication Use System
Medication Order
(Prescribing)
Preparation
Administration
& Dispensing & Documentation
Patient
Monitoring
Complete orders
Pharmacist
Review &
Assessment
Response to
therapy
Do Not Use
Abbreviations
Dispensing &
delivery to
units
MAR’s
RN to verify
medication
transcription
Completeness,
clarity and
accuracy
critical
Five Rights
•
•
•
•
•
Right patient
Right drug
Right dose
Right time
Right route
Do Not Use Abbreviations
• May NOT write
–
–
–
–
–
–
–
–
QD
QOD
U
Trailing zero, e.g. 5.0
ug for microgram
IU
MS or MSO4
TIW
• Instead write
–
–
–
–
–
–
–
–
daily
every other day
units
5 mg
microgram
international unit
morphine
three times weekly
RN Responsibilities
• Verifying medication order
• Coordination of administration &
documentation of all routine, PRN & STAT
medications
• Administration of all IV solutions, central
line fluids & piggyback solutions
LPN RESPONSIBILITIES
• Verify medication orders
• Safe administration of all permitted
medications (PO, IM, SQ, Routine IV infusions,
Accepted IV piggybacks [antibiotics, antivirals, GI meds],
select IV push medications following specific training)
• Refrain from administering unauthorized
medications (blood/blood products, titratable IV
infusions, IV push medications, chemotherapeutic agents,
PCA or epidural medications)
Respiratory Therapist’s
Responsibilities
• May accept & document telephone orders
for respiratory/inhaled medications (e.g.,
inhaled bronchodilators, sodium bicarb, etc)
• May administer & document inhaled
medications
Dietitian Responsibilities
• May accept & document telephone orders
for diets or nutritional supplements
• May provide & document oral nutritional
supplements to patient
PHARMACIST
RESPONSIBILITIES
• Managing Medication Use System
– Order assessment & processing
– Dispensing functions and drug distribution
• Clinical Functions
– Ensure appropriateness of orders
– Identify and resolve drug related problems
– Resources to MD’s, Nursing, Patients, etc.
MEDICATION ORDERING
PRACTICES
• Telephone orders may be accepted at any
time; individual accepting telephone orders
must:
– Write order
– Read back written order
– Document read back
• Verbal orders may only be taken during
emergencies or when MD is scrubbed in for
sterile procedure
Prior To Administration...
• Medications must be verified by an RN or
LPN prior to administration
• Identify patient appropriately:
– Medication: Compare patient name & account
number on armband & MAR
– Blood: Compare patient name & medical record
number on armband & blood
Medication Scheduling
• First dose of routine doses should be given
within 2 hours of order
• Oral medication should be scheduled to
maximize patient sleeping times
Cultures Before Antibiotics
• When cultures are ordered prior to
antibiotic administration, notify MD if
cultures have not been obtained within 2
hours of written order
• Physician is to specify how to proceed
Labeling Open Medications
• Sterile saline IV flush bottles are intended
as one use only; discard any unused portion
after withdrawing desired amount
• Other medications that are multi-use vials
(e.g., insulin) must be labeled with date &
time opened, as well as initials of individual
who opened the vial
Other Labeling Issues
• If medication is drawn up into a syringe but
there is a delay in administration, the
syringe must be labeled with medication
name, dose, date, time drawn up & initials;
such medications should NOT be left lying
on countertops, etc., but should be secured
appropriately
Other Labeling Issues (Cont.)
• Leave oral medications in wrappers until
ready to administer; it is not acceptable to
put pill into med cup in med drawer
unlabeled
Checks & Balances
• A double check with an RN is required for dosage
calculation for specific drugs:
– heparin
– insulin
– thrombolytics
• Prior to administration, an independent double
check of the dosage drawn up is required for:
– heparin
– insulin
Checks & Balances (Cont.)
