JCI Nursing Chow Tze Hwa February 15, 2016
What every nurse needs to know to get ready Know your patient, care plan, discharge plan, guideline, pathway. IPSG 1 RRT Fall risk Nutritional referral and adequate intake- check patient intake, know how to answer Rehabilitation/functional need Pain, assess and reassess if given medication Post operative/procedure plan of care- vital sign frequency the same
continued Pressure ulcer care Isolation procedure Educate care giver, family member IPSG 5 wash hands PPE Name tag LASA, high risk medications, high concentration Patient being sedated must be recovered before discharged
continued Controlled substance log book, since January Document every medication given include enema Do not let family member be responsible for decubitus care, administer medication unless under your supervision. Double check at bedside with another nurse and against patient arm bang and MAR How to find physician privileges Quality data, unit specific, and service/department specific IPSG 2: SBAR, verbal orders, critical values VAP, central line, bladder bundle, and surgical bundle
continued Restraint as the last resort, must release for movement every 2 hours Oral care, hygiene, deep breath and cough, Activities, try to get patient out of bed unless order not to Who can shut off oxygen Fire extinguishers, next means of egress Social service referral DNR, hospice, palliative care Do not push medications more than 5 cc, slowly. Do not leave medications are the bedside Do not touch the inner syringe Do not use single dose medications as multiple dose. IV should not be unhooked, should have a different line.
Last minute check every day Clean uniform, wear name badge, cut your nails, hair up. Keep patient door closed, unit free of flyers and announcement, posters etc. Post quality data in conference room to show surveyor using statistical graph Check for any outdated supplies include lab tubes Nothing on the floor in the patient s room Do not leave medication cart unattended, clean all carts Know your patients- fall risk, restraint, DNR, diabetic, going home, total census number Must document nursing assignment, try to maintain same nurse Clean out patient refrigerator, public refrigerator, make sure food are dated Keep medication refrigerator clean and date all medications
How to answer questions Look at surveyor, do not look down, do not look at the interrupter or look at your head nurse If you don t know the answer do not make up answers Only answer the questions, if not ask why do not answer why, if it is a leading questions most likely it is a yes answer. Let the surveyor finish talking before answer or interrupt. If did not ask to see any thing in writing do not go get it. Need to know how to read medical equipment check tag Ask for permission to clarify, do not attempt to answer or try to answer for others Make sure patient bedside is clean and free of clutter
Definite sites will be visited Dental, dialysis, top 5 surgical and medical units, operating room, neuro ICU, surgical ICU, CCU, OB, psychiatric, nuclear medicine, radiation, clinic, pediatric, radiology, laboratory, blood transfusion, pharmacy, TB isolation room, cardiac cath, and GI procedure rooms.
What every physician should know Pre-procedure/surgical note- purpose make sure patient condition did not change from your prior assessment. Brief post procedure notes must be written prior leaving the procedure area, include complications, blood loss, specimen sent, pre procedure diagnosis, post procedure diagnosis, actual procedure, implant number, who performed and any assistance, date and time of responsible procedure. Implant care instruction provided to the patient/family Lidocaine given as local should be documenting amount and %
continue Must read what your resident has written, try to write legibly, date and time all your written comments Treatment plan, must consider when other specialist is needed and read their notes, such as dietician, social worker, rehabilitation therapist, and nursing Order must have clear diet and activities for all patients Remember not written not done, must see patient daily and document Focus on the patient, talk medical, don t go into anything else such as Taiwan health regulation or Taiwan accreditation Know you quality data, why you collect them, and what you do with it. Listen more let the surveyor talk, don t interrupt them such as we have it, we know.
continue wait till the question is finished before answer. They like to teach so let them, ask them any suggestions and how they do it in their country or what is the best way to comply without a lot of extra work. Look at the surveyor when answer questions, watch your body language IPSG 4 time out, IPSG 5 handwashing, IPSG 2 SBAR, verbal orders, critical values Order diagnostic test should document rationale All inpatient should order diet and activities Current medication list obtain on admission Sedation must assess patient first
Do not keep other patient information at separate location, patient medical record or recording of patient information should be kept in the medical records. If did not ask to see documents don t show it All irrigation, medication on the sterile field should be labeled.