care for the procedure-bound patient - cape fear valley

Training & Development Department Transforming mind, body, and spirit through lifelong learning

Care for the Procedure-Bound Patient

Ruhama Bond, RN Education Coordinator Updated Oct 28 2013


Objective

Integrate principles of patient safety, patient self-determination, and informed consent in caring for a patient before, during and after an invasive procedure

• according to CFV policies/procedures • in simulated situations

4

National Patient Safety Goals Goal 1 - Patient identification Goal 7 –Healthcare-associated Infections

5

Never Events

• Object left in during surgery

• Surgical site infection • Manifestations of poor

blood sugar control • DVT, PE after surgery


Patient Rights

• Be informed of rights before treatment • Be given information in understandable

way • Refuse recording, photographing or

filming of care • Make decisions about development/

planning of his/her care


Patient Rights

• Have alternative to treatments discussed, including no treatment. Be informed of outcomes of treatment. Refuse care

• Make Advance Directives • Have pain assessed & managed in a

timely manner


Patient Responsibilities

• Provide a complete and accurate medical history to the extent possible.

• Ask MD/RN what he/she may expect for pain relief

• Report changes • Provide copy of Advance Directives


Policies Administrative Manual • Advance Directives • Consent • Critical Result/Values • Critical Tests • Correct Procedures/Surgical Site/Side Verification/Time Out • Do Not Resuscitate (DNR) Status including MOST FORM • Patient Rights and Responsibilities • Universal Protocol Nursing Manual • Post-Operative Care • Pre-Operative Care for Surgical Patients, Checklists and Skin

Prep Guideline


Who Does What Where?

• Physician’s Office • CFV Registration • Admission to Nursing Unit • Patient Relations?


Universal Protocol is key 1. Two patient identifiers

2. Correct site identification & marking

3. Time Out

Everyone, every time

Everyone – “motionless” prior to incision

Pre-op holding

Advance Directives Definitions

• Declaration of a Living Will – A written document that allows a patient to

give explicit instructions about medical treatment to be administered when the patient is terminally ill or permanently unconscious; also called an advanced directive



• Durable Power of Attorney for Health Care – Document that gives your designated

healthcare agent broad powers to make health care decisions including the power to give consent to a physician to initiate or stop any treatment to keep you alive




• Advance Instruction for Mental Health Treatment – Your health care agent will act accordingly

to how your health care agent believes you would act if you were making treatment decisions


Do Not Resuscitate

Physician: • Writes order on Doctor’s Order Sheet • Documents conversation with

patient/family in Progress Notes • Two RNs may take a telephone DNR

order. • Physician must sign the order in 24

hours


DNR/DNI Two licensed nurses verify: • Order – for DNR & to Rescind DNR • Purple armband with Pt identification • Purple dot on spine & front of chart

Transport – In-house – Out of facility

MOST


Do Not Resuscitate Revoked by the patient – their right! • Verification/documentation by 2

licensed nurses • Remove dots, armband • Notify MD, obtain clarifying order


Informed Consent

What must be included? – Specific procedure, including site – Risks of the procedure – Benefits of the procedure – Alternatives to the procedure including

risks & benefits of each So… who obtains it?

– MD, DPM, DO, DDS, PA, NP


Informed Consent

Who can give consent? – Patient – Health Care Durable Power of Attorney – Legal Guardian – Spouse (NC does not recognize Common

law marriages)


Informed Consent What if patient/designee does not speak

English? – Patient Relations has list of approved

Translators – Cyracom translators are available by

telephone 24/7

• Who witnesses the signature? • NURSES


Informed Consent

What does the RN/LPN do? – Clearly complete consent form – Verify understanding & signature – Re-verify if signed in MD/DO office – Notify MD/DO if patient/designee does not

seem to understand


Informed Consent

Other things to clarify: – Anesthesia – Blood Products – DNR status – Pictures, videotapes, observers – SSN

One consent per procedure

Time Out • Time out is completed before every

surgical procedure. • Everyone remains motionless. • One person verifies all boxes on the

time out sticker. Every box must be addressed.

• When completed place in the progress notes


TIME OUT TAKEN FOR � Bone Marrow � Lumbar Puncture � Chest Tube Insertion � Thoracentesis � Circumcision � Incision & Drainage � CVC Insertion � Other: ____________

� Consent Verified/Agreement on procedure � Correct patient identity � Correct position � NA � Site/Side marked � NA � Verification of correct tray, equipment, implants � Verified sterility of instruments/ tray

� Relevant Lab / x-rays available � Yes � No � NA

� Need to administer antibiotic/ irrigation fluid � NA � Safety precautions based on patient history/ medications in use � NA � Medications labeled and verified � NA

TIME OUT TAKEN BY Physician’s Name/ Licensed Independent Practitioner Staff Signature Date Time Patient’s Name DOB

• When • Who • How • Time Out

Sterile Indicators

• The following slides are examples of sterile indicators used at Cape Fear Valley Health System.

• When preparing for a procedure always check the date on pack if applicable and for sterility.



Preparation

How do we make sure the patient is ready for the procedure?

The Universal Checklist is your guide


Preparation When order is written * / Evening Before • Signed Consent* • H&P or consult by surgeon within 24 hr* • Note which tests are ordered* • Patient teaching* • IV access • Bath/shave/clip


Preparation Evening before • Results on chart • Full page of patient labels Morning of • Essential medications w/ sip of H2O

– Cardiac meds, antihypertensives – Pain medications – Give correction dose of Insulin


Preparation Just before • Vitals - includes SpO2, Accucheck • Void • Remove PCA/telemetry • Jewelry/hairpieces/teeth/fingernails • Current MAR-printed off MAK • Med Reconciliation Transfer Form • Antibiotics – send ‘em! • Site Marking in Pre-Op Holding • Time Out prior to incision


She’s Baaack!

• Meet her within 5 minutes • SBARR report • Review Post-op Orders • Assess with PACU RN • Reinforce Teaching with her &

Family/SO


Objectives

Patient Safety!! • Informed Consent • Advance Directives • Procedure Preparation