Patient Care Orientation

1
Patient Care Orientation

• Part Two

2
Restraint Use
3
Your Role In Restraint Use

• The restraint event begins with the RN
  assessment. Other disciplines contribute data to
  this assessment.
• Alternatives to Restraints
• Each department has its own set of restraint
  alternatives that they have chosen for use with
  their patient populations. Alternatives must be
  trailed and documented before restraints can be
  considered. Each policy has a list of restraint
  alternatives.
• M/U has 3 types of restraints
• Waist Restraint disposable
• Velcro Tying Restraints disposable
• Velcro Locking Restraints cleaned and reused
• There are 7 points of restraint taught to the
  staff as well as positioning the patient on the
  bed.
• 1 point waist restraint
• 2 points most frequently are the two wrists
• 3 points waist and wrists
• 4 points ankles and wrists
• 5 points ankles, wrists and waist
• 7 points ankles, wrists, waist and biceps
• The patient can be positioned face up or face
  down based on status. When ankles are in
  restraints they should be anchored straight to
  the bottom of the bed and not spread eagle to
  the sides of the bed.

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Restraints Continued

• Safe discontinuation Restraints will be removed
  one at a time as the RN assesses the patients
  readiness for restraints to be removed. The
  patient must never be in one point of restraint
  unless that is a waist restraint. When a patient
  is in four point restraints the RN should remove
  an ankle or wrist first. The next restraint
  removed must be the opposite limb for example
  if the right wrist is removed the next restraint
  removed is the left ankle. The time of
  discontinuation must be charted.
• There are two restraint policies (AKN)
• Restraints for Non-Behavioral or Acute Medical
  Surgical Care
• Restraint/Seclusion for Behavioral Management of
  Patients
• There are basically 3 exclusions to the policies
• Devices used to aid with positioning and/or keep
  immobilized during medical, dental, diagnostic or
  surgical procedures.
• Adaptive/supportive devices, such as braces,
  orthopedic appliances which are used for
  voluntary support to achieve proper body position
  or alignment.
• Use of forensic restraints (such as handcuffs or
  shackles) applied by law enforcement officials.

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Restraints Continued

• Restraints for Non-Behavioral or Acute Medical
  Surgical Care (AKN)
• This policy is used for anticipated situations
  when there is a need to restrict the patients
  free movement and access to the tubes, drains,
  etc. (Restraint during detoxification is to
  follow the medical/surgical restraint policy.)
• The order is for 24 hours and the preprinted
  order set must be used. The MD will authenticate
  the order within 24 hours along with their face
  to face assessment of the patient and the need
  for continued restraint on this preprinted order
  set.
• The patient will receive the following cares at a
  minimum
• Q hour CMS
• Q 2 hours Fluid, elimination and repositioning
• TID and PRN Food
• Q12 hours ADLs and hygiene
• Cares are documented on the flow sheet.
• The MD will complete a face to face assessment
  for continued need every 24 hours.
• RN re-assessments are done q 8 hours.
• If after a period of time without restraints the
  patient needs to have them re-applied, a new
  order must be obtained.

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Restraints Continued

• Restraint/Seclusion for Behavioral Management of
  Patients (AKN)
• This policy is for unanticipated situations of
  sudden aggressive behavior that could result in
  harm to self or others.
• The order is age dependent there are order sets
  for each age group. The MD will authenticate the
  order within 24 hours.
• A MD Face to Face Assessment is completed within
  1 hour after the restraints have been applied.
• Care for the patient includes 11 staffing the
  entire time they are in restraints and cares
  given the same as the acute med/surgical policy.
  The patient will be checked every 15 minutes and
  those checks documented.
• The order renewal and face to face MD
  reassessment are guided by the age of the patient
  as follows
• Order Renewal
• Adult (18 yr.-older)
• Adolescent (9-17 yrs)
• Child (under 9 yrs.)
• Face to Face Assessment
• Adult Q 8 hours
• Adolescent and child Q 4 hours
• Once restraints are released the patient will
  have a debriefing with the staff and it will be
  documented in the chart. The family, patient and
  staff will also have a debriefing and it will be
  documented as well. The only exception is if the
  patient does not want the family involved.

