1. Garden Park Medical Center Nursing Orientation Program
Presented by the Education Department
Nursing Orientation

2. Objectives – All Nursing Service
Philosophy of Nursing
Hourly Rounding
Vital Signs and MEWS
Supplies
Communication
Infection Prevention
Intake & Output
Oxygen Safety
Fall Prevention
Ulcer Prevention

3. Objectives - Nurses Code Blue/Crash Cart Skin Assessment
Pain Management
IV Therapy Policy
Medication Management –see handouts

4. Philosophy of Nursing
It is our belief that the purpose of Nursing is based on an adaptation of the models of Dorothy Orem (" to help people to meet their self-care needs") and Sister Callista Roy ("to promote a person's adaptation").

5. Hourly Rounding Safety Rounds Fall Risk Rounds
Patient Rounds are performed HOURLY on days
Every two hours on nights
Document in Meditech
Fall Risk Rounds

6. Vital Signs and I & O
Meditech Screens
MEWS

7. Modified Early Warning Score (MEWS)
An Introduction
Developed by M. Lynn, MSN BSN RN / Education Coordinator 2/2012; Revised 6/2012

8. MEWS Policy
MEWS physiologic parameters include systolic blood pressure (SBP), heart rate (HR) in beats per minute, respiratory rate (RR) in breaths per minute, temperature (T) and neurologic status.
Using weighted criteria, the parameters are assigned a numerical rating and transferred into an aggregate score. A total score of ≥ 5 may be associated with an increased risk of clinical deterioration.
MEWS scores will be included as part of the routine vital signs monitoring.
Licensed and unlicensed caregivers will perform MEWS monitoring and documentation activities every 4 hours.
MEWS scores are calculated in Meditech at the time of documentation.
MEWS scores of ≥ 5 will be reviewed by licensed staff;
Notification of the score may occur via phone, pager, status board or computer generated report.
 MEWS scoring criteria requiring patient assessment for Clinical Deterioration by licensed staff include:
A score that has increased by 2 points since the last set of vital signs
A score that is 5 or greater

9. Modified Early Warning Score (MEWS)
Transforms physiological data and using weighted criteria, determines an aggregate score that may be used to categorize clinical deterioration and direct care.
The score will be determined electronically and displayed on each patient’s status board.
In 2001, Subbe et al. validated a Modified Early Warning Score (MEWS) that demonstrated a significant relationship between the score and transfers to the ICU or death. The score is comprised of five measures:
1.   Blood pressure
2.   Heart rate
3.   Temperature
4.   Respiratory rate
5.   Level of Consciousness  (AVPU)

10. Why use MEWS?
MEWS is a monitoring aid to clinical judgment, a marker of critical illness, and an indicator of physiologic trends.
It is intended to trigger critical thinking and assessment prior to making care decisions.

11. VITAL SIGNS + LOC = MEWS SCORE!
MEWS Scoring system uses Vital Signs and Level of Consciousness
Vital Signs:
Systolic blood pressure
Heart rate in beats per minute
Respiratory rate in breaths per minute
O2 Sat
Temperature
Level of Consciousness
Neurologic status (Alert; or reacts to Voice; Pain; or is Unresponsive)

12. LOC = Scoring the AVPU ALERT = SCORE OF ZERO (0).
The patient is awake and fully responsive, can answer your questions, can see what you are doing.
REACTING TO VOICE = SCORE OF ONE (1).
The patient responds to your voice, but may be drowsy, keeps his eyes closed and may not speak coherently.
*NOTIFY and collaborate with nurse
REACTING TO PAIN = SCORE OF TWO (2).
The patient is not alert and does not respond to your voice, but a painful stimulus (such as shaking shoulders or pinching ear lobe, elicits a response.
*NOTIFY nurse immediately
UNRESPONSIVE = SCORE OF THREE (3).
The patient is unresponsive to any of the above.
*CNA or Patient Care Tech Actions

13. MEWS SCORING MEWS SCORE Vital Signs 3 2 1
COMPONENTS
MEWS SCORE
Vital Signs 3 2 1
Systolic Blood Pressure (mmHg)
<70
71-80
81-100
≥200
Pulse Rate (HR) (bpm)
<40
41-50
51-100
≥130
Respiratory rate (bpm)
<9
9-14
15-20
21-29
≥30
Temperature (0C)
<35
≥38.5
LOC
Alert
Voice
Pain
Un-responsive
AVPU score

14. How to MEWS
MEWS score is obtained upon completing the Vital Signs + LOC
Record Temperature, Blood Pressure, Pulse Rate, Respiratory Rate, SpO2, and LOC – AVPU
The MEWS score will automatically be calculated
Notify a higher level care provider if MEWS score is greater than 5 or develops a 2 point change from previous recorded measure

