CCTC AI Record Updated for November 26, 2015 Revisions CCTC Nursing Documentation Information Brenda Morgan, CNS, CCTC
A Few Points Use tick boxes to identify protocols that are in effect (e.g., VAP prophylaxis, electrolyte protocol); you don t need to write this narratively Describe abnormal findings and patient specific details in the narrative space
A Few Points It is assumed that monitoring will be according to CCTC standards (be sure you know what they are by reviewing website) You don t need to describe routine care in the narrative note The test of whether monitoring is performed as per standard is the actual documented assessments
Reminders means that everything is the same as per the last entry before arrowing began If you chart that something is abnormal or outside of defined/normal limits, remember to document the return to normal before arrowing If the last entry is an abnormal finding, arrowing over means the abnormal state is continuing
Document a * to indicate that a descriptive entry had been made to the Data-Assessment-Response (DAR) section of the AI record
Reminders Document the Plan of Care at the start of the shift (days and nights) At end of shift, summarize the response to the plan or any plan modifications Communicate the plan/modifications to oncoming shift to ensure that the loop is closed and issues do not get dropped
Reminders Narrative charting should focus on significant findings, interventions and patient response Routine care per standard does not require narrative entries unless response is not within normal of defined parameter; record in graphic record REMEMBER to document patient response to interventions
Physician Notification When you page/speak with a physician about a problem, include the name of the physician in the documentation When you document that a physician is notified, outline briefly the specific information communicated (don t just state MD updated E.g., Dr. X notified of low BP, oliguria and tachycardia.
Complete new assessment at the start of each shift.
Enter the date, admission day AND time when assessment performed.
Document the details for findings that are not Within Defined Limits (WDL). If there is insufficient room in the initial shift assessment, use Panel 2 and 4.
Panel 1: Neuro Section To reduce the chance of missing an important neurological change, always perform a neurological assessment together with the outgoing shift to confirm findings/descriptions of findings.
Neuro/Comfort Section WDL applies only to very rare ICU patients who are completely awake, oriented X3, communicating normally and have normal motor strength All patients should have a neurological assessment performed and documented at the start of each shift and PRN
Neuro/Comfort Section Assess motor strength to assess for focal findings and to identify generalized weakness of critical illness Refer Bedside Assessment tools for assessment tools/tips Make note if patient s neurological findings may be influenced by sedatives or other agents
Neuro/Comfort Section Describe deficits clearly; add DAR note if more space is needed. Describe patient response in detail using straight forward language Clearly identify the type of stimulus used and the patient response (e.g., eyes open to voice, abnormal extension to trapezius squeeze) Complete neuro section of 24 Hour Flowsheet
Neuro/Comfort Section Gag is normal if stimulation of BOTH sides of the oral pharynx elicits response
Neuro/Comfort Section Normal cough should be able to bring secretions forward.
Neuro/Comfort Section Trauma is responsible for clearance and must enter an order to confirm that precautions are cleared.
Neuro/Comfort Section There must be documentation in the AI record of consent. Consent can wait till morning on the night of application, but there must be a DAR note to explain your decision and selection of LEAST restraint. Consent is required by Ontario law. Continued use without consent is a violation of the least restraint act.
Neuro/Comfort Section Document ICP, CPP and leveling in the 24 Hour Flowsheet Record reference code for zeroing Codman Express
Neuro/Comfort Section The order of assessment should be Pain, Agitation (MAAS score) and Delirium (PAD). Pain and Agitation should be assessed at the start of each shift, with each PRN medication and Q4H PRN for all patients in CCTC. Delirium is screened once during the second half of the shift.
Neuro/Comfort Section SWAP tool is available on all nursing desk tops and can be obtained by clicking on the icon from the critical care analgesic or sedation care set.
Neuro/Comfort Section Screen all patients who are receiving continuous infusions of narcotics or sedatives with the SWAP tool every shift, to assess readiness for sedation reduction.
