Student Max Nursing Clinical Core Competency Orientation Materials Mercy 2011

1. Student MaxNursing Clinical Core Competency Orientation MaterialsMercy2011

2. Advance Directives

3. Inpatients • All inpatients will be asked to review and sign the “Acknowledgement of Advance Directive Information” form by the RN responsible for admitting the patient. If the patient is unable to review and sign, RN should attempt to have the paper signed by • Patient’s guardian, if one exists • Patient’s spouse • Patient’s adult children • Patient’s parent • Patient’s adult sibling, a majority if more than one exists. • The RN must sign and date the form and the unit’s Division Secretary must place the original form in the chart.

4. Inpatients (continued) • Additional copies may be made for the patient as needed. • For those patients who do not have an Advance Directive or have not supplied a copy, the person completing the form should document the patients wishes on the form. • Nurses at Mercy Allen Hospital utilizes the initial nursing admitting assessment form when obtaining information on Advance Directives.

5. Questions Regarding Advance Directives • If the patient or their next-of-kin have questions regarding advance directives, please consult the following individuals • Monday through Saturday during normal working hours, call Spiritual Care Department at the Mercy Regional Medical Center, or Social services at Mercy Allen Hospital • Weekends and off shifts Monday through Friday—Administrative Supervisors at the Mercy Regional Medical Center or the Chaplains at Mercy Allen Hospital

6. IV policies

7. IV Tubing Change Policy • All tubing changes are every 72 hours with the exception of: • TPN or Hyperalimentation tubing is to be changed every 24 hours • Blood tubing after each unit • All solution changes are at least every 24 hours. No IV solution, including flushes, may hang for more than 24 hours • If IV related septicemia is suspected, the IV tubing must be changed every 24 hours.

8. Secondary IV Tubing • Several different piggyback medications can be administered via the same secondary tubing by utilizing the back flush method of clearing the secondary line between doses • If the secondary tubing is disconnected from the primary tubing, a new cap must be applied to the end of the tubing upon disconnection

9. Falls

10. What is a Fall? • Any unplanned decent to the floor • This includes lowering a patient to the floor.

11. The Morse Falls Risk Scale is used at Mercy • It is evidence based and shown to help decrease falls • The assessment includes scores from 0 to >45 • Scores less than 25 are considered low risk • Scores between 25-44 are considered moderate risk • Scores greater than 45 are considered high risk • Additional considerations • Patient scores may be increased if they have additional risks of • Altered bowel and bladder • At risk medications

12. Falls Risk Assessment • Risk assessment must be completed for all patients upon admission • After admission, a falls risk assessment must be completed daily and when there is a fall or change in patient status • Care plans must be updated daily with falls risk assessment changes

13. Stryker Beds • Zero all Stryker beds, weigh the patient and then set the falls alarm to the middle zone. • You MUST re-arm the alarm after tending to patient needs. • If the patient is quick, you may need to set the falls alarm to the smallest zone

14. Post Falls Assessment • If a fall occurs, follow the post falls algorithm • Be sure to have the post falls order sheet available when contacting the physician • Immediately after a fall, an assessment must be completed and charted • A SafeCARE report must be completed

15. Post Falls Assessment • If the patient is on anticoagulants (such as Coumadin) the physician must be notified immediately regardless of injury status • If there is injury noted or change in mental status, the physician must be notified immediately • If there is no injury noted and the patient is not on anticoagulants, the physician must be notified within 24 hours • The family must be notified of the fall

16. Organ and Tissue Donation

17. Hierarchy of Consent/Authorization • Donor designation per Ohio BMV or other legal document • Spouse (common law is NOT recognized in Ohio) • Adult son or daughter • Parent • Adult brother or sister • Grandparent • Guardian of the person • Person authorized to dispose of the body

18. Organs Any person who has suffered a lethal, or potentially lethal, head injury or disease and is hemodynamically maintained with mechanical ventilation and is in the critical care setting Tissues Any person who has suffered cardiopulmonary death in any unit of the hospital and is not maintained with mechanical ventilation. Potential Organ/Tissue Donors

19. OneCall for Life1-800-558-5433 • Call BEFORE approaching next-of-kin • Call within 1 hour of suffering cardiopulmonary death. • PRIOR to declaration of brain death on ALL patients with Glasgow Coma Scale of 3-5. • Before discussing DNR orders with family on mechanically ventilated patients with neurologic injury or insult and PRIOR to the discontinuation of any life support measures.

