Nursing Module Annual Update Section 6 - PowerPoint Presentation

Slide1

Nursing Module

Annual Update Section 6Slide2

Accucheck

-Blood Glucose

WAIVED TESTING or POCT

(

Point-of-care testing). Policy LAB 47020

POCT is medical testing at or near the site of patient care. Results are received sooner and allow for immediate clinical management decisions to be made.

The Clinical Laboratory at SBMC has oversight of ALL POCT performed.

IMPORTANT! PERFORM POCT ONLY IF YOU ARE COMPETENT and have documentation verifying the competency! Clinical Staff PLEASE REVIEW THE POLICY ON LINE

.

Remember the compromised patient-low BP, HR, poor perfusion, on vasopressor drips, may require glucose to be draw as the

accucheck

may not be accurate in a low perfusion state. Slide3

Advanced Directives

End of life should be a respectful dignified event.

Not all deaths are good, especially if family member disagree on choices.

Patient should be encouraged to have an advanced directive.

ELNEC is something all nurses should understand, for more information go to:

http://

www.aacn.nche.edu/elnec

Slide4

Anticoagulate Therapy

Coumadin NPSG 03.05.01

Provide patient and family education

Adverse drug reactions and interactions

Importance of follow-up monitoring

Food-drug interactions

Compliance with drug regime

New Heparin Protocol

See education on Tracker Trainer regarding Anti

Xa

monitoring

Reversal with ProtamineHalf life 30-90 minutes Slide5

Anticoagulate Therapy cont.

Requires a programed pump with 2 nurse verification of rate, dosage and labs.

LMWH-

Lovenox

,

Fragmin

3-6 hour half life

Dosed at 12 or 24 hours intervals

Adverse affects-bleeding, pain at injection site

Heparin Induced Thrombocytopenia (HITS)

Platelets <50,000, positive HIT panel

Occurs 5-14 days after introduction to heparinDiscontinue all Heparin

Argatroban

dripSlide6

Biosurveillance

Used to monitor patient for early signs of Sepsis. The computer will alert when VS and labs indicate the patient has a potential for becoming septic.

Early goal directed therapy remains the standard of care for patients identified as septic.

Anticipate and advocate for orders that include a blood lactate level, blood cultures, and diagnostic testing.

Septic patients should receive broad spectrum antibiotics within 1 hour of recognition.

For hypotension or a lactate > 4

mmol

/L, administer 30mL/kg fluid bolus.

(Schell-

Chaple

& Lee, 2014)Slide7

How does it work?

The tool in Cerner will run automatically every 10 minutes on every Inpatient, Observation, and ED patient age 16 and over.

When a patient screens positive for SIRS or Sepsis, an alert will fire to the primary nurse for the patient.

This alert will provide the nurse with the specific criteria that caused the trigger.

This alert will notify the nurse regardless of which patient’s chart the nurse is logged into.

Nursing will receive alerts for SIRS and Sepsis.

Providers will receive limited Sepsis alerts.Slide8

How does it work? What alerts?

The SIRS alert will fire with 3 signs of SIRS:

Temp <36 or >38.3 C

HR >95

RR

>

23

Glucose > 140 mg/

dL

and < 200mg/

dL

(without indication of diabetes)WBC >12k or <4k or Band >10%

The Sepsis alert will fire with 2 SIRS criteria and 1 sign of organ dysfunction:

Lactate >2.0

mmol

/L

SBP <90 mmHg or MAP <65 mmHg

Bilirubin 2.0 mg/

dL

<

x < 10.0 mg/

dL

Creatinine increase of > .5 mg/

dL

over 72 hoursSlide9

Biohazard Waste

It has been observed and reported that nursing will take their IV tubing into the dirty utility room and throw them on the tops of red containers. This is not an acceptable practice. EVS is not responsible for discarding IV tubing, bags or other refuse. It is important that nurses dispose of their trash in the proper receptacle's. Slide10

Blood Administration

New protocol transfusion only if Hgb

<7

Blood causes inflammatory response in body. Only should be used for poor perfusion or oxygenation

Blood products:

1 unit ↑

Hgb

1gm &

Hct

3%

FFP-INR >1.5

Platelets- transfuse <10,000 1 unit increases 30,000-60,000 plateletsSlide11

C-diff Protocol

Patients having 3 or more loose, watery, liquid stools: once documented this will Alert in your system

Place in preemptive contact isolation

Practice excellent hand hygiene using soap and water

Send a stool specimen to test for C-diff

If patient comes in from SNF with report of diarrhea send specimenSlide12

Central Line Dressings

Peripheral Inserted Central Catheters (PICC)/Central lines require a dressing change every 7 days and PRN soiled.

When PICC line placed protocol must be ordered to prompt dressing change in activities

Dressing should be clean/dry/dated/timed/nurses initials

Central line dressing kit should be used for dressing change

It is to the patient’s benefit to get central lines out ASAP-notify MD if no longer needed. Slide13

Chain of Command

Utilization of the proper chain of command improves the problem solving process.