Neuro/Comfort Section Attempt weaning automatically if SWAP is passed (weaning protocol can as per routine orders). Weaning protocols are available from the Protocols Page of the CCTC website under Analgesic orders and Sedation orders.
Neuro/Comfort Section If SWAP assessment is failed, review sedation plans during rounds. *Even when deep sedation remains the target, slow and cautious reduction can be attempted to see if targets can still be achieved with less medication (except when neuromuscular blockade is in use).
Neuro/Comfort Section Describe the plan for sedation. Wean means to reduce sedating drugs as tolerated as per routine orders. Maintain means to continue the current sedation targets. Describe plan if > 1 agent to be weaned or not as per analgesia orders. *Even when deep sedation remains the target, slow and cautious reduction can be attempted to see if targets can still be achieved with less medication (except when neuromuscular blockade is in use).
Neuro/Comfort Section Identify whether patient is receiving any antipsychotics (including PRN only) Examples of antipsychotic medications: haldol, lamotrigine, loxapine, olanzapine, methotrimeprazine, quetiapine, risperidone
Neuro/Comfort Section If antipsychotics are in use, assess for signs of EPSE/NMS (see Delirium Protocol) If positive, * and DAR Remember to assess QT interval if patient receiving antipsychotics
Neuro/Comfort Section Screen ALL patients > 24 post admission for delirium during the second half of EVERY shift. Screen patients even if they are not ventilated Screening is used to help identify potential delirium and to monitor delirium progress following initiation of treatment
Neuro/Comfort Section Document the time when the screen was completed. Screen during second half of shift to ensure sufficient time to assess for symptom fluctuation Report screen results as screen positive (if ICDSC is > 4) or screen negative (if < 4 ) during rounds and communicate during shift-to-shift handover.
Neuro/Comfort Section 0430 Record the time that the screen was completed Screen for pain, VAMAAS and delirium at same assessment point
Neuro/Comfort Section 0430 3/10 If patient able to self-report, circle NRS and enter pain score as 0-10/10
Neuro/Comfort Section 4/8 0430 If patient is unable to self-report, circle CPOT and enter pain score as 0-8/8
Neuro/Comfort Section 4/8 4 0430 Assess for agitation using MAAS score Enter the MAAS or score (unventilated patient) or VAMAAS (ventilated patient)
Neuro/Comfort Section 4/8 4 5 0430 Circle all of the ICDSC (Intensive Care Delirium Screening Checklist) criteria that apply Give one point for each item circled and enter the score out of 8 for the ICDSC
Neuro/Comfort Section If any criteria from 1-7 change between between day and night shift or throughout your shift, assign a point for #8 symptom fluctuation.
Neuro/Comfort Section 4/8 1A 0430 If MAAS < 2 (and sometime if it is 2), patient s level of consciousness is too low to screen for delirium.
Neuro/Comfort Section 1/8 1A U/A 0430 If MAAS is too low, complete the Pain and MAAS score and record the Delirium Score (ICDSC) as U/A This section must be completed for ALL patients even if sedation is too deep for screening
Respiratory Section
Respiratory Section Identify and oxygen or ventilation support that is in use
Respiratory Section Describe the oxygen and ventilator settings as well as the type of airway in use
Respiratory Section Use the codes to illustrate on the diagram the type of breath sounds heard. REMEMBER: edema, secretions and atelectasis is most prevalent in the lower lobes (or bases); you need to listen to the back of the patient to hear the bases
Respiratory Section List any thoracic tubes here and describe chest drainage tube assessments
Respiratory Section Select VAP Prophylaxis to indicate that VAP Prevention strategies are in place (e.g., HOB elevation, oral rinse with CHG, teeth brushing, subglottic drainage tube, enteral feeding or TPN within 48 hours of admission and sedation reduction/minimization
Respiratory Section Identify oxygen/ventilator targets/orders Add other therapies (e.g. prone until 0300 hrs, PCO 2 orders for patient with Traumatic Brain Injury)
