GUIDELINES TO

CLINICAL CARE

For Preceptored Students and Clinical Instructors

April 23, 2012

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Clinical Care Throughout this module you will be introduced to some of North

York General Hospital’s specific policies, procedures and best

practices guidelines.

Please note direct links to policies and procedures are only

available on the Nursing Units and on the Hospital Intranet site.

You will need to review them early in your placement here at

North York General Hospital

This module provides a basic overview on Clinical care,

assessment and treatment of the patient. It provides a guide on

basic physical assessment and outlines basic expectations for

medication administration, Intravenous therapy, oxygen therapy,

pain assessment, falls prevention and skin and wound care.

Nursing Students and Clinical Instructors are expected to practice

in collaboration with the point of care nurses.

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Table of Contents

Page No.

Basic Head–to-Toe Assessment 3 Medication Administration Guidelines 5

Narcotic & Controlled drugs

Transcription of orders

Intravenous Therapy 9 Oxygen Therapy 12 Documentation Guidelines- 17 Medical/Surgical Program

Students and Interns 18

Interprofessional PowerForms 18

Shift Expectations for Documentation 19

Best Practices & Evidence-Based Nursing Documentation 20

Documentation – Specialty Units 23 Pain 24 Skin & Wound 30

References 31 Appendices

- List of Policies for review

- MAR Variance Report - Braden Scale for Predicting Pressure Sore Risk

- Condensed Pressure Ulcer Clinical Pathways - Woundcare Comparison Unit Cupboards

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Basic Head to Toe Assessment

Airway / Breathing

Respiratory rate

Respiratory effort

Oxygen Saturation

Air entry

o adequate o adventitious breath sounds

Circulation

Warmth of skin

Heart rate

o regularity/rhythm/rate

Pulses

o strength and regularity

o central vs. peripheral

Perfusion

o capillary refill o skin color (eg pale, mottled)

Neurological

Level of consciousness

Mental status, interaction

Activity, movement, muscle tone

GI/GU

Bowel sounds

Appetite

Bowel movement

Emesis

Hydration status

o Urine output

o Moist oral mucosa o Skin Turgor

Warning Signs

Red Flags of Respiratory Distress

Tachypnea

Mechanics of breathing

o Retractions of intercostal muscles

o Tracheal Tug

o Nasal flaring

o Grunting on exhalation

o Prolonged expiratory phase

Diminished air entry

Change in breath sounds

o Stridor

o Wheezing

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Late signs

Skin color changes-dusky/cyanotic

Inaudible air entry

Apnea/irregular respiration

Changes in level of consciousness/activity Bradycardia

Red Flags of Cardiovascular Collapse

Tachycardia

Altered perfusion

o Skin

Prolonged capillary refill > 3Sec

Increased core to skin temperature gradient

o Brain

Altered level of consciousness/activity

Decreased response and appearances

o Kidneys

Decreased urinary output <30ml/hr

Decrease in pulse quality

Late signs

Decreased response to pain

Flaccid tone

Hypotension

Bradycardia

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Medication Administration Guidelines

"Administering a medication is a continual process and goes beyond

the task of simply giving medication to a client" (CNO, 2010)

Roles and Responsibilities of RNs & RPNs

Medication Administration Policy – II-226

Medical Order Policy II-290

There are three controlled acts that Registered Nurses & Registered

Practice Nurses are authorized to perform:

Performing a prescribed procedure below the dermis or a mucous

membrane

Administering a substance by injection or inhalation Inserting an instrument, hand or finger

o beyond the external ear canal

o beyond the point in the nasal passages where they normally

narrow

o beyond the larynx

o beyond the opening of the urethra

o beyond the labia majora

o beyond the anal verge o into an artificial opening in the body

Review the College of Nurses reference document: Legislation and Regulation,

RHPA: Scope of Practice, Controlled Acts Model

Roles of Nursing Students in Medication Administration

Nursing students must:

Have the knowledge (indications, contraindications, dose,

interactions, adverse effects, route and knowledge of how to

administer drug safely) skill, and judgment to assess the

appropriateness of the medication for a particular patient Know patient drug allergies

Nursing students need to assess:

The developmental stage of the (infant/child/adolescent patient)

Any alterations in the patient’s condition or functional status which

interferes with the physical capacity to take oral medications

The patient’s and or family level of understanding, knowledge of

each medication and their readiness to assume self medication administration

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Competent medication administration includes:

Preparing the medication correctly

Ensuring the Rights:

o right PATIENT

o right DRUG

o right DOSE

o right TIME

o right ROUTE

o right SITE

o right REASON

o right DOCUMENTATION

Monitoring the patient while administering the medication

Appropriately intervening as necessary

Evaluating the outcome of the medication on the patients health

status

Documenting the process

When preparing and administering medications:

A copy of the order (Medication Administration Record (MAR)/ Electronic

Medication Administration Record (eMAR) should be used as a reference to check the correct dose three times.

