Download Pancreatitis Nursing Practice Guidelines

SOUTHWEST NOVA DISTRICT HEALTH AUTHORITY
NURSING REFERENCE MANUAL
NURSING PRACTICE GUIDELINES
Title: Guidelines for Completion Daily Care Record SWDACAR
Reference Policy Number
III-100
Authorized by: Joyce d’Entremont
(District Director of Nursing)
Authorized by: Patty Roberts
(Nurse Manager)
Submitted by: Linda Wilson
(Clinical Resource Coordinator)
Guideline Number: III-100-5
Date-O: June 2011
R: July 2013
(Signature)
(Signature)
(Signature)
LEGEND
 RN/ LPN/ CCA initials: The form is divided into sections. Each section has an area at the end of the
staff completing the section to initial. Sign and time only the areas of care you have completed.
 Enter a Y if you agree with the assessment statement.
 Enter an N if you disagree with the assessment statement (if applicable follow up with a nurses note).
* Record using asterisk (*) if change in condition occurs, record the time and follow up in the progress
notes.
 Enter an * to indicate a progress note.
 Enter NA if does not apply to your patient.
 Enter R when patient refuses.
______________________________________________________________________________________
Daily Care Record Page 1
DATE:
Insert Month/ Day(s)/Year.
Previous weight, today’s weight and weight changes
Actual Time performed: Time vital signs performed.
Vital Signs
 Temperature: Record a dot on space corresponding to temperature. May connect dots for a graph.
All recorded temperatures are oral. If not oral identify type using the legend.
 Pulse: All recorded pulses are radial. If apical identify using legend.
Rhythm:* if irrigular
 Respirations: Record number breaths/minute.
 Blood Pressure: All recorded BP are electronic. Record M when it is taken manually.
 If ordered to be taken in certain position (standing, lying, sitting) indicate using legend. Postural
blood pressure may necessitate a progress note
 SPO2: Record % of oxygen saturation.
.
 RN, LPN or CCA Initials: Initial of nursing staff obtaining data and recording data.
 CCA Reported to: Record printed full name of RN or LPN i.e. reported to J. Doe
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use
D:\684085871.doc
Page 1 of 6
Title: Guidelines for Completion Daily Care Record SWDACAR
Reference Policy Number

III-100
Guideline Number: III-100-5
RN, LPN are to co-sign CCA vital signs documentation.
Note: If there is a change in the patient’s vital signs/patient condition and/or based on the nursing
assessment further interventions are required including retaking of vital signs, follow up with a progress
note to include the assessment, intervention/s and outcome.
Actual time Performed Time assessments performed.
 FiO2: Record as delivered (4 L, 2 L, 28%, R/A).
 Delivery Mode: Record mode as per legend. (NP, NRB etc.)
 Deep breathing: Record Y if patient took deep breath. Record UP if patient is unable to.
 Spirometry: Record number of float balls raised i.e 1/3 or NA.
 Ankle Pumping: Record Y if patient ankle pumped. Record UP if patient is unable to perform.
Pain Assessment:
Record Y* if patient has pain and N if no pain.
Nausea:
Record Y* if patient has nausea and N if no nausea.
If Yes * for pain or nausea record assessment, intervention and outcome on progress notes.

RN or LPN Initials: Initial of nursing staff obtaining data and recording data.
OTHER
 DI Test: Record time left for test and time returned and initials
1000 chest x-ray JD
 Specimens: Record time specimen obtained, specimen type, initials 1000 Urine C&S JD
 Measurements(cm): Record time, location, length in cm, initials
1000 L+ calf 34 cm JD
 Family/team meeting: Time of meeting and refer to progress notes for information.
If no DI tests, specimens, measurements or family/team meeting record N/A.
_____________________________________________________________________________________
Daily Care Record Page 2



DATE:
Insert Month/ Day(s)/Year.
Record initial assessment time in 1st column block (i.e. initial assessment time)
Complete column by using legend and initial at end of each section. If aspects of assessment done at
a later time; record in 1st column with time
To indicate any changes from the initial assessment, use the 2nd column to record the time, your
initial and an * indicating a progress note.
Cognitive/Perceptual column:
 Isolation type: check mark type of precautions the patient is on
 Least Restraints, security, side rails, bed alarm, neuro observation sheet: circle appropriate answer
 Record Y at end of shift if patient’s status checks completed as per policy, N* if not completed and
follow up in progress note.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use
D:\684085871.doc
Page 2 of 6
Title: Guidelines for Completion Daily Care Record SWDACAR
Reference Policy Number

