Nursing Services WEIGHTS AND VITAL SIGNS MONITORING AND DOCUMENTATION

Transcription

1 FLORIDA STATE HOSPITAL OPERATING PROCEDURE NO STATE OF FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES CHATTAHOOCHEE, September 5, 2017 Nursing Services WEIGHTS AND VITAL SIGNS MONITORING AND DOCUMENTATION 1. Purpose: a. To provide the physician, Advanced Registered Nurse Practitioner/Physician Assistant, nurse, and Dietitian with guidelines to monitor the resident s dietary requirements, body weight, and vital signs. b. To provide baseline information to insure continuity of care for all residents. 2. Scope: This operating procedure applies to all nurses and to all direct care staff that are authorized to take weights and vital signs at Florida State Hospital. It also applies to the Medical Unit Supervisor for maintenance of the scale and to designated staff. 3. References: a. Clinical Nursing Skills by Smith, Duell and Martin, Current Edition b. American Heart Association Guidelines for Blood Pressure, October 19, 2009 c. Morrison Extended Care Diet Manual, Current Edition d. Health and Rehabilitative Services Manual, Quality Management and Review (January 1, 1993) e. Children and Families Operating Procedure 155-5, Supervision of Unlicensed Assistive Personnel Performing Nursing Delegated Assignments in Mental Health Treatment Facilities 4. Policy: Weights and vital signs shall be monitored/recorded at least weekly or more frequently as indicated or as ordered by a physician (vital signs include blood pressure, temperature, pulse and respiration). These procedures may be performed by direct care staff according to unit. When there are significant changes from the usual weight and vital signs as identified in this procedure, the vital signs shall be rechecked and immediately reported to the nurse. A monthly progress note of significant changes in weights and vital signs in any resident shall be documented in the resident s medical record by the Registered Nurse or Physician or Advanced Registered Nurse Practitioner, or Physician Assistant. In evaluating weight gain or loss, all units shall use ideal body weight (IBW) with the exception of units in Health Care Services which also use usual body weight (UBW). 5. Procedure: a. Weights Routine Weekly: This Operating Procedure supersedes: Operating Procedure dated June 3, 2016 OFFICE OF PRIMARY RESPONSIBILITY: Nursing DISTRIBUTION: See Training Requirements Matrix

2 (1) Time spans should be consistent, i.e., if the resident is weighed on Monday the first week, he/she shall be weighed on Monday thereafter. (2) All weights shall be taken at the same time of day, preferably before meals or the early morning hours after voiding (measures to protect privacy must be maintained). All weights obtained shall be noted on Form 35, Weight and Vital Signs. Assigned staff will complete the Weight and Vital sign Worksheet (Form 273) and ensure information is transferred to Form 35. If resident declines to remove heavy clothing/boots, document on Form 35. (3) When changes from the previous weight of five pounds more or less are observed, direct care staff shall immediately recheck, re-balance scale, re-weigh, check against first weight and immediately report to the nurse. Nursing will follow up to ensure accurate weight or determine need for additional actions. (4) Scales shall be balanced each week by unit staff when weekly weight is taken. Scales are balanced by checking the scale balance and adjusting the balance until it remains suspended in air without touching the top or bottom. The Medical Unit Supervisor shall request quarterly the calibration and balancing of the scales by hospital engineering staff (by using a set of standard weights). ARAMARK staff shall record signature and date the scales are balanced on a tag on the scales. The Medical Unit Supervisor will request the digital scales calibration every six (6) months by a Clinical Engineered technician on contract. (5) The resident will stand on an upright balance beam scale, sit on a chair scale, or lie on a weighing bed scale. If resident refuses weight, the assigned staff will document a minimum of two (2) attempts throughout the shift to obtain the weight measurement. Documentation of attempts shall be noted on the worksheet and Form 35. (6) All weights shall be recorded in the resident s chart on the Weight and Vital Sign Form (Form 35). The employee who enters the weight on Form 35 shall initial the entry then sign and initial at the bottom of the page. This data shall be incorporated in a weekly/monthly summary in the progress notes by the Registered Nurse or physician or Advanced Registered Nurse Practitioner or Physician Assistant. (7) The Unit Treatment and Rehabilitation Senior Supervisor I will review weekly weights and vitals completed by assigned staff to ensure completion and enter signature at the bottom of the page. The Unit Treatment and Rehabilitation Senior Supervisor I will obtain the ward nurse signature and date on worksheet and provide him/her a copy. (8) The Unit Treatment and Rehabilitation Senior Supervisor I will forward a copy of the weekly weights to the Nurse Manager, Physician, Unit Treatment and Rehabilitation Senior Supervisor II and Clinical Dietitian assigned to the unit. The Nurse Manager will maintain the Weight and Vital Signs worksheet for a period of six (6) months for administrative purposes. (9) Newly obtained weight shall be compared with previous weight by the Nurse, to determine possible weight change. (a) If the weight reveals a significant change from the previously recorded weight, the Nurse shall check the weight for accuracy. (b) The Nurse shall notify the physician and clinical dietitian when the resident s weight loss falls into one of the categories on Attachment 1, Undesirable Reportable Weight Loss, and if the resident s weight falls above or below the Ideal Body Weight Range for height on Attachment 2. Either weight loss or weight gain may be evaluated by a calorie count. See Attachment 3 for instructions. 2