Firstly, when one identifies the vial/ syringe/ bottle/ bag/ powder/

capsule/ tablet the medication is in

Secondly, when one is preparing the medication Thirdly, after one has completed the preparation process

The nursing student must ensure that the right medication is administered to the correct patient by:

Checking the patient's identification number (on the ID band secured

to the patient) and name on the order (e.g.MAR)

Identifying patient via two methods (e.g. ID band # and name as

stated by patient or caregiver and/ or Date of birth )

Where applicable use caremobile device for Medication Administration and documentation

When preparing and administering medications, the nursing student

must:

Administer it within 30 minutes of the scheduled time Document the medication administration on the MAR

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Independent Double Checking, Double Signing and Documentation of Medications

Who can independent double check?

RN, RPN, CNS/NP, physician, pharmacist, pharmacy technician, RRT, MRT and Clinical Instructors

What needs to be independent double checked?

Certain medications (listed below) require a double check, double sign and

documentation when administered to the patient.

Potentially highly toxic drugs (e.g. Digoxin, Heparin, Insulin,

Narcotics)

Medication for newborn infants

Antineoplastic agents

Continuous medication infusions (e.g. Dopamine)

On the in-patient Paediatrics Unit all medications must be independently double checked

Independent double check:

EACH clinician should complete the checks and calculations independently. The

results of their checks must concur.

What Are You Double Checking?

Infusion pump check:

Right drug for right patient

Pump set correctly at start of infusion for ordered rate

All subsequent rate changes At change of shift/handover

The double check process:

1. Check order: name, medication, dose, route, date and time of order

2. Prepare medication

3. Hand over: prepared medication, container & order to 2nd check

4. Check strength of medication, dose

5. Ask the second check to read out loud: name, strength of the

medication written on the container label & the dose that has been

drawn up

6. Go to patient and check: name band against order

7. Verify pump settings

8. Administer medication 9. Document

Essential Tips for Safe Practice

Know the medication

Confirm patient information

Double check orders and verify with others if uncertain

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Avoid abbreviations

Use a leading zero before a decimal (e.g. 0.5 ml)

Minimize distractions when drawing up medications Communicate with patients and families

Narcotic and Controlled Drugs

Nursing Students will obtain and have all narcotics and controlled drugs co-signed on

the narcotic record by a RN or RPN of NYGH.

The narcotic and controlled drugs may be co-signed by the Clinical Instructor, since

he/ she is supervising the student.

Students and their Clinical Instructors are not to count end of shift narcotic.

Clinical Instructors may carry the Narcotic keys while supervising the students.

Transcription of Orders

Consolidation students are allowed to transcribe physician’s order, if they have

received orientation from their preceptor. All transcriptions must be countersign by

the most responsible nurse.

All transcription will be done in accordance with the policies, procedures and

protocols of NYGH.

NOTE

Students cannot take verbal/ telephone orders from physician

TIP: Medical/ Surgical/ Cancer Care/Paediatrics – Inpatient Units Electronic

Medication Administration Record – eMAR; Medication will be administered

And Documented using the Caremobile Device

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Intravenous Therapy

Students may monitor an established infusion of IV fluids/ blood products/ TPN via

peripheral and central line.

Nursing Students, who have been taught the theory and have demonstrated their

competence, may administer IV medications above the drip chamber, with a

RN/RPN/ Clinical Instructor in attendance

Students in Consolidation or Preceptorship who have been taught the theory and

skills and whose competency have been established by the preceptor may flush a

peripheral saline lock with saline solution.

Students in Consolidation or Preceptorship who have been taught the theory and

have demonstrated competence, may change central venous access device dressings

and lines with the preceptor in attendance.

Indications for IV Therapy

Supply parenteral fluids to:

o maintain daily requirements

o restore losses

o replace ongoing losses

o maintain electrolyte balances

o correct fluid & electrolyte disturbances

Administer blood and its components

Administer parenteral medication (e.g. antibiotics, chemotherapy,

analgesics)

Administer TPN (Total Parenteral Nutrition)

Provide intravenous access in case of an emergency

Provide access for diagnostic purposes (e.g. dye injection prior to a procedure)

Common IV Solutions

Sodium Chloride 0.9% (0.9 NaCl)

Sodium Chloride 0.45% (0.45 NaCl)

Dextrose 5% / Sodium Chloride 0.9% (D5W / 0.9 NaCl)

Dextrose 5% / Sodium Chloride 0.45% (D5W / 0.45 NaCl)

Dextrose 5% / Sodium Chloride 0.2% (D5W / 0.2 NaCl) Dextrose 5% in Water (D5W)

Common IV Additives

KCl - Potassium Chloride

Mg++ - Magnesium

Ca++- Calcium

PO4 - Phosphate NaHCO3 - Sodium Bicarbonate

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IV Therapy

IV solutions are medications. Students are expected to work in collaboration

with the nurse to ensure patient receives the ordered solution and additives at

the ordered rate. IV solutions often have similar packaging, therefore, ensure

that you exercise care and use the double checking procedure when

administering intravenous solutions. It is imperative that solutions and

lines are label with the name, date, solution, your signature and time

hung.