Respiratory Section Identify orders are plans for ventilator change E.g. ARDNet protocol or start TM trials up to 1 hr TID as tolerated Be sure to identify if patient is to be rested overnight
Respiratory Section Remember to re-fri for patients in CCTC with new symptoms or coming from ward (it isn t just ED)
Respiratory Section Use this to elaborate upon abnormal findings or patient specific plans
Cardiovascular Section
Cardiovascular Section Identify monitoring lead at the start of each shift and confirm that all leads are in the correct chest position POST A COPY of the rhythm strip at the start of each shift and document analysis on the strip Record your analysis here *One full page strip can be posted to display ECG rhythm and all required waveforms
Cardiovascular Section Document pulse assessment
Cardiovascular Section Document the time in seconds to capillary refill; > 2 seconds is prolonged (cold ambient room temperature can prolong refill) Assess for symmetry (e.g., delay on one side suggests a local flow obstruction versus generalized shock) Upper and lower can be assessed; delayed refill in great toes is suggestive of shock or peripheral vascular disease
Cardiovascular Section Document skin temperature, colour and any abnormality of the skin texture Charted detailed skin assessment in Integumentary diagram
Cardiovascular Section Identify how BP measured Describe quality of arterial line waveform and identify if positional
Cardiovascular Section If a patient has a pacemaker, assessment should include: Site: insertion site (e.g. Left SC) for a temporary or permanent transvenous pacemaker or the status of transvenous pacemaker pads (e.g., pads intact, change at 1200 hrs)
Cardiovascular Section Identify where pads are placed (e.g., anterior and posterior or anterior only) Change transcutaneous pads every 2 hours if in continuous use, every 6 hours if intermittently used and every 12 hours if pads in place but no pacing. Inspect for skin burns.
Cardiovascular Section Pacemaker TYPE: Permanent, temporary transvenous or trancutaneous AND the 3 (temporary) or 5 (permanent) letter pacemaker code Patients with permanent pacemakers should carry a wallet card that identifies the pacemaker code and setting; if unavailable, information may be may be available in Power Chart or by calling pacemaker clinic
What do the Code Letters Mean? Example VVI: This code is frequently used in temporary (transvenous or transcutaneous) pacing. It would indicate that the pacemaker only has the ability to pace or sense the ventricle and the response to a sensed event would be to inhibit. This is what we frequently call a demand ventricular pacemaker.
What do the Code Letters Mean? Example DDDMD: Five letter codes are used to describe permanent pacemakers that have programmable features (can speed up when the patient exercises). In this example, there would be both an atrial and a ventricular wire in place so that both the atria and ventricle can be sensed and/or paced as needed. The M indicates that the device has been programmed for more than one function and D means it can have both programming or rate changes AND shock capability.
Cardiovascular Section The pacemaker Rate is the Set Rate (HR should not fall below this rate) The MA is also called the output. This is the amount of current that will be delivered to the heart with each paced beat (measured in milliamps or MA). The pacemaker should be assessed each shift to ensure that it captures when the rate is increased above that of the patient and identify whether it can sense the patient s own beats.
Cardiovascular Section The Sens. Is the sensitivity setting. Record the sensitivity in mvolts. This reflects the size that a native beat has to reach in order for the pacemaker to recognize or sense it Turning the sensitivity down or to the left will make the mvolts number higher. These would mean that the patient s own QRS would need to be taller or stronger in order to be detected (less sensitive) Turning the sensitivity up or to the right makes the mvolt numbers lower. This identifies that the QRS only needs to reach this height in order to be detected which makes the pacemaker more sensitive.
