Global Care Services Clinical Orientation Manual PDF

GLOBALCARE SERVICES INC. CLINICAL ORIENTATION MANUAL Welcome to GlobalCare Services! At GlobalCare Services, we specialize in connecting highly skilled international registered nurses with hospitals and healthcare facilities in the United States. Our personalized recruitment solutions...

GLOBALCARE SERVICES INC. CLINICAL ORIENTATION MANUAL Welcome to GlobalCare Services! At GlobalCare Services, we specialize in connecting highly skilled international registered nurses with hospitals and healthcare facilities in the United States. Our personalized recruitment solutions eliminate the administrative burden of recruiting, allowing our clients to prioritize the delivery of exceptional care to patients and residents. Ensuring your seamless transition to the United States is our topmost priority. The GlobalCare Services team is dedicated to facilitating your integration, enabling you to function as a competent professional nurse in this dynamic healthcare environment. This Clinical Manual serves as an important guide as you embark on the next phase of your career. It covers fundamental knowledge and essential topics, providing a review of your clinical skills while highlighting the nuances of practicing as a registered nurse in the United States. Drawing from personal experiences and learning, this manual is tailored to enhance your understanding of the unique aspects of nursing in this setting. It's important to note that GlobalCare Services assumes no liability or responsibility for any errors, assumptions, or conclusions drawn from this manual. All third-party trademarks mentioned herein belong to their respective owners. Facility policies may vary, so ensure access to your facility’s policy manual upon deployment to stay in compliance with hospital policies and procedures throughout your nursing career. By the end of this course, you will have a 30-item knowledge test and will be required to send a recorded video of the following skills: ⚫ Complete Head-to-toe Assessment ⚫ IV insertion and removal ⚫ Foley Cather insertion and removal Send a copy of the following: ⚫ SBAR Charting Following the review of your submissions, our Nurse Clinical Specialist will schedule a one-on-one Zoom meeting to provide feedback and address any queries. Upon successful completion, a certificate of achievement will be awarded. This course is self-paced and should be completed within 6 weeks after we assign it to you. Best of luck on your journey with GlobalCare Services! Georgina Avancena, President  TABLE OF CONTENTS PATIENT RIGHTS ---------------------------------------------------------------------------------3 INFECTION CONTROL ---------------------------------------------------------------------------4 Hand Washing Five Moments of Handwashing Principles of Aseptic Technique Standard (Universal) Precautions Contact Precautions Droplet Precautions Airborne Precautions Handling and Disposal of Infections Waste MOVING AND LIFTING PATIENTS ------------------------------------------------------------7 Body Mechanics Type of Mechanical Assist Device Patient Transfers FALL SAFETY ---------------------------------------------------------------------------------------8 Fall Risks Factors Common Medications that contributes to Falls Falls Risk Scoring/Assessment (Morse Score) Nursing Interventions FIRE DRILLS and SAFETY ------------------------------------------------------------------------16 Evacuation Fire Exits P A S S and R A C E Mnemonics PATIENT RESTRAINTS ---------------------------------------------------------------------------17 Type of Restraints Alternative to Restraints Reducing Restraints Risk Restraints Order and Duration Documentation and Assessment Changing the Culture in Restraints MEDICATION SAFETY ----------------------------------------------------------------------------21 10 Rights of Medications Administration Software Guardrails Locked Medications Minimizing Interruptions and Distractions DEMENTIA -----------------------------------------------------------------------------------------26 Definition Clinical Manifestations Nursing Considerations END OF LIFE CARE --------------------------------------------------------------------------------28 Hospice and Palliative Services Advance Directives Type of Advance Directives Patient Self-Determination Act (PSDA) 1 CULTURAL AND RELIGIOUS CONSIDERATION --------------------------------------------31 HEALTH INSURANCE