IV Maintenance

IV solution bags and syringes are to be replaced at least every 24

hours

IV tubing is changed at a minimum of every 96 hours with

continuous sets

Intermittent infusion set are changed every 24 hours

Tubing, bags and syringes are labelled with the date and time

of change and documented on the Kardex, where applicable

IVs are re-sited Q96hr and as necessary based on assessment

At the beginning and end of your shift, and when hanging a new bag

of solution, check the IV solution against the doctor’s order to ensure the correct solution is being administered

IV Site Assessment & Care

Continuous IV should be assessed hourly and documented on the

flowsheet, where applicable

Look specifically at insertion site, as well as above and below

Palpate and inspect site for puffiness, redness, skin temperature (very

warm or very cool), wetness, streaking, and/or cording

Compare limbs - is there generalized edema or is only the limb with

the IV edematous?

Assess patient’s comfort level - is the IV site tender to touch or

painful as fluids administered?

Remove interstitial or blocked PIV cannulas

Observe IV dressing for cleanliness and intactness

DO NOT REINFORCE wet or soiled tapes; cleanse the site with

chlorhexidene 2% with 70% alcohol, allow to air dry then reapply

dressing.

Never rely on your IV pump as a means of confirming patency - the

pump may continue to infuse the IV solution into the surrounding

tissues of an infiltrated IV

When disconnecting an IV, ensure that the end of the line is capped

in an aseptic manner. If becomes contaminated, discard the line.

Use positive pressure to saline lock IVs (Use turbulent flow to flush

in a push pause technique)

Positive pressure is established by clamping the catheter at the

same time as saline is flushed. Problem solves and trouble shoots with the unit nurses.

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Potential IV Complications

IV complications are largely preventable. It is important to identify and treat

complications, and the goal is to prevent complications by:

Constant monitoring

Maintaining asepsis

Thorough assessment

Troubleshooting IV sites

Most Common Complications

Infiltration/ Extravasation: Dislodgment of cannula from the vein

with IV fluid being infused into the surrounding tissue

Site Infection: Infection at the IV insertion site

Haematoma: Localized swelling filled with blood resulting from a

break in a blood vessel Phlebitis: Inflammation of the vein

SAFETY TIP:

Please ensure the IV tubing spike is cut and discard in the sharps container

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Oxygen Therapy

The goal of oxygen therapy is to relieve hypoxemia, decrease work of

breathing and to reduce myocardial stress. Oxygen is considered a medication

and is therefore administered in the lowest possible concentration to produce

the most acceptable oxygenation without causing toxicity. Students are

expected to work collaboratively with the nurse to ensure oxygen is

administered safely.

Overview:

Oxygen is a potent drug

Aggressive decompression of the gut is a prerequisite to securing the

airway

Selection of oxygen delivery device must be matched to the FIO2

requirements of the patient

Nursing assessment includes respiratory and neurological assessments,

including chest auscultation and the monitoring of oxygen saturation

Nursing interventions associated with securing the airway and selection of

the appropriate O2 delivery include mouth care to prevent drying of

mucous membranes, correct attachment of tubing to prevent skin

irritation/erosion

RT is availability 24/7 for emergency management of the airway

INDICATIONS

Hypoxemia PaO2 < 60 mmHg

SaO2 < 90%

Oxygenation Failure

PaO2 < 60 mmHg or SaO2 < 90% with FiO2 > 0.50

WHO REQUIRES OXYGEN THERAPY?

4 factors influence the transport of oxygen from the alveoli to the pulmonary

capillaries:

1. Diffusion defects: Thickness of alveolar wall, area available for gas

exchange and the partial pressure difference between the alveoli and the

capillaries.

E.g. Lung fibrosis, pulmonary edema

2. Ventilation perfusion mismatch:

a. Deadspace: Ventilation with no perfusion. E.g. PE, hypoperfusion

b. Intrapulmonary shunt: Alveoli are perfused but not ventilated.

