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Templates for Preceptors by 7whRxUKP

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									Table of Contents
Unit-Specific Information –
Introduction and Overview of Unit ..............................................................................................................46
     Unit Welcome Letter ....................................................................................................................... 46
       o Orientation Objectives ............................................................................................................ 47
       o Unit Orientation Guide (Week to Week) ................................................................................ 47
       o Unit Self-Learning Modules/Videos ...................................................................................... 48
             Tools for Planning Orientation Tasks and Schedule ....................................................................... 48
             General Orientation to Work Site………………………………………………………………….48
              o RN Orientation Timeline check sheet ..................................................................................... 53
              o RN Mentorship Orientation Calendar ...................................................................................... 55
              o RN Orientation Calendar ........................................................................................................ 56
              o RN Ongoing Competency Assessment Optional Preceptor/Orientee Teaching
                 Worksheet              ............................................................................................................. 57


Orientation to Unit Terms, Patient Care Diagnoses, and Equipment
Frequently Encountered....................................................................................................................................59
     Definitions of Unit Roles and Terms - ............................................................................................ 59
            Specialized Language & Terms for This Unit ................................................................................. 59
                  o Patient Diagnosis and Ortho/ Trauma Definitions ........................................................... 59
                     o      Diagram of Tubes and Drains ........................................................................................... 62
                     o      Definitions and Care of Tubes and Drains ........................................................................ 64


Physical Orientation to Unit Resources ...................................................................................................66
    Hunt & Find .................................................................................................................................... 66


Unit Culture .............................................................................................................................................................67
    Basic Expectations .......................................................................................................................... 67
           o Practice Expectations ........................................................................................................ 67
                     o      Performance Expectations ................................................................................................ 68
            Team Values & Principles............................................................................................................... 69
                 o Team Values ..................................................................................................................... 69


Roles and Responsibilities of Unit Staff ...................................................................................................70
    Contact Names/Numbers .............................................................................................................. 70
            Unit Shift Duties - ........................................................................................................................... 70
            Unit Meals/Breaks ........................................................................................................................... 74
            Shift Management .......................................................................................................................... 74
            Discharge Planner…………………………………………………………………………………..75
            Practice Reminders and Efficiency Tips ......................................................................................... 75
            Admission and Discharge Routines ................................................................................................ 76
            Pre- and Post-Procedure Care ......................................................................................................... 77
Scheduling Information .....................................................................................................................................78
    Unit Scheduling Process             ....................................................................................................... 78
          o RN Scheduling Guidelines - ............................................................................................ 78
                   o      Wage RN Staff - .............................................................................................................. 79
           Routinely Scheduled Meetings ........................................................................................................ 79


Unit Communication, Documentation, and Quality Monitoring ...................................................80
    Team Meeting ................................................................................................................................ 80
           Unit Daily Routines/ Reports ......................................................................................................... 80
           Guidelines for Giving Report ......................................................................................................... 81
                 o RN to RN Report - ........................................................................................................... 80
                   o      RN to RN Shift Report -                                                                                                         81
                   o      RN to PCA/LPN Report - ................................................................................................. 82
           Unit Worksheet / Worksheet Key ................................................................................................... 82
           Monitoring Standards ...................................................................................................................... 83
                o                          ............................................................................................................. 83
                o                        ............................................................................................................... 83
T E M P L A T E S   F O R   N U R S I N G




                                                                                           4
                                                                                            Chapter




Unit-Specific Information

Introduction and Overview of Unit
Welcome to the Orthopedics and Trauma unit 6 East! We are glad you are joining our team of patient care
providers. Our unit is a challenging and rewarding setting in which to work. We, the nursing staff, strive
to maintain a professional yet relaxed environment where patients, families, and staff feel comfortable and
supported.

A multi-disciplinary approach to care is essential to meet the complex needs of our patient population.
You will find the unit social worker, nutrition support nurse, clinical pharmacist, physicians, therapists,
joint coordinators, nurse practitioners and chaplains eager to assist you in meeting the needs of your
patients. Furthermore, we are proud of the teamwork demonstrated each day by our multi-disciplinary
team.

6 East is a 30-bed adult ortho/trauma unit, housing patients with:
     Traumatic injuries of the head, abdomen, chest, and skeletal fractures
     Total joint replacements and revisions
     Spine surgery
     Sports injuries
     Bone disease/ infection

The targeted length of your orientation period is based on your experience level, usually from 6 to 8
weeks. A schedule will be provided for you that will follow your preceptor’s schedule. Your orientation
goals will be mutually determined based upon your previous nursing experience and individual needs.
Your preceptor will be working closely with you, giving ongoing feedback. It is your responsibility to
communicate any concerns or problems to your preceptor in a timely manner.

As the unit Orientation Coordinator, Nancy Brammer, will be helping to plan and track your orientation,
along with Wanda Roszak, our administrative assistant. We will monitor your progress, and will be
available as a resource to you and your preceptor. Your preceptor will complete a written evaluation of
your progress at the midpoint and at the end of your formal orientation. As an adult learner, your input is
expected and needed throughout the entire orientation to ensure a meaningful, successful experience.




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This manual contains a list of the objectives to be met during orientation. An ongoing competency
assessment and evaluation (OCAE) form will need to be completed initially as a self-assessment tool, and
by the end of orientation as documentation of competency for the RN clinician position. This checklist, as
well as other mandatory competency and equipment checklists, and the orientation evaluation form, are to
be kept in your personnel file. Please bring this Orientation Manual with you each day so you and your
preceptor can maintain ongoing documentation. The OCAE form will be kept on the unit in a competency
notebook in the admin office.

We look forward to working with you and making your orientation a good learning experience!

6 EAST STAFF 

Orientation Objectives -
       Orientee will demonstrate the specialized nursing care of adult hip replacement patients.
       Orientee will demonstrate the specialized nursing care of adult knee replacement patients.
       Orientee will demonstrate the specialized nursing care of adult shoulder arthroplasty.
       Orientee will demonstrate the specialized nursing care of adult multi-trauma patients.
       Orientee will demonstrate specialized care of spine patients.
       Orientee will demonstrate the specialized care of orthopedic hand and foot surgery patients.
       Orientee will demonstrate the specialized care of closed head injured patients with mild to moderate
        head injuries.



Unit orientation guide

   Week 1      General Orientation
   Week 2      Scheduled patient care with your preceptor to complete hours required.
                        Day 1 with preceptor – observation
                        Day 2 with preceptor – care for 1-2 patients
   Week 3      With guidance from preceptor, care for 2-3 patients.
   Week 4      Continue to increase patent load with emphasis on learning experiences with as many
               different diagnoses as possible. Orientee to demonstrate an understanding of directing
               patient care utilizing the multidisciplinary approach, seeking appropriate consults, and actively
               providing patient and family teaching.
   Week 5      Care for at least 1 complex trauma patient or a patient with a complicated associated surgery.
               Gradually increase the number of patients to care for daily. Actively seek new learning
               opportunities.
   Week 6      Concentrate on organization and prioritization skills. By the end of this week, the Orientee
               should have the opportunity to care for a full patient load, under direct supervision of
               preceptor.
   Week 7      Follow night shift preceptor’s schedule
                        Night # 1 – Care for a partial patient load to familiarize to night shift routine.



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                        Night #2 & 3 – Gradually increase number of patients cared for.
    Week 8     Focus on organization and prioritization skills. Care for full patient load under direct
               supervision of night preceptor.

Note:
Day night rotators and FT night staff will complete 3 weeks each on day shift and night shift. Time will be set aside
for you to read modules, shadow members of the 6 East team, attend unit orientation class, spend time in O.R., etc.

6 EAST Nurses only to complete PCA’s and PCT’s only to complete PCA/PCT and RN to
complete PCT and RN only                        *=mandatory
   Aspen Collar Video*
   VAC CD
   Foot Pump/SCD Video
   Chest tube module
   Falls & Falls prevention CBL*
   Domestic violence awareness
   Dalteparin
   Moving patients safely
   CIWA CBL *
   Adult Acute care insulin infusion CBL *
   Hazardous drugs safe handling
   How to order a wound VAC
   Informed consent process
   Bathing and skin monitoring *
   Central line management CBL
   Hand off of care CBL *
   Medical emergency response team (CBL)*
   PCA pump:Baxter
   SCI part 1 and 2 (CBL)*
   Wound vacuum assisted closure (CBL)*
   Oxygen management: Adult acute care (CBL)
   Performing an accurate EKG (CBL)*
   Code 12:In hospital licensed health care providers (CBL) In-hospital PCA’s *
   Defibrillator for nurses and physicians (CBL)*
   Defibrillator for non-licensed*
   Stroke review: PCA/PCT
   Feeding pump (CBL)*
   CL insertion and thoracentesis in the adult
   Concussion management*
   Discharge considerations*
   Epidural infusion for analgesia*
   Principles of patient education
   QR track: Quality and Safety Event Reporting training
   IV insertion and infusion therapy*
   IV practice standards*
   IV Therapy practice improvement
   IV Pump-Alaris
   RN Delegation



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   Signs of abuse
   Specimen acceptance/ rejection criteria*
   Admin. of blood and blood components
   Designated agent: Nurse controlled analgesia
   Abuse or neglect
   Regulated Medical Waste
   Bowel management
   Clairvia
   Pain management for HCP

Yearly:

   Restraint retraining: RN staff-CBL
   Phillips defibrillator training-Class
   Restraint retraining: Non-RN HCP-CBL
   Whole blood glucose testing Accucheck-CBL and run controls in October
   Annual respiratory fit testing-Month of birthday-class
   Annual TB-Month of birthday-class

Preceptor Program-class

Tools for Planning Orientation Tasks and Schedule:

Name ____________________________ Assigned Preceptor________________________
Orientation Start Date__/__/__    Orientation End Date__/__/__

                               Part I. General Orientation to the Work Site

Activity                                                          At the completion of orientation
                                                                  Know:
Unit

