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Student Max
Nursing Clinical Core Competency
Orientation
Materials
Mercy
2011
Advance Directives
Inpatients
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All inpatients will be asked to review and sign the “Acknowledgement of
Advance Directive Information” form by the RN responsible for admitting the
patient. If the patient is unable to review and sign, RN should attempt to have
the paper signed by
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Patient’s guardian, if one exists
Patient’s spouse
Patient’s adult children
Patient’s parent
Patient’s adult sibling, a majority if more than one exists.
The RN must sign and date the form and the unit’s Division Secretary must
place the original form in the chart.
Inpatients (continued)
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Additional copies may be made for the patient as needed.
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For those patients who do not have an Advance Directive or have
not supplied a copy, the person completing the form should
document the patients wishes on the form.
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Nurses at Mercy Allen Hospital utilizes the initial nursing admitting
assessment form when obtaining information on Advance
Directives.
Questions Regarding Advance
Directives
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If the patient or their next-of-kin have questions regarding
advance directives, please consult the following individuals
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Monday through Saturday during normal working hours, call
Spiritual Care Department at the Mercy Regional Medical
Center, or Social services at Mercy Allen Hospital
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Weekends and off shifts Monday through Friday—
Administrative Supervisors at the Mercy Regional Medical
Center or the Chaplains at Mercy Allen Hospital
IV policies
IV Tubing Change Policy
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All tubing changes are every 72 hours with the
exception of:
 TPN or Hyperalimentation tubing is to be changed
every 24 hours
 Blood tubing after each unit
All solution changes are at least every 24 hours. No IV
solution, including flushes, may hang for more than 24
hours
If IV related septicemia is suspected, the IV tubing must
be changed every 24 hours.
Secondary IV Tubing
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Several different piggyback medications can be administered via
the same secondary tubing by utilizing the back flush method of
clearing the secondary line between doses
If the secondary tubing is disconnected from the primary tubing, a
new cap must be applied to the end of the tubing upon
disconnection
Falls
What is a Fall?
Any unplanned decent to the floor
 This includes lowering a patient to the
floor.
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The Morse Falls Risk Scale
is used at Mercy
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It is evidence based and shown to help decrease
falls
The assessment includes scores from 0 to >45
 Scores less than 25 are considered low risk
 Scores between 25-44 are considered moderate
risk
 Scores greater than 45 are considered high risk
Additional considerations
 Patient scores may be increased if they have
additional risks of
 Altered bowel and bladder
 At risk medications
Falls Risk Assessment
Risk assessment must be completed for
all patients upon admission
 After admission, a falls risk assessment
must be completed daily and when there
is a fall or change in patient status
 Care plans must be updated daily with
falls risk assessment changes
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Stryker Beds
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Zero all Stryker beds, weigh the patient and
then set the falls alarm to the middle zone.
You MUST re-arm the alarm after tending
to patient needs.
If the patient is quick, you may need to set
the falls alarm to the smallest zone
Post Falls Assessment
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If a fall occurs, follow the post falls
algorithm
Be sure to have the post falls order sheet
available when contacting the physician
Immediately after a fall, an assessment
must be completed and charted
A SafeCARE report must be completed
Post Falls Assessment
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If the patient is on anticoagulants (such as Coumadin)
the physician must be notified immediately regardless of
injury status
If there is injury noted or change in mental status, the
physician must be notified immediately
If there is no injury noted and the patient is not on
anticoagulants, the physician must be notified within 24
hours
The family must be notified of the fall
Organ and Tissue Donation
Hierarchy of Consent/Authorization
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Donor designation per Ohio BMV or other legal
document
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Spouse (common law is NOT recognized in Ohio)
Adult son or daughter
Parent
Adult brother or sister
Grandparent
Guardian of the person
Person authorized to dispose of the body
Potential Organ/Tissue Donors
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Organs
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Any person who has
suffered a lethal, or
potentially lethal, head
injury or disease and is
hemodynamically
maintained with
mechanical ventilation
and is in the critical care
setting
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Tissues
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Any person who has
suffered
cardiopulmonary death
in any unit of the
hospital and is not
maintained with
mechanical ventilation.
OneCall for Life
1-800-558-5433
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Call BEFORE approaching nextof-kin
Call within 1 hour of suffering
cardiopulmonary death.
PRIOR to declaration of brain
death on ALL patients with
Glasgow Coma Scale of 3-5.
Before discussing DNR orders
with family on mechanically
ventilated patients with
neurologic injury or insult and
PRIOR to the discontinuation of
any life support measures.
Hand off of Care
Hand Off of Care
“Hand off” communication needs to be
standardized by use of the Kardex.
 Opportunities to ask and respond to
questions are critical.