Cardiovascular Section If a pulmonary artery catheter (Swan Ganz ) is in place, identify the catheter position as close to the insertion site into the introducer (AKA Cordis) Remember: A pulmonary artery catheter can still migrate into a spontaneous wedge position or recoil with the tip in the right ventricle without any change in the insertion point. Use the Pulmonary Artery and Flotrac Checklists to ensure all appropriate monitoring is performed A daily Chest Xray is required to rule out distal placement of the tip (which increases the risk for both pulmonary infarction and hemorrhage)
Cardiovascular Section IPC is intermittent pneumatic compression device (AKA SCD)
Reminder: Required Waveform A waveform must be posted to the chart upon admission, insertion and Q shift if the patient has a femoral, IJ or SC central venous line to reconfirm tip location/rule out arterial or interstitial locations (excludes PICC/HD lines). If a patient has both a femoral and IJ/SC central venous line, BOTH require waveform assessment If an arterial line is in place, post a waveform to the chart to confirm adequacy of waveform. One full page waveform can be printed to confirm ECG, arterial, central venous waveforms and ICP.
Reminder: Required Waveform Tick to indicate that waveform is posted and analysis included on printout. ICP can be printed simultaneously on the single printout (which is why it was included under CV section).
Understanding Full Page Printing When you print a full page of waveforms or review a screen shot, the order that the waves appear is defined by the Monitor MODE; you cannot change the order of either the printed or displayed waveforms unless you change the MODE. The MODE is displayed in the top right hand corner of the monitor CCTC Gen. shown here is the default
Understanding Full Page Printing When the mode is CCTC Gen. the waveforms that can be printed are as follows (printed in this order): Wave 1: ECG 1 Wave 2: P2 (regardless of the pressure being measured on P2) Wave 3 P1 (regardless of the pressure being measured on P1) Wave 4 ECG 2 Wave 5 P4 (regardless of the pressure being measured on P4)
Understanding Full Page Printing Normally, we use P2 for CVP, P1 for arterial line and P4 (is unused). Thus, a typical printout in CCTC Gen. is: ECG wave CVP wave (P2 content) Arterial wave (P1 content) ECG 2 Blank (P4 content) The order of printing is by pressure module, not wave. If P1 is used for CVP and P2 is used for the arterial line, the printout from CCTC Gen. mode will be: ECG wave Arterial wave (P2 content) CVP wave (P1 content) ECG 2 Blank (P4 content)
Understanding Full Page Printing Swan Ganz mode will display and print waves from P1, P2 and P4, but the printout order is changed to: Wave 1: ECG 1 Wave 2: P4 (regardless of the pressure being measured on P2) Wave 3 P1 (regardless of the pressure being measured on P1) Wave 4 ECG 2 Wave 5 P2 (regardless of the pressure being measured on P4) In the snapshot display, the 2 nd ECG position is moved to the bottom (display sequence is slightly different than printout)
Understanding Full Page Printing The Swan Ganz MODE should be used if you are putting in a Pulmonary Artery Catheter. By using this mode, other default settings are initiated to streamline insertion and monitoring. For example, use of the Swan Ganz MODE will also turn on the correct temperature modules for measuring both blood temperature from the pulmonary artery and the injectate temperature during cardiac ouptut measurement.
Temperature e digit fields are default settings in the Swan Ganz Mode Appears as soon as pressure is connected to P4.
Understanding Full Page Printing If you need > 2 pressure waveforms (e.g, a second central line or an ICP waveform) you need to obtain a P3 or P4 module If a P4 module is used P1, P2 and P4 will print in either CCTC Gen. or Swan Ganz Mode Waveforms measured using a P3 module will NOTE be displayed unless you change to CCTC Neuro Mode. Use the CCTC Neuro Mode will display and print ALL pressure modules (P1, P2, P3 and P4). Use this mode if you are using both a P3 and P4 module.
Understanding Full Page Printing How to Change Modes: Go to Admit/Discharge from the navigation bar. Choose Select Mode Choose the desired mode When you change modes, alarms settings will return to the defaults. All patient data is saved and can be retrieved in the new mode setting.
ECG and all waveforms (including ICP) can be printed on a single page. Use CCTC NEURO MODE if you use a P3 module (both P3 and P4 will print in this mode). P3 waves will NOT print in the CCTC Gen. or the Swan Ganz modes. Instruction on the use of Modes/Printing can be found from the CCTC Procedures menu under Monitor Modes
What Does a Normal ICP Waveform Look Like? Looks like an arterial waveform with an extra bump in between the peak and dicrotic notch. Three bumps labeled P1, P2 and P3. P2 and P3 are normally lower than the P1 pressure.