E.g. consolidation, atelectasis, alveolar edema

3. Right to left shunt:

Refractory to oxygen

Small physiologic shunt (bronchial circulation)

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4. Cardiac output: Determined by preload, afterload and contractility.

If CO is decreased, the amount of oxygen available at the tissues may

be decreased.

Oxygen is carried in the blood in 2 ways:

1. Dissolved (2%)

2. Bound to hemoglobin (Hb) – the primary carrier of oxygen (98%)

The amount of oxygen in the blood is determined by the oxygen carrying

capacity and the cardiac output.

SIGNS OF RESPIRATORY DISTRESS

Tachypnea, dyspnea

Use of accessory muscles, increased abdominal movement

Tachycardia

Restlessness

Sweating

Hypoventilation

Reduced level of consciousness

Cyanosis

SUPPLEMENTAL OXYGEN

Room Air = 21% Oxygen

Supplemental oxygen increases the partial pressure gradient for oxygen, thereby:

WOB

HYPERVENTILATION

TACHYCARDIA

WORK OF HEART - d/t improved oxygen delivery to the heart

When Is Oxygen Therapy Alone Not Enough?

If the surface area available for gas exchange is reduced significantly due to for

example, extensive alveolar edema, consolidation, atelectasis or decreased

compliance, mechanical ventilation using PEEP may be required.

GOAL PaO2 > 60 mmHg or SaO2> 90%

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OXYGEN DELIVERY DEVICES

2 Categories: Low-flow devices

High-flow devices

Whether a device is classified as a low-flow or high-flow system depends on the

total flow of gas from the oxygen device and whether it meets the patient’s peak

inspiratory flow (how deep they take a breath)

Peak inspiratory flow rate:

Normal = 60 lpm

Respiratory Distress = patients short of breath may have a higher peak

inspiratory flow

High flow systems have a total flow of gas > 60 lpm

A. LOW-FLOW SYSTEMS The FiO2 is variable or not fixed.

FiO2 varies with:

1. Oxygen flow rate

2. Patient’s peak inspiratory flow

3. Patient’s minute ventilation = RR and Tidal Volume

The nasopharynx or the face mask itself act as an oxygen reservoir

Room air is entrained because the gas flow from the oxygen device is

insufficient to meet the patient’s peak inspiratory flow requirements.

1. Nasal Prongs

Oxygen flows from the nasal prongs into the patient’s nasopharynx. During

inhalation, entrained air mixes with the reservoir of oxygen.

Nasal prongs are used to provide low level supplemental oxygen (22 –

44%)

Maximum flow should be limited to 6 L/min (↑ resistance in tubing and

airway)

High flow rates may be uncomfortable and cause dry mucous membranes

1 lpm of O2 = ↑ FiO2 by 4%

Eg. 1 lpm = 24%

2 lpm = 28%

Advantage: comfortable, eat and speak

Little effect whether patient is mouth breathing or nose

breathing.

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2. Oxygen Masks

Simple Mask

Delivers 40-60% at flow rates of 6-10 L/min

A minimum O2 flow rate of 6 L/min is required to

prevent rebreathing of exhaled CO2

Non-Rebreather Mask

Delivers FiO2 80-100%

A mask with openings on it and a reservoir bag attached

A minimum O2 flow rate of 12-15 L/min is required to

prevent rebreathing of exhaled CO2

A collapsed reservoir bag indicates inadequate O2 flow

Isolation Mask

HI – OX 80 Mask: A solid mask (no holes) with a filter for the exhaled air.

There is a valve to prevent exhaled air from entering the reservoir bag.

USED FOR ***RESPIRATORY DROPLET ISOLATION PATIENTS***

B. HIGH-FLOW SYSTEMS The FiO2 is fixed.

Flows meet or exceed the patient’s peak inspiratory flow so extra

entrainment of room air does not occur

Consists of an adjustable air-entrainment port, which determines specific

oxygen concentrations. Openings in the delivery device become smaller as

higher concentrations of oxygen are used (i.e. less entrainment of room air)

1. Venti – Mask

Variable colored connectors ranging from 24 – 50% oxygen

concentration.

2. Nebulizer

Misty OX nebulizers are used at NYGH. FiO2 33-95%

(100% with plugs)

Can be connected to a tracheostomy mask or an

aerosol mask.

NEVER SWITCH FROM A HIGH FLOW SYSTEM TO

A LOW FLOW SYSTEM WITHOUT CALLING RESPIRATORY THERAPY

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MONITORING

Patient:

Clinical assessment such as signs of respiratory distress, work of breathing,

cardiovascular status (e.g. BP, HR)

Assessment of physiologic variables: PaO2 or SaO2

Equipment: On the patient care units,

All oxygen delivery systems > 50% will be checked by the RRT at least once a

day

All Tracheostomy patients will be checked by the RRT once a day

WHAT ABOUT COPD PATIENTS?