15. MEWS score also Automatically Updates to the Status Board
No MEWS score = MEWS Vital Sign Data missing!

16. What to do with the Score?
Techs or CNAs: LOC or AVPU of V (1) notify nurse and collaborate; score P (2) or U (3) notify nurse IMMEDIATELY
Nurses: A MEWS score may trigger a Rapid Response Team (RRT) consultation if the score has increased by 2 points since the last set of vital signs or if the score is five (5) or greater for the first time.
Anticipated benefits derived from utilizing the MEWS scores include timely response to changing patients’ conditions, decreased resuscitation events and decreased patient mortalities.

17. LICENSED CARE PROVIDER
Reassess patients with MEWS score greater than 5 or with a 2 point change from previous recorded measure
Activate RRT
Notify physician as indicated

18. Cards on capsules and badge
reminders

19. Calculation of Modified Early Warning Score System (MEWS) Parameters
Components
Score 3 2 1
Systolic Blood Pressure (SBP) (mmHg)
< 70
71-80
81-100
≥ 200
Pulse Rate (HR) (bpm)
< 40
41-50
51-100
≥ 130
Respiratory rate (RR) (bpm)
< 9
9-14
15-20
21-29
≥ 30
Temperature
< 950F F
≥ F
Neurological Status (LOC)
AVPU score
Alert
Reacts to Voice
Reacts to Pain
Un-respon-sive
Symbols: ≥ equal to or greater than > greater than < less than 0F degrees Fahrenheit
LOC Level of consciousness (notify nurse for V, notify immediately for P or U)

20. BE SURE CAPSULE STAYS PLUGGED IN!!
Capsule Instructions
Scan ID badge
Enter your Network Password
Tap the Sign In button
Tap the Set Up button to begin
Tap the Patients button to see the patient list in your unit
Scan the Patient’s Arm Band
Tap Confirm if you have the right patient
Attach BP cuff, Pulse Ox & take vitals with blood pressure machine
Take Temperature
Tap the Get Vitals to get the vital signs to the screen Touch the Modifier for each Vital sign
Tap Temp and type in and tap how temperature was taken
Tap the Resp to get clock and count respirations; type in
Tap More to get to second screen for LOC and O2 Mod
Review the Vitals on the screen
Tap Edit to make corrections
Tap Send Vitals if all vitals are correct
It will show: Vitals Submitted
BE SURE CAPSULE STAYS PLUGGED IN!!
MEWS score increase by 2 points or initial score of ≥ 5 may trigger RRT or call to next level of care provider

21. Supply chain – PAR Levels
Be sure to charge items appropriately
Maintains PAR levels
Color-Coded Bins

22. Supply Chain Organization
What’s up with the BINS?
Supply Chain Organization

23. Respiratory (Warehouse)
Respiratory supplies
These items are charged out per patient

24. NON-stock Items Lead nurse/charge nurse must reorder these supplies
Will not be “automatically” replaced! Watch your par level!

25. Warehouse Items EXAMPLE: Sleeves for the ice machine
These items are not “charged” to the patient but are part of a “procedure”
SCANNING is a MUST for Restocking purposes!
Scan to the Patient if it is a single item
Scan to Floor Stock if is a box item
EXAMPLE: Sleeves for the ice machine
Scan the entire sleeve to the floor
Place entire sleeve near the ice machine
All items in the blue bins MUST be SCANNED

26. Communication SBAR- (Hand-off) Occurs at change of shift report
Transfer of patient from one level of care to another
Don’t forget MED REC!
Transfer patient from one department to another
Breaks where primary caregiver relinquishes patient to another caregiver
Transfer of patient from one facility to another facility

27. Communication Shift Report
All personnel of the on-coming shift are to report for duty by 6:45 a.m. or 6:45 p.m.
Verbal report
Nursing assistants answer lights, telephones, etc. On – coming nursing assistants take vital signs, fill ice pitchers, etc. during report time.

28. Communication Critical Values
All test results reported by phone require a write-down, read-back process
Critical test results shall be called from the testing department to qualified/licensed individuals only.
ALL INITIAL critical test results (when not addressed by a standing protocol) will be called to the physician or physician agent
Notification takes place within 30 minutes from the time the test result is received.