20. Hand off of Care

21. Hand Off of Care • “Hand off” communication needs to be standardized by use of the Kardex. • Opportunities to ask and respond to questions are critical. • The primary objective is to provide accurate information about a patient’s care, treatments, services, current conditions, or anticipated changes.

22. Process for Effective Communication • Includes a process for verification of received information including repeat back or read back as appropriate. • Opportunity for the receiver of the hand off information to review relevant patient history, previous care, treatments, and services. • Interactive communications allowing for opportunity for questions between the caregiver and receiver of patient information. • Interruptions during hand off should be limited in order for information to be conveyed accurately. • Information must be accurate in order to meet patient safety goals.

23. Communication Tools • Shift report with SBAR Kardex • Admission Transfer Form • Golden Rod • Stat Com

24. SBAR Kardex Is Used: • At change of shift report • When a patient is going for a test or procedure • When turning over care to another nurse for any other reason Should be Updated: • With new orders • Chart checks • Change of shift report • After central line dressing change • Change in patient code status

25. SBAR Kardex Info • A taped or verbal report is used to communicate to the new caregiver all aspects of the patient’s care, changes, future tests and treatments. • The report should be concise, accurate, pertinent, and informative so the new caregiver has a good picture of each patient and the patient’s needs for the new shift.

26. SBAR Report of Patient Admission/Transfer • This form is used when a patient is admitted from the ER or transferred from another unit. • The sending caregiver fills out the form. • When the patient is coming from the ER the form is sent via pneumatic tube system. • The receiving caregiver reviews the report and calls the ER if he/she has any questions. • The patient is then received within one half hour of receipt of the admission/transfer form.

27. Admission/Transfer (cont’d) • When the patient is transferred from an in house unit, the sending nurse fills out the form and calls report to the receiving nursing unit. • Both the sending and receiving caregivers sign, date, and time the bottom of the form.

28. Using SBAR When calling a physician: • The SBAR form helps you to convey a detailed picture of the situation you are calling about and provides the physician with information needed to make a treatment decision for the patient • Forms are available on units and should be filled out before a call is placed • Forms can be passed on to the next shift so the oncoming staff knows why a call was placed • Always identify yourself, give the hospital and area you are calling from • Have the patient’s chart and pertinent information available • Be direct and get to the point • Write down and then read back any phone orders that are given to verify accuracy

29. The Golden Rod • The Golden Rod is used when a patient is transferred to an extended care facility, Behavioral Health or the Rehab Unit. • The form is to be filled out concisely and accurately. • The physician’s orders are transcribed to the Golden Rod. • The Nursing summary page is completed by the nursing unit. • A phone report is given to the receiving facility before the patient is discharged. • Hospital to Hospital transfers do NOT require a Golden Rod.

30. StatCom • After assignments are made, StatCom is updated with the names and phone numbers of the caregivers • Other departments can then call the caregivers directly to update • The patient profile will be updated with pertinent patient information such as falls risk, isolation precautions, etc.

31. Post-op Care & Wound Care

32. Basic Post-op Care • Assess respiratory status & pulse ox • Monitor VS & note skin warmth, moisture & color • Assess surgical site & wound drainage systems • Assess level of consciousness, orientation & ability to move extremities • Connect all drainage tubes to gravity or suction as indicated • Assess pain level, characteristics (location, quality) • Check time, type, & route of last pain medication • Assess effectiveness of pain medication • Position patient to enhance comfort, safety & lung expansion • Assess IV patency & infusions for correct rate & solution • Reinforce deep breathing & leg exercises • Provide information/updates to patient & family

33. Post-Op Care Recovery on floor following PACU • Post-op VS unless otherwise ordered, are Q 15 min. x 4, Q 30 minutes x 4, Q 1 hour x 4, then Q 4 hours • Preventative pain control • Nursing interventions to promote wound healing- allow the escape of blood & serous fluids that can otherwise serve as a culture medium for bacteria • Be aware of signs of infection, e.g. any temp > 101 F, chills, cough; redness, tenderness or drainage from around incision; pain or burning on urination. • Patient education begins early, start education on post-op care preoperatively & throughout hospital stay to improve patient compliance when discharged

