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
  trialed and documented before restraints can be
  considered, unless immediate application is
  required for patient safety.
• Mercy and Unity have 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.

4
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.

5
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.)
• Prior to initiating restraints, the RN contacts
  the MD to enter an electronic order or to obtain
  a TORB (telephone order read-back). If immediate
  restraint placement is necessary for patient
  safety, the order must be obtained as soon as
  possible after the application.
• The order is for 24 hours. A physician must
  perform a physical examination of the patient
  within this time period. If the initial order was
  obtained as a TORB, it is co-signed within 24
  hours.
• The following assessments will be done at a
  minimum
• Visual check (patient actions) q2hrs
• Circulation check q2h
• Range of motion q2h
• Fluids q2h
• Food/meal q2h
• Elimination q2h
• Safe application of restraints ongoing
• RN re-assessments for restraint need ongoing
• The MD will complete a face to face assessment
  for continued need every 24 hours.
• If after a period of time without restraints the
  patient needs to have them re-applied, a new
  order must be obtained.

6
Restraint Documentation

• Document restraint assessments and monitoring on
  electronic restraint flow sheet
• Documents changes in plan of care based on
  patient response
• Document educational needs of patient and/or
  family

7
Restraints Continued

• Restraint/Seclusion for Behavioral Management of
  Patients (AKN)
• This policy applies to 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 that will be
  documented in the electronic medical record. 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.

8
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.

9
Patient Care Information
10
National Patient Safety Goals

• To provide our patients with a safe healing
  environment we have initiated safety goals around
  the care of the patient. Some of the goals you
  should become familiar with include
• 2 Patient Identifiers
• Unacceptable abbreviations
• Clinical Alarms
• Time Out Surgical Site Marking
• Reduce hospital acquired infections hand hygiene
• VORB/TORB
• Medication Safety labeling, look-alike,
  sound-alike meds, limit number of drug
  concentrations
• Communication Handoffs
• Medication Reconciliation
• Fall risk assessment
• Increased patient involvement in own care
• Suicide and violence risk assessment
• We will discuss several of these goals in greater
  depth in subsequent slides.

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• Matching the right patient to the right treatment
  or service
• When obtaining blood samples or administering
  medication or applying the patients armband, two
  patient identifiers will be used to compare to
  the same two printed identifiers on the lab
  request, medication record, or patients medical
  record.
• Patient Identifiers Include
• Patients stated name and date of birth are
  compared against the printed name and DOB on the
  medication record, specimen label, or medical
  record.
• Patients unable to state their name and DOB
• Verification by a family member
• Verification by carefully matching the name and
  DOB on the wristband with the same info on the
  medical record, specimen label.
• A patient room number will never be used as a
  method of patient identification or verification.
• Exception to above is the administration of blood
  products. In this instance, use patient name,
  birth date and social security number.

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Unacceptable Abbreviations

• We have developed a list of abbreviations that
  are not approved for use within the medical
  record (documentation, notes or orders).
• Orders written with an unacceptable abbreviation
  will not be accepted or executed.
• Unacceptable orders will be clarified by the
  nurse and documented as a verbal order before
  executing.
• Ask the unit charge nurse for more information
  regarding unacceptable abbreviations
• Clinical Alarms
• Goal Improve the effectiveness of clinical
  alarms.
• Examples of clinical alarms are cardiac monitor
  alarms, fetal monitor alarms, apnea alarms, door
  alarms, elopement / abduction alarms, infusion
  pump alarms, bed alarms, bathroom alarms or
  respirator alarms
• Clinical Alarm Considerations
• Clinical alarms are basically all patient care
  equipment containing alarm functions
• Alarm functions should be managed/adjusted by the
  assigned staff RN or other hospital designee.
  Collaborate with the charge nurse if you are
  having difficulty setting/adjusting alarm
  parameters with your patients.
• Alarm policies are practiced
• If an alarms fails, a Patient/Visitor Safety
  Report is completed, Risk Management is notified,
  and the equipment is immediately sent to Clinical
  Equipment Services (CES) for evaluation

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Time Out

• Goal Eliminate wrong site, wrong patient, wrong
  procedure/surgery.
• Done prior to local injection/incision/start of
  procedure in surgery or any other patient care
  area.
• Surgical Site Marking The surgical site is
  marked for correct site and laterality, per
  policy.
• Time Out The circulating RN reads the patients
  full name and procedure including site / side,
  from the consent form. All members of the
  surgical team listen and confirm the correct
  procedure, patient, surgical site and side
  (laterality).

