GENERAL CARE ROUTINES FOR ALL PATIENTS
STANDARDS OF NURSING CARE IN CCTC (SONC)

  1. Maintain Patient Safety
  2. Demonstrate Accountability
  3. Assess Patient
  4. Participate in Care Planning
  5. Communicate Findings
  6. Monitor Vital Signs
  7. Monitor Temperature
  8. Promote Integumentary Integrity
  9. Promote Buccal Integrity
  10. Promote Oral Hygiene


  1. Promote Hygiene
  2. Continuous IV Infusions
  3. Verify IVs
  4. Independent Safety Check
  5. Change IV Tubing
  6. Filter IV Meds
  7. Filter or Vent Micro Air (Special Circumstances)
  8. Change Dressings
  9. Change Foley Catheter
  10. Review Orders

STANDARD OF NURSING CARE

RATIONALE FOR STANDARD

Ensure 4 moments of hand hygiene are met when performing assessments and/or managing monitoring equipment.

Perform risk assessment and select appropriate PPE based on patient diagnosis and procedure being performed.

 1.

Maintain Patient Safety

No bay/room will be left without a RN in attendance.

 1.



Critically ill patients require continuous monitoring, and are at risk for developing sudden condition changes or complications due to invasive monitoring devices (e.g., unplanned extubation).

 2.

Demonstrate Accountability

Each RN in CCTC is responsible for the monitoring and coordination of care for any patient(s) assigned to his/her care, during the assigned shift.

Each RN in CCTC communicates relevant information regarding assessment findings, the plan of care, interventions, diagnostic tests, medical orders, patient response and family status during patient care rounds, at end-of-shift report, and prior to breaks away from the bedside.

 2.



To promote comprehensive and continuous patient care.

 3.

Assess Patient

Each RN performs a comprehensive, systematic assessment of his/her assigned patient at the start of each shift.

Assessment findings and nursing care plans are documented in the 24 - hour Assessment and Intervention (AI) record at the start of each day shift. Each parameter assessed is recorded on the AI tracking form. These findings are monitored on an ongoing bases.

Documentation to confirm the patient's status is required for each parameter q4h, and prn if change has occurred. Findings that remain unchanged at the q4h assessment period may be tracked as an "arrow over" in the AI tracking record. This indicates that there has been not change since the last documented assessment, and that the nursing care plan for this parameter continues as recorded in the initial 0700 hrs assessment.

A Data, Assessment and/or Response (DAR) note must be documented in the AI flow sheet if findings are not Within Normal Limits (WNL), or have changed since the last recorded notation.

 3.



These are consistent with Victoria Hospital's documentation standard for focused charting by exception.

 4.

Participate in Care Planning

Each RN participates in team rounds, documents the plan of care in the AI record and communicates plans with other members of the team, including oncoming nursing staff.

 4.



To promote continuity of care.

5.

Communicate Findings

Each RN is responsible for communicating relevant findings about the patient's condition to the CCTC physician and to the Charge Nurse. Relevant findings include results of ordered diagnostic tests, abnormal lab results, changes in the patient's response to interventions, deterioration in the patient's condition or the need expressed by family members to communicate with a member of the medical team.

5.



To ensure prompt and appropriate medical intervention and care is provided.

 6.

Monitor Vital Signs

Vital signs are monitored continuously (ECG, SpO2 and invasive pressures) or intermittently (such as NIBP or pulses). 

Values are documented in the graphic record and documented q1h and prn for all acute admissions. Patients not requiring invasive monitoring, who are stable, may have frequency reduced to q2-4h and prn.

 6.

 

Nurses are expected to increase the frequency of monitoring based on clinical assessment/decision-making.

 7.

Monitor Temperature

Temperatures are monitored at admission, at the start of each shift and q2-4h for all acute admissions.

Patients on cooling or warming blankets, neuromuscular blocking agents, on dialysis, or patients admitted with acute trauma or brain injury require continuous or q1h temperature monitoring with q1h documentation.

If temperature is <35, monitor temperature via bladder catheter or pulmonary artery catheter. NOTE: the standard thermometers do not measure below 34 degrees. .