Hunt and find list                                       Where the basic supplies are on
Work schedule                                            the unit.
   4-6 week                                              Contact-Salli Whitman-scheduler
   Daily
Request book                                             How to request time off
Vacation schedule
Personnel Roles:                                         General understanding of roles
      Nurse Director ( Jill Laird-Saunders, RN, MSN )
      Nurse Manager (Joel Anderson, RN, MSN)
      Administrative Assistant (Wanda Roszak)-(2-1782)
      Advanced Practice Nurse 2 (Laura Beech, RN, MSN, CCRN, CNS)-#6949
      Orthopedic Nurse Practitioner (Pat Marohn, RN, MSN, ACNP)-#2543
      Trauma Nurse Practitioner (Mary Deivert, RN, MSN, ACNP)-#3779


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       Joint Coordinators (Beth Joyce, RN-#6905 and Liz Gochenour, RN-#4799)
       Discharge Coordinator (Salli Whitman, RN)
       Health Unit coordinator (HUC)
       Patient Care Assistant (PCA)
       Storeroom clerk-#9383
       Dietary-#1521
       Physical Therapy-(Pete Simons-#6685, Tom Faisant-#4083)
       Occupational Therapy (Erica Umback-#6318)
       Social work (Jill Guiffre-#4313, )
       Pharmacist –
     Chaplain
Physician coverage
       Orthopedic Medical Director (Mark Abel, M.D.)           Call chain, who to call for
       Trauma Center Director (Jeff Young, M.D.)               different problems.
       Trauma Center Assistant Director (James Calland, M.D.)
       Orthopedic clinical faculty-
    1. THA-Dr.Brown, Dr. Saleh, Dr.Cui
    2. TKA-Dr. Saleh, Dr. Brown, Dr. Diduck, Dr. Kahler
    3. Orthopedic oncology- Dr. Foster
       Attending
       Fellows
       Resident (2nd and 3rd year)
       Intern (Resident 1st year)
       Pat Marohn (ACNP) for ortho-#2543
     Mary Deivert (ACNP) for trauma-#3779
Patient flow/ Worksheet and tools
       Daily assignment sheets                                Purpose and usage of basic tools
       Admissions sheet
       Daily Unit Forecast (DUF)
       Uncharted medications sheet
       Bed board
     Call bell and pager
Giving report on patients                                      Expectations for concise report
     What is important
     Using the patient profile
     Taping and time
     Update report to shift manager
Patient Information-Basics                                     Purpose and usage of basic
     Printouts (Patient list, Patient worksheet)              patient care tools
     Verbal orders
     Patient treatment plan(PTP)
           Printing a new PTP
  New orders
  Ordering equipment
  Initiating patient profile                               Tools for patient management
  Using “subgroups” to chart on patients                   and organization


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     Sending MIS-O-Grams


PYXIS
    Obtaining medication
    What is in PYXIS
    PYXIS problems-resolving, who to call- (2-3848)
    Printing a personal “Activity Report” to chart narcotics
Medications
    Using Micromedex                                         6 EAST Guidelines and practices
    Scheduling IV’s
    Replacing medications
    Policies on verifying medications
    IV meds, nurse vs. MD                                    IV medication reference
    Insulin
    Changing medication times
    Charting medications (2 hour standard)
          PRN medications
    Quality report-completing reports related to meds
Documentation                                                 Location and usage of key forms
    Adult screening tool for multidisciplinary care
    Clinical Data flow sheet
    Supplemental flow sheet
    Allergies
    Restraint flow sheet
    CIWA flow sheet
    PCA flow sheet
    Progress notes
Shift Manager Role
    RN and PCA assignments
    Discharge planning rounds
    Resource and support for staff
        Planning lunches, answering questions, etc.
    Collaborating with discharge planner
        Admissions, discharges, transfers
Communication and Leadership
    Staff Meetings
    Practice committee
    Professional development
    Annual competencies
    Annual performance appraisals
    Bulletin boards
    Quality Support Team
    PCA Meetings



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Observation experiences
     Physical Therapy (Peter Simons)
     Discharge coordinator (Salli Whitman, RN)
     HUC (Wanda Roszak)
     Respiratory Therapy Supervisor (Chad Gibbs)
     PACU/SAS (Tina Knicely)
     SW ( Jill Guiffre)
     OT (Erica Umback, Jennifer Misiura, Barb Nidiffer)
     Joint coordinators (Beth Joyce and Liz Gochenour)
Evaluation of staff in orientation                                    Evaluation and feedback
     Evaluation criteria
     Preceptor
Ortho Trauma core curriculum (TBA)                                    Offered Spring and Fall
BLS certification                                                    Successful completion
6 East/ Health system references
     Acute care procedure manual                                     Where they are, when to
     Health system policy manual                                      use
     Administrative policy operations manual
     Isolation manual
     Safety program manual
     6East resource manual
     6E Orthopedic resource book
Process improvement
     Practice, development and policy improvement                     Individual role and
     Meetings                                                         responsibility for practice
     Quality reports                                                  improvement
     Documentation audits (form)
     Blood administration audits-Deb Sukley
     Clinical pathways (trauma guidelines, hip fracture and total joint pathways)
6 East Initiatives
     Patient satisfaction                                         6East QI
     Arthroplasty quality project
     Link                                                        Responsibility to stay informed
     Mailbox inservices
     Staff meetings
     Email
     OSA Pilot
State performance evals
     Levels of achievement- 3
     Attendance policy
Performance factors
     Technical excellence
     Continuous improvement
     Decision making


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     Self management, teamwork and leadership
     Communication and interpersonal skills
     Customer service
Role of your supervisor
     Quarterly meetings
Clinical career ladder
     Behaviors
     Portfolios due
     Advancement
     Resources
     JCAHO accreditation survey responsibilities




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                                                             RN O RIENTATION
                                                                T IMELINE
 Employee___________________________ Preceptor _________________________ Orientation Start Date:________

 Home phone number____________________ Cell phone Number __________________ Call:____________
                FIRST STEPS:                                                   COLLECT FROM EMPLOYEE:

                                                    Copy of AHA/BLS Card
     Meet for lunch Monday
                                                    Printed Net Learning Transcript
     Preceptor assigned
                                                    POCT Skills checklist
     Schedule given
     Ch. 4 manual                                  RN Orientation Competency Assessment and Evaluation (OCAE) form
     Locker and mailbox (Wanda)                    Copy of TB Mask Fitting card and TB test and color blind Form (employee health)
     Unit orientation class



                                           FORMS THAT NEED OFFICE STAFF ATTENTION:
          Place RN Ongoing Competency Assessment Form (OCAF) in white binder with OCAE
          Copy of MRX competency
          Access to secured area (have manager sign and fax to 4-5596)
          Agreement – Have employee sign job description
                                                        EMPLOYEE TO COMPLETE:
                        Net Learning:                                                            Complete:
          Complete all pre-assigned modules                                Complete self-assessment on OCAE Form
          OC-enroll in the 6East CBL’s/Time to complete                    Equipment to review: (Orientation class)
          Shadow Physical therapy-1 hour                                   Phillips defibrillator (MRX)
          Shadow Occupational therapy-1 hour                               EKG machine
          Shadow Joint coordinator-8 hours                                 CPM machine (PT)
          Shadow Social worker-1 hour                                      Lumbar drain
          Shadow R.T.- 4 hours                                             Cryocuff
          Shadow HUC- 2 hours                                              Stryker drain/ autotransfuser
          SAS/PACU- 4 hours                                                Doppler
          Operating room- 4 hours                                          Stryker needle
                                                                            Chest tube
                                                                            Bladder scanner (6W)
                                                                            Suction/ Ambu bag (RT)
                                                                            OSA/Narcan mailbox inservice
                                                                            Central line dressing change


                    MIDPOINT EVALUATION                                                    END OF ORIENTATION
 Midpoint Evaluation Date: ____________                             End of orientation: Projected End date: ______ Actual End Date:
 ____ Review progress on RN OCAE Form                               _______
                                                                    ___ Employee Evaluation of Orientation
 ____ Re-programming of PCA pump demonstrated (must                 ___Completed RN OCAE Form (by 5th month, New grad by 9 month)
 include change in prescription, drug concentration, changing of
                                                                    ___ Mid & final evaluations done
 the drug)
                                                                    ___ Meeting with assigned Clin 3
                                                                    ___
                                                                    Portfolio due 5 months from hire date: __________
                                                                    (Except wage employees & Clin 1’s – 9 months)




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                                                      CLINICAL HISTORY:




         RESUSCITATION TRAINING:                             PERSONAL INFORMATION:
 _______ AHA/BLS Card Expires                                Address:
                                                             Social Security # (for parking, secured access & PYXIS):
                                                             Phone number:
                                                             Employee #:
                                                             Birthday:
                                                             Email address:

                                                       SHIFT HIRED INTO:
         Clin 2/ Wage: 6-8 weeks                             Clin 1: 3 months               PCA/PCT: 4-6 weeks
         Week 1: General orientation/ Unit class.
         Week 2: Charting, unit routines, meds.
         Week 3: Focused care of 1-2 patients.
         Week 4: Providing care for 3-4 patients.
         Weeks 6-8: 2-4 hours with RT, PT, HUC. Time to complete CBL’s, Full patient assignment with preceptor backup.
                                                    ORIENTATION SCHEDULE:




                                                      SPECIAL REQUESTS




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                                 UNIVERSITY         OF    VIRGINIA MEDICAL CENTER

                                     RN MENTORSHIP ORIENTATION CALENDAR
Orientee:                                                               Preceptor: _________________

Phone # : ______               Unit: _____          Hire Date: ________             Midpoint: _______ End Date: _____

  SUN             MON                   TUE                WED                       THU                        FRI             SAT
       ___
                                                                           0830-1200 MIS Training       0830-1200 MIS
                                                                           part 1                       Training, part 2
                       Patient    Care                                     1230-1400
                      Services    Orientation                              RN Mentorship program        Below
                                                                           




                                                                                                                                      Clinical Week 0
                                                                                                        1300-1700
                                                                                                         Complete Unit
                                                                                                             based
                                                                                                             Orientation Self
                                                                                                             Learning
                                                                                                             Modules and
                                                                                                             NetLearning
                                                                                                             Modules in 6E
                                                                                                             conference
                                                                                                             room See ***
                                                                                                             Below




