Edutracker.com



Nursing Review of Key Practice Points

(Joint Commission Findings)

0 CE

Directions for Completion

This practice review is required for nursing at the St. Luke’s University Hospital and St. Luke’s - Allentown Campus.

1. Before proceeding to the posttest, be sure you have read and completed all components contained in this document.

2. Exit the final page and complete the posttest for this education.

← “Take Test”

← Remember, no attendance record is needed.

← Completion of the posttest will be sent electronically to your EduTracker record once a 100% is achieved.

← Print the Certificate of Completion and present to your manager

Questions should be directed to your manager.

To see links, hover mouse over the link, press Ctrl key and click.

Once on policy manual opening page, search for policy name.

Nursing Review of Key Practice Points

Our recent unannounced Allentown-Bethlehem Joint Commission Accreditation Survey led to several citations due to inconsistencies in practice or staff responses. St. Luke’s submitted a Plan of Correction to address, and ultimately correct, the specific issues.

The information that follows was developed to ensure our healthcare providers know and understand specific nursing practice points.

Education to address citations related to other staff and physicians is being addressed separately.

MEDICATIONS

The survey found unsecured medications.

Storage and Control:

• Medications will not be stored at the bedside.

• Medication storage areas/carts/WOWs must be locked at all times when not in use.

Medications (of any kind) should not be left out/unattended in common areas; this includes charting areas, WOWs, countertops, bedside tables, patient rooms, etc.

Staff finding unsecured medications should notify the RN immediately.

Policy reference: Medication Administration [NPPM: D-17]

PAIN ASSESSMENT & REASSESSMENT

Pain assessments/reassessments and documentation was found to be inconsistent with policy.

• All pain assessments and reassessments need to include a numeric value for patient pain rating/score in addition to a description when documented.

• Policy reference: Pain Management [NPPM: D-23]:

PAIN MEDICATION ORDERS

The survey found that pain medication orders were incomplete and/or lacked clarity and/or did not accurately reflect an indication; such orders were not clarified.

A complete pain medication order must include the following:

• Medication name

• Dose

• Route

• Frequency

• Indication (intensity of pain)

One medication per indication: mild, moderate, severe, breakthrough.

1) The same medication should not be ordered for more than a single intensity/indication.

2) Two different medications should not be ordered for a single intensity/ indication unless the order specifically addresses a lower dose for a lesser intensity.

3) Two different medications should not be ordered for a single intensity/ indication unless the order specifically addresses different routes related to the patient’s clinical condition.

To assure consistency, the following pain intensity rating will be utilized:

• 0 (No pain)

• 1–3 (Mild pain)

• 4–6 (Moderate pain)

• 7–10 (Severe pain)

RN Role:

Pain medication orders must be verified at the time of transcription/profile verification to ensure that an indication for administration based on pain intensity is included.

Incomplete orders, orders which are unclear, or orders which contain the same medication for more than 1 indication will be clarified by the RN with the prescriber. A clarification order will be written.

Concurrent physician and pharmacist education is taking place; more eyes checking should decrease the problem.

The following examples were developed to ensure understanding. When in doubt, clarify the order!

Example A:

“Morphine 5 mg IV push every 60 minutes prn for severe pain.

Morphine 5 mg IV push every 60 minutes prn for moderate pain.

Tylenol 1000mg PO every 4 hours prn for mild pain or headache.”

The morphine order requires clarification because the same dose is ordered for both moderate and severe pain. (#1 above)

Example B:

“Dilaudid 3 mg IV push every 2 hours prn moderate pain.

Tylenol with codeine 2 tabs every 4 hours prn moderate pain.”

In this example, 2 different medications are ordered for the same intensity/indication which forces the RN to make a decision about which to administer and/or leads to confusion around whether both can be given within the same timeframe. This order requires a clarification. (#2 above)

Example C:

“Morphine 5 mg IV push every 2 hours prn for severe pain.

Change to Percocet 2 tablets PO every 4 hours prn for severe pain when tolerating food and fluids.”

Both orders in this example are for severe pain but there is a limitation based on patient’s ability to tolerate PO therefore this order is acceptable. (#3 above)

CODE CARTS

When questioned, RNs were unable to describe the process for code cart checks. When asked to demonstrate, RNs were unable to demonstrate defibrillator checks.

Policy reference: Code Blue [APPM: #12]

• The entire cart is checked for outdates and contents monthly by RN or designee or when the lock is broken after an arrest.

• Registered Nurse will apply green lock to code cart after verifying medication tray packing intact.