Normal ICP: Decreased Brain Compliance Note that P2 or P3 have become equal to or higher than P1. The entire waveform may merge together into one full figured bump. These subtle changes may demonstrate that brain is tight before the pressure rises significantly and offers an earlier warning.
Cardiovascular Section Describe any additional abnormal findings or patient specific plans/actions.
Cardiovascular Section Remember to initial page.
IV Solutions Section
IV Assessment Section R IJ Introducer R IJ Double lumen Brown White Blue L forehand #18 peripheral On left column, list all central and peripheral venous lines and lumens and include: 1. Side of body (L/R) 2. Insertion site 3. Type of catheter
Documentation Standards for IV Solutions R IJ Introducer R IJ Triple lumen: Brown White Blue L forehand #18 peripheral 0.9% Normal Saline CVP/0.9% normal saline Levophed TPN Saline Lock On right column, record ONLY the SOLUTION and MEDICATION ADDED. This documentation identifies where solutions are running. If you change either the site, solution or medication, you must make a DAR entry to indicate the change.
IV Solutions Section R IJ Introducer R IJ Triple lumen: Brown White Blue L forehand #18 peripheral 0.9% Normal Saline CVP/0.9 % normal saline Levophed TPN Saline Lock Include all central and peripheral access (including locked catheters) ONLY chart infusion solution and name of medication added Do not chart rate or concentration
IV Solutions Section R IJ Introducer R IJ Triple lumen: Brown White Blue L forehand #18 peripheral 0.9% Normal Saline CVP / 0.9% normal saline Levophed TPN Saline Lock *Remember this should be also updated on the kardex If you change sites for any medication, * and DAR (e.g., the norepinephrine is in the introducer at the start of the shift and you switch it to the white port at 1400 hrs)
Gastrointestinal Section Document abdominal assessment here.
Gastrointestinal Section Document bowel sounds. If bowel sounds are not heard, document not heard as this does not mean they are not present and is not alone a contraindication to feeding.
Gastrointestinal Section Remember to document bowel function. Unless contraindicated, check for impaction Q 3 Days and ensure bowel routine is initiated. NOTE: Bowel Routine is NOT PRN for patients with spinal cord injury. Patents must have bowel movement at least Q2 Days.
Gastrointestinal Section Document use of fecal management system.
Gastrointestinal Section Tick if bladder pressure is being monitored
Record diet. Gastrointestinal Section
Gastrointestinal Section Document feeding tube and identify location of feeding tube tip
Gastrointestinal Section Confirm if GI prophylaxis and prokinetic in use
Gastrointestinal Section Tick if care sets have been initiated for: Bowel Routine Insulin Protocol DKA Protocol
Gastrointestinal Section Document identification and assessment of GI ostomies.
Gastrointestinal Section All other GI tubes are documented here.
Gastrointestinal Section Use lines for abnormal findings or patient specific plans. Protocols and routine care standards do not need to be describe unless changes have been made.
Genitourinary Section
Genitourinary Section Document urinary drainage tubes, stents and/or ileal conduit (urinary diversion systems) here.
Genitourinary Section Document here if patient is voiding without the use of a tube.
Genitourinary Section Document urine volume. Blank line is to describe volume that is not WDL (e.g., < 0.5 ml/kg or high volume output)
Genitourinary Section Describe urine appearance here.
Genitourinary Section Document dialysis, dialysis type and catheter.
Genitourinary Section Document perineum assessment.
Genitourinary Section Tick if electrolyte protocol is in use. You do not need to narratively describe the orders or expected monitoring for this or other care sets once you identify they are in use.
Genitourinary Section Use blank spacing to describe abnormal findings or actions that are unique to this patient s care or response.