• Those drips that require precise dosing
and/or titration must be administered via an
infusion pump
• When programming changes in IV heparin
or insulin, a second RN witness is required
Insulin Procedures
• Rounding: if the dose is 0.5 units or greater,
round up to the nearest whole number; if the
dose is less than 0.5 units, round down to
the nearest whole number
• Only insulin syringes are to be used for
insulin administration
• Discard insulin vials 4 weeks after opening
• Insulin may be stored at room temperature
after opening
Hypoglycemia
• If a hypoglycemic reaction occurs or the
blood glucose is < or = 60, shut off insulin
drip (if present) & treat the patient
according to hypoglycemic guidelines
Irrigating Solutions
• Label bottles with date & time when opened
• Discard all irrigation solutions 24 hours
after being opened
Controlled Drug Procedures
• All narcotics are kept in PYXIS
• Students/Faculty will be issued temporary
PYXIS access numbers by the charge nurse
as necessary
• In the event of a drug discrepancy,
personnel are expected to remain on the unit
until all discrepancies are found or
accounted for
Waste Procedures For Controlled
Drugs
• There should be no wasted narcotics except for
partial doses
• A controlled drug waste will be witnessed &
electronically “co-signed” by an RN in PYXIS
• If an entire dose of an oral or injectable drug is
refused, broken or not used for any reason, it
MUST be returned to the Pharmacy by PYXIS
or manually by the RN, LPN or student
Waste By Broken Ampules
• In the event of a broken ampule, the
breakage should be witnessed by an RN &
the broken glass returned to pharmacy with
a discrepancy report
Medications From Home
• A patient may not take medications from
home unless the pharmacy does not have
that particular drug
• If the patient presents medications from
home, they should be:
– sent home with the patient’s family, or
– locked up with the patient’s valuables if there is
no one to take them home
Medications From Home (Cont.)
• If indicated & the physician writes the order
that the patient is to take the home meds:
– The medications must be sent to pharmacy for
identification
– The medication must be written on the MAR as
a scheduled medication
– Medication must be kept in Medication Cart on
unit, not at bedside
– Doses must be documented as per usual
DOCUMENTING MEDICATION
ADMINISTRATION
• Medications are documented on 3 types of
Medication Administration Records (MAR)
– Computer-generated Medication Administration
Record (CMAR) : this is a 24 hour MAR
(Atlanta & Forsyth)
– Preprinted Medication Administration Record
(MAR): this is a multi-day MAR (Atlanta)
– Manually transcribed (hand-written) MAR
(Cherokee)
DOCUMENTATION OF
ROUTINE MEDS
• Use 24 hour clock to document time
• All routine medications will be charted on
the Routine Medication Administration
Record (MAR)
• Dressing changes are scheduled &
documented on the MAR
DOCUMENTATION OF
ROUTINE MEDS (CONT)
• Document the EXACT time (e.g., 0842
instead of 0800) of administration of the
following:
–
–
–
–
–
Aminoglycosides
Vancomycin
Antiarrhythmics
Theophyllines
Digoxin
Documenting PRN Meds
• All PRN medications will be charted on the
PRN MAR at the time they are administered
• Documentation to include initials, dosage,
route &/or site
• Effectiveness of PRN medication must also
be documented using the effectiveness
codes
Special Documentation
Requirements
• All insulin will be charted on the diabetic
flow sheet
• All anticoagulants will be charted on the
Routine MAR if they are regularly
scheduled; Coumadin ordered on a daily
basis is recorded on the “one time only”
section of the Routine MAR
Documentation Of Single Dose
Meds
• All one time only medications will be charted on
the Routine MAR in the “one dose medication”
section in departments with preprinted MARs
• All preop medications will be charted on the
Routine MAR in the “one dose medication”
section in departments with preprinted MARs
• On units using CMARs, single dose & pre-op
meds will be charted as a scheduled dose
General Med Documentation
• If a generic drug is given, the generic drug
name is automatically used on the CMAR
• Each individual who transcribes or records
medications will also identify
herself/himself on the signature form
• Allergies are automatically recorded on the
CMAR; on units using pre-printed MARs,
all allergies must be recorded on the MAR
in addition to the Master Allergy Sheet
Medications Not Given
• When documenting a med not given on CMAR,
the time of the dose is circled, the time is initialed
& the appropriate code for reason is to be noted
• When documenting a med not given on a preprinted MAR, initial the appropriate time slot,
circle initials & place the appropriate code for
meds not given beside circled initials
• The physician must be informed if a patient
refuses or misses a dose of medication
DISCONTINUATION OF MEDS
ON PRE-PRINTED MARS
• When a scheduled med is discontinued, it
will be stamped or written “D/C” on the
MAR
• When a PRN medication is discontinued, it
will be stamped or written “D/C” on the
MAR
• All D/C’d meds must be verified by an RN
with initials & date
DISCONTINUATION OF
MEDS ON CMARs
• In the appropriate column, document the
date & time the med is stopped
• Place initials in the appropriate column
• Draw a diagonal line through the
medication, place stop date, time & initials
in “Stop” column”, “X” out remaining shift
boxes that will not be given
• All D/C’d meds must be verified by an RN
with initials & date
QUESTIONS??
• Feel free to ask your charge nurse, preceptor
or instructor
BEST WISHES!
• We look forward to seeing you soon!