PORTABILITY and ACCOUNTABILITY ACT (HIPPA) -----------32 COMMON MEDICAL EQUIPMENTS USED -------------------------------------------------34 *BASICS OF EPIC CHARTING- INCLUDED DURING FEEDBACK ZOOM CALL VIDEO LINKS FOR CLINICAL SKILLS ----------------------------------------------------------35 Head-to-Toe Assessment Starting and IV Central line dressing change Kangaroo Pump Starting a Feeding Blood Transfusion Bladder Scan for Urinary Retention Foley Catheter Insertion Foley Catheter Removal Linen Change PPE Donning and Doffing POINTERS FOR RETURN DEMONSTRATION -----------------------------------------------36 REFERENCES --------------------------------------------------------------------------------------37 2  PATIENT RIGHTS Right to be informed about the care you will receive. Right to get information about your care in your language. Right to make decisions about your care, including refusing care. Right to know the names of the caregivers who treat you. You have the right to safe care. Right to have your pain treated. Right to know when something goes wrong with your care. Right to get an up-to-date list of all your current medications. Right to be listened to. Right to be treated with courtesy and respect. How to Protect Your Patient Rights While there are laws in place to protect your rights as a patient, you have responsibilities as well. To better protect yourself and ensure peace of mind, there are several things you can do: Ask questions if you do not understand what your healthcare provider is telling you. Seek a second opinion if you are not getting the information you need in a language you understand. Request a cost estimate before agreeing to any treatment. The estimate should itemized and include all associated costs, such as anesthesia services or facility costs. Prepare a living will or durable power of attorney for healthcare so that your wishes are adhered to if you become incapacitated. If you have a billing dispute, contact your insurance company or engage a patient advocate to walk you through the process of lodging a dispute. If you have been discriminated against, file a civil rights dispute with the Office of Civil Rights at (800) 368-1019. 3  INFECTION CONTROL Infection control prevents or stops the spread of infections in healthcare settings. This site includes an overview of how infections spread, ways to prevent the spread of infections, and more detailed recommendations by type of healthcare setting. There are 2 tiers of recommended precautions to prevent the spread of infections in healthcare settings: 1. Standard Precautions are used for all patient care. They’re based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient. 2. Transmission-Based Precautions. They’re the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Hand Hygiene Hand washing is considered the most important single procedure for preventing nosocomial (hospital- acquired) infections. Hand washing is a basic form of sanitation and a required part of all infections control measures. 5 Moments of Hand Hygiene 4 The principles of Aseptic/Sterile Technique: 1. All materials in contact with the wound and used in the sterile field must be sterile. 2. Gowns are considered sterile in front from chest to the level of the sterile field. The sleeves are also considered sterile from 2” above the elbow to the stockinet cuff. 3. Sterile drapes are used to create a sterile field. Only the top service of a draped table is considered sterile. 4. Items should be dispensed to a sterile field by methods that preserve the sterility of the items and the integrity of the sterile field. 5. Motions are from sterile to sterile areas and from non sterile to non sterile areas. 6. Movement around a sterile field must not cause contamination of that sterile field. 7. When sterile ever a sterile barrier is permeated, it must be considered contaminated. 8. Every sterile field should be constantly monitored and maintained. There are three different types of transmission/isolation precautions: 1. Contact Precautions—used for infections, diseases, or germs that are spread by touching the patient or items in the room (examples: MRSA, VRE, diarrhea, illnesses, open wounds, RSV). 2. Droplet Precautions—used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). 3. Airborne Precautions—used for diseases or very small germs that are spread through the air from one person to another (examples: tuberculosis, measles, chickenpox). 