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
11. Promote Hygiene
12. Change IV Tubing
13. Change Dressings
14. Review Orders
    

STANDARD OF NURSING CARE

 1.

Maintain Patient Safety

No bay/room will be left without a Clinical Nurse 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 Clinical Nurse is responsible for the monitoring and coordination of care for patients assigned to his/her care, during the assigned shift.

Each Clinical Nurse 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 Clinical Nurse 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 Clinical Nurse 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 Clinical Nurse 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 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.

 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 tube placement, consultation with the respiratory therapist for tube repositioning. Oral airway or bite block is considered if needed to prevent injury to the tongue or ETT obstruction due to biting.

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.

Change IV Tubing

IV tubing is changed per hospital protocol. Tubing is changed q 96 h and prn for central or peripheral lines, q 12 h for propofol infusions, q 24 h for lipid solutions, and q 24 h or q 2 units for blood products. Tubing changes are documented in the graphic record and kardex. IV tubing is labeled with the date changed.

12.

Consistent with hospital guidelines. Lipids and propofol pose additional risk for bacterial collection.

13.

Change Dressings

Central line dressings are changed q 2 days (tape and gauze)and prn, when using Tegaderm transparent dressing change q 7days and prn when occlusivity is disrupted.
Document dressing changes in the graphic record. Use a tick mark to identify that the wound is well approximated, non-redenned with minimal drainage. If wound is not WNL, place an "*" on the graphic record and make a DAR note in the AI record.

13.

To promote wound inspection and to communicate findings.

 14.

Review Orders

All orders must be reviewed and signed by a CCTC resident or Consultant prior to being initiated. Upon return from the OR or admission from a ward, all medications and preop orders must be rewritten. "Re-order medications" is not acceptable.

 14.

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