Obstetrical/Gynecological Pregnant Patients: Download Admission Guidelines and Checklist for Care of Pregnant Patient in CCTC Post Partum Patients: Download Checklist and Guidelines for Care of Post Partum Patients Educational reminders/instructions on how to perform post partum assessment are provided on website.
Obstetrical/Gynecological Rule out Pregnancy: All patient < 50 should have pregnancy rule out by pregnancy test (this is usually done in ED; should be sent in CCTC if it has not been obtained) If patient has had a hysterectomy or is immediately postpartum, the appropriate box to identify why pregnancy test is not required. *Spelling error post partem X2 will be corrected to post partum with next printing
Obstetrical/Gynecological If pregnant, document number of weeks and days This is described as 26 and 1 for 26 weeks and one day
Obstetrical/Gynecological Pregnant Patients: Confirm that admission/q shift checklist for a pregnant patient has been activated.
Obstetrical/Gynecological Describe fetal monitoring plan
Obstetrical/Gynecological For postpartum patients, identify date of birth and neonates information Status can be used to identify stillbirth, NICU, at home with maternal grandmother etc.
Obstetrical/Gynecological Tick to confirm activation of PostPartum Admission/Q Shift Checklists Instructions/educational reminders are included in these documents
Obstetrical/Gynecological Document feeding plan/mother s wishes regarding lactation and breast/nipple assessment
Obstetrical/Gynecological Document fundal height and tone
Obstetrical/Gynecological Use this code to record pad saturation * and DAR if more space is required and document in the AI nurses notes section
Integumentary Section Complete the Braden score each shift Circle the appropriate score for each of the 6 criteria to show calculation Record the final score out of 23
Integumentary Section Document the bed surface
Integumentary Section Describe wound care/skin care plan Use AI nurses notes if more room is required
Integumentary Section Use this area to show lines, tubes and wound locations
Integumentary Section Describe mobility plan Specifically identify goals (not just AAT ) For example, attempt weight bearing at bedside or up in chair with lift
Other Section Document resuscitation code
Other Section Identify precautions Negative Pressure has been added as an option If patient refuses consent, a blood transfusion refusal form must be completed and ALL options refused or accepted Ensure that Blood Transfusion Lab is notified and form is faxed
Other Section Verify correct armband Tick yes if on patient If unable to place on patient, explain why and identify where the armband is located
Other Section This section MUST be ticked if emotional support or assistance with ADLs is selected
AI-DAR Section Reassessment and narrative nurses notes section. D: data A: action R: response Remember the R!
AI-DAR Section Highlight in point form the plan of care following morning AND afternoon rounds. Review plan from previous shift before rounds to ensure intended actions have not been missed. If plan changes, document modifications. Be sure that documentation shows closure of the loop by summarizing plan outcome at the end of your shift.
AI-DAR Section NEW
AI-DAR Section Reminder to provide summary charting at least once per shift on use around comfort, delirium screening and wound care.
AI-DAR Section Reminder to provide summary charting at least once per shift on Patient Comfort. This should include weaning actions and response to weaning of medications. Plan for sedation is outlined in initial assessment. Minimum charting is an end of shift summary to describe patient comfort and response to treatment or weaning.
AI-DAR Section Reminder to provide summary charting at least once per shift on Delirium. This should include screening results, assessment for causes of delirium if present, treatment and response to treatment/weaning of medications. Include non-pharmacological actions. Assess QTc and EPS/NMS with initial assessment and PRN. Document abnormal findings here if present.
AI-DAR Section Document if risks change from initial assessment, bed changes, wound descriptions and any interventions to address/prevent skin issues. If no change from initial assessment and no wound care interventions, arrow over.
AI-DAR Section Reassess and add updated DAR or arrow over if unchanged from initial assessment Q 4 H and PRN for the following: 1. Neurological assessment 2. Respiratory Assessment 3. Cardiovascular assessment 4. GI assessment 5. GU assessment
AI-DAR Section DAR PRN when indication exists.