3 b. Vital Signs Routine Weekly: (1) All vital signs shall be monitored according to the policy section of this procedure and documented in the resident s chart on Form 35, Weight and Vital Signs flow sheet, which shall reflect a continuous sequence of all vital signs throughout the resident s hospitalization. This data shall be incorporated into the weekly/monthly summary in the progress notes by the Registered Nurse or Physician or Advanced Registered Nurse Practitioner or Physician Assistant. (2) Vital signs shall be monitored/documented by licensed nurses or direct care staff. The American Heart Association Guidelines, October 19, 2009 for blood pressure readings are as follows: >120/80: Within normal range > /80-89: Pre hypertension 140/90 and over: Hypertension (Should be evaluated immediately) (3) Direct care staff who monitor/document vital signs shall notify a nurse IMMEDIATELY anytime the following variations occur and document nurse notification in the progress and event notes: Blood Pressure: < 90/60 or > 140/90 (See American Heart Association Guidelines above) Pulse: < 60 or >100 Respiration: < 16 or >24 Temperature, Axillary: > 98 Temperature, Oral: > 99 Temperature, Rectal: > 100 Temperature, Tympanic: >99 SPO2 (if performed) < 90 % (4) The nurse will complete a manual reading of the blood pressure anytime there are concerns related to the readings produced by the vital sign machines and follow up as appropriate. c. Non-Routine Weight and Vital Signs: (1) The assigned ward nurse will check orders for non-routine weight and vital signs. (2) The assigned ward nurse will notify the Unit Treatment and Rehabilitation Senior Supervisor I of orders and will document these orders on the communication log. (3) The Unit Treatment and Rehabilitation Senior Supervisor I will assign direct care staff to carry out order and assigned direct care staff will document completion of the weight and/or vital signs on Form 35. (4) Any abnormal readings will be reported to the assigned nurse immediately for follow up and documented in the resident s progress and event notes. d. Follow-up on significant findings: (1) If there is a significant change in the weight or vital signs that requires monitoring or treatment, the physician will write an order for monitoring or treatment. The medical plan will reflect the changes. 3

4 (2) The Nurse is responsible for making the clinical judgment as to when to notify the physician of significant changes in weight and vital signs. (Current Clinical Nursing Skills edition). e. Computer Entry: The unit Nurse Manager or designee shall provide a copy of the resident s weight on admission and monthly by the 25 th of each month to the unit Medical Unit Supervisor or designee for computer entry. (This is essential for Pharmacy compliance with State Manual 180-1). 6. Training Requirements: A check in the box below indicates which employees within the department are required to read this operating procedure and when they will receive training at Florida State Hospital. Employees within identified departments will also be required to review the policy each time it is updated. Department All Employees Clerical Dental Dieticians, Laboratory, Special Therapy, X-Ray Techs Direct Care Emergency Operations Environmental Services (Aramark) Financial Services Food Services Health Information Services Human Resources Information Systems Legal Materials Management Nursing Operations & Facilities (Aramark) Pharmacy Physician/ARNP (Prescriber) Professional Development Psychology Quality Improvement Recovery Planning Rehab Services Resident Advocacy/Risk Mgt. Social Services Supervisors/Managers Volunteer Services Other: Medical Unit Supervisors Worksite Education X X X X New Employee Orientation Discipline Specific Training Annual Update Signed Original on file in Quality Improvement Program BOB QUAM Chief Hospital Administrator Attachments: 1. Undesirable Reportable Weight Loss 2. Ideal Body Weight Ranges 3. Instructions for Completing a Calorie Count 4