                                                                                                                                      Week 1
                                                                                                                                      Week 2
                                                                                                                                      Week 3
                                                                                                                                      Week 4
                                                                                                                                      Week 5




To Contact Wanda Roszak, AA: dial 2-1782 or arrive at 6E Nurses Station and request to speak to Wanda
Nancy Brammer, 6East Orientation coordinator
Laura Beech 6 E Clinical Nurse Specialist 924-9356 or Cell phone: (434) 962-5241 (local) Pager 434-970-6949




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                          UNIVERSITY               OF    VIRGINIA MEDICAL CENTER

                                               RN ORIENTATION CALENDAR
Orientee:                                                             Preceptor: _________________

Phone #: ______           Unit: ____       Hire Date: ________            Midpoint: _______ End Date: _____


  SUN              MON                TUE                WED                       THU                           FRI              SAT
        ___
              08-1630            08-1700           0830-1700             0830-1200 MIS Training       0830-1200 MIS Training
                                                                                                      1300-1700
                       Patient   Care                                    1300-1500                    Contact Wanda (see
                      Services   Orientation                             Contact Wanda – see          instructions below) and




                                                                                                                                        Clinical Week 0
                                                                         instructions below to        Complete Unit based
                                                                         Finish Unit based &          Orientation Self Learning
              If wage:                                                   NetLearning Modules          Modules and NetLearning
              13-1700                                                    See *** Below                Modules in 6E conference
              Work on                                                    1500-1700                    room See *** Below
              NetLearning                                                Ortho Services Orientation
              modules                                                    Class 6 East Conference
                                                                         Room. Please Bring all
                                                                         Orientation Materials with
                                                                         you




                                                                                                                                        Week 1
                                                                                                                                        Week 2
                                                                                                                                        Week 3
                                                                                                                                        Week 4
                                                                                                                                        Week 5




To Contact Wanda Roszak: dial 2-1782 or arrive at 6E Nurses Station and request to speak to Wanda
Nancy Brammer 6E Orientation Coordinator
Laura Beech 6E Clinical Nurse Specialist: 924-9356 or Cell phone: (434) 962-5241 (local)




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                            6East ACUTE CARE RN
                        Ongoing Competency Assessment
                Optional Preceptor/Orientee Teaching Worksheet -
This guide is NOT part of the employee file. This is NOT a substitution for the Ongoing Competency
Assessment Form (OCAE). All Documentation must be on the OCAE form.

This guide is used to assist new & experienced preceptors in the development of the orientee. This guide
provides additional and more detailed information to assist the preceptor in teaching the orientee.
                                                                                                    CCS-PM
Demonstrates care of the patient with an Epidural catheter
Demonstrates care of the patient on an insulin infusion                                             CCS-PM
                                                                                                    http://hsc.virginia.edu/
Demonstrates care of the patient on CIWA
                                                                                                    detox/
Demonstrates care of the patient with Spinal cord injury (SCI)                                      CCS-PM
Demonstrates care of the patient with Chest tube                                                    CCS-PM
Demonstrates care of the patient s/p head injury                                                    CCS-PM
Demonstrates care of the patient with a Zassi- bowel management device                              MCPM
Demonstrates care of patient with Vacuum assisted closure device (VAC)                              CCS-PM
Demonstrates care of the patient with a C-collar                                                    CCS-PM
Demonstrates care of the patient with continuous passive motion device (CPM machine)                CCS-PM
                                                                                                    Clinical Engineering
Demonstrates care of the patient with foot pump machine
                                                                                                    website Users manual
Demonstrates care of the patient with uncleared spine                                               CCS-PM
Demonstrates care of the patient in traction                                                        CCS-PM
Demonstrates care of the patient with a Lumbar drain                                                CCS-PM
Demonstrates care of the patient with a cryocuff                                                    www.aircast.com
Demonstrates care of the patient with a Stryker drain autotransfuser                                www.stryker.com
Demonstrates care of the patient s/p Total joint arthroplasty                                       CCS-PM
Demonstrates care of the patient with an ostomy                                                     CCS-PM
Demonstrates care of the patient with wound drain                                                   CCS-PM




Ongoing Competency Assessment Form (template)
Optimal patient assignments:
     Total Knee arthroplasty
     Total Hip arthroplasty
     Multi-Trauma
     Infected hardware/ bone/ wound
     Spine surgery
     SCI
     TBI
     Post A-Gram
     Thoracentesis/ Chest tube insertion
     CHI



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         Chest Drainage:
       Verbalizes RN role in Chest Tube insertion
            o What supplies are needed
            o Setting up chest tube drainage system
       Manages a Chest Tube Drainage System (hemopneumothorax, pleural effusion, empyema,
        etc.)
         Set up new chest tube
         Assess for proper functioning
         Discuss appropriate troubleshooting techniques for malfunction
         Check for air leak
         Change system
           Measure and record drainage
           Demonstrates use of Equipment

       Maintains Epidural pump according to MD order and procedure.
         Assess sensory, motor deficits
         Record on Acute Pain Management flow sheet
         Assess function of pump and tubing
         Assess catheter site, and dressing

       Foot Pump/SCD
         Applies boots
         Troubleshoots alarms

        VAC
                   Preparation
                   Implementation
                   Documentation
        Zassi
              Preparation
              Insertion
              Daily maintenance
              Documentation
        S/P THA/TKA
             Preparation of equipment
             Implementation
             Special considerations
             Documentation
        CIWA
             Identify patient
             Evaluate risk of withdrawal
             Recognize alcohol withdrawal early
             Minimize withdrawal sequelae
             Individualize treatment per guideline

        Insulin Infusion
             Identify patient
             Initiate infusion per guideline (Per HO order)
             Follow insulin infusion protocol for acute care
             Identify hypo and hyper glycemia and treat per protocol
             Protocol for transport off-unit
             Conversion to subcutaneous
             Documentation




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        Spinal Cord Injury
             Identify types
             Assessment
             Systems management
             Complications
             Stabilization devices
             Special considerations
        CHI
             Assessment
             Special considerations
             Documentation
        Cervical collar
             Equipment and sizing
             Implementation
             Special considerations
             Pt teaching
             Documentation
        Spinal precautions
             Equipment
             Implementation
             Documentation
        Traction
             Types
             Equipment
             Implementation
             Special considerations
             Complications
             Documentation
        CPM Machine
             Set up
             Implementation
             Pt. teaching
             Documentation

        EKG machine
            Indications for use
            Application
            Implementation
            Documentation
                      
      Knee Cryocuff
              Application
              System maintenance
              Special considerations
Ostomies: Resource David Mercer, RN, Ostomy nurse consultant, PIC # 6168
Demonstrates Ostomy Care
        Changes bag
        Empties
        Administers medication
Properly position or move patient with fracture, limb amputation, or other musculoskeletal injury
       Overbed trapeze bar
       Balanced Traction
       Cast/Splint/Brace/Sling




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Drains:

         Manages patient with a Lumbar Drain (Becker)
                Assessment and monitoring
                System maintenance
                Special Considerations
                Complications
                Documentation
         Manages Stryker drain (empties, reinfusion procedure)
             o Assessment and monitoring
             o System maintenance
             o Blood reinfusion
             o Complications
             o Special considerations
         Manages JP, hemovac drains
             o Equipment
             o Implementation
             o Special considerations
             o Complications
             o Documentation

Medications:
    Demonstrates safe use of PCA pump
       Discusses commonly ordered ortho trauma meds and patient monitoring
           o DVT prophylaxis, ulcer prophylaxis, antibiotics, analgesics, anticoagulants, etc.
    Demonstrates Drug Specific programming using IV infusion pump
           o Locking mechanism for certain High Risk meds




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Orientation to Unit Terms, Patient Care Diagnoses, and
Equipment Frequently Encountered

Definitions of Unit Roles and Terms -
Shift Manager/Charge Nurse—Experienced Clin 2/3/4’s function in this role. The SM is responsible for
the coordination of the shift, shift assignments, and unit-based bed coordination. They need to be updated
on patient issues such as clinical changes or family issues. They also need to be notified if staff needs
assistance with their assignment. They are your immediate unit resource. Please let them know if you
have any questions. All carry a pager.

Discharge Coordinator—comprised of an experienced Clinician (Salli Whitman, Clin 3). This nurse
carries a pager for our area M-F 08-1600. The discharge coordinator coordinates discharge planning and
assists with a goal of SAFE D/C by noon.

Manager—Joel Anderson, RN- Follows up on quality and staff issues and generally oversees the
professional operation of the unit.

Administrative Assistant—Wanda Roszak- Supervises our HUC group and oversees the operational
systems for the unit.

Care Coordinators- Beth Joyce, RN, Clin 3 and Liz Gochenour, RN, clin3 follow Total Joint patients.

Nurse Practitioners- Pat Marohn, ACNP- Covers all Orthopedic surgery patients, assisting resident with
following patients, order entry, etc. and Mary Deivert, APN2-Covers long-term trauma patients to ensure
coordination of care from admission to discharge.

Clinical Nurse Specialist- Laura Beech, APN2- Serves, manages and supports internal and external
customers. Assists in quality performance and improvement, competency assessment, identifies and
addresses safety issues, identifies and addresses educational issues, assists with the professional
development of others, identifies and addresses system issues, evaluates effectiveness of care and applies
an action oriented approach to problem solve.



Specialized Language & Terms for This Unit -
Patient Diagnosis and Ortho/ Trauma Definitions

Orthopedic terms

    Total hip, knee and shoulder arthroplasty- Surgical removal of the joint replaced by an artificial one.
    DJD- Degenerative joint disease.
    Lumbar drain- A closed sterile system that allows the continuous drainage of CSF from the subarachnoid
    space.
    Radiculopathy- Pain as a result of nerve root compression. Cause can be narrowing, and impingement on a
    spinal nerve or from herniated nucleus pulposus (HNP), or spondylosis.