29. Infection Prevention Standard Precautions
Gloves
Gown
Mask/eye protection
Transmission based precautions
Particulate mask
Surgical mask
Table
Is (should) my patient (be) in Isolation? Check Status board

30. Diet and Intake and Output
MUST be documented on all patients!
Important part of Pressure Ulcer Prevention!
Handout
Nutrition EMAR
Nutrition flowsheet in Meditech

31. DON’T FORGET NUTRITION!
Use the Nutrition Flowsheet in Meditech to document meals
Remember Nutrition “EMAR”
If patient eats ≤75% of meals, order nutrition supplement and consult the Registered Dietician (MD order not needed)
Refer to Nutrition Formulary
Nutrition Care Manual on GP Web (look under Wound Care for high Protein diet sheet)

32. Nutrition Flowsheet

33. Bariatric Patients - Diets

34. Alerts FNS patient is Bariatric

35. Nutrition EMAR!

36. Nutrition Care Manual on GP Web

37. Click the Client Ed. Tab

38. Scroll and find topic

40. Oxygen Safety

42. Garden Park Medical Center
NPSG Patient Falls
Use Fall Risk assessment in MediTech
If meets 2 or more criteria-place on fall alert program
Communicate fall alert in hand-off report
Nursing Orientation

43. Fall Prevention and Injury Reduction Matrix
(Assumes Universal Falls Prevention Implemented) +
RISK OF
FALL _
+ RISK FALL/-- RISK INJURY
Implement fall reduction interventions
Assess, intervene and communicate if injury risk changes
+ RISK FALL/+ RISK INJURY
Implement fall reduction interventions
Implement injury prevention interventions
Assess, intervene and communicate if fall risk or injury risk changes
--RISK FALL/--RISK INJURY
Assess, intervene and communicate if fall risk or injury risk changes
--RISK FALL/+RISK OF INJURY
Implement injury prevention interventions
Assess, intervene and communicate if fall risk changes
- RISK OF INJURY FROM A FALL +

44. Arm band; yellow socks; patient teaching

45. MediTech Documentation: Focused Pt Rounds
AKA: Fall Prevention Rounds

46. Prevent pressure ulcers!
Turn Q2
Float Heels
4-P’s Rounding hourly on days; Q2 on nights
Pad bony prominences
Use turn clock

47. Pad Bony prominences

49. Nursing Assistants/Secretaries/Techs are excused
Nursing-Specific

50. Garden Park Medical Center
CODE BLUE REVIEW
Nursing Orientation

51. CALL THE CODE Press the Code Blue Button in the room or department OR
Dial 7777

52. INITIATE HIGH QUALITY CPR
BLS / CAB
Circulation
Airway
Breathing

53. CODE CART Bring the Code Cart into the patient’s room/department
Attach patient to defibrillator’s cardiac monitor and assess the rhythm

54. GET READY!

55. Always wear gloves and any other appropriate PPE Don’t forget the back board! Ensure the patient has at least patent, large bore IV Set up for wall suction Prepare for intubation using the Respiratory Roll (drawer 3)

56. DOCUMENT

57. Skin Assessment and Wound Care
Skin assessment is done
On admission
Every shift
As needed
Wounds/ulcers/injury should be photographed
Skin Care Products to prevent skin break down are available
Document Location, Size , Description and color

58. Braden Pressure Ulcer Risk Assessment
Sensory Perception ability to respond meaningfully to pressure-related discomfort
1. Completely Limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR limited ability to feel pain over most of body surface.
2. Very Limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body.
3. Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
4. No Impairment: Responds to verbal commands, has no sensory deficit which would limit ability to feel or voice pain or discomfort.
Moisture degree to which skin is exposed to moisture
1. Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
2. Very Moist: Skin is often, but not always, moist. Linen must be changed at least once a shift.
3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day.
4. Rarely Moist: Skin is usually dry, linen only requires changing at routine intervals.
Activity degree of physical activity
1. Bedfast: Confined to bed.
2. Chairfast: Ability to walk severely limited or non-existent. Cannot bear weight and/or must be assisted into chair or wheelchair.
3. Walks Occasionally: Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.
4. Walks Frequently: Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.
Mobility ability to change and control body position
1. Completely Immobile: Does not make even slight changes in body or extremity position without assistance.
2. Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
3. Slightly Limited: Makes frequent though slight changes in body or extremity position independently.
4. No Limitations: Makes major and frequent changes in position without assistance.
Nutrition usual food intake pattern
1. Very Poor: Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR is NPO and/or maintained on clear liquids or IV's for more than 5 days.
2. Probably Inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding.
3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered. OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.
4. Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
Friction and Shear
1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation lead to almost constant friction.
2. Potential Problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.
3. No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.