Misleading notion that if too much oxygen is given to COPD patients, they

will lose their drive to breathe since their respiratory drive is oxygen

dependent as opposed to hypercarbic dependent.

Remember, it is the oxygen content of the blood not the inspired oxygen

concentration

PaO2 NOT FiO2

The patient needs whatever concentration of oxygen necessary to return the PaO2 >

60mmHg

For those COPD patients who are oxygen sensitive, titrate oxygen to PaO2 >

55mmHg or SpO2 88 – 90%. This is the normal range for them.

Start high and work downwards.

Must treat hypoxemia first!

TIP: Consult with the Critical Care Response Team, if patient condition is

deteriorating by calling ext 6002

TIP: Be aware of emergency equipment, location and functioning

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Documentation Guidelines

Please review – Clinical Documentation Policy – II-280

Electronic Documentation on

Medical/ Surgical/Cancer Care In-patient Programs & Paediatrics Unit

General Guidelines

Students and Clinical Instructors are expected to abide with the policy and work in collaboration with the nursing staff

GUIDELINE 1

Documentation must be accurate and true. It should be clear, concise, and patient

focused, including:

Date & Time

Identification of person(s) involved

Clear identification of the individual who made the entry* (supporting policy)

Patient condition or concern

Information provided to or received from other caregivers

Collaboration undertaken with other caregivers, including outcomes and/or

proposed courses of action

Assessment, interventions, and recommendations where professional

judgment was exercised

GUIDELINE 2

Documentation should not contain unfounded opinions or conclusions.

Whenever, drawing conclusions or making recommendations, supporting data should

be recorded. (CNO, Nursing documentation standard, 2005)

GUIDELINE 3

Documentation should be well organized, chronological and completed promptly after

providing care.

GUIDELINE 4

In the event of an error or late entry, modifications can be made to an electronic

entry as soon as possible.

GUIDELINE 5

Documentation must be kept private and confidential.

Protect information from unauthorized access (Privacy of Personal & Health

Information, V-25; Confidentiality-Patient Information, II-40)

Ensure the security and confidentiality of information that is transferred or released (see privacy policy & transfer/release policy)

GUIDELINE 6

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Interprofessional progress notes (IPN) when required will be written in a SOAP

(Subjective, Objective, Assessment, Intervention/Plan) format

All students’ documentation must be

reviewed by the Clinical Instructor or

preceptor before adding an entry into the

patient’s record.

Nursing Students

All Nursing Students may document on profession specific PowerForms as

appropriate and apply the “sign” function upon completion.

Nursing students may document on interprofessional PowerForms and apply

the “sign” function upon completion. These notes are in “authorized” status.

The instructor or preceptor is responsible for reviewing the student

documentation upon completion and noting verification on the

Interprofessional Progress Note.

Preceptored student will review each clinical scenario with the assigned nurse,

prior to documentation

Students are not permitted to initiate an Order of any kind. If there is

eyeglasses in front of an order this is an indication that the orders

still need to be reviewed by the most responsible nurse.

INTERPROFESSIONAL POWERFORMS

All members of the Interprofessional team have the ability to document on the

following:

a. Patient History PowerForm

b. Interprofessional Progress Note

c. Communication/ Notification PowerForm

The Interprofessional Progress Note (IPN) must have a subject line reflective of the

contents of the note. The documentation format for the IPN will be SOAP. SOAP is

an acronym that stands for the categories of subjective information, objective data,

assessment/analysis, and plan of care.

The IPN may be used under the following situations:

a. When information cannot be captured on a PowerForm (ex:

communication with families, family conferences, incident)

b. To document a code or any other emergency situations. Note: Code Blue

form will remain on paper.

c. To document verification of a student entry on an interprofessional

PowerForm (ex. The student’s documentation on the Adult Patient History

PowerForm has been reviewed and is accurate.)

The Communication/ Notification PowerForm is to be used by all members of the

team in the following manner:

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Communication that has already occurred between Health Care Professionals either

in person or via the telephone is documented using the SBAR section of this

PowerForm.

Non-urgent communication/notification for the physician is documented using the

“Message for Physicians” section of this PowerForm.

SHIFT EXPECTATIONS FOR DOCUMENTATION

1. At the beginning of your shift or new assignment of patients, the

following will be completed:

A Shift Assessment of every system must be assessed when performing a

head-to-toe. However, dependent on the patients condition and the nurse’s

judgment a more in depth assessment may be required therefore the

detailed assessment section will be completed.