Continuous temperature monitoring by bladder, esophageal or pulmonary artery catheter is required during hypothermia protocol, with q1h documentation.

7.



Fever monitoring is an important indicator of infection. Prompt detection of infection can influence patient outcome. Critically ill patients have multiple risk factors for infection.

Decreased muscle activity, cooling or warming surfaces, fluid resuscitation or hypothalamus injury can cause rapid temperature changes. Hypothermia can cause coagulopathies, myocardial depression, pneumonia and arrhythmias.

Temperature < 36 degrees is abnormal. Hypothermia requires further investigation and may be a sign of a serious problem such as severe sepsis, hypothermia or other disorders.

8.

Promote Integumentary Integrity

All immobile patients are repositioned and have their skin inspected q2h and prn. Skin assessment findings and interventions implemented to treat altered skin integrity are documented q shift and prn in the AI record.

On-line skin scoring is completed for all new admissions and every Sunday and Wednesday.

8.



Very few patients in CCTC have skin integrity that is WNL, due to multiple factors including: low albumin levels, edema, decreased nutritional status, use of vasopressor agents, impaired mobility and sensation and organ dysfunction.

Information from the skin scoring program is used to determine the best bed surface.

9.

Promote Buccal Integrity

Oral inspection is performed q shift. Findings not WNL must be documented in the AI record. If skin integrity is altered as a result of ETT tube placement, consultation with the respiratory therapist for tube repositioning is required.

Oral airway or bite block is considered if needed to prevent injury to the tongue or ETT obstruction due to biting.

Oral and nasal inspection should be performed Q shift and prn to assess for mucosal breakdown related to drainage and feeding tubes.  Reposition or removed and replace tubes if there is evidence of trauma.

9.

The ETT or patient biting is a common mechanism of oral injury.

 

10.

Promote Oral Hygiene

Oral care is performed and documented in the graphic record q4h and prn. Teeth should be brushed q shift as part of the oral care routine, alternating with chlorhexidine application q shift.

Do not use mouth washes or toothpaste within 2 hours of chlorhexidine application. If nystatin rinses are being used, wait 2 hours following nystatin administration prior to chlorhexidine rinse See Procedure for Oral Care.

10.



There is evidence that chlorhexidine application is associated with a reduction in Ventilator Associated Pneumonia (VAP).

Chlorhexidine may reduce the number of gram positive bacteria in the oral cavity. Flavoured toothpastes or antibiotics may interfere with chlorhexidine's activity.

Chlorhexidine can leave a brownish film on the teeth; this can be readily removed during the patient's next dental cleaning.

11.

Promote Hygiene

All patients are bathed OD and prn. Routine bathing is done during in early evening when possible. Chlorhexidine bathing is performed q24hrs with 2% chlorhexidine foaming skin cleanser. Please refer to the Chlorhexidine Bathing Protocol. Bathing routines should be coordinated to facilitate sleep whenever possible. Individualized routines are developed for long term and/or awake patients.

Peri-care/catheter care is provided q 6-12 h and prn.

Hair washing is done q weekly and prn. Rinseless hairwashing systems are only used when hairwashing trays are contraindicated.

11.



Hygiene needs must be balanced against the need for patient sleep, with consideration given to patient preferences and normal routines.

Rinseless systems eventually accumulate in the scalp. They are only appropriate for short term, occasional use.

12.

Continuous Intravenous Medications and IV Therapy

All continuous medication infusions (e.g., vasopressors, insulin, heparin, amiodarone) must be administered using a dedicated male luer lock IV tubing set (or equivalent tubing that has no IV injection ports).

A secondary infusion line should never be connected to a continuous medication infusion.

Continuous medications must be programmed as a primary infusion using the infusion pump library.

If you want to run the medication with another compatible medication, the infusions must be connected using a Y connecter as close to the patient site as possible.


12.


 

To prevent inadvertent disruption, dilution or alteration of the medication infusion.

13.

Verify IV Therapy

At the start of each shift and PRN, assess each IV infusion (including those with and without medication added) to confirm that the correct solution is infusing at the correct rate, and that the bag has not expired.