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Final Restraints Comments

• Notify hospital leadership if the patient remains
  in restraints for more than 12 hours. They will
  be involved in reassessment of the need for
  restraints. During the day it is the Nurse
  Manager, on other shifts it is the Administrative
  Supervisor.
• If the order for restraint was obtained from an
  MD that is not the attending physician, then the
  attending must be notified. The attending will
  have more information about the patient that may
  impact the continued use of restraints.
• Remember to document and get credit for all the
  alternatives that you attempt before during and
  after restraint are utilized.

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Patient Care Information
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Vital Patient Care Issues

• Patient Bill of Rights
• Patients have the fundamental right to receive
  considerate healthcare that safeguards their
  dignity and respects their cultural,
  psychological and spiritual values
• The Patient Self-Determination Act of 1990
• What is it?
• A Document based on a law that states the rights
  that patients have while in a facility
• Available in 6 languages and Braille.
• Why is it Important?
• The law requires that all patients or their proxy
  receive this information upon admission.
• Patient Registration Department gives the patient
  the document.
• What do I do?
• Verify and Document that the patient or proxy
  received the document.
• Explain that these are their rights as a patient.
  
• Ask them to read it.
• Document on medical record that you did this.
• Answer any questions they may have.

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Vital Patient Care Issues

• Grievances
• What is it?
• A verbal or written complaint that cannot be
  promptly resolved to the patients satisfaction
  by staff present
• Why is it important?
• It is a patient right
• It is a customer service issue.
• What do I do?
• Try to promptly resolve the issue by the staff
  present (with-in your scope of practice).
• If not resolved, give patient the options of
  talking to the Patient Rep, Manager, or
  Administrative Supervisor, or to the Office of
  Health Facility Complaints (OHFC) listed in the
  Patient Bill of Rights
• Vulnerable Adult
• What is it?
• All patients in a health care facility are
  considered to be vulnerable.
• Why is it important?
• It is a MN Statute/ law.
• What do I do?
• If patient alleges Abuse, Neglect, Harassment or
  Maltreatment while hospitalized-
• Assure patient safety immediately

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Vital Patient Care Issues

• Informed Consent
• What is it?
• Informed decision making and consent is required
  for all medical procedures and treatments with
  more than slight risk, or that may change the
  patients body structure.
• Why is it important?
• To assure that the patient has adequate
  information in order to engage in informed
  decision making regarding their treatment. Use
  of the Verification of Informed Consent Form is
  required to verify all surgical, invasive
  cardiac, endoscopic procedures and any procedure
  requiring biopsy of tissue or use sedation which
  results in loss of protective reflexes.
• What do I do?
• Hospital staff preparing the patient for the
  procedure will verify the procedure, site or
  side, and the patients understanding of the
  proposed procedure and document on this form.
  The form is a two sided form one side is
  completed by the MD, the other side is signed by
  the patient and witnessed by hospital staff.

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Vital Patient Care Issues

• And Finally
• Sentinel Events A sentinel event is defined as
  any unanticipated death or serious injury
  resulting in a major permanent loss of function
  not attributed to natural course of affected
  persons illness or underlying condition or
  an event such as infant abduction, hemolytic
  transfusion reaction, surgery on wrong patient,
  wrong body part, medication error resulting in a
  life threatening affect on health status.
• All employees are responsible to immediately
  report to their supervisor any patient events
  that met the definition of a sentinel event and
  complete the appropriate form. An initial
  investigation will occur within the first 36
  hours of the event.
• A near miss is a significant event that could
  have been a sentinel event. These should also be
  reported so that processes can be re-evaluated to
  prevent future misses or sentinel events.

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Advance Directives

• Key Points to Consider
• The admitting nurse must ask all inpatients if
  they have an Advance Directive (AD) and, if not,
  whether they would like additional information or
  assistance.
• No patient is required to have an AD.
• Completing an AD while the hospitalized may not
  always be the most appropriate time or place. It
  may be more appropriate for the patient to take
  the forms home following discharge so the patient
  has the option to discuss their wishes with
  family, clergy and Medical physician.
• DNR and DNI status is independent of, but can be
  a component of, Advance Directives. A patient
  does not need to have an AD to request DNR or DNI
  status, nor is DNR or DNI always a component of a
  patients AD.