59. Skin Prevention Guidelines – based on Braden Scale
Low Risk
15-18
Moderate Risk
13-14
High Risk
12 or Less
Assess skin daily for redness and evidence of pressure damage
Visualize from head to toe.
Keep skin clean and dry
Moisturize dry skin; avoid between toes
Use pads; if diapers are used avoid taping while in bed
Use protective barriers for incontinence
Use self-adherent foam to protect sacral area
Use Protective Border Dressing
Minimize Pressure
Encourage increased mobility and activity
Protect heels by elevating bilateral lower extremity on pillow placed under calves with heels floating free or use heel protection device
Encourage patient turning and repositioning every two hours
Turn and reposition patient every two hours
Use turn clock.
Do not turn onto a body surface that is still reddened from previous episode of pressure loading.
Position using pillows while the patient is in bed
Assess/Manage friction and shear
Decrease friction and shear
Use lift pads
Use Trapeze bar
Use mechanical lifts as needed.
Elevate head of bed only as necessary for meals, treatments and medical necessity
Do not massage reddened areas
Avoid use of donuts, water filled gloves, cut outs and synthetic sheep skin
Support Surfaces
See Support Surface Guidelines
Use GPMC’s standard therapeutic Air Therapy Beds
Consult Dietitian
Monitor dietary intake
Encourage fluids unless contraindicated
Encourage supplements if ordered
Encourage PO intake
Consider intake of high calorie, high protein supplement

60. Pain Management Policy Highlights
The patient’s self report is the single most reliable indicator of the existence and intensity of pain
Patient ranks his/her pain on appropriate Scale
Discuss previous experiences and helpful interventions
Ask the patient how he/she feels.
Patient should describe pain to include location, intensity, duration and how pain affects activities of daily living.

61. Pain Types
Acute pain - is the sudden onset of pain due to injury, surgery, or medical illness. Acute pain is short-term and usually resolves in a few days.
Chronic pain - is that pain that exists beyond an expected timeframe for healing, typically for six months or more.

62. Pain Scale on the 1-10 ruler
Mild Pain – falls in the range of 1-3 on the pain ruler.
Moderate Pain – falls in the range of 4-5 on the pain ruler.
Intense Pain – falls in the range of 6-7 on the pain ruler.
Severe Pain – falls in the range of 8-10 on the pain ruler.

63. Wong & Baker
Use for children older than 3 years or cognitively impaired

64. Neonatal Infant Pain Scale (NIPS)
Behavioral scale utilized with both full-term and pre-term infants.
Composed of six (6) indicators:
facial expression
cry
breathing patterns
arms
legs
state of arousal

65. Documentation Initial pain screening on Nursing Admission Assessment
Pain assessment is required (AT LEAST) once each shift
Patient/family education
Reassessment of pain and effectiveness of intervention, treatment or medication within an hour using appropriate pain scale

66. IV Therapy Policy
MS BON R&R
LPN v LPN II
Policy highlights
IV Access

67. Scope All Registered Nurses (RN)
IV Certified Licensed Practical Nurses (LPNs) are limited to the stipulations contained in the Mississippi State Board of Nursing Rules and Regulations.
LPNs (non-IV certified) may not initiate or manipulate peripheral intravenous therapy but are able to assist the RN in the care of the patient by “observing, recording and reporting to the appropriate person the signs and symptoms which may be indicative of change in the patient's condition.”1
Radiology Technician/Nuclear Medicine Technicians – are limited to the administration of parenteral intravenous radiographic contrast media and/or nuclear medicine markers as applicable (after obtaining appropriate informed consent as applicable).

68. Initiation of peripheral IV therapy
Peripheral intravenous therapy will be initiated by appropriately prepared staff within the scope outlined above.
No more than two attempts for IV access per nurse and no more than four attempts at IV access per patient before contacting the MD to initiate IV Access Protocol.

69. Site Selection
Adult - non-dominant arm or hand: cephalic and basilic veins in the lower arm and the veins in the dorsum of the hand
Leg and foot veins should not be used without a specific order from the physician due
Antecubital veins can be used if no other venous access is available.
Pediatric - the most distal site possible, and avoid placing the I.V. line in the child's dominant arm or in areas of flexion if possible. Avoid previously used or sclerotic veins.
Infant - a scalp vein

70. Site Selection
Selection of a venipuncture device and site depends on the type of solution to be used; frequency and duration of infusion; patency and location of accessible veins; the patient's age, size, and condition; and, when possible, the patient's preference.
Refer to Policy.