For any SAFETY/QUALITY concerns requiring prompt resolution, contact the following personnel until the issue is resolved:

Notify immediate Supervisor

Notify Director

Notify House Supervisor or Division chair (M.D.)

Notify Chief of Staff if M.D. related.

If you feel that the chain of command has not met your expectation, contact the Quality Department at 881-4443. If the Quality Department does not adequately address the concern, you may contact the Joint Commission by calling 630-792-5000. Follow Chain of Command-Problem Resolution Procedure Policy HR 05012Slide14

Clinical ALARMS

Alarms are intended to alert

assigned

healthcare professionals of potential problems that may compromise patient safety and they must be managed

appropriately

Clinical Alarms must be audible at all times

Must be set to be heard above competing noise in unit

HCW must respond to all alarms

Critical (life threatening) alarms must be verified as “on”, parameters verified at shift change

Alarms may only be suspended if patient is off equipment, or nurse is working with patient (ex: bathing)

Alarm Fatigue-noise from too many alarms causes HCW to ignore

Revise alarms to patient condition

Appropriate skin preparation

Proper lead placement

Clinical alarms include: ventilator/BIPAP, fetal monitors, cardiac monitor, PA/art lines, IABP, IV/PCA pumps, infant security, blood bank refrigerators,

bovie

, dialysis machines, pulse ox.Slide15

Communication using SBAR

All nursing reports should be given using SBAR:

Situation (S) name, reason for admit, MD

Background (B) give history

Assessment (A) brief assessment of pertinent issues with patient.

Recommendations (R) what needs to be followed up on.

Remember when getting report from another department-you are going to complete a head to toe assessment when you get your patient, you should rely on your own assessment and not expect every intimate detail on your patient. Slide16

Dialysis Verification

2 RNs to go over and validate the

Hep

-B Antigen results in Cerner prior to transporting the patient to dialysis.

Sign the Dialysis Checklist.

If the patient is being dialyzed at the bedside the same verification is required. .

This

process will be done on every dialysis patient before being dialyzed.Slide17

DNR-things to know

When we are in downtime the big computer (724) prints out information but the DNR is buried in the middle of a large amount of paperwork so please mark patient charts or

cardex

.

We need to continue orange DNR forms for patient safety (physician should order in

C

erner as well) Slide18

Fatigue Management Strategies

The best method to manage fatigue is to get adequate sleep.

Ways to manage fatigue:

Have conversations with others

activity—get up and move

Caffeine in moderation

Take a break

Using lighting to stimulate wakefulness

Use a buddy system if you are fatiguedSlide19

Hand Hygiene

http://

www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

handwashing guideline from CDC

http://www.cdc.gov/handhygiene/training/interactiveEducation

/

Hand Hygiene Training

Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings).Slide20

HIPAA

Patient privacy includes:No photos

No discussions regarding health information in elevators, cafeteria, or any area where another can overhear.

No information given over the phone without access code

Remember not only is the hospital fined but so is the individual staff member up to $25,000. Slide21

Insulin

Humalog/

Novalog

-fast acting (15min) short term, covers meals

Regular-peak 30-60 min lasts 2-4hours

NPH-mid level works for 6-8 hours

Lantus-long acting 20 hours called basal bolus dose, covers normal basal metabolic functions.

Don’t share bottles-single patient use-single use in areas where not medication storage is available.

Don’t forget evening snacks—can cause insulin reaction in early morning hours. Slide22

Interpreters & Equipment

Qualifications:

Comfort in the medical setting, understands significance of the health problem

Preserves confidentiality

Multiple Roles:

Translator of Language

Culture Broker

Patient Advocate: Convey expectations, concerns

Minimize jargon

, e.g., “machine to look at your heart” instead of “EKG”

Nonverbal communication = 60% of all communication

Nodding may indicate politeness, not comprehensionBilingual interviewing takes at least twice as long as monolingual interviews!

It is because we are different that each of us is SPECIAL!Slide23

IV Information

IV tubing & bag good for 96 hours unless otherwise marked

Medication drips mixed in pharmacy good for 12 hours *once IV room is complete will extend to 24 hours.

Curos

caps required on tubing

All tubing to be dated and labeled

IV bags should be assess for use by date

IV sites need

drsg

, date, time, and initialsSlide24

Medication Management

Assess name & birthday as well as scan for safety

Inform patient of what they are taking, why, side effects, possible adverse reactions

Store only in acceptable areas (locked med room in

pyxis

)

Never leave meds on top, inside, on keyboard of WOW

Never leave meds at bedside for patient to take “with breakfast”Slide25

Medication continued

Remember IV solutions, oxygen, electrolytes are all meds.

Bags with electrolytes should be in med rooms

Give meds on time, if unable to give meds take back to

pyxis

. Do not store meds on your person, on WOW, etc.