- Vital Signs as per physician order and/or nursing judgment

Activity of Daily Living will be documented on every patient throughout

the shift. This form captures basic care including mobility, hygiene, Falls

Prevention interventions and nutritional intake

Intake & Output Tab: All Intake and output will be documented on the

INTAKE & OUT TAB throughout the shift and as per unit standard/ nursing

judgment and or physician’s order.

Discharge Planning Overview: Discharge planning documentation should

be started as soon as discharge needs are identified and interventions are

done by anyone on the team. The powerform can be retrieved from the

ADHOC folder

Patient’s History: will be updated and modified as information becomes

available–one form to be initiated for patient admission, thus access form

through Form Browser

2. On-going/follow up assessment and treatment of the patient’s will be

documented at a minimum every four hours and will include:

Applicable assessment/ intervention/ monitoring forms will be Adhoc from

the Folders to support documentation. For example: Comfort, Suctioning,

PRN response, Observation and Education Forms

Initiate the “communication and notification powerform” or documenting on

the Interprofessional note – using SOAP or narrative

TIP#1: In addition to the shift assessment, the students will adhoc

Powerforms to support communication, interventions, monitoring

and treatment.

TIP#2: The initial assessment MUST be completed within three hours

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BEST PRACTICES & EVIDENCE-BASED NURSING

DOCUMENTATION

NURSING STUDENTS AND CLINICAL INSTRUCTORS ARE EXPECTED TO WORK IN

COLLABORATION WITH THE ASSIGNED NURSE TO IMPLEMENT AND DOCUMENT CARE

PROVIDED

1. Recommendations for Skin & Wound assessment, care and associated

interventions will include:

o 5 years and older Braden Assessment and Braden Q for Paediatrics

(<5years old) will be captured with the Admission assessment. A

score will be visible on the Patient Care Summary.

o Braden or Braden Q Assessment is tasked every Tuesday

o The pressure ulcer prevention plan and management patient plan,

will populate if one of the 3 Inclusion criteria is present: patient >

65 years old; Braden score equal/ less than 16

o Consult with interprofessional team as required, documenting

communication using the Communication and Notification

PowerForm.

2. Recommendations for Restraints and associated interventions will be

documented using forms in the “Restraint Adhoc Folders. Document the

patient/family/SDM’s choice in the patient’s health record; Document the

rationale for the application of restraint in the patient’s health record; Obtain

and document verbal consent from the patient (if the patient is capable) or

from the SDM (if the patient is not capable)

3. Substitute Decision Maker Powerform – SDM can be documented on the SDM

powerform – access the powerform from the ADHOC folder. Documented

information will be displayed on the patient care summary.

The following PowerForms can be used when documenting Restraint

Assessments/Interventions:

o The Least restraint/ last resort PowerForm

o Observation PowerForm

o Comfort Measure PowerForm

o PRN response PowerForm

o Interprofessional Progress Note (Narrative)

o Communication and Notification PowerForm

4. Pain assessment will be documented with the initial assessment and re-

evaluated at a minimum every 4 hours and ongoing.

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o Pain will be assessed at the beginning of the shift within the Adult/

Paediatrics Shift Assessment

o Pain score is displayed on the patient care summary

i. Pain score at rest

ii. Pain score with activity

iii. Acceptable pain intensity

o Ensure supporting documentation addresses and capture

interventions & monitoring:

i. Examples of PowerForm that can be used: Comfort measure

PowerForm, PRN response PowerForm

ii. Use the IPN only if needed

o Patients with PCA, PCEA or CADD initiate the Parental Opiod

Administration/ Monitoring PowerForm

i. Document assessment/ findings and interventions as

necessary and as per Policy

ii. For patient’s with Epidural, initiate the Epidural PowerForm

o Report significant findings verbally and initiate the Communication

and Notification PowerForm to document follow up action

o Re-evaluate/ re-assess patient response to pain Q1-2hr or as

needed

o Document outcome on the 24hr Pain Outcome Evaluation

PowerForm

5. Elderly Patients - SPPICES (Stability, Polypharmacy, Pain, Incontinence,

Confusion, Eating, Skin) is a screening tool for patients 65 years and older to

identify and prompt initiation of interventions/referrals. The SPPICES

powerform will be tasked on admission for patient 65 years and older.

Complete the SPPICES powerform following the Basic Admission Assessment

and the Adult Admission Powerform. Follow up referrals will automatically be

made to the appropriate professionals, once checked off.