34. Prevention of complications • POST-OP PATIENTS are at risk for complications, e.g. Atelectasis, Pneumonia, DVT, Pulmonary Embolism, Constipation, Paralytic Ileus, Wound Infection • Educate on correct use of Incentive Spirometry • Deep breathing & coughing q 2 hours until discharge • Early ambulation, no later than 1st post-op day and elastic compression stockings to promote venous return • Leg exercises & frequent position changes to stimulate circulation • Patient should avoid positions that compromise venous return, e.g. raising the catch on the bed, placing pillows under knees, sitting for long periods, dangling legs with the pressure at the back of the knees • Administer pain medication as prescribed so the patient will feel like moving-Encourage the patient to take pain medication before pain is unbearable

35. Wound Care Ongoing assessment of the surgical site involves: • Inspection for approximation of wound edges • Integrity of sutures or staples • Assessing for redness, warmth, discoloration, swelling, unusual tenderness or drainage • The area around the wound needs to be inspected for reactions to tape or trauma from tight bandages • Assess output from wound drains & record all new drainage • Amount of drainage is assessed frequently • Excessive amounts of drainage must be reported to the surgeon • Increasing amounts of fresh blood on the dressing must be reported immediately • Documentation of dressing changes includes description of the wound, the actual dressing change procedure & patient tolerance

36. Vaccines

37. Vaccine Assessment • Ohio law requires hospitals to assess adult patients for both the Pneumococcal & Influenza vaccines. • Our policy is to assess on admission and, if eligible, administer as soon as the patient is afebrile. • Influenza vaccine eligibility is assessed from the last week of September until the last day of March. • Pneumococcal vaccine is available throughout the year for those adults who are 65 or older without contraindications.

38. Stericycle

39. Stericycle • Red Sharps Containers • Sharps that do not contain any medications • Empty syringes (oral and IV) • Empty ampules • Red Bags (Regulated Medical Waste) • Blood Saturated materials • Biohazardous waste • Blue Container (no waste code) • Any item that has the possibility of leaking must first be put into a ZIPLOC bag. No free fluids, controlled substances or sharps! • Partial IV bags and bottles with medication • Tablets-whole, broken or partial • Partial Medication vials

40. Stericycle • Black container (sharps with left over pharmaceuticals • Syringes with pharmaceuticals that has NOT come in contact with a patient • Big Black container (waste code BKC) • Partial IV bags, bottles and vials • Tablets-whole, broken or partial • Aerosols or inhalers

41. Stericycle • IV drain disposal • The following medications can be disposed of down a normal drain • Saline • Dextrose • Electrolytes • Lactated Ringers • Any IV with a non-hazardous, non-controlled substance RX instilled in it should go in the blue container • Black Container is for any IV with a hazardous, non-controlled substance medication in it. • Controlled substances are still disposed of down the drain with a witness

42. MEWS

43. MEWS (Modified Early Warning System) • Based on patient’s vital signs • Must be completed on admission, every 4 hours for the first 24 hours and then every 8 hours. • Must also be completed every 4 hours post-operatively for the first 24 hours and then every 8 hours. • Does not need to be completed when the patient is a DNRCC. • This is done on adult patients only. • Not done on Rehab, Critical Care, OB or Behavioral Health.

44. Point of Care Testing

45. Point of CarePre-Analytical Responsibilities • Quality control testing regulated by CMS & CLIA (Clinical Laboratory Improvement Amendments) • Correct identification of patient and test to be performed • Good specimen collection technique • Ensure the analyzer is operational • Maintain quality control samples • Maintain annual competency requirements for performance of point of care testing.

46. Point of care testing • Common point of care testing that nursing routinely performs are blood glucose monitoring, I-Stat and hemocult

47. Point of CareAnalytical Quality • All staff who operate Point of Care testing (POCT) equipment must have an awareness of and are responsible for: • The meaning of the results they generate • Analyzing any required QC samples • Confirming any results that don’t make sense • Documenting and addressing error codes that occur with patient testing • Notifying the appropriate caregiver and/or physician of critical values obtained • Recording results in the patient chart and/or downloading the device to transfer results to the lab system

48. Medication Administration Safety

49. Valid Physician Orders • Must include: • Date order is written • Name and dose of medication • Route and frequency of medication administration • The purpose for all PRN medications • Sign and date order by Licensed Independent Practitioner per hospital Policy • Order must be legible • Must NOT have • Prohibited abbreviations • Must not be unclear, must be legible. If not legible or clear, clarification must be occur.

50. Don’t forget the Five Rights • Right Patient • Right Medication • Right Dose • Right Route • Right Time