Don’t take one patients meds into another patient room.Slide26

Medication Reconciliation

When completing the medication reconciliation for patients arriving from another facility, remember the meds listed are those the patient takes at home.

Please don’t include medications started at the previous facility as then the Nurse practitioners discharging the patients think the patients have these meds at home and prescriptions are missed. Slide27

Medications Requiring a Filter

Drug

Filter Size (micron)

Abciximab

0.22

Amiodarone

0.22

Cyclosporine

0.22

Diazepam infusion

0.22 or 0.5 (give IVP/IM/PR route) not very stable in solution

Digoxin Immune Fab

0.22

Infliximab

1.2 or less

Lipid

1.2

Lorazepam infusion

0.22

Mannitol

0.22

Does not include Antineoplastic

Agents

Filters will be sent up with medication from pharmacySlide28

National Patient Safety Goals

NPSG.01.01.01 patient identificationNPSG.01.03.01eliminate transfusion error

NPSG.02.03.01effective communication

NPSG.03.04.01medication safety

NPSG.03.05.01anticoagulant safety

NPSG.03.06.01accurate patient medication information

NPSG.06.01.01clinical alarms

NPSG.07.01.01 nosocomial infections

NPSG.07.03.01 MDRO safetySlide29

NPSG cont.

NPSG.07.04.01catheter related infectionsNPSG.07.05.01surgical site infection

NPSG.07.06.01 indwelling catheters

NPSG.15.01.01suicide risk

Universal Protocol-correct surgical site

UP.01.01.01correct patient in OR

UP.01.03.01time out in surgery

UP.01.02.01 site marking in ORSlide30

Negative Pressure Rooms for Airborne Isolation

People who work or receive care in health-care settings are at higher risk for becoming infected with M. tuberculosis; therefore, it is necessary to have a TB infection control plan.

The infectiousness of a TB patient is directly related to the number of droplet nuclei carrying M. tuberculosis (tubercle bacilli) that are expelled into the air.

Infection occurs when a person inhales droplet nuclei containing M. tuberculosis, and the droplet nuclei traverse the mouth or nasal passages, upper respiratory tract, and bronchi to reach the alveoli of the lungs.

In TB clinics, hospitals, and other inpatient settings, patients known to have TB disease or suspected of having TB disease should be placed in a TB AII room immediately. (AII=Airborne Infection Isolation)

NURSES MAY NEVER UNPLUG OR TURN DOWN THE HEPAFILTER ON A TB PATIENT.Slide31

Organ Donation

Nursing Role: Notify One Legacy of patient with potential for death who are:

On ventilator with one or more triggers:

Prior to DNR or terminal wean

Loss of one or more brainstem functions

Report every death within 1 hour

Do not mention Organ Donation to family

http://donatelifecalifornia

to become a donor

Make sure to notify your family of your wishesSlide32

POLST

Patient Order for Life Sustaining Treatment

POLST gives seriously ill patients more control over end of life care. The form is bright pink and the patient and their physician sign it to indicate the patient wishes. The patient is instructed to post this on their refrigerator and emergency rescue teams are instructed to look for this when entering a home. It can prevent patient unnecessary end of life measure the patient doesn’t want.

For more information go to http://www.polst.org/Slide33

Restraints

Restraints/seclusion,

is used

only when clinically justified (patient is pulling at tubes/lines/ dressings OR is violent /self-destructive or threatening the physical safety of others).

Discontinue at earliest possible time, regardless of scheduled expiration of order. Restraints/seclusion should only be implemented when other, less restrictive measures have been attempted/considered and failed.

It is important to use the least restrictive restraint and discontinue them at the earliest possible time, regardless of scheduled expiration of order.

Documentation: It is imperative that documentation include: a complete/valid

order and documentation in the electronic health record of nurse monitoring. Documentation should include alternatives/response

to alternatives/ and

pt

& family education addressed, and an updated care plan that addresses restraints.Slide34

Stroke Review

Any change in patient neuro status call safety net unless in ED or ICU

Code stroke nurse will activate code stroke.

Get VS, blood sugar, start NIHSS

Once stroke identified patient will go to CT to rule out hemorrhagic stroke.

Administer

tPA

within 60 min

Pneumatic stockings are required

Make sure patient is given education upon dischargeSlide35

Wound Care

Want to become good at staging wounds?https://members.nursingquality.org/NDNQIPressureUlcerTraining

/

NDNQI training teach is excellent.

Documentation of wounds are where many lawsuits are occurring

Proper staging of pressure ulcers is an expectation of nursingSlide36

Stage One Slide37

Stage TwoSlide38

Stage ThreeSlide39

Stage FourSlide40

Deep Tissue InjurySlide41

Unstagable

Wound is completely covered by eschar or slough making it impossible to know the true size and depth of the wound. Slide42

Where to go from here

Move on the exam. You must score 90% or better to pass

This is all important information but more importantly, these are all things we should be knowledgeable about and doing in our daily practice.