6. Falls Prevention Program aims to decrease the number of falls and the

severity of falls.

o For Adult patients - Morse Falls Risk Assessment will be completed

on all inpatients, within 24 hours of admission, every Wednesday,

on transfer and PRN. Patient at risk for fall is determined by a

Morse Falls risk score > 45

o For Paediatrics patients - Humpty Dumpty Falls Risk assessment

will be completed on admission, every shift and PRN. A score of 12

or above

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i. The nurses will decide whether to use the high risk

interventions or Universal safety precautions

ii. The last documented score will reflect on the Patient Care

Summary

The following PowerForms can be used when documenting Falls

Interventions:

o High Risk Intervention powerform

o Observation PowerForm

o High risk intervention protocol powerform from the ADHOC folder

o Use the Communication/Notification PowerForm to document

communication that has already occurred between Health Care

Professionals either in person or via the telephone

7. IV and Central line care will be assessed and documented on the initial shift

assessment and as necessary

o IV site assessment/care and maintenance will be documented in

the Adult Shift Assessment PowerForm at the beginning of shift

and ongoing

o IV care and maintenance is captured within the Initial shift

assessment.

o If the patient has a Central Access Venous Device (CVAD) i.e PICC

line insitu, care and assessment will be documented on the Central

line Insertion Care Removal PowerForm.

o If the patient has a subcutaneous line, the assessment and care is

documented on the Subcutaneous line Insertion Care Removal

PowerForm.

o Intake & Out TAB will be used to capture IV Therapy

documentation

o Use the Communication/Notification PowerForm to capture

communication that has occurred in person or via telephone

o Use the IPN to document outstanding concerns or issues

If a patient has experienced a fall, a Post Fall Assessment powerform MUST be completed

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Documentation - Specialty Units

(ICU/ Mother & Baby Unit/ Mental Health Unit )

Charting by Exception (CBE) using a SOAP format, is being used by some

specialty units. This acronym refers to:

S - Subjective data

O - Objective data

A - Assessment/Analysis

P – Planning

Note: Documentation may vary from unit to unit. Please refer to unit specific guidelines for documentation.

Signature Profile

The Signature Profile is a permanent hospital record of the printed name, status,

signature and initials of the health care professionals and students providing care for

the patient.

Each person signs the Signature Profile once for the duration of the patient’s hospital

stay. The Signature Profile remains with the patient’s chart.

Writing must be legible

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PAIN

Pain Screening

All patients are screened for the presence of pain or discomfort at the beginning of

each clinical interaction.

Pain Assessment

A comprehensive approach to the assessment of pain is required, recognizing that

patients’ self - report* is the single most reliable indicator of the presence of pain.

Ongoing and systematic pain assessment assists the caregiver to evaluate the

current pain management plan and implement changes as required. Pain

assessment, where clinically appropriate, should consider pain at rest (R) and during

activity (A). Pain intensity and relief after intervention, as reported by the patient,

will be assessed and documented:

When screening indicates the presence of pain and a clinical intervention has

been initiated, pain must be reassessed at the time of anticipated effect

Following any known pain producing event or activity

Upon each new report of pain

Assess:

Intensity (0-10 numeric rating scale, Faces)

Location and radiation

Quality (i.e. sharp, burning)

Aggravating or alleviating factors

Associated signs and symptoms

Past pain management strategies and effects

Pain Assessment Scales

The use of pain assessment scales is recommended for screening and assessing

pain.

Five research based, population appropriate assessment tools are printed on a

single, laminated sheet. Copies are available in patient care areas ((See Addendum

1).

Choose one of the following scales that is applicable to the patient population.

0-10 Numeric Rating Scale (NRS)

Present Pain Intensity/Verbal Descriptor Scale (PPI)

Colour Visual Analog Scale (VAS)

Revised Pain FACES scale

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Pain Assessment of Specific Populations

Self-report is the best indicator of pain.

In the populations listed below, the following assessment measures may be used:

Cognitively impaired: Behavioral indicators and/or family report and physiologic

indicators (ie: increased heart and resp. rate etc).

Pediatric: see above plus Body Outline, FLACC (see addendum)

Neonates: behavioural/observational & physiological indicators

Elderly: Self reported using scale of 0-5, mild, moderate or severe

Language barrier: translated pain cards

Note:

1. Pain assessment of patients during labour and birth is performed in

accordance with Maternal Child System policies and procedures.

2. Personal goal for pain relief will be obtained from patients with chronic pain.

(personal goal for pain relief is individualized. Some patients may want

intervention for a pain score of 4 while another patient may not want

intervention for a score of 7. The goal is that the patient has been supported

and educated to make an informed decision.)

3. Where self report is not a feasible option, pain assessment must incorporate

age appropriate behavioral and/or family report and physiologic indicators.

4. Pain assessment of patients who are receiving epidural/PCA/CADD infusions is

performed in accordance with the specific monitoring policies and procedures.

5. Upon transfer, every patients’ treatment plan will be communicated to the

team in the receiving unit/area.