 The primary objective is to provide
accurate information about a patient’s
care, treatments, services, current
conditions, or anticipated changes.
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Process for Effective
Communication
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Includes a process for verification of received information including
repeat back or read back as appropriate.
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Opportunity for the receiver of the hand off information to review
relevant patient history, previous care, treatments, and services.
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Interactive communications allowing for opportunity for questions
between the caregiver and receiver of patient information.
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Interruptions during hand off should be limited in order for
information to be conveyed accurately.
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Information must be accurate in order to meet patient safety goals.
Communication Tools
Shift report with
SBAR Kardex
 Admission
Transfer Form
 Golden Rod
 Stat Com
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SBAR Kardex
Is Used:
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At change of shift report
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When a patient is going
for a test or procedure
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When turning over care
to another nurse for any
other reason
Should be Updated:
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With new orders
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Chart checks
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Change of shift report
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After central line dressing
change
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Change in patient code status
SBAR Kardex Info
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A taped or verbal report is used to communicate to the
new caregiver all aspects of the patient’s care, changes,
future tests and treatments.
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The report should be concise, accurate, pertinent, and
informative so the new caregiver has a good picture of
each patient and the patient’s needs for the new shift.
SBAR Report of Patient
Admission/Transfer
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This form is used when a patient is admitted from the
ER or transferred from another unit.
The sending caregiver fills out the form.
When the patient is coming from the ER the form is sent
via pneumatic tube system.
The receiving caregiver reviews the report and calls the
ER if he/she has any questions.
The patient is then received within one half hour of
receipt of the admission/transfer form.
Admission/Transfer (cont’d)
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When the patient is transferred
from an in house unit, the
sending nurse fills out the form
and calls report to the
receiving nursing unit.
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Both the sending and
receiving caregivers sign,
date, and time the bottom of
the form.
Using SBAR
When calling a physician:
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The SBAR form helps you to convey a detailed picture of the
situation you are calling about and provides the physician with
information needed to make a treatment decision for the patient
Forms are available on units and should be filled out before a call is
placed
Forms can be passed on to the next shift so the oncoming staff
knows why a call was placed
Always identify yourself, give the hospital and area you are calling
from
Have the patient’s chart and pertinent information available
Be direct and get to the point
Write down and then read back any phone orders that are given to
verify accuracy
The Golden Rod
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The Golden Rod is used when a patient is transferred to
an extended care facility, Behavioral Health or the
Rehab Unit.
The form is to be filled out concisely and accurately.
The physician’s orders are transcribed to the Golden
Rod.
The Nursing summary page is completed by the nursing
unit.
A phone report is given to the receiving facility before
the patient is discharged.
Hospital to Hospital transfers do NOT require a Golden
Rod.
StatCom
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After assignments are made, StatCom is
updated with the names and phone
numbers of the caregivers
Other departments can then call the
caregivers directly to update
The patient profile will be updated with
pertinent patient information such as falls
risk, isolation precautions, etc.
Post-op Care & Wound Care
Basic Post-op Care
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Assess respiratory status & pulse ox
Monitor VS & note skin warmth, moisture & color
Assess surgical site & wound drainage systems
Assess level of consciousness, orientation & ability to move
extremities
Connect all drainage tubes to gravity or suction as indicated
Assess pain level, characteristics (location, quality)
Check time, type, & route of last pain medication
Assess effectiveness of pain medication
Position patient to enhance comfort, safety & lung expansion
Assess IV patency & infusions for correct rate & solution
Reinforce deep breathing & leg exercises
Provide information/updates to patient & family
Post-Op Care
Recovery on floor following PACU
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Post-op VS unless otherwise ordered, are Q 15 min. x 4,
Q 30 minutes x 4, Q 1 hour x 4, then Q 4 hours
Preventative pain control
Nursing interventions to promote wound healing- allow the escape
of blood & serous fluids that can otherwise serve as a culture
medium for bacteria
Be aware of signs of infection, e.g. any temp > 101 F, chills, cough;
redness, tenderness or drainage from around incision; pain or
burning on urination.