Tubing from each IV solution should be followed from the bag to the patient’s access site to verify the following:

• Pump is correctly programmed
• IV clamps are open
• Bag height for primary and secondary lines are correct
• There is no precipitate, blood or leaking in the tubing or at the patient’s access site
• The IV site is patent and within define limits

Every bag of IV fluid that is hung (plain crystalloid or with medication added) must be bar code scanned and signed off in the MAR

Quick charting is only acceptable for emergency situations or where the order is entered after the infusion is started).


13.

As part of our routine safety checklist and to identify errors promptly.

14

Independent Safety Check

An Independent Double Check is a process in which a second practitioner conducts a verification. Such verification can be performed in the presence or absence of the first practitioner. In either case, the most critical aspect is to maximize the independence of the double check by ensuring that the first practitioner does not communicate what he or she expects the second practitioner to see, which would create bias and reduce the visibility of an error.


The second practioner is required to co-sign the electronic Medication Administration Record (eMAR) following independent double check by logging into the patient’s electronic patient record and completing the Witness Field or document by initialling the bedside flow sheet for rate changes and transitions in care.

As per LHSC policy, perform independent double checks for the following medications:

  • Cytotoxic agents (all routes),
  • Insulin infusions (intravenous),
  • Heparin infusions (intravenous), and
  • Opioid infusions (intravenous, epidural & Patient-Controlled Analgesia PCA).

Nurses should also request an independent safety check for medications that require unusual dosing or calculations at the bedside, or when indicated at the nurse’s discretion.

14  

15.

Change IV Tubing

Change Standard IV Tubing as follows:

 

While there is no set time for routinely changing standard tubing for maintenance or infusion IVs for either central or peripheral lines, tubing should be changed under the following conditions:

  • If there is leaking, precipitate or persistent blood noted in the tubing
  • With all new vascular access sites
  • When the IV solution is changed to one that is not compatible with the previous solution (e.g. vasoactive agents and bicarbonate)

Change   intermittent IV tubing every 24 hours (e.g., tubing used for intermittent antibiotics, piggy backed infusions or phenytoin).

 

Change Solution Specific tubing/IV bags as follows:

 

  • Vasoactive medications when indicated on the bag
  • Vasopressin bag every 24 hours (unstable after 24 hours)
  • Insulin infusion bags and tubing every 24 hours at ~1600 hrs (becomes unstable after 24 hours)
  • Propofol bottles and tubing every 12 h
  • Lipid or amino acid complex (TPN) solutions and tubing i every 24 h; TPN requires a filtered tubing

 

  • Standard blood tubing used for blood product administration must be change every 4H and/or after 2 units of blood product administration (whichever comes first).
  • A new blood set must be used for EACH unit of platelets
  • Tubing changes when using the Level 1 Rapid Infusor should occur when the speed of delivery stabilizes; platelets should not be infused via the rapid infusor  
  • Document tubing changes in the graphic record and on the kardex; place a label on all IV tubing with the date of change


15.



Consistent with hospital guidelines. There is  no evidence for benfit or harm if tubing is changed on a PRN versus routine basis.

Lipids and propofol pose additional risk for bacterial collection.

Some infusions require regular bag changes for stability reasons (e.g., insulin or vasopressin).

16.

Filtering of IV Medications

Inline or built in filters are required for a number of medications to prevent particulate embolism.

To capture particulate, a filter of 0.2 or 0.22 micron size is required.  Examples of medications that require filters:

  • Amino acids (TPN without lipids including 2 and 1)
  • Mannitol
  • Phenytoin
  • Amiodarone
  • Medications identified in the medication administration instructions of the MAR

Lipid molecules are 0.5 microns in size, therefore, TPN products that contain lipids require a filter that is bigger than 0.5 microns.  For lipids of 3 and 1 solution, a filter of 1.2 microns is used.

A filter that is 0.2 or 0.22 micron size can also vent microscopic air.

Blood products including PRBC, platelets, plasma and cryoprecipitate must be administered with a blood filter (170 to 260 micron size). 