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Advance Directives Continued

• If the patient has an Advance Directive
• Obtain a copy from the patient or their old
  medical record. If a copy is not available,
  document on the pathway your efforts to obtain
  the AD from the family.
• Nurses should place the AD in the most current
  medical record and must verify that it
• Reflects the patients current wishes and
• That it is a valid (written, dated, patients
  name and signature is notarized or witnessed, it
  contains healthcare directives and /or the names
  of the agent or proxy.
• If a patient wants DNR or DNI status, contact the
  MD. An order from the physician is required
  prior to implementing DNR or DNI status. Verbal
  or telephone orders require two RNs.
• If the nurse is unable to reach the MD or is
  unsuccessful in obtaining a response from the
  physician, they must communicate escalate the
  issue to a higher authority to obtain MD follow
  through.

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Advance Directives Continued

• If the patient does not have an Advance
  Directive
• The admitting nurse must ask if the patient wants
  additional information
• If the patient says no, document on pathway.
• If the patient says yes, provide with Allina
  Advance Directive booklet.
• If the patient has questions or requests
  assistance, consult chaplain, social worker,
  administrative supervisor, or a member of the
  ethics committee. Remember patients are not
  required to complete the form.
• If a patient says yes, but they would like to
  take it with them, document on pathway.
• If the patient chooses to complete the form then
  place the completed form on the front of the
  chart and inform the physician.

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Information for Non-Employee Staff Assigned to
Patient Care

• Dress Standard
• Nametag with employee name, job title and photo
  must be work at all times.
• All clothing must be neat, clean, well fitting,
  non-transparent, in good condition. Employees
  are to be free of offensive odors (including
  perfumes and colognes).
• Appropriate barrier clothing, including masks and
  eyewear, is work in accordance with infection
  control precautions.
• You may wear scrub uniforms or dresses, culottes,
  or pants and tops with sleeves, except ceil
  blue. A warm-up jacket with any matching print
  is acceptable.
• Point of Care Testing
• Non-employees may not perform point of care
  testing.
• Wireless Phones
• All caregivers will sign out a phone at the
  beginning of the shift.
• Return phone prior to the end of the shift.
• Answer phone, identifying self by name and title.
• Confidentiality is to be maintained at all times.
• Clean phone with disinfectant prior to use.

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Information for Non-Employee Staff Assigned to
Patient Care

• PATIENT SAFETY
• Physical Safety
• Call lights will be placed within easy reach of
  the patient.
• Beds will be kept in low position.
• Bed wheels will be kept in locked position except
  during transport.
• Floors will be kept free of spills.
• All ambulatory patients will use foot coverings.
• Restraints/seclusion will be implemented
  following the Patient Care Policy on restraints
  and seclusion.
• Equipment
• Faulty equipment is reported to Facility
  Operations or Bio-Medical Departments immediately
  and tagged out of service.
• Equipment brought from home by patients is
  limited to personal care items, such as electric
  razors and hair dryers, and must be checked by
  Bio-Med.
• Risk Management Safety Reports
• Any incidents with a potential or actual adverse
  occurrence involving patients, families,
  visitors, volunteers, physicians, employees, or
  students must be reported. Patient Visitor
  Safety Report is the tool used to document the
  event.
• A visitor with an obvious injury due to an
  incident on hospital property is to be encouraged
  to be evaluated by a physician in the Emergency
  Department.
• Notification of incident is to include the charge
  nurse, department manager and/or the
  administrative supervisor.

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Information for Non-Employee Staff Assigned to
Patient Care

• STAFF SAFETY
• Personal Injury and Potential Health Hazards
• Questions or incidents related to personal injury
  or potential health hazards are to be referred to
  Occupational Health Services and/or
  Administrative Supervisor.
• Responsibility of Non-Employee Nurse
• Non-employee nurses will function within the
  guidelines identified by the unit charge nurse in
  accordance with the hospital policies and
  procedures.
• Non-employee nurses will not be responsible
  forDischarge planningCharge nurse functions
• PROCESS FOR WORK ASSIGNMENTS
• Report to the Staffing Office 30 minutes prior to
  the start of the assigned shift. Be ready to show
  your nursing license and picture identification.
• CPR certification is verified prior to
  assignment.
• Check with the charge nurse for assignment and if
  this is new unit for you then orientation to the
  physical layout of the unit is needed, as well as
  any populations specific considerations.
• Complete billing slip/timecard and present to the
  staffing office for a signature before leaving
  the facility.
• The Administrative Supervisor must approve all
  overtime prior to working overtime.