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    Myelopathy- Pain as a result of spinal cord compression, which can be caused by long standing progressive
    compression from spondylosis or ossification of the ligament or acute disc herniation.
    Herniated nucleus pulposus (HNP)- The intervertebral discs are herniated, bulging, and protruding.
    Spondylosis- Degenerative disc disease and the progressive changes that occur as a result.
    Spondylolisthesis- Slipping of the vertebrae. Commonly caused by degenerative changes related to chronic
    motion between two vertebrae that results in anterior subluxation.
    Spondylolysis- A defect in the pars interarticularis (bony region between the superior and inferior articulating
    processes of an individual vertebra.
    Spinal stenosis- Congenital or acquired narrowing of the spinal canal.
    Osteoporosis- Characterized by low bone mass and structural deterioration of bone tissue. Patients are more
    susceptible to fractures.
    Neoplastic spine disease- More than 95% is metastases from cancers of the breast, lung, prostate, myelomas or
    lymphomas. Spinal involvement can lead to vertebral collapse and instability, causing pain and potential
    neurologic compromise. Surgical spinal intervention may be indicated to treat tumor-induced neurologic
    compromise or fracture.
    Discectomy- Removal of disc to relieve pressure on the neural elements of the spinal cord. More commonly a
    fusion is performed utilizing graft material, with plate fixation to prevent disc collapse and kyphosis.
    Corpectomy-Removal of one or more of the vertebral bodies and the adjacent discs, thereby decompressing the
    spinal canal. Requires stabilization and a graft.
    Disc arthroplasty- Artificial disc. Preserves motion at the disc space, thus stimulating normal movement.
    Laminectomy-Removal of the vertebral lamina to decompress the spinal cord.
    Spine fusion- Surgical stabilization of the spine by fusing the vertebrae involved.
    WBAT-Weight bearing as tolerated.
    TTWB- Toe touch weight bearing.
    NWB- Non-weight bearing.
    CPM- Continuous Passive Motion.
    Hemiarthroplasty or Unicondular TKA- Partial joint replacement. (Dr. Diduck, Dr. Brown).

TRAUMA TERMS

    C – COLLAR - Neck support worn to protect the fractured cervical spine or ligament injury.
    CLOSED HEAD INJURY (CHI) - trauma patient that has sustained an impact to the head without an open
    injury. These patients experience confusion, combativeness, impulse behavior and restlessness. They and their
    families have special needs and must receive a lot of support. These patients typically require a private room
    where a calm atmosphere can be maintained. Along with the CHI, they usually have other injuries as well.
    TBI- Traumatic Brain Injury.
    EXTERNAL FIXATOR - Metal framework with pins that are inserted into broken bones to support the bones
    while they heal. The area around the pins needs to be cleaned every 8 hours.
    LOG ROLL - Process of rolling a patient that has a spinal fracture like a straight log to prevent further injury to
    the patient which could result in paralysis.
    MOTOR VEHICLE CRASH (MVC) - A trauma patient hospitalized for injuries sustained in a car accident.
    MULTI-TRAUMA - A trauma patient hospitalized for injuries sustained from any type of accident: MVA, fall,
    skiing etc.
    SPINAL FRACTURE - One or more of the patient’s spinal bones are fractured/cracked or broken. Sometimes
    this results in the patient being paralyzed.
    DVT-Deep venous Thrombosis.
    Myoglobinuria-Injured muscle tissue releases myoglobin, which enters the circulation and results in acute renal
    failure if untreated.



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    PE- Pulmonary embolism-
    Spine clearance- Required on all trauma patients before getting OOB.
    SIRS- Systemic Inflammatory response syndrome- Comprised of > than 2 of the following: Temp>38.3 C or <36
    C, WBC >12,000 or <4,000 or >10% bands, HR >90 bpm, RR >20 bpm, hyperglycemia >120mg/dl, altered
    LOC, lactate > 2mmol/L, decreased capillary refill.
    NSAIDS- Non-steroidal anti-inflammatory medications.
    Splenectomy- Surgical removal of the spleen. Requires vaccines w/in first 7 days.


GENERAL TERMS
    ABCESS - A pocket of fluid under the skin, near an organ, or in a body cavity (i.e. in the abdomen)
    CEREBRAL VASCULAR ACCIDENT (CVA) - Commonly known as a stroke. A blood clot somewhere in
    the body breaks free and travels through the bloodstream to the brain, causing damage to that area of the brain.
    LEVEL OF CONSCIOUSNESS (LOC) - Refers to the patient’s awareness of who he is, where he is, the date
    & time.
    RESTRAINTS - Devices that restrict the patient’s mobility to prevent the patient from hurting or injuring
    himself. Requires a doctor’s order.
    DOPPLER - A piece of equipment that will pick up a venous and arterial pulse.
    PULSE OXIMETER - A monitor to check the blood oxygen level in a patient. There is a probe that will fit on
    one of the digits




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Definitions and Care of Tubes & Drains
Tubes that drain the stomach
     GASTRIC TUBE (G tube) A tube that goes through the abdominal wall directly into the stomach
     draining gastric secretions.
           Can also be used for tube feeding.
           Drainage should be Green/yellow in appearance
           Immediately notify MD if drainage resembles coffee grounds or if the drainage contains
              blood

     NASOGASTRIC TUBE (NG Tube) a tube that is inserted through the nose into the stomach. It
     drains gastric/stomach secretions.
           Usually hooked up to wall suction: low constant (80-100 mmHg)
           Drainage should be green/yellow in appearance
           Notify MD if drainage resembles coffee grounds or if the drainage contains blood
           Can also be used for tube feeding

Feeding Tubes
        JEJUNUM TUBE (J tube) A tube that goes through the abdominal wall directly into the
        jejunum, usually used for tube feedings.

        DOBHOFF A small tube placed through the nose and into the stomach, duodenum, or jejunum.
        Used for tube feeding.

        PEG- A percutaneous endoscopic gastrostomy tube is a tube placed into the stomach through the
        abdominal wall and can be extended into the small bowel. Used for feeding and medication
        administration.

Urine Drains
        NEPHROSTOMY TUBE (Neph tube) A tube that is inserted into the flank and goes directly into
        the kidney. The urine is typically bloody. Notify MD if drainage is bright red blood.

        SUPRA PUBIC TUBE (SP) A tube that is inserted into the abdomen just above the pubic bone
        and goes directly into the bladder. Drainage can sometimes be bloody. Notify MD if drainage is
        bright red blood.

General Drains
        JACKSON PRATT DRAIN (JP) A drain that is located in the abdomen to drain fluid. At the end
        of the tube is an egg shaped bulb that is squeezed after it is emptied to provide suction. Right after
        surgery, drainage is bloody but gradually becomes straw-colored after several days. Notify MD for
        excess amounts bright red bloody drainage or change in drainage.

        CHEST TUBE (CT) Tube inserted between the ribs to drain fluid off the lungs. This tube is
        connected to a drainage chamber called a Pleural Vac. This chamber may be connected to wall
        suction. Fluid will be bloody.

        VON SONNENBERG DRAIN - Drain that resembles a JP drain but has a stopcock that allows the
        nurses to flush the tube. This drain is normally used to drain cysts or abscesses. Drainage is
        usually creamy looking and has a foul odor.



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        HEMOVAC DRAIN-A round drain with springs inside that must be compressed to establish
        proper suction.

        STRYKER DRAIN- Autotransfusion system that allows recovery of the patient’s own blood for
        reinfusion after a surgical procedure that involves substantial blood loss.


IV Tubes (give fluids into the veins)
        PERIPHERAL LINE - An IV placed in a small vein, placed by a nurse, located on the arm, hand,
        or feet.

        CENTRAL LINE - IV placed in a large vein, placed by a doctor, located on the upper chest or
        neck of the patient.

        PICC LINE - IV placed in the inner aspect of the upper arm. Placed by Special Procedures or IV
        Team Specialists. Used for long-term IV use in the hospital or home.

Pain Control
        PCA PUMP (Patient Controlled Analgesia) - This machine contains pain medication that goes
        directly into the patient's IV. The patient must push the button to get the prescribed dose of pain
        medication.

        EPIDURAL - A thin tube that is inserted through the back into the spine to provide pain control.
        A small pump gives a constant infusion of medicine through the thin tube. Sometimes patients
        have numbness or weakness in their legs. Be careful when getting them out of bed. It is best to
        have someone assist you in getting the patient out of bed.

        Peripheral Nerve Catheter- Used for post-op pain relief in orthopedic patients. Proposes better
        pain control and use of less narcotics.

        Cryocuff- Knee cold and compression dressing. Surrounds the knee with pressurized ice water.
        Helps control swelling, edema, hematoma, and pain.

        Total joint pain pathway- Pathway developed to minimize use of narcotics by providing pain
        control from pre to intra to postop setting. Also provides means for the patient to receive longer
        acting oral medications and scheduled analgesics, etc.