Patient education begins early, start education on post-op care
preoperatively & throughout hospital stay to improve patient
compliance when discharged
Prevention of complications
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POST-OP PATIENTS are at risk for complications, e.g. Atelectasis,
Pneumonia, DVT, Pulmonary Embolism, Constipation, Paralytic
Ileus, Wound Infection
Educate on correct use of Incentive Spirometry
Deep breathing & coughing q 2 hours until discharge
Early ambulation, no later than 1st post-op day and elastic
compression stockings to promote venous return
Leg exercises & frequent position changes to stimulate circulation
Patient should avoid positions that compromise venous return, e.g.
raising the catch on the bed, placing pillows under knees, sitting for
long periods, dangling legs with the pressure at the back of the
knees
Administer pain medication as prescribed so the patient will feel like
moving-Encourage the patient to take pain medication before pain
is unbearable
Wound Care
Ongoing assessment of the surgical site involves:
 Inspection for approximation of wound edges
 Integrity of sutures or staples
 Assessing for redness, warmth, discoloration, swelling, unusual
tenderness or drainage
 The area around the wound needs to be inspected for reactions to
tape or trauma from tight bandages
 Assess output from wound drains & record all new drainage
 Amount of drainage is assessed frequently
 Excessive amounts of drainage must be reported to the surgeon
 Increasing amounts of fresh blood on the dressing must be reported
immediately
 Documentation of dressing changes includes description of the
wound, the actual dressing change procedure & patient tolerance
Vaccines
Vaccine Assessment
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Ohio law requires hospitals to assess adult patients for
both the Pneumococcal & Influenza vaccines.
Our policy is to assess on admission and, if eligible,
administer as soon as the patient is afebrile.
Influenza vaccine eligibility is assessed from the last
week of September until the last day of March.
Pneumococcal vaccine is available throughout the year
for those adults who are 65 or older without
contraindications.
Stericycle
Stericycle
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Red Sharps Containers
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Sharps that do not contain any medications
 Empty syringes (oral and IV)
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Red Bags (Regulated Medical Waste)
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Empty ampules
Blood Saturated materials
Biohazardous waste
Blue Container (no waste code)
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Any item that has the possibility of leaking must first be put into a
ZIPLOC bag. No free fluids, controlled substances or sharps!
 Partial IV bags and bottles with medication
 Tablets-whole, broken or partial
 Partial Medication vials
Stericycle
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Black container (sharps with left over
pharmaceuticals
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Syringes with pharmaceuticals that has NOT
come in contact with a patient
Big Black container (waste code BKC)
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Partial IV bags, bottles and vials
Tablets-whole, broken or partial
Aerosols or inhalers
Stericycle
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IV drain disposal
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The following medications can be disposed of down a normal drain
 Saline
 Dextrose
 Electrolytes
 Lactated Ringers
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Any IV with a non-hazardous, non-controlled substance RX instilled in it should go in
the blue container
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Black Container is for any IV with a hazardous, non-controlled substance medication
in it.
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Controlled substances are still disposed of down the drain with a witness
MEWS
MEWS
(Modified Early Warning System)
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Based on patient’s vital signs
Must be completed on admission, every 4 hours for the
first 24 hours and then every 8 hours.
Must also be completed every 4 hours post-operatively
for the first 24 hours and then every 8 hours.
Does not need to be completed when the patient is a
DNRCC.
This is done on adult patients only.
Not done on Rehab, Critical Care, OB or Behavioral
Health.
Point of Care Testing
Point of Care
Pre-Analytical Responsibilities
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Quality control testing regulated by CMS & CLIA
(Clinical Laboratory Improvement Amendments)
Correct identification of patient and test to be
performed
Good specimen collection technique
Ensure the analyzer is operational
Maintain quality control samples
Maintain annual competency requirements for
performance of point of care testing.
Point of care testing
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Common point of care testing that nursing
routinely performs are blood glucose
monitoring, I-Stat and hemocult
Point of Care
Analytical Quality
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All staff who operate Point of Care testing (POCT) equipment
must have an awareness of and are responsible for:
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The meaning of the results they generate
Analyzing any required QC samples
Confirming any results that don’t make sense
Documenting and addressing error codes that occur with patient
testing
Notifying the appropriate caregiver and/or physician of critical
values obtained
Recording results in the patient chart and/or downloading the
device to transfer results to the lab system
Medication Administration
Safety
Valid Physician Orders
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Must include:
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Date order is written
Name and dose of medication
Route and frequency of medication administration
The purpose for all PRN medications
Sign and date order by Licensed Independent Practitioner per
hospital Policy
Order must be legible
Must NOT have
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Prohibited abbreviations
Must not be unclear, must be legible. If not legible or clear,
clarification must be occur.
Don’t forget the Five Rights
 Right
Patient
 Right Medication
 Right Dose
 Right Route
 Right Time
Pain Management
Pain Scale
Pain Control
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All patients have a right to appropriate assessment and pain
management
Make sure you reassess pain and document measures to
relieve pain. After administration of pain medications,
reassessment must occur within one hour of administering
pain medication.
At the Mercy Regional Medical Center, SOP 600.134 lists
pain management strategies that are available—you may
review this for a complete list.
Pain scales are also available in Spanish
Pain assessment must include: onset, location, duration,
characteristics, aggravating factors, relieving factors and
treatment.