III-100
Guideline Number: III-100-5
Orientated, speech clear, moves all extremities (MAE), able to follow commands, acknowledges
information/direction: record Y or N* indication follow up in progress notes.
Activity/Exercise
 Cardiac telemetry sheets: Circle NA or Y
 Upper extremities (skin warm and dry)
 Lower extremities (skin warm and dry)
 Pedal edema, breathing patterns, cough/secretions: Record Y or N* to indicate follow up with
progress notes.
 Breath sounds: Record initial chest auscultation findings for lobes. If adventitious sounds present, a
follow up assessment required.
Activity Level: Circle appropriate level
 Activity times: Record time occurred, type of activity and duration.
 Mobility aids: Record NA or type of aid used: walker, cane, trapeze.
 Alternative support surface: Record NA or type: gel pads, ROHO, total care bed.
 ADL training: Circle NA or Y.
 ROM: Circle NA or record the number of times per shift.
 Turn q 2h in bed/q1h in chair: Circle NA or Y or N
 Eyes closed: 1, 2 , 3 based on legend
______________________________________________________________________________________
Daily Care Record Page 3
DATE: Insert Month/ Day(s)/Year.
Nutrition/ Metabolic:
 Circle appropriate answer in fields.
 Bowel Sounds: Record time performed and using four quadrants grid, indicate if bowel sounds are
present or absent. + = present; 0 = absent.
 NG location/ suction: Note the location (left or right nare) of the NG and if suction is applied note
the type in the space provided.
 Wound VAC Therapy Flow Sheet: NA if patient does not have a wound. Y if has wound and the
flow sheet must be used to record data.
 VAC q2h check: Record pressure setting (example = 125) and at end of shift Y if all criteria met.
If criteria not met on q2h checks, record *N and in progress notes record the criteria not met,
the assessment, interventions to resolve issue and outcome.
 VAC: Volume marked / exudate color: Check volume q2h and at end of shift record volume marked
@ (example @ 25 mLs). AND describe exudate color.
As per flow sheet; “A rapid increase in bright, red blood in the VAC tubing or canister requires immediate
investigation and discontinuation until bleeding is controlled. Contact physician STAT”
 Dressing: Location and time/s assessed or NA.
 Continuous Ambulatory Drug Deliver: NA or Y.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use
D:\684085871.doc
Page 3 of 6
Title: Guidelines for Completion Daily Care Record SWDACAR
Reference Policy Number

III-100
Guideline Number: III-100-5
Safety subcut catheter inserted: Record data in progress note.
Elimination:
 Urinary and Bowel Patterns: Circle appropriate information and record data.
 Description urine: Describe clear, cloudy, foul odor, concentrated etc.
 Description of stool: Indicate number of bowel movements and if loose, constipated, diarrhea, etc.
 Ostomy bag time: Emptied or changed: Record time and if either empty OR changed.
Activity/Exercise:
 Circle appropriate information and record data.
Note: Foley catheter care is provided a minimum of once per shift or more frequently as necessary.
____________________________________________________________________________________
Daily Care Record Page 4
DATE: Insert Month/ Day(s)/Year.
Intravenous (IV) Access:
Beginning of shift IV access done ,check completed y@______(record time) to verify solution, rate,
volume to be absorbed (TBA), tubing for continuous infusion or a saline lock site check .
IV columns are completed when:
 Initiating an IV via peripheral or central route (and/or) saline lock or continuous infusion
 Changing an IV bag (and/or)
 Changing the IV rate (and/or)
 Discontinue IV(and/or)
 End of shift : Document all intravenous lines infusions (include To Be Absorbed (TBA) or a
notation for a saline Lock
Time: Place the actual time that the IV was assessed/intervention performed.
 Saline Lock, IV, CVAD, Location and Condition:
 Record site location.
 Site Assessment using the Infusion Nurses Society Phlebitis Scale.
Document the grade number based on site assessment
Refer to Perry & Potter: Clinical Nursing Skills & Techniques (2014) INS Phlebitis Scale pp 707.

IV solution type/volume and port connection:
 Record solution (i.e. normal saline, ringers lactate, etc).
 Record solution and volume of bag (i.e. 1000ml bag or 500ml bag, etc.) for initiation and
solution change.
 Record port according to legend. (For example the IV D5W is connected to the saline lock,
heparin is connected to the first port on the D5W line).
 Not to be used to record iron dextran, blood components and intermittent medications.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use
D:\684085871.doc
Page 4 of 6
Title: Guidelines for Completion Daily Care Record SWDACAR
Reference Policy Number
III-100
Guideline Number: III-100-5


Rate mLs/hr: Record rate of solution infusing for all interventions.
Discard (mLs): If the solution is changed or discontinued, record the amount of fluid left in the
previous bag.
 ABS (mLs): Record amount of fluid absorbed on bag/solution change based on TBA.
For “End of shift check and/or with discontinuation of IV”, record absorbed mLs as per infusion
device.
 TBA (mLs): Record approximate amount of fluid left in bag on bag change and at end of shift.
 Tubing Change: Record tubing change Y completed, NA if not applicable.
CVAD: Record time CVAD dressing change and/or cap change and initial.
IV Insertion/Discontinuation:
 On insertion; record time, type, gauge, location, cannula intact. Under comments, either saline
locked or refer to table above for specifics.
 On discontinuation; record time, type, gauge, location, cannula intact. Under comments, D/C.
 If more than one attempt, * and record unsuccessful attempts in progress notes.
Nutrition:
 Circle level of assistance: self, assist, total.
 Diet Type: If patient on enteral feed, check enteral feed box.
 Under breakfast, lunch, dinner and evening snack, record percentage (%) of food taken as per
legend.
Intake:
 Record mLs taken by each route listed. If the patient has not taken any fluids in a section, then
record slash /. Record if ice chips or sips.
 Record total mLs of fluid intake for each 12h shift.
 In addition at end of night shift, perform 24 h intake calculation.
Output:
 Record total mLs of output by each route including colour.
 Record mLs of fluid output for each 12 h shift.
 In addition at night shift, perform 24 h output calculation.
 24 h Balance: record the difference between 24 h in and 24 h out.
Cumulative:
 Performed on nights.
 Nursing is to carry the 24 hour cumulative total from the previous day forward and record it under
the previous cumulative balance.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use
D:\684085871.doc
Page 5 of 6
Title: Guidelines for Completion Daily Care Record SWDACAR
Reference Policy Number

III-100
Guideline Number: III-100-5
Then to find the current cumulative balance, the product of the 24 h balance and the previous
cumulative balance.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use
D:\684085871.doc
Page 6 of 6