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Physical Orientation to Unit Resources
    Hunt & Find -
        Staff lounge and lockers                 Dressings and Supplies
        Conference rooms, offices, Day                 o   Dressing supplies (4X4’s,
           room                                             kling, kerlex)
        Copier                                         o Ostomy supplies
        Fax machine and number                         o Nasogastric tubes, Kangaroo
        Floor equipment                                    bags
                oCode cart                              o Foley catheters, drainage bags
                oDefibrillator                          o Specimen containers
                oEKG machine                            o Isolation supplies
                oDynamap                                o Thermometers, accucheck
                oDoppler                                    strips
                oStryker needle                         o Bedpans, urinals
                oBed scales                             o Covaderm and acticoat
                oO2 sat monitors                            dressings
                oDiligentTM minimal lift                o Linens
                 equipment                              o Respiratory supplies (tubing,
             o CPM Machine                                  masks, set up equipment)
             o Cryocuff                           Dirty utility room
             o Bladder scan (6W)                        o Linen bags
        Medications / Pyxis                            o CMC containers
             o Medication carts-Return box              o Dirty maxi-slide and blue tube
                 at bottom- Access code-6612                bag
             o Pyxis ( IV fluids, narcotic        Forms and Unit Resources
                 drawer key, PCA keys, tube             o Admission (Arm bands, Data
                 feeding, stock drugs and                   Base, Care plan, D/C planning
                 narcotics)                                 tool)
             o Pharmacy in                              o Discharge planning book.
             o Refrigerated meds /                      o Patient teaching supplies,
                 nonrefrigerated IV meds                    diabetes teaching materials.
        Safety equipment                               o Flowsheets
             o Fire extinguishers, fire safety          o Nutrition Room Service
                 route                                      Forms
             o Medical gas shut-off valves        Telephone numbers
        Clean Utility Room                             o Staff
             o Blood draw equipment               Manuals: procedure, fire, Infection
             o IV tubing, needles, connectors       Control, standards.
         Lift Equipment                           Care of valuables
                 Steady                           Emergency Exits
                 Encore                           Fire extinguishers & Fire Plan
                 Tempo                           Area for CPM machines & ace wraps
                 Maxi-slides                     Code for ortho room-135
                 Transfer tubes




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Unit Culture
Basic Expectations -
Practice Expectations -
In an effort to promote a professional, clean, safe, and organized work environment, the following practice
expectations are essential to this process.
Each employee will. . .
    Maintain professional demeanor with patients, families, and staff.
    Communicate to HUC and designated cover person when taking breaks.
    Notify HUC before taking the last storeroom item or last Xerox copy of a form.
    Generally keep all work and break areas free of empty cups/soda cans and utensils.
    Refrain from occupying work station area if at all possible and if using this space, answers phones
      and intercom.
    Use a bar code sticker or writes name and history number on form when adding care plans or other
      forms to patient charts.
    Notify desk person when making pages to desk phone.
    Limit the number of incoming and outgoing personal phone calls. (Staff will not be pulled from
      patient rooms for incoming calls, except in cases of emergency; if the staff member is not visible
      from the desk a message will be taken and the staff member’s work not interrupted.)

PCAs/PCTs and RNs will . . .
      PATIENT ROOMS:
       Restock bedside counter with supplies that the patient regularly needs (dressing materials, suction
        materials, etc.); judicious placement of supplies is essential.
       Keep bedside tables, counters, and anterooms clean and organized (discard used medicine cups, gauze
        wrappers, needle covers, etc.).
       Return unused linen to linen cart at the end of your shift. (Clean linen that has been on the bedside
        counter, chairs, etc. can not be returned to the linen cart.)
       Remove dirty linen and towels from rooms and bathrooms as soon as possible.
       Put basins and bath supplies away in bedside cabinet when through.
       Label all bedpans, urinals, hats, and drain cups in semiprivate rooms.
       Rinse urinals, bedpans, hats, drain cups thoroughly after use.
       Remove unused equipment from room and discontinue in MIS.
       Notify housekeeping if CMC boxes are full and/or replace.
       Notify housekeeping if hand washing materials are running low or empty.
       Make sure all patients have access to call bell, urinal, telephone and bedside table before you leave
        the room.
       Request that housekeeper take away full needle boxes and replace with empty ones.
       Use contaminated material boxes appropriately (i.e. do not discard uncontaminated materials in box).
       Leave all IVAC thermometers, oximeters, dynamaps, accuchecks, etc. in an alcove near the med carts
        (NOT in a patient’s room), so that they may be readily accessed by other staff members.



      ISOLATION ROOMS:
       Stock isolation anterooms with gowns, gloves, and masks at end of shift.

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          Discard paper gowns when leaving isolation room and make sure a large trash can is available for
           gown disposal outside of the room.
          Stock isolation rooms with stethoscope.
          After Discharge, remove O2 tubing, suction tubing and canisters
          Supplies left in the rooms of patients who have been on Airborne (AFB) or Airborne Contact (i.e.
           disseminated herpes zoster) or Droplet (flu precautions) DO NOT need to be discarded unless visibly
           soiled or the package contaminated in some way.
          Supplies left in the rooms of patients who have been on Contact or Contact Droplet DO need to be
           discarded.
Performance Expectations -
Every staff member is ultimately accountable for his/her own professional development. Through the process
of peer review and ongoing formal evaluation with clinical leadership,

Each staff member:
    Will provide colleagues with information regarding performance on a regular basis through the peer
       review process.
    Seeks feedback on a regular basis as shift manager or patient care provider.
    Receives peer review with an open mind to hearing others’ viewpoint.
    Offers feedback as constructive critique of behaviors, not personalities.
    Is responsible for own level of competence in delivering safe patient care.
    Completes organizational, service center, and population- specific competency modules on an annual
       or as-needed basis.
    Completes training and demonstrates competence in use of all patient care equipment.
    Records continuing education on ongoing competency assessment form.
    Is accountable for their knowledge and understanding of new information relevant to patient
       care and service center operations.
    Will demonstrate flexibility in achieving core scheduling hours.
    Will be held responsible for their use of unplanned PTO.

Registered Nursing Staff:
    Will meet institutional and service center documentation guidelines.
           o Patient data base completed.
           o Plan of care current.
           o Progress notes per standard.
           o Patient/family education documented.
           o Documentation audit completed per unit standard.
    Will demonstrate compliance with medication documentation policies.
    all orders charted against by end of shift
    all “Override” medications from PYXIS charted in MIS
    “Uncharted meds” printed, reviewed, and charted prior to leaving for shift.
    Narcotic inventory current. This is the responsibility of all licensed staff!




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Team Values and Principles -
Team Values

The following are care issues essential to providing quality patient care in an efficient, timely and professional
manner.
Patients will:
     Receive needed pain medication in a timely manner (< 15 minutes).
     Get out of bed/ambulate as often and as long as they need/desire.
     Have the opportunity to receive emotional support from the staff.
     Have their IV lines managed so that they remain patent with flow.
     Have their toileting needs met in a timely manner (<15 minutes).
     Have appropriate nourishment at the time they need/desire.
     Have coaching with pulmonary toilet per Incentive Spirometer order.
     Know who their caregivers are by name and responsibility.
     Have their call lights answered courteously and promptly and their needs/desires met promptly by
        whomever is available/capable.
     Be discharged in an organized, timely manner with their home care needs adequately planned.
     Have a clean, orderly room.
Other issues include...
     The use of Multidisciplinary Care will occur to ensure the best treatment for each patient.
     Patients will be informed about time of shift change/report-giving process.
     RNs will participate in daily multidisciplinary rounds while ensuring confidentiality and timely report-
        giving.
     RNs should anticipate pain medicine requests, especially prior to change of shift.
The stated guidelines have been compiled with input from a cross-section of patient care staff with the purpose
of:
     ensuring patient comfort, security, and safety;
     facilitating efficient and effective care delivery between shifts;
     conserving equipment and supplies to keep patient care costs low;
     Maintaining an organized tidy unit which runs smoothly for patients and staff;
     conserving energy in all forms; and
     Promoting an atmosphere of consideration for the needs of others.
Team Mission:
        Staff working on 6 East are devoted to serving the patient and their support system. Our work is
        focused on delivering excellent patient care in a team context. As team members, we each are
        responsible for all the patients on the unit. Every team member is important. All team members
        contribute to the positive working atmosphere of the unit and enable our team to be the best it can be.




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Roles and Responsibilities of Unit Staff
Contact names and numbers
      Richard Whitehill, M.D. Spine and joint
      Francis Shen, M.D. Spine/ General ortho
      Khaled Saleh, M.D. Adult reconstruction for hip, knee
      Mark Miller, M.D., Sports medicine, ortho
      Quanjun Cui, M.D., Ortho, joints
      David Kahler, M.D., Ortho trauma, sports medicine
      David Diduch, M.D., Sports medicine, ortho
      Abhinav Chhabra, M.D., Hand, Upper extremities
      Francisco Caycedo, M.D., Foot and Ankle
      Eric Carson, M.D., Trauma, sports/shoulders
      Thomas Brown, M.D., Hip and Knee reconstruction
      Vincent Arlet, M.D., Spinal deformity and trauma
      Mark Abel, M.D., Spine deformity and trauma
      William Foster, M.D. Orthopedic Pathology
      Joel Anderson, Manager 6East- 982-3146, pager # 3847
      Wanda Roszak, Administrative Assistant- 982-1782
      Erica Umback, Occupational therapist- #6318
      Jill Guiffre, Social work- #4313
      Salli Whitman, Discharge coordinator-
      Beth Joyce, Joint Coordinator- 3-6905
      Liz Gochenour, Joint coordinator #4799
      Mary Deivert, ACNP trauma service- #3779
      Pat Marohn, ACNP ortho service- #2543
      Stella Provost, Lead PT #4413
      Laura Beech, Clinical Nurse specialist, 6 East- 924-9356, Pager# 6949
      Pharmacist- #2440
      Storeroom clerk- #9383
      Trauma resident on call- #1450
      Orthopedic resident on call- #1206
      Acute pain service resident on call-#1593 regional #1656
      Continuum home health
      Catering associate- #1521
      Equipment room-2-0937
      Infection control nurse inpatient- #1243
      Prosthetics and orthotics- #4711
      Pharmacy- 4-5255
      Radiology-4-9400




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Unit Shift Duties -
DAY SHIFT RESPONSIBILITIES

Receive report from night shift via bedside rounds.

      Check your assignment and ask appropriate questions of night shift .If PCA is co-assigned to any of your
      patients, give updated, pertinent information regarding their care (i.e. inform them of patients who need to
      be fed, those having procedures, change in diet orders, level of mobility, etc.)
      Make general rounds on assigned patients (hourly checks). Don’t forget to introduce yourself. Observe:
                  general condition
                  oxygen/respirations
                  armband
                  IV site and fluids
                  Status of drains / chest tubes
                  Restraints
                  SCD’s
                  CPM
                  Cryocuff
                  PCA/epidural
                  Pain control
                  Trapeze
                  etc
         Review Patient Treatment Plan (PTP). (Meds, dressings, activity orders, diet, etc.)
         Obtain accucheck data and give ordered insulin.
         Complete pre-op checklists on charts of patients scheduled for O.R. or special procedures.
         RNs who are working 12 hours are to complete their physical assessment between the hours of 07:00
          to 11:00, whenever possible.
         Assure AM vital signs and weights are documented, report them to medical team if appropriate.
          Complete weights before breakfast if possible.
         Breakfast is served at 0830.
         Prepare patients for breakfast. Assure that patients in isolation rooms receive their trays. Feed and
          assist patients or ensure PCA are able to assist patients who are unable to do so.
         Order early lunch for patients who have returned from procedures for which they were NPO at
          breakfast.
         Medications may be given within an hour of their designated time on the PTP. Check appropriateness
          of schedule for medications requiring specific instructions (e.g. ac, pc, interactions with food, current
          vital signs, and upcoming procedures).