Other products such as prothrombin complex concentrates are prefiltered during product pooling by the Blood Transfusion Lab.

After product delivery, only PRBCs should be kept in a cooler (if provided). Keep plasma, platelets and cryoprecipitate at room temperature.

 

16.

 

To prevent particulate embolism.

 

17.

Special Situations: Micro Air Prevention

If a patient requires additional filtering to prevent micro air (e.g, in a patient with a patent forman ovale or ventricular septal defect), 3 different methods can be used.

 For Micro Air Venting of Standard IV Therapy or Infusions:

 

  • Use TPN tubing with a 0.2 or 0.22 micron filter. Use the set that does not have an injection port below the tubing
  • Inline 0.2 or 0.22 micron filters can be used but must be located below the last IV injection port
  • Do not piggyback any IV's or administer medication between the filter and patient's IV site

 

Preventing Micro Air During Blood Product Administration

 

A blood filter DOES NOT prevent microscopic air. Blood products administered when micro air prevention is required must be given with both a blood filter (180 micron) and air venting filter (0.02 micron).

 

Level 1 Hot Line (Figure 1)

 

A Level 1 Hot Line can be used to both warm and vent micro air from IV fluid or blood products.

A blood filter is required when blood prodcuts are administered using the Level 1 warmer. Note that the L-10 air vent is NOT a blood filter.

If micro air protection is required, an inline L-10 45 micron air vent must be added (can be obtained from OR). This vent has poduction information that states it contains latex, however, the latex does not come in contact with the fluid pathway and Smith Medical has confirmed that this vent may be used in patients with latex allergy.

The L-10 vent should be changed at least EVERY 3 HOURS to maintain air venting capabilities.

 

Level 1 Rapid Infusor

 

When using the Level 1 Rapid Infuser, the blood filter AND air filter are automatically included.

17.

 

Air venting is indicated in patients who are at risk of microscopic air bubble transmission to the left sided-circulation like a patent foramen ovalve (PDA).

The risk of air embolism to the brain increases if the pulmonary pressures are higher than normal (e.g., pulmonary hypertension, coughing, suctioning or during labour).

Hotline Warmer

Figure 1: Hotline Level 1 Warmer (required L-10 inline vent to remove air and blood filter to administer blood products).

 

 

18.

Change Dressings

The preferred method for central line dressings is to use a transparent dressing with chlorhexidine (unless allergy exists) and to change the dressing q 7days and prn (when occlusivity is disrupted or visibly soiled.

Site should be examined and palpated Q shift.

If adherence or moisture prevents successful adherence of a tansparent dressing, gauze dressings are used and changed Q 24 hours (to allow for site inspection and cleaning).

Document dressing changes in the graphic record. Use a tick mark to identify that the wound is well approximated, non-reddened with minimal drainage. If wound is not WDL, place an "*" on the graphic record and make a DAR note in the AI record.

Update the Kardex to communicate the date of the dressing change and record the date changed on the dressing.

18.



To promote wound inspection and to communicate findings.

19.

Urinary Catheters

Hourly fluid balance monitoring is required for all critical care patients unless there is a written order to discontinue.

Change Foley catheters to a silastic catheter after 7 days.  Change silastic catheters PRN when there is an indication (not routinely by a set date). 

Change catheter if a new microorganisms is identified in a urine culture.

 

19.



Most patients in critical care have multifactorial indications for close fluid balance monitoring.

 

There is no indication that routine changes to a bladder catheter are beneficial.

A positive urinary culture may indicate colonization of the catheter.  Positive cultures should only be treated if a patient is symptomatic.

 20.

Review Orders

All orders must be reviewed and electronically signed by a CCTC resident or Consultant prior to being initiated.

 

Upon return from the OR or admission from a ward or ED, a medication reconcillation must be done electronically.


20.



To ensure the CCTC team is aware of all patient interventions.

 

 

Bmorgan 1988

Last Update:July 26, 2017, October 18, 2017

 

BM/KK

LHSCHealth Professionals

Last Updated October 18, 2017 | © 2007, LHSC, London Ontario Canada