Painful Procedures and Pain Inducing Activities

Assess need for analgesic prior to any painful procedure (i.e. chest tube

insertion, paracentesis, biopsy, lumbar puncture) and prior to pain inducing

activities (i.e. ambulation or turning).

Collaboration of team to decide most appropriate prep prior to procedures.

Documentation

Population specific documentation is required. Clinical area staff are accountable to

follow area Standards to ensure clear communication among the Interdisciplinary

Health Care Team,

On admission a detailed assessment is completed.

If the patient is having a new pain (different to prior assessed pain assessments)

then a note is completed.

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Following surgery an assessment of the patient’s pain is documented.

A pain score that is greater than 4 warrants reassessment of the current treatment

plan.

A score of greater than 6 requires action and documentation unless otherwise

negotiated in the plan of care with the patient. The intervention will be negotiated

between the health care team and the patient.

Pain is the 5th vital sign and will be documented on the vital signs record or with the

vital signs on the PCA or epidural monitoring screens. (At rest or with activity as

clinically relevant) Assessment of pain for labor and birth is documented on the

labour and birth record.

PATIENT EDUCATION

The patient and family will receive education concerning the plan of care in terms of

pain management. Pain education should be developmentally appropriate and

considerations made for literacy, culture and language barriers.

Information regarding the importance of reporting uncontrolled pain is explained to

the patient.

As well as, the significance of reporting untoward reactions (ie. nausea).

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Sources. Bieri D, et al. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: Development, initial validation and preliminary investigation for ratio scale properties. Pain 1990;41:139-150.

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Faces, Legs, Activity, Cry, Consolability (FLACC) Behavioural Observational Tool

(2 months to 7 years)

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SKIN & WOUND All nurses and students are expected to assess their patient’s skin for the potential

to break down and for the presence of any existing wounds upon admission.

Documentation is essential to provide best care for our patients.

Risk factors such as incontinence and difficulty turning are to be managed by

nursing. (Please advocate for your patients to be turned and repositioned every 2

hrs.)

After receiving instruction as to how to perform a Braden Scale, the consolidation

student may perform such assessment. The Braden Scale will be completed on all

patients within 24hrs of admission and every Tuesday thereafter.

Once a Braden Scale has been done, a patient plan should be initiated if the patient

has been deemed high risk (scores 16 or less). There are 5 patient plans:

1) Prevention,

2) Stage I,

3) Stage II,

4) Stage III and

5) Stage IV.

If your patient is in need of The Prevention of Pressure Ulcers Plan, please bring your

assessment to the attention of your Preceptor or Clinical Instructor. will be initiated

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References

College of Nurses of Ontario (2008). Practice Standard- Documentation. Toronto,

ON. (Author)

College of Nurses of Ontario (2009). Practice Standard- Supporting Learners.

Toronto, ON. (Author)

North York General Hospital (2004). Policies and Procedures for the Care and

Maintenance of Peripherally Inserted Central Catheters

North York General Hospital (2006). Policies and Procedures for Braden Scale

North York General Hospital (2008). Policies and Procedures for Pain Standard

Perry, A.G., Potter, P.A. (2006). Clinical Nursing Skills and Techniques. (6th ed.)

Toronto: Elsevier Mosby

Register Nurses Association of Ontario (2006). Best Practice Guideline: Assessment

and Selection of Vascular access device. Retrieved March 20, 2006 from

www.rnao.org

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APPENDIX A

REVIEW THE FOLLOWING POLICIES ON THE INTRANET

Go to link Policies and Procedures:

1. II Abuse of Patients

2. II-30 Code-White-Violent Patient

3. II-35 Code Blue-Cardiac Arrest

4. II-36 Code Pink- Paediatric Cardiac or Respiratory Arrest

5. II-38 Code Pink-Adolescent (Adolescent Cardiac Arrest)

6. II-50 Consent to Treatment (blood transfusion consent)

7. II-60 Death: Notification of Coroner

8. II-70 Death-Forms Completion & Notification

9. II-137 Policy of Least Restraints

10. II -100 Identification of Patients

11. II-280 Clinical Documentation Policy

12. II- 90 Falls Prevention Policy

13. II-290 Medical Order

14. II-226 Medication Administration

15. II-270 Transcription and Verification

16. II- 300 Nursing Text book

Go to link Programs and Services Occupational Health and Safety;

hyper link Programs and services

1. WHMIS Education - New employee education PPT

2. Sharps injury prevention - Policy

3. Slips and Falls

Go to link Programs and Services Privacy Office

1. V-65 Disclosure of Personal Information

2. V-25 Privacy and Data Protection

YOU ARE EXPECTED TO FAMILIARIZE YOURSELF

WITH ALL HOSPITAL/UNIT POLICIES

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