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        Complete physical assessments by 1000 or before patient leaves floor for procedure. Assure that all
         treatments, beds and baths are completed. Be sure all vital signs, treatments, changes in patients’
         conditions are documented on Clinical Data Flow Sheet. Ensure patient safety by monitoring use of
         side rails, bed position, and restraint flow sheet.
        Assist in planning appropriate care for discharge (nursing home transfer forms, home health
         evaluations, discharge instructions), contacting appropriate multidisciplinary team members (eg.
         physical therapy, social work).
        Perform accuchecks 30 minutes before lunch. Lunch is served at 1230.
         Schedule Patient controlled analgesia narcotic bags/ epidural bags (if not a floor stock) for bag change
     if running low.
        Obtain report from co-assigned PCA. Assure documentation of I & 0’s, changes in patients’ conditions
         on flow sheet, notifying medical team of any significant changes.
        Obtain lab values, report abnormal values to MDs. Assure all medications are charted (scheduled, now,
         PRN, Stat).
        Give 1500 meds.
        Document Restraint Flow Sheet through 1530.
Evening Shift Responsibilities

        Obtain assignment and do bedside reports, which begin at 15:00 for PCAs and 19:00 for nurses.
        Check your assignment and ask appropriate questions of day shift. (You may have care on some or all
         of your patients or a PCA may be co-assigned).
        If PCA is co-assigned to any of your patients, give updated, pertinent information regarding their care
         (i.e. inform them of patients who need to be fed, those having procedures, change in diet orders, level
         of mobility, etc.).
        Make general rounds on assigned patients (Hourly rounds). Don’t forget to introduce yourself. Observe
         general condition, oxygen, armband, IV site and fluids, status of drains/chest tubes, restraints and pain
         control.
        Fill out treatment sheet, referring to Patient Treatment Protocol to review care.
        Assess 1600 vital signs, report them to medical team if appropriate.
        Perform accuchecks 30 minutes before dinner and give appropriate medication.
        Assure patients are set up for dinner.
        Dinner is served at 1745.
        Assure that patients in isolation rooms receive their trays.
        Assure any new admits or patients returning from procedures for which they were NPO receive diets
         and trays if appropriate (diet orders may need to be changed).
        Medications may be given within an hour of their designated time on the PTP. Check appropriateness
         of schedule for medications requiring specific instructions (e.g. ac, pc, interactions with food, current
         vital signs, and upcoming procedures).
        Assess learning needs and provide teaching, documenting on patient education plan. Update home
         health referrals, nursing home transfer information as needed.


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        Perform hs accuchecks and give hs snacks to diabetics as ordered.
        Be sure all vital signs, treatments, changes in patients’ conditions are documented on Clinical Data
         Flow Sheet. Ensure patient safety by monitoring use of siderails, bed position, and restraint flow sheet.
        By 2200 obtain report from co-assigned PCA. Assure documentation of I & O’s, changes in patients’
         conditions on flow sheet, notifying medical team of any significant changes.
        Be sure I & O’s are totaled for 24 hour period.
        Obtain lab values. Assure all medications are charted (scheduled, now, PRN, Stat).
        Give 2300 medications.
        Document restraint flow sheet through 2330 for those individuals working 8 hour shifts.


Night Shift Responsibilities:

        Obtain assignment and receive bedside reports on assigned patients from evening shift nurse. (starts at
         2300).
        Check your assignment and ask appropriate questions of evening shift . (You may have care on some
         or all of your patients or a PCA may be co-assigned)
        If PCA is co-assigned to any of your patients, give updated, pertinent information regarding their care
         (i.e. inform them of patients who need to be fed, those having procedures, change in diet orders, level
         of mobility, etc.)
        Make general rounds on assigned patients (introducing yourself). Observe general condition, oxygen,
         armband, IV site and fluids, status of drains/chest tubes, restraints
        RNs who are working 12 hours are to complete their physical assessment between the hours of 19:00
         to 23:00, whenever possible.
        Assess 2400 vital signs; report them to medical team if appropriate.
        Remove water pitcher from all patients NPO for special procedures.
        Make night rounds on assigned patients every hour.
        Perform accuchecks as ordered and give appropriate medication or treatment.
        Perform treatments as ordered.
        Draw blood from central lines and PICCs if ordered, check all lab reminders (should print at 0400).
        Begin 0600 treatments at 0530. Make sure all patients are properly prepared for all special tests. Begin
         pre-op checklist as indicated for special procedures.
        Medications may be given within an hour of their designated time on the PTP. Check appropriateness
         of schedule for medications requiring specific instructions (e.g. current vital signs, upcoming
         procedures).
        Update home health referrals, nursing home transfer information as needed.
        Update patient profile in MIS when time permits. Complete any nursing orders in MIS that are out of
         date (i.e. old transfusion orders, old treatment orders, etc).
        Assure all treatments are completed as scheduled.



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        Assessments must be documented by each nurse caring for patient. Be sure all vital signs, treatments,
         changes in patients’ conditions are documented on Clinical Data Flow Sheet.
        Ensure patient safety by monitoring use of siderails, bed position, and restraint flow sheet.
        Obtain report from co-assigned PCA by 0500. Assure documentation of I & O’s, changes in patients’
         conditions on flow sheet, notifying medical team of any significant changes.
        Obtain lab values. Assure all medications are charted (scheduled, now. PRN, Stat).
        Perform A.M. accuchecks at prior to meal delivery.
        Give all other 0700 medications and chart.
        Document on restraint flow sheets through 0730.

Unit Meals/Breaks -
        Whoever is at a point to take a meal break first, RN covers RN and PCA covers PCA. Pagers are given to
         the staff covering. Seek out the other for a workload/clinical update prior to going on break.
         Documentation of coverage for meals and breaks should be on the nursing assignment sheet.

        Notify the HUC. ALL PATIENTS MUST HAVE RN COVERAGE AT ALL TIMES.

        The HUC or PCA/RN will then write in the following information on the assignment sheet in ink: name,
         time of break, and coverage.

         The person returning from break will notify the HUC of their return to the unit. Return time is to be
         indicated on the assignment sheet.



Shift Management -
“Shift Management” is the continuous process of assuring and assessing the appropriate use of resources to
provide for the effective delivery of quality patient-centered care. The role of the shift manager is extensive.
The shift manager must direct the flow of patients into and off the unit. They continually assess the acuity of
patients, with reference to the skill and experience level of staff, and make and readjust assignments
accordingly. The shift manager collects data regarding patient acuity, ADT’s, and staff mix. Key elements of
discharge planning and coordination of care are also the responsibility of the shift manager. The shift manager
plays a critical role in the smooth running of the unit. The non-negotiable tasks of shift management are
outlined below. These are the tangible elements of shift management that must be completed each shift. These
tools have emerged to enhance the ability of the shift manager to function effectively and with accuracy. The
shift manager is a clinical resource, efficiency promoter, and often cheerleader!

PATIENT UPDATE to the SHIFT MANAGER
Please plan to spend about 5 min during your shift to give the Shift Manager (Charge Nurse) a verbal update on
your patient’s progression towards discharge. Positive and negative progression is noted on the SM report
sheet. This information is shared at the Discharge Planning meetings and assists the SM in identifying staffing
needs for the next shift.

Information the Night shift RN’s need to give the SM during Patient update report: the patient’s post op day or
hospital day, a notation of pertinent tubes/drains, pain management, what is the most important issues for this
patient, # of family members with overnight passes and are they staying in the room, the expected plan for the
day, teaching needs, and # of patients in restraints and if order is current.

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Day Shift RN’s will need to provide the SM with pertinent patient clinical changes, patient travels/procedures
& results if known, and progress towards discharge.

The shift manager strives to obtain a verbal clinical update, rather than having other RN’s fill in information
for them. Obviously there will be times when that is unavoidable. The update from each RN is critical to the
shift manager’s ability to accurately assess the patient acuity and needs of the unit at large.

All staff are encouraged to use the shift management report form to identify issues with service delivery or
recognize system problems. The managers review these reports carefully and follow up with issues.

The night shift manager will start the unit worksheet for the new day. A patient list, printed from MIS, is the
template. Add rooms and patients with history # to the bottom of page so it is a one page tool. Above the
patient’s name their hospital day or post-op day with brief diagnosis should be written. Use a sharp pencil to
create the unit worksheet and it makes updates and changes easy to complete!

The shift manager, in conjunction with the primary RN, will critically assess nursing orders. For example:
does a POD 4 patient really need a bed weight or should they stand? Or does a patient ordered for routine vital
signs need them q4 because they have a PCA machine?

The activity, frequency of VS, diet, FS, wts, and special consideration should be written next to the patient’s
name using identified codes. This worksheet will be updated by each shift manager and RN to ensure the
accuracy of information. It works well to update the unit worksheet when getting clinical updates from RNs.

Discharge rounds are led by the shift manager/discharge coordinator. Each nurse is expected to come and
provide a brief report on their patients during discharge planning time which is M-F from 08:30 to 09:00. The
report given in discharge rounds is succinct and requires only a few minutes of the nurse’s time.

Discharge Planner
Goal of discharge planner is to increase support to the bedside care providers, and to promote positive
patient and family outcomes.

Discharge Planner:
     Is responsible for the continuous process of assuring and assessing the appropriate use of resources to
       provide assistance in discharging patients.
     Accountable for discharges, to promote the best flow of patients through the service center.
     Is a clinical resource, problem solver, or an extra pair of hands!