• Each department/Patient Care Unit which houses a code blue cart will assign RN or designee to conduct the following checks.

o Code cart/defib is checked daily in areas where there is 24 hour continuous operation

o In all other areas, the cart/defib is checked each time the area is opened/accessed for patient care

• Checks must be documented on the Code Cart Checklist:

o Defibrillator check on ac/dc power and on battery

o Oxygen tank volume

o Intact lock* and lock number

(*See policy for details on handling locks which are not intact when checked)

When the code cart is being checked or is open for any reason, it may not be left unattended.

Every RN should know how to check the defibrillator on ac/dc power and on battery.

Click on link to view procedure: (Do not share this link)

OXYGEN TANK STORAGE

OSHA regulation requires us to contain, separate, and label full and empty gas cylinders.

The attached picture demonstrates the compliant process of oxygen cylinder storage which is required in a hospital and hospital ambulatory environment.

[pic]

CARE PLANS

Care plans were not patient specific or individualized for patient needs, did not identify barriers, and/or did not identify goals for discharge.

Policy reference: Patient Care Process: Including Admission, Assessment/Reassessment and Patient Plan of Care [NPPM: B-02]

Plan of Care

• Plan of Care will be documented via the appropriate documentation vehicle; electronic or paper.

• The RN will coordinate the planning, implementation, and evaluation of the plan of care. All members of the care team may contribute to the patient plan of care.

• Patient outcomes, whenever possible, will be mutually set with the patient and family.

• These outcomes will be realistic, measurable and consistent with the medical plan of care.

• The plan of care will be reviewed/revised as patient care needs are identified and/or when the patient’s needs change.

• The RN will evaluate and record the patient’s progress toward the outcome(s) per the plan of care.

• With all patients, consider the need for care plans related to fall risk, pain, language or learning barriers.

Poor Care Plan Examples:

• Dialysis patient had a goal of wnl BUN. Attainable? UNLIKELY!

• Post-op knee replacement patient had a goal of pain free. Attainable? UNLIKELY!

Better Care Plan Examples:

• HF patient has a goal to obtain/record accurate daily weights.

Attainable? MOST LIKELY!

• Hip replacement patient. Is a fall risk care plan necessary?

YES - due to change in mobility!

• Spanish-speaking 89 year old with diabetes on new insulin. What types of care plans are probably necessary?

o Language/learning barrier

▪ Involve the family

▪ Use of interpretation services (CyraCom) for all patient/family teaching

o Blood glucose monitoring

o Insulin administration

o Visual barrier?

--------------------------------------------------------------------------------------------------------------------

Thank you for completing this review of important information.

You are expected to know and understand the information applicable to your role in nursing.

If you have questions about the information, please contact your manager.

Exit this document.

Click on “Take Test”

After completing the posttest, PRINT your certificate of completion and give it to your manager.

COMPLETION is required by August 4, 2013.

Critical Care Nurses Only: RASS Review

Continues Next Page

Critical Care Nurses Only: RASS Review

SEDATION & ANALGESIA for MECHANICALLY VENTILATED PATIENTS in ICU

• For patients requiring sedation for prolonged periods, the use of continuous and intermittent

infusions is associated with easier and quicker attainment of target sedation scores.

• “Goal-directed delivery” of sedatives is best accomplished by the use of sedation scales.

• The Richmond Agitation-Sedation Scale (RASS) was developed by a team at Virginia

Commonwealth University

RASS

• Less than 20 seconds to perform

• Highly reliable among healthcare providers

• Physician will order the target sedation score

• Documentation of RASS scores at a minimum q4hrs with assessments, titration rate change

of sedatives, and change in patient condition

Critical Care Standards of Practice and Guidelines of Care at SLUHN

I. Patients maintained on continuous sedation drip will have a daily sedation break to assess

underlying neurological function, unless otherwise ordered. These breaks must be documented.

II. Document sedation levels in Care Manager using the appropriate scale (i.e. RASS).

Unwanted Side-Effects of Sedative Agents

Under-sedation: Over-sedation:

Fighting the ventilator Delayed awakening/extubation

V/Q mismatch Tolerance, tachyphylaxis

Accidental extubation Withdrawal syndrome

Catheter displacement Delirium

CV stress – ischemia Prolonged ventilation

Anxiety, awareness CV depression

Post-traumatic stress disorder Sleep disturbance

[pic]

-----------------------

PATIENT SAFETY FIRST!

Full and empty tanks may NOT be stored in the same rack.

This decreases the potential for a caregiver to attaching an empty tank to a patient needing transport.

Portable E or large H (freestanding) tanks must be secured in a wooden constructed box, chained, or metal wheeled apparatus.

FULL

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download