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Medication Safetyand Documentation Overview
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Medication Safety

• Allinas Nine Principles for Medication Safety
• Do no harm
• The Five Rights
• Right Patient
• Right Medication
• Right Route
• Right Dose
• Right Time
• Nothing is taken for granted
• Communication clarify, ask questions
• Teamwork work with MD, pharmacist and patient.
• Report chart significant patient information,
  medication given or omitted on Medication
  Administration Record (MAR)
• Safety is a system
• Engage the patient
• Inform the organization complete the
  Pt./Visitor Safety form, do not record your
  completion of this on the pts. medical record, do
  not speculate to the cause of the event on your
  charting
• Learning is the goal of medication safety

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Medication Safety

• Safe Delivery Principles
• Protocols for high risk medications
• NO KCL on units
• Patient information _at_ point of care
• Pharmacist on rounds
• Allergy wrist bands
• Computerized MARs
• Bar coding

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Medication Safety

• High Risk Medications
• Heparin/anticoagulants (requires 2
  signatures)
• Insulin ( requires 2 signatures)
• PCA Pumps (requires 2 signatures)
• Antibiotics (IV)
• Concentrated electrolytes (KCL)
• Benzodiazipines
• Narcotics
• Chemotherapy
• Anyone Writing Orders
• Please DO
• - Write clear legible orders
• - Date and time all orders
• - Print your name under you signature
• - Use leading zeros when writing decimals (0.1)
• - Telephone/Verbal order read back (TORB / VORB)
• Please DO NOT

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Information Services and Clinical Systems
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Documentation Overview

• Mercy Hospital nursing units and Unity Hospitals
  ICU utilizes Eclipsys, a computerized medical
  record system.
• Unity Hospital nursing units utilizes a paper
  documentation system.
• There are general documentation consideration
  that pertain to both hospitals and both systems.
• General Documentation Guidelines
• Date and time all entries
• Write legibly and sign name and title (RN, LPN)
• Validate all new orders
• RN only
• Initiate and sign appropriate pathway/plan of
  care on admission
• Assess and document changes in patients
  condition
• Daily-24 hour focus note-patients response to
  plan of care
• All new orders must be co-signed by RN
• Each shift

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Documentation Overview

• Documentation Time Frames-
• These are Medical Surgical parameters this
  differs on specialty units
• Complete physical assessment within 2 hours
• Admission History within 8 hours reassessment
  of patient every 8 hours
• Initiate Pathway within 2 hours - updated every 8
  hours and individualized, including outcomes met
  and new interventions to address progress or lack
  of progress.
• Patient Story Updated every shift. All problems
  must have a related outcome on the pathway.
• Pain Assessment Upon admission, at least every 8
  hours and upon discharge. Reassess after every
  pain medication or intervention administered.
• Education Pages Patient education documented,
  including evidence of learning reviewed every 8
  hours.
• Focus Notes Upon admission, discharge, transfer,
  new findings, significant events, physician
  notification, response to plan of care at a
  minimum of every 24 hours. Use DAR format (D-
  data, A action, R response)
• Initiate discharge plan within 24 hours of
  admission

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Documentation Overview

• Other assessments areas and issues (bolded
  titles are key focus items and are audited)
• Bill of Rights
• Advanced Directives/Health Care Directives
• Domestic Abuse Assessment - Patient must be alone
• Medication History
• Functional Status Assessment
• Nutrition Assessment
• Skin Assessment determined by Braden Risk Score
• Fall Risk Assessment
• Latex Allergy Assessment
• Pain Assessment and Management
• Patient and family education
• Assessment/Reassessment
• Pathway is considered the Plan of Care
• Discharge planning
• Patient Transfer forms and EMTALA forms
• Utilize your colleagues and leaders on any and
  all documentation questions or concerns.

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In Closing...

• Final Considerations

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Department Specific Orientation Checklist

• Minimally, your department specific orientation
  should include the following items
• Location of
• Crash Cart
• Emergency Equipment
• Fire Safety
• Personal Protective Equipment
• Evacuation Map
• Orientation to
• Documentation process and related technology
• Medication administration and related technology
• Accessing policies, procedures and other
  resources
• Hospital and unit care quality improvement
  initiatives
• Demonstration of quick release tie and
  application of locking restraints (required for
  anyone working with patients).

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You Have Completed Part Two!Please turn in the
checklist used for this training program to
your agency.

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