Practice Reminders and Efficiency Tips -
Patient Care & Preparation Tips:
     Tape all Foleys to prevent urethral tension.
     Begin room preparation for admissions/post-ops when time permits (suction gauge, IV pole, trapeze,
        IVAC pump, O2 setup, Cryocuff, etc.).
     Welcome patients to the unit as they arrive (orient the person to the room, point out room # and
        telephone #, and take initial set of vital signs. Be sure and instruct patient on call bell use immediately.)
        This is the responsibility of the first person into the room.




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Medications/Medication Carts:
   Remember to always use two identifiers before doing any patient care intervention.
   Reorder PRN medications when last dose is used.
   Order a new PCA bag when removing last one from Narcotic Drawer. This ensures that a new bag is
      available in the narcotic drawer for the next shift.
   Mention in report how much epidural fluid is left in the bag and the status of the next bag (a new bag
      will be placed in the narcotics drawer if less than 3 hours hanging in the bag and not stocked in
      PYXIS).
   A narcotic waste will be recorded on the appropriate narcotic form or in the PYXIS machine,
      depending on where the medication was originally removed. For example, if a PCA bag is taken from
      PYXIS then it should be wasted in PYXIS; if an epidural bag is taken out of the drawer it should be
      accounted for on the appropriate narcotic inventory sheet.
   PCA pump shift totals should be cleared every four hours when documenting volume infused and
      completing Pain Flow Sheet.

Patient Care/Courtesy:
     Remember to always use two identifiers before making any intervention.
     Date and change all tubing according to policy
     Change IV bags according to policy.
     Leave at least 3 hours’ worth of fluid in all IV bags at change of shift.
     Change and date PCA tubing every 72 hours
     Change and label TF bag every 24 hours. Remember, no greater than four hours’ worth of tube feeding
        up at a time. Leave at least 2 hours’ worth of tube feeding hanging at change of shift.
     Attempt to anticipate patient requests prior to giving report.
     Remove previous shifts PTP’s and orders when reviewing PTP’s at the start of each shift.
     Remove completed orders from PTP at end of shift.
     Write patient name, Hx Number, and room number on IV board when requesting IV restart for a
        patient.
     Change Central Line Dressings Q 7 days or if visibly soiled.

DISCHARGE TIPS:
    Promptly notify HUC when discharge has vacated the room.
    Bring D/C paperwork with door side chart to desk for breakdown.
    Complete Discharge Note, Care Plan, and Education Plan.

Admission and Discharge routines -
When you are notified by the charge nurse that you will be getting an admission, inform the PCA/LPN that you
are working with and assist in getting the room prepared for the admission. If the patient is coming from
PACU, ER, outside facility, Short Stay Unit, another unit, or a clinic, you will receive report on the patient.
When a patient arrives on the unit, the admitting team needs to be notified that the patient has arrived.
Admission orders will need to be put into the MIS system.

Discharge

If the patient is transferring to another facility (nursing home, hospital, correctional facility), you will need to
call report to that facility. Remember to include list of meds the patient is to continue to take at home after
discharge. Discharge summary to transferring facility.



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Discharge with home health: Discharge Considerations

    During Discharge Rounds, discuss and document estimated length of stay, identify specific discharge needs
     that require planning prior to discharge
    Patients can be discharged to:
          -Home with family/community support
          -Home with a referral to home health with nursing and therapy support
          -Facility that assumes responsibility (Nursing Home, HealthSouth, Assisted Living, Outside Hospital)
    When reviewing discharge instructions, consider what you would want to know if you were assuming care
     of the patient after discharge.
    Social Worker on Unit helps with discharge needs & community resources
    UVA Continuum Liaison helps with home health and home infusion needs (924-9083)
    Goal for discharges –discharged by noon

Day before Discharge
 MD should enter preliminary discharge orders and tests for discharge
 MD should dictate discharge summary for anticipated Nursing Home/Rehab discharges
 Confirm discharge date/time/plan with patient and team
 If patient going home on IV Meds, finalize dose.
 Preliminary orders “prepare patient for discharge” entered

Morning of Discharge
 When first on duty, review discharge orders for patients being discharged and confirm plan with MD
 By 0900- All discharge orders and medication scripts are entered
 Patients with preliminary orders “prepare patient for discharge” entered from the previous day must have
   “discharge today” or “revise discharge order” entered in MIS
 If patient with DNR order, must have completed a Durable DNR form

Share the Plan—Smooth Discharges are a Team Effort

Pre- & Post- Procedure Care -
Pre-op’ing a patient may begin on admission, but is the responsibility of the nurse receiving the pre-op orders
to begin preparing the patient for surgery.
The responsibility of the evening nurse includes:
      All necessary pre-op teaching has been given to both the patient and family (see pre-op teaching
         check list and make sure you document)
      All orders on the PTP have been carried out (i.e. ordering SCD’s, beginning IV therapy, etc)
      It is the MD’s responsibility to consent the patient

The responsibility of the night nurse includes:
      Making sure the patient has had a bath and operative area has been prepped if needed.
      Completing the pre-op checklist in front of the chart (which includes making sure pre-op meds are
         given or taped to the chart and vital signs have been taken and recorded).

A night nurse is not required to wake a patient up if that patient is not scheduled until later that day, but these
responsibilities should be carried out, especially if the patient is the first or second case. If, however, for some
reason the night nurse is unable to carry out the above duties, he/she should pass it on in the morning report so
that the day nurse is aware and can respond accordingly.


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                                6 East Orthopedics / Trauma
                                 RN Self-Staffing Guidelines
                  6 week schedule (divided into three 2 week sections)

                  80 hours every two weeks for fulltime employees or relative hours based on percent of
                   employment ( .9 = 72 hours, etc)

                  At least 80 hours need to be off shift hours (off shift = 1500-0700) every 6 weeks.
                   When additional off-shift hours are required, these hours will be equally distributed
                   among all rotating staff members.

                  Weekend rotation will continue to be every third weekend 12 hour shifts. Switches
                   may be made among staff members. Additional weekend shifts will be picked up
                   evenly among the staff in order to provide adequate staffing numbers for every shift.

                  Each staff member may request 3 days off per schedule (not PTO, just requested days
                   off). A special effort will be made to accommodate these requests on the final
                   schedule.

                  Vacation and scheduled sick leave PTO requests should be placed in the time and
                   attendance book. The dates requested as well as the date the request is made should be
                   included.

                  No more than 2 RNs may take PTO at any one time. Requests will be honored in the
                   order they were noted in the time and attendance book. (If three requests are made for
                   the same time period, the requests of the first two RNs will be granted).


TIPS

              Remember to not request too many Monday/Friday shifts as days off.

              Fill in your off-shift hours first.

              Be sure to turn in your schedule by the date posted on the unit.


              Date written            11/01                     ________________________
              Revised                 11/05                     Madeline Jones RN, BSN, MBA
                                                                PCSM



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WAGE RN STAFF, 6 East Unit-Based –
Unit-Based Wage Scheduling Guidelines
Greetings and thank you for continuing to choose 6 East as your practice area! As our staffing needs and
resources evolve we continue to evaluate how we are managing our most precious resources. To that end there
are four objectives for continued development of our scheduling and management guidelines for our local wage
pool staff.
    1. Keep minimum consistency with wage guidelines (cancellation, unscheduled leave, etc)
    2. Keep our overall scheduling process as streamlined and time efficient for the scheduler as possible to
         keep scheduler management time minimized.
    3. Promote predictable, reliable scheduled hours.
    4. Assure that holiday coverage with a shrinking classified staff pool is safe, fair, and satisfying to all our
         staff.

Scheduling process: all wage staff will submit a schedule by the due date.
As we are utilizing our wage staff very much like core staff, we apply the same attendance policy to wage as
classified staff. This is also in line with what other units are doing. The threshold is 5 occurrences in 6 mos or
7/year. Wage staff who hit this ceiling will not be allowed to submit pre-scheduled hours for 30 days as the
consequence for this level of issue.

     1.    We must evolve our holiday coverage system to assure that holidays can be covered more predictably
          with our full range of RN staff. Holiday guidelines for pool require 1 major and 1 minor and 1 family
          holiday per year. Wage staff are to sign up on a year-long master grid for their preferred holiday
          commitment to allow our scheduler to plan ahead for total coverage of the unit. A defined number of
          wage slots on each holiday are available for staff to sign up into. Like our regular staff, you must sign
          up for a 12 hour shift. The grid will be posted August 1st and the process repeated each year in August.

     2. Weekend scheduling coverage: Wage staff is required to work a minimum of 24 weekend hours per
        month. Each wage RN (except for those working predominantly weekend hours) will be assigned a
        weekend ‘color’ similar to what we do with regular RN staff. When you are signing up for weekend
        hours you should sign up on your assigned weekend color (see posted wage weekend list). If you
        cannot do this, communicate by a note on your grid to the scheduler.

Thank you, and as ever, your work here is appreciated!

Routinely Scheduled Meetings -
Participating on unit-based Committees:
         Education committee
         Practice committee
         Quality Support Team/Committee
         Leadership
         PCA Meeting
         Staff meeting




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Unit Communication, Documentation, and
Quality Monitoring
Unit Daily Routines/Reports -
RN to RN Report: 6East RN staff report nurse to nurse via bedside rounding. All RN staff is encouraged to
clarify specifics of care completed and yet to be delivered as needed during these sessions. Please make every
effort to be timely in giving and receiving report so that shift change moves quickly.

Report to PCA: RN staff is expected to communicate with the assigned PCA for each of their patients to
clarify delegation of care specifics for the shift. Additionally, as care needs/plan changes through the shift
RN’s are expected to keep the PCA informed of pertinent details. PCA’s begin their shift using the unit
worksheet to take vital signs and visit patients in their assignment while RN’s are in report.

RN to Physician Report: Call the physician if there is a change in the patient's status or if you have questions
about an order. Many physician teams welcome nurses to listen in on their rounds of the patients.

Charge Sheets: Charge sheets are located in a notebook in the middle of the nurses’ station. Charges need to
be recorded for supplies used during the 12 hour day shift and the 12 hour night shift. Please take time to
record these charges on all of your patients prior to leaving for your shift.