5 SUMMARY OF REVISED, ADDED OR DELETED MATERIAL No changes were deemed necessary at this time. 5

6 Undesirable Reportable Weight Loss Current Weight <1 Week >1 week to <1 month >1 month to <3 months # 2 or more # 5 or more # 7 or more # # 3 or more # 7 or more # 10 or more # # 4 or more # 9 or more # 13 or more # # 5 or more # 10 or more # 15 or more # Report weight loss to Clinical Dietician Attachment 1 Page 1 of 1 6

7 Ideal Body Weight Ranges DETERMINING IDEAL BODY WEIGHT (IBW) BASED ON HEIGHT TO WEIGHT: THE HAMWI METHOD Frame Size Females Males Medium Allow 100 lb. for first 5ft. of height plus 5 lb. for each additional inch. Subtract 2.5 lb. for each inch less than 5 ft. Small Subtract 10% Subtract 10% Large Add 10% Add 10% Allow 106 lb. for first 5 ft. of height plus 6 lb. for each additional inch. Subtract 2.5 lb. for each inch under 5 ft. Source: Nutrition and Your Health: Dietary Guidelines for Americans. 3 rd ed. Washington, DC: US Depts. of Agriculture and Health and Human Services; Home and Garden Bulletin No Hamwi GJ. Changing dietary concepts, In: Danowski TS (ed). Diabetes Mellitus: Diagnosis and Treatment, Vol. 1. New York: American Diabetes Association, Inc.; 1964: The above method of calculating Ideal Body Weight (IBW) is also referred to as the 5 foot rule. Table H-1: Weight Loss as an Indicator of Malnutrition (1, 2) Time Significant Weight Loss (%) Severe Weight Loss (%) 1 week 1 to 2 >2 1 month 5 >5 3 months 7.5 >7.5 6 months 10 >10 Determination of Frame Size Method 1: Wrist Measurement Frame Size (r values) = Height (cm) Wrist Circumference (cm) r values 1 inch=2.54 cm Females Males Interpretation Method >11.0 >10.4 Small frame 1. Measure individual height in centimeters(cm) Medium frame 2. Measure the smallest part of the individual s wri centimeters. <10.1 <9.6 Large frame 3. Divide the height by the wrist circumference to derive r value for frame size. Look at table to th interpret frame size of individual. Reference-Morrison Manual for Extended Care, 2009 Attachment 2 Page 1 of 1 7

8 1. Physicians/ARNP s Responsibility Instructions for Completing a Calorie Count Order a Calorie Count by specifying the number of days to be included. On the physicians order form indicate: 3 day, 5 day, or 7 day Calorie Count. 2. Nursing Responsibility A) Inform the appropriate clinical dietitian by telephone or that a Calorie Count has been started for a resident. B) Designate staff to perform Calorie Count. C) Record the percentage of EACH food item consumed at EVERY meal time as specified. Record any other foods and beverage consumed from the canteen, at snack time and/or at activities for the specified time period that the Calorie Count is occurring. The resident s meal ticket may be used for recording items consumed at meal time. A total of 9 meals (3 day Cal Count) or 15 meals (5 day Cal Count) must be available for consecutive days as ordered. Use 0%, 25%, 50%, 75%, or 100% by each item. Also indicate the correct day on each tray ticket: e.g. Jan. 20, Jan. 21, Jan. 22. For Example: The results should look like this: TRAY TICKET STAFF RECORDS Jan 20 Lasagna 1 cup 25% Cheese roll 1 each 0% Apple Juice 8 oz 100% Parmesan Cheese 1 pkt 25% Tender green salad ½ cup 75% Etc. Canteen: 6oz bag of potato chips 100% 12oz can of regular soda 100% HS snack: milk 1 cup 75% Sandwich: meat, cheese, 20 slices Bread 25% D) Inform the appropriate clinical dietitian (when ALL tray tickets have been completed) that the Calorie Count is ready. 3. Clinical Dietitian Responsibility A) Check to be sure all data is complete. If not, ask nursing for additional information and/or request additional days for Calorie Count to continue if the data is not available. B) When all information is available, calculate the total Calories, Protein, and any other nutrient content deemed appropriate for the individual resident. C) Record Calorie Count in the Progress section of the medical record and make recommendations as needed. Attachment 3 Page 1 of 1 8