Skin and Wound Care
Prevention of Skin Break Down is Key
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RN assessment at admission for any actual skin impairments and
use the Braden Scale for predicting patients at risk
The lower the Braden score, the higher the risk for skin
breakdown
Educate patient and family about risks
The Wound Care Nurse is available for consultation—when in
doubt call for help!
For wounds that are present on admission, complete the Present
on Admission Progress Note and inform the physician for
diagnosis documentation. If the wound is not documented on
admission, Medicare / Medicaid will not pay for the treatment of
this wound
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** Report all hospital-acquired wounds or breakdowns in SafeCare*
Red Rule
Hourly Rounding
Red Rule is Right
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The Red Rule Competency is for all associates and volunteers. Our role is
to:
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We must:
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Pay attention to detail
Have a questioning attitude
Communicate clearly
Hand-off effectively
Work with each other to make sure that everyone is following the same quality principles
Use 2 patient identifiers at all times
Identify each patient, every time with 2 identifiers & match to orders/requisitions, etc.
Examples of appropriate patient identifiers:
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Patient Name; Patient Birth-date; Medical Record Number; Account Number; Photo in
current medical record; Social Security Number
The two most common identifiers we use at Mercy are patient name and birthdate
Hourly Rounding
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Hourly Rounding is an expectation on all patients
Hourly the following will be assessed: Pain / Position and Potty
Perform an environmental Sweep of the room:
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Look for call lights
Bedside table
Water
Urinal
Phone within reach
The following is the outcome of Hourly Rounding:
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Decrease in Decubitius Ulcers
Decrease in patient falls
Increase in patient compliance
Increase in Patient satisfaction
Increase in Employee Satisfaction
Core Measures
Purpose of Core Measures
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Core measures were created by The Joint
Commission in an effort to improve the
quality of health care by implementing a
national, standardized performance
measurement system.
Core Measures
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The Core Measures were derived largely from a
set of quality indicators defined by the Centers for
Medicare and Medicaid Services.
They have been shown to reduce the risk of
complications, prevent recurrences and otherwise
treat the majority of patients who come to a
hospital for treatment of a condition or illness.
Core Measures help hospitals improve the quality
of patient care by focusing on the actual results of
care
Core Measures
 The
5 categories of Core Measures
are Acute Myocardial Infarction, Heart
Failure, Surgical Care Improvement
Project, Community Acquired
Pneumonia and Stroke.
Core Measures
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To improve clinical performance, Centers for Medicare &
Medicaid (CMS) require hospitals to report data on specific
evidence-based performance measures.
Referred to as “Core Measures,” these include:
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Acute Myocardial Infarction;
Heart Failure;
Pneumonia;
Surgical Care Improvement Project (SCIP)
Stroke
Also included for review are behavioral health cases;
Evidenced-based Medicine
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Patient care research has shown results of improved
patient outcomes when the Core Measure criteria is
followed, such as:
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Mortality & Morbidity
Disability
Length of Stay
Re-admissions
Questions
1. All IV solutions including flushes may hang for:
a.
b.
c.
d.
72 hours
12 hours
24 hours
3 days
2. A patient who is a high falls risk must have the following:
a. Yellow Falling Star sign outside patient room
b. Yellow socks
c. Yellow arm band
d. Falls alarm for bed / chair alarm
e. All of the above
Questions
3.
Core Measures were derived from a set of quality indicators . Core Measures help hospitals
improve the quality of patient care by focusing on the actual results of care.
a. True
b. False
4. The Kardex is used with hand off of care when:
a. Patient is receiving a blood transfusion
b. Patient is discharged
c. Passing medications
d. Shift report or turning over care of patient to another nurse for any reason
Questions
5. The goals of “Hand off” of care are:
a. Opportunity to ask questions to care givers
b. Standardized communication
c. Provide accurate information about patient care, treatments,
and current conditions, and recent or anticipated changes
d. All of the above
6.
You must wait until the day of discharge to give patients a pneumococcal or influenza
vaccine.
a. True
b. False
7. It is essential that LifeBanc is called within 1 hour of a patient suffering cardiopulmonary
death in the matter of organ and tissue donations.
a. True
b. False
Questions
8. Hourly rounding is required to be done on all patients. The three P's stand for: Pain / Potty
/ Position.
a. True
b. False
9. Which one is NOT one of the 5 Rights in Passing Medications and assuring Medication
Safety:
a.
b.
c.
d.
e.
Right Medication
Right Time
Right Gender
Right Route
Right Patient
Questions
10. Staff who operate Point of care testing equipment must have an awareness of and are
responsible for:
a. The meaning of the results they generate
b. Notification of critical values obtained
c. Confirming results that don’t make sense
d. All of the above
Orientation Quiz Answer Sheet
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