Staff Injury Report: All Staff (full time, part time, and wage) that suspect a personal injury related to
performing their job must fill out an “Accident Report for Workers Compensation Claim” form and report the
injury to the Shift Manager, Team Manager, or to the PCSM.

Narcotic: Narcotics in PYXIS are counted three times per week. (Monday- day shift, Wednesday – evening
shift, and Friday – night shift). Narcotics in drawer must be counted q shift prior to any licensed staff leaving at
the end of their shift. Any discrepancies must be resolved or documented at time they are found.

Stock Drug: Found in PYXIS: indicated by (flstk) proceeding medication order on PTP.
IV fluids and tube feedings are stocked in PYXIS.

Uncharted Medications: At the end of the shift, Each RN is responsible for their list of uncharted scheduled
and now/Stat medications for their shift. Each RN is responsible for charting all uncharted meds before leaving
the unit




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GUIDELINES FOR GIVING REPORT
RN to RN Shift Report –
The best report will give the nurse following you all the VITAL information which that nurse needs to provide
excellent care. The shift report is not the place to make personal judgments about a patient’s behaviors or
attitudes. By using derogatory terms regarding our patients we prejudice the nurse following us towards that
patient and erode our own level of professionalism.

                            SO KEEP IT BRIEF, MAKE IT FLOW, GIVE US THE FACTS!!!!

     1. Patient name and room number
     2. Why are they here and what did they have done and the date (surgery/procedure, significant medical or
        surgical history)
     3. Vital signs ONLY if significantly different from baseline or if there is a trend we should be aware of
        i.e. steadily increasing temp or a BP increase that has not been controlled – what meds have you given
        for these problems – Tylenol? metoprolol? How much? When?
     4. What fluids are running and what is the rate?
     5. What tubes does the patient have? What is the quantity, quality or character of the drainage? Has it
        changed over your shift (i.e. purulent drainage, Hemoccult positive drainage or decreased urine
        output)?
     6. System assessment information only if significant – decreasing LOC and increasing SOB are
        significant. Breath sounds and bowel sounds if not normal.
     7. What PRN meds have you given and when?
     1. What blood products or boluses have been given or are expected to be given during the next shift –
        what are the lab values? HCT? K?
     2. Is the patient pre-op or pre-procedure? What has been done to prepare this patient? What still needs to
        be done?
     3. What does the patient incision/dressing look like? Does it need to be changed? Are there any
        precautions?
     4. Are any orders pending that have not been charted in the computer? If so, who is going to enter them?
        Is the medication here yet?
     5. What meds have not been given and what treatments have not been instituted?
     6. What is the status of teaching that has been done or planned?
     7. Are there any patient/family concerns?

Example report: 70B – patient X is a 31 yo, POD #1 Left TKA. VSS. Neurovascular check intact. D51/2 NS
@ 75/hr into left peripheral line- patent. Patient has Foley draining QS, and an NG tube to LCS, scant green
drainage, Heme negative. Patient medicated with 4 mg Morphine IV push for pain at 8/10. Patient medicated
with 12.5 mg phenergan IV push at 1430 for nausea.. Abdomen is soft and non-distended, no flatus. NPO for
now. Patient pain at 1500 4/10 and no longer nauseated. Cryocuff and SCD’s on. Patient incision is open with
dry dressing. Crit stable at 35. Plan: PT/OT to see, advance CPM, Cryocuff, IS, discharge planning for POD#3
to home with HH.




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RN to PCA/LPN Report –

          The PCAs/LPN’s will begin the work of the day immediately following patient assignments. It is
           expected that you will help with unmet patient care needs from the previous shift, and help handle
           immediate patient care needs. Invest a few minutes in reviewing your unit worksheet.
          A workload negotiation (delegation) and clinical update (report) will occur between the RN/PCA and
           RN/LPN no later than 1.5 hours into the shift. Both the RN and PCA/LPN should seek to accomplish
           this.
          A sign off report between RNs and PCAs, and the Shift Manager and HUC, should be obtained at the
           end of the shift identifying work to be completed, pertinent clinical data, and status of patient flow as
           relevant to each role.

UNIT WORKSHEET KEY AND SAMPLE WORKSHEET-
GENERAL                I & O = Intake and Output                              POD = Post-op Day
                       HD = Hospital Day                                      UOP = urine output
                       FS or Accu √ = fingerstick                             HOH = Hard of hearing
                         D/C = discharge                                         BW = bed weight
                         Wt = weight                                             CT = Chest Tube
                         OR = Going to Operating room                            Ⓘ = Isolation Room
                          LOC = Decreased level of Consciousness/awareness
                         Restraints = restrictive devices being used on the patient
                         CIWA = Scale used to monitor and treat Drug Withdrawal
                         Guaiac = testing stool for blood

ACTIVITY:              OOB = out of bed                                    TTWB-toe touch weight bearing
                       WBAT-Weight bearing as tolerated                    BRP = Bathroom Privileges
                       NWB-Non-weight bearing                              Flat Bedrest

DIETS                  NPO = nothing by mouth                              CL = clear liquids
                       FL = full liquids                                   ADA = Diabetic diet
                       Reg = regular diet                                  Renal = renal diet
                        Cal Cts = Calorie counts                             TF = Tube feedings running
                        ♥ = Heart Healthy Diet                               Mech = Mechanically Altered/Soft


VITAL SIGNS            Q4 = 0 0 , 0 4 , 0 8 , 1 2 , 1 6 , 2 0
                       Q8 = 0 0 , 0 8 , 1 6
(Q = every)
                       O2 Sat = oxygen saturation



Monitoring Standards (6 E)
VITAL SIGNS
 Q Shift and Routine (00-08-16)
 Q 4 hours (00-04-08-12-16-20)
 Record all vital signs on Clinical Data Flow Sheet
 Complete within 12 hours of previous assessment

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ASSESSMENTS
 Full System Assessment completed by each new RN assigned to patient (minimum q 12 h)

WEIGHTS
 RN is responsible for assuring that both standing and bed weights are performed and documented.

SAFE (Staff against Falls Everywhere) Program:
 We are running this program to decrease the patient falls on our units.
 Please make sure that you review this with your preceptor and review the information sheets in our
doorside charts.
 SAFE Category Low Falls Risk, Moderate Falls Risk, and High Falls risk is recorded with each
assessment.
 Hourly monitoring required for Moderate Risk and half-hour monitoring required for High Risk patients.
Monitoring noted on front of the Clinical Data Flow Sheet.

ACCUCHECKS
 Routine (30 min AC, HS, and 0300)
 Insulin drips (q 1-2 hours)
 JCAHO requires that the pt’s whole Hx #, and the user’s Employee ID# (or you can scan your badge bar
code) be entered each time.
 Refer to your orientation manual for tips and use your SM as a resource.

Lumbar drains:
 Please pay particular attention to the drains on your spine patients. Many of these require special care and
monitoring.

Salem Sumps
 Can be inserted by RN’s and LPN’s. Verify placement with you before the use of the Salem Sump.
 Nurses on 6E are not to insert Dobhoff or Keofeed tubes. MDs will insert these and must get abdominal x-
ray to verify placement before use.

PCA Pump Programming and Monitoring
 We have a high volume of these on our units. This is considered a high risk / high use patient equipment.
Please ensure that you are comfortable using and checking these machines. Refer to the yellow pocket card
given to you in General Orientation.
 Pump programming and loaded medication bag concentration is compared to PTP q8 hours.
 PCA initiation, Pump Dose, and Medication Changes must be verified and co-signed by another RN.
 When bolusing from PCA remember to stay with the med until the bolus is in and press start to restart
previous PCA settings.

IVAC Pumps
 IVAC pumps with Insulin, Heparin drips are placed on panel lock and can only be cleared by RN.
Medications checked by 2 RN’s-Insulin, heparin drips and PCA pumps.

PYXIS
 PYXIS Override Medications need to be charted in MIS. Please check your overrides prior to completing
your shift.




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Patient Prep Tips
Pre-procedure check list, consent. Hand off of care
Bowel Prep:
 Endoscopy procedure: Administer bowel prep per order. When giving Golytely, administer complete
dose until patient bowel movements are clear. If patient is not progressing or if BM’s are not clear at the end
of ordered dose notify MD. NPO 6-8 hours. Checklist. Consent. HOC.
 Pre-op: Ensure type and screen. NPO after MN. Antibiotics on call to O.R. Consent for procedure. Consent
for blood transfusion. Hand off of care. INR <1.5, Plt >100, no aspirin for 7 days. No Coumadin for 3 days.
 MRI: Screening sheet
 CT scan: Drainage procedure- NPO 4 hours. IV. Consent. Checklist. HOC.

Med. cart codes:             6E 6612

Bedside Report:
 0700, 1500, & 2300
 0710-0730, 1510-1530, 2310-2330 Nurse to Nurse report
 Nurse to PCA report by 0800, 1600, 0000

PTP’s & Unit Pagers:
 At the beginning of the shift, print PTP’s on all your assigned patients and sign out a unit pager. Please keep
pager on vibrate mode and return it at the end of your shift.

Shift Manager:
 Plan to give SM patient update and acuity numbers sometime during your shift.
 Please see the SM for any questions if you are unfamiliar with anything (i.e. PCA pumps, chest tubes,
trachs).

Tips:
 Frequently check your assigned mail slot at the desk for new medical orders.
 RNs on 6E take verbal orders only in emergent situations
 At the end of every shift:
      Check MIS for your Now/ Stat and Scheduled uncharted meds
      Check PYXIS for override medications.
      Chart them before you leave.

Total Joint Replacement:
   - Ensure Trapeze on bed- Have to call clin. Engineering (4-2391) and give pt. weight.
   - CPM machine for knees
   - SCD’s on non-op knee, Bil. Legs on THA.
   - IS Q 1 hour while awake
   - INR and anticoagulant teaching for patient. (Document)
   - Pain protocol- q1hour pain scores.
   - Cryocuff for TKA/ ice for THA
   - Blood conservation system protocol
   - Hip precautions teaching
   - PT/ OT consults




Reviewed/Updated 8/2010


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