*2,3. Competence Assessment, Planning & Evaluation (CAPE) Tool for All Nurses 1 on Medical Units

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1 Competence ssessment, Planning & Evaluation (CPE) Tool for ll Nurses 1 on Medical Units 1 of 7 ssumption: These competencies are in addition to the CPE Tool for all nurses in VH and CPE Tool for ll Nurses in cute Care.. Organizes, Coordinates, and Plans Care Effectively for Patients 2 With Medical llnesses * ELDER LERT RNBC 2,3 1. ssesses patient s fears, perceptions and understanding of medical illness /diagnostic tests etc., and encourages verbalizations of questions and anxieties is sensitive to the patient s vulnerability related to diagnostics/admission to hospital 2. Differentiates between needs of older adults *2,3 vs. younger adults by utilizing knowledge of age-related changes and incorporating into plan of care for older adult medical patient. 2,3,4 3. dmits patient respectfully: asks admission information, before patient has undressed, if applicable initiates &/or reviews planning for discharge follows admission routine takes immediate actions related to high risk factors, such as llergies, RO, etc. demonstrates a non-judgmental, empathic attitude re: patient s lifestyles, which may have contributed to medical illness. (e.g. V Do have the Learning ctivities 2 See: Care of Older dults During cute Hospitalization cute Care Nurses Orientation CPE Tool adapted with permission from Children s and Women s, Vancouver, B.C.

2 Competence ssessment, Planning & Evaluation (CPE) Tool for ll Nurses 1 on Medical Units 2 of 7 RNBC Drug Use, HV +, Hep. C, DS, People living at Risk etc.) scertains who is the MRP 2,3 4. Collects data from a variety of sources: Patient & Family/Significant others Chart Medical History dmission document/checklists dmission lab data/diagnostic tests Old chart (if indicated) nter-disciplinary team members 3 5. ssesses, prioritises, and plans care of patient by differentiating between: unstable patients patients receiving diagnostic tests &/or treatment stable patients 2,3 6. Utilizes knowledge of pathophysiology of disease which has created need for patient s admission, and concurrent medical illnesses 5 7. Utilizes adult learning principles and selects appropriate resources for teaching patient about diagnostic tests, treatments, etc. 1,2,3,4 8. Utilizes knowledge of Most Responsible Physician (MRP) Policy and Medical Rules/Regulations in relation to physician responsibility for patient care Knows how to find out who is the pt s MRP Do have the Learning ctivities ll Nurses Orientaion CPE Tool adapted with permission from Children s and Women s, Vancouver, B.C.

3 Competence ssessment, Planning & Evaluation (CPE) Tool for ll Nurses 1 on Medical Units 3 of 7 RNBC Do have the Learning ctivities and uses correct processes for contacting MRP Utilizes knowledge about the House Physician s role appropriately Knows when and how to contact physicians in urgent situations (e.g. sudden change in pt s status) Recognizes circumstances, related to medical care, which may cause a potential or actual adverse event in a pt. s care; Reports same to immediate charge nurse/clinical nurse leader/manager for assessment &/or referral to CQP Recognizes the interconnectedness between nursing and medical care, which includes, but is not limited to: Continual communications with MRP; clarifications re: physician orders &/or medical management plan(s) Use of pre-prepared orders appropriately including obtaining physician confirmation before implementing. Discerning when pre-prepared order may not be appropriate for individual pt. and follows up with physician re: same Knows where to access and how to use pertinent medical/interdisciplinary guidelines CPE Tool adapted with permission from Children s and Women s, Vancouver, B.C.

4 Competence ssessment, Planning & Evaluation (CPE) Tool for ll Nurses 1 on Medical Units 4 of 7 RNBC for own clinical area (e.g. guidelines for conscious sedation) dentifies situations in which guidelines are not implemented correctly, and notifies appropriate clinical leaders re: same 2,3, 5 9. Utilizes knowledge concerning Bed Utilization by being: ware of each of their patient s MRP; medical management plan (as evidenced through medical progress notes & physician order sheet) & reporting the absence of MRP or medical plan to Clinical Nurse Leader Do have the Learning ctivities 1 ll Nurses Orientation CPE Tool adapted with permission from Children s and Women s, Vancouver, B.C.

5 Competence ssessment, Planning & Evaluation (CPE) Tool for ll Nurses 1 on Medical Units 5 of 7. Provides comprehensive care to patients with medical illnesses * ELDER LERT RNBC *2,3 1. Differentiates between needs of older adults vs. younger adults by utilizing knowledge of age-related changes and incorporating into plan of care for older adult medical patient Performs initial and ongoing assessments of pt. (e.g. head to toe assessment, cognitive and functional assessment) 2,3 3. Collects and analyzes data from verbal and written shift reports, chart (e.g. patient history, laboratory/diagnostics results, patient/family awareness of results etc.) 2,3 4. Utilizes knowledge of pathophysiology and manifestations of patient s existing medical illnesses and is able to differentiate between expected outcomes related to illness/tests vs. unexpected outcomes (e.g. SOB, chest pain) f unexpected outcomes present, takes appropriate actions (e.g. immediate contact with physician, etc.) Do have the Learning ctivities 2 Care of Older dults During cute Hospitalization cute Care Nurses Orientation ( ) CPE Tool adapted with permission from Children s and Women s, Vancouver, B.C.

6 Competence ssessment, Planning & Evaluation (CPE) Tool for ll Nurses 1 on Medical Units 6 of 7 RNBC 2,3,5 5. Utilizes knowledge of diagnostic tests &/or treatments and adult learning principles during diagnostic period (e.g. uses verbal explanations, visual aides etc.) facilitates and correctly prepares patients for scheduled tests or treatments 2,3,4,5 6. Develops and implements, with the patient and multidisciplinary team (including the MRP), a plan of care based on the individual s needs. (Monitors diagnostics, analyses assessment data and takes appropriate actions, administers medications as ordered, incorporates patient/family teaching, ensures adequate nutrition, maintains and enhances patient s level of mobility in consultation with physiotherapist, addresses patient s psychosocial needs in consultation with Social Worker) 2,3 7. Uses nfection Control Manual as resource for information pertinent to clinical setting Utilizes knowledge of infection control standards in caring for patients with infections on unit 2,3,4 8. cknowledges and supports pt./family s transitions related to diagnosis, and possible changes as a consequence of diagnosis (e.g. need for further treatments or lifestyle changes etc.) Do have the Learning ctivities 2 Unit Orientation / 1-2 See: Care Plans 1 cute Care Nurses Orientation ( ) CPE Tool adapted with permission from Children s and Women s, Vancouver, B.C.

7 Competence ssessment, Planning & Evaluation (CPE) Tool for ll Nurses 1 on Medical Units m m 7 of 7 RNBC 1,2,3,4 9. Supports an ethical decision-making process which honours a patient s right to confidentiality (re: diagnosis/pathology), right to make choices during hospitalization (e.g. active treatment vs. palliative care) advocates for the pt. s rights during the course of hospitalization 2,3,5 10. Evaluates plan of care with patient and multidisciplinary team (including MRP) and makes necessary changes/alterations in plan as demonstrated by comparing clinical outcomes to care plan goals 2,3,5 11. Continues discharge planning and makes adjustments as needed, based on individual patient s needs (e.g. discerns barriers for discharge and works actively to problem solve same in collaboration with others) knows how and when to contact Manager, Bed Utilization/Utilization Coordinator Do have the Learning ctivities 1 Practice on Unit 1-2 Practice on Unit 1-2 Unit Orientation / ( ) CPE Tool adapted with permission from Children s and Women s, Vancouver, B.C.