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Safety Ethical Situations

• If you encounter a potential hazard or unsafe
  situation in our hospital or if you have an
  ethical concern regarding our practices or a
  patient care situation, you should discuss this
  with the charge nurse.
• We encourage reporting of safety concerns,
  incidents, hazards and ethical concerns.
• We have committees and processes in place to
  address these issues and make changes when
  appropriate.
• Concerns reported to the charge nurse may be
  escalated to the unit leadership.
• You may be asked to complete an on-line (AKN)
  Patient/Safety Visitor Report or Area of
  Concern Form to document the events.
• When in doubt fill it out!

15
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 in the electronic 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 of sedation
  that results in loss of protective reflexes.
  This form is also used for blood transfusion
  consents.
• 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 (Consent)
  ideally is completed by the MD, the other side
  (Verification) 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 (AD)

• 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 (AD) Continued

• If the patient has an Advance Directive (AD)
• Obtain a copy from the patient or their old
  medical record. If a copy is not available,
  document your efforts to obtain the AD from the
  family.
• Nurses should place the AD in the shadow chart
  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 the issue to a
  higher authority to obtain MD follow through.

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Advance Directives (AD) 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 in electronic
  medical record.
• 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 accordingly.
• If the patient chooses to complete the form then
  place the completed form on the front of the
  shadow chart and inform the physician.

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Information for New-Employee Staff Assigned to
Patient Care

• Dress Standard
• Nametag with employee name, job title and photo
  must be located at or above waist level on
  employee 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
  cigarette smoke, 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.
• 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 and
  throughout shift.

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Information for New-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. The on-line 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 New-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
  forCharge nurse functions
• PROCESS FOR WORK ASSIGNMENTS
• Report to the Staffing Office 30 minutes prior to
  the start of the assigned shift. You will need to
  show your nursing license and picture
  identification prior to getting your assignment.
  Failure to provide your nursing license will
• 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 population-specific considerations.
• Complete billing slip/timecard and signature
  before you leave the PCU. Then present completed
  billing slip 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
26
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 electronic
  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 in the patients. 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 Initiatives
• Protocols for high risk medications
• NO stock KCL on units
• Patient information _at_ point of care
• Pharmacist on rounds
• Allergy wrist bands
• My Med List
• Medication Verification/Reconciliation

• Use of acceptable abbreviations
• Use of leading zeroes when writing decimals (0.1)
• Computerized MARs
• Look Alike/Sound Alike Meds
• Therapeutic Duplication

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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
• Use leading zeros when writing decimals (0.1)
• Telephone/Verbal order read back (TORB / VORB)
• Use acceptable abbreviations
• Complete medication reconciliation
• Please DO NOT

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Documentation Overview

• Excellian Mercys and Unitys electronic
  medical record
• Means of recording the patients episode of care,
  provide on-going communication among the
  interdisciplinary team of healthcare providers,
  and to maintain a record of historical data for
  audit, future reference and research
• Computerized physician order entry and charting

30
Documentation Overview

• Documentation Expectations Time Frames
  (Med-Surg specialty area times will differ)
• Complete Physical Assessment within 2 hours of
  arrival on unit
• Admission History within 24 hours
• Pain Assessment upon admission at least every 8
  hours at discharge. Reassess after every
  intervention.
• Education should be resolved as teaching
  completed all unresolved areas must be addressed
  at time of discharge
• Notes
• Should occur through care plan whenever possible
• Necessary upon admission, transfer, or death, and
  upon discharge if a specific outcome is not met.
• RN to write note every 24 hours in response to
  the Plan of Care
• Use of DAR format preferred
• Discharge planning begins on admission

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Documentation OverviewOther Assessment Areas
and Issues

• Bill of Rights
• Advanced Directives/Health Care directives
• Domestic Abuse Assessment Patient must be
  alone completed within 24 hours.
• Medication History
• Functional Status Assessment
• Nutrition Assessment
• Skin Assessment (Braden Scale)
• Fall Risk Assessment
• Latex Allergy/Sensitivity Assessment
• Pain Assessment/Management
• Patient Family Education
• Discharge Planning
• Patient Transfer Forms/EMTALA

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In Closing...

• Final Considerations

33
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 manager or continue on to Part Three based
on the directions from your manager.

• Press the ESC key to end