71. Venous Access Flowchart

72. Site Assessment
During I.V. therapy, the nurse must continually assess the patient and the infusion to prevent fluid overload and other complications.
Adult – at least every four hours or as warranted by the intravenous fluid infusing
Pediatric/Infant – at least hourly

73. IV SAFETY
Utilize I-TRACE at any point when the manipulating, maintaining, accessing or discontinuing an intravenous line
Label High-Alert Intravenous fluid at the y-sites. Labels should be adhered to line or tubing at the time of insertion to avoid mislabeling
(Refer to Medication Management policy)

74. Infection Prevention Practice
Start IV’s using IV start kit & chlorascrub prep
“SCRUB the HUB” – utilize a friction motion with chlorascrub pad prior to accessing ports
Saline lock hub
Central line ports
Tubing ports

75. Infection Prevention Practice
Use a transparent dressing over the hub, then tape over the dressing to secure the cannula. Step by step instructions here.

76. Infection Prevention, cont’d
Table 1- Frequency of IV cannula, tubing, solutions and dressing changes
IV device used for
Solution
Tubing (including extension sets and/or stopcocks)
Cannula
Dressing
Regular IV cannula or locks
Maximum of 24 hours
72 hours
Transparent dressing – when visibly soiled or loose
Gauze & tape 48 hrs
Blood soiled or oozing sites 24 hrs
Peripheral parenteral nutrition
24 hours
Lipids
Blood or blood products
Within 4 hours of obtaining from blood bandk
After each unit (including filter)
Propofol
12 hours

77. IV Certified LPNs MAY
(1) Initiate the administration of board-approved IV fluids and medications via a peripheral route;
(a) The peripheral route does NOT include midline or midclavicular catheters.
(b) Approved IV fluids and medications include electrolyte solutions with vitamins and/or potassium, IVPB antibiotics, IVPB anti-fungals H2 blockers and proton pump inhibitors (PPIs) provided such fluids and medications are appropriate for IV administration;
(c) IV fluids and medications must be commercially prepared or premixed and labeled by a RN or registered pharmacist;
(2) Maintain patency of a peripheral intermittent vascular access device using a non-therapeutic dose of a flush solution;
(3) Assist the RN in the administration of midline, midclavicular or central venous infusion of approved IV fluids by checking the flow rate and changing the site dressing. ONLY.
Reference: MS Board of Nursing Rules & Regulations

78. IV Certified LPNs May NOT
(1) Initiate, regulate, add or administer medications to or discontinue a midline, midclavicular or central venous line;
(2) Administer or add the following to a peripheral venous line:
(a) IV push or bolus medications;
(b) IV medications other than those in Section 3.3a (1) (b) above;
(c) Parenteral nutritional agents other than vitamins;
(d) Blood, blood components, plasma, plasma expanders;
(e) Chemotherapeutic agents.
(3) Perform any advanced acts of IV therapy listed in Section 3.3 a. with patients under two (2) years of age;
(4) Perform any advanced acts of IV therapy listed in Section 3.3a. with pediatric patients age two (2) years and older unless:
(a) The patient is on a unit solely and specifically for pediatric patients; and
(b) The LPN certified in IV therapy is experienced and competent in the provision of care to pediatric patients; and
(c) A registered nurse is physically present on the pediatric patient care unit where IV therapy is being administered and is readily available to respond as needed.
Reference: MS Board of Nursing Rules & Regulations

79. Documentation
All patient care interventions are to be documented in Meditech
Medication administrations (including bag changes) are to be documented on eMAR.
At a minimum, documentation of assessment of the peripheral intravenous site by an RN or an IV certified LPN must be every four hours.

80. DOCUMENTING IV Therapy
IV Therapy MAY NOT be delegated to unlicensed persons
The assistants MAY document the care that they CAN and DO provide for the patient
IV Therapy I &O’s (and enteral feedings) should not be documented by Techs or C.N.A.’s

81. THANK YOU for your attention
Please refer to the policy for details.
Policy is found in the GP Web – P&P – Patient Care – IVT Policy

82. PRODUCT
Lifeshield Neutron reflux valve – to be used on ALL central line ports

83. PRODUCTS
CLAVE Needle-free connector to be used on ALL PIV ports

84. PRODUCT
STATLOCK for Peripheral IV – stabilization device for indwelling PIV

85. PRODUCTS
CHG (ChloraPrep) applicator in IV start kits

86. PRODUCT
ProtectiveIV Safety IV cannula (Video available on GP web)

87. PRODUCT
Hospira Pulm A pumps (training on Healthstream)

88. Garden Park Medical Center
Medication Safety
Pharmacy Review
Med pass is time for education
Include actions and side effects
Document all education
Nursing Orientation

89. Patient Teaching - Medications