5 Handling and Disposal of Infectious Wastes Remember these simple points dealing with infectious materials/waste (ex: blood and bodily fluids, human tissue, sharps, needles, scalpels, IV tubing): All infectious waste is placed in closeable leak proof containers which are color coded, labeled or tagged with the biohazard symbol. Waste must be separated into appropriate containers. Biohazard bags are used for contaminated materials that are saturated with blood or other potentially infectious material. Sharps must not be recapped. Sharps must be placed in approved puncture-resistant biohazard sharps container to the ¾ full mark. Fluids must be emptied into sewer system. Fluid-filled containers that cannot be emptied prior to disposal must be placed in biohazard receptacle. Always protect yourself by wearing personal protective equipment when handling infectious waste 6  MOVING AND LIFTING PATIENTS Good Body Mechanics 1. Start any body movement with proper alignment and balance. 2. Enlarge base of support and/or lower the center of gravity toward the base of support 3. Adjust your working area to waist level and keep your body close to the area 4. Avoid stretching as this causes muscle fatigue and strain and places the line of gravity outside the base of the support reporting in instability 5. Face in the direction of the task. Avoid twisting your back. 6. When moving a heavy object, face in the direction of the force. 7. Tighten the muscle in your bottom and tummy before lifting or moving any object 8. Carry objects close to your body and close to the base of support. 9. When lifting heavy objects, squat rather than stoop. 10. Use the weight of your body to push objects. 11. Avoid working against gravity whenever possible. 12. Make your body movements smooth and rhythmic. 13. Use mechanical aids to move heavy objects 14. Make sure the locks are on the wheels of mechanical devices when loading and unloading 15. Use your palm when grasping and lifting objects – extend your fingers and hand around the object when you lift it – use the strength of your entire hand. Patient Transfers Patient transfer can be defined as moving a patient from one flat surface to another. The most common patient transfers are from a bed to a stretcher and from a bed to a wheelchair. While seemingly intuitive, successful patient transfers rely on understanding each patient’s specific needs while simultaneously adhering to evidence-based guidelines. Common Mechanical Devices Used ⚫ Gait Belts/Transfer Belts with handles ⚫ Rollator ⚫ Walker ⚫ Lift cushions and lift chairs ⚫ Powered sit-to-stand or standing assist devices ⚫ Transfer boards – wood or plastic (some with movable seat) ⚫ Portable lift device (sling type); can be a universal/ hammock sling or a band/ leg sling ⚫ Variable position Geri and Cardiac chair ⚫ Portable lift device (sling type); universal/hammock sling or a band/leg sling irs ⚫ Ambulation assist device ⚫ Ceiling mounted lift device ⚫ Trapeze Bar 7  FALL SAFETY Research has identified many risk factors that contribute to falling—some of these are modifiable. Most falls are caused by the interaction of multiple risk factors. The more risk factors a person has, the greater his/her chances of falling. Healthcare providers can lower a person’s risk by reducing or minimizing that individual’s risk factors. What healthcare providers can do to prevent falls? Providers should talk to their patients about their health goals. Then, determine which modifiable fall risk factors can be addressed to help them meet their goals. Effective clinical and community interventions exist for the following fall risk factors: ⚫ Vestibular disorder/poor balance ⚫ Vitamin D insufciency ⚫ Medications linked to falls ⚫ Postural hypotension ⚫ Vision impairment Foot or ankle disorder Home hazards ⚫ Foot or ankle disorder ⚫ Home hazards Risks factors are categorized as intrinsic or extrinsic: INTRINSIC FACTORS EXTRINSIC FACTORS ⚫ Advanced age ⚫ Lack of stair handrails ⚫ Previous falls ⚫ Poor stair design ⚫ Muscle weakness ⚫ Lack of bathroom grab bars ⚫ Gait & balance problems ⚫ Dim lighting or glare ⚫ Poor vision ⚫ Obstacles & tripping hazards ⚫ Postural hypotension ⚫ Slippery or uneven surfaces ⚫ Chronic conditions including arthritis, stroke, ⚫ Psychoactive medications incontinence, diabetes, Parkinson’s, dementia ⚫ Improper use of assistive device ⚫ Fear of falling 8 Common Medications that Contributes to Falls 9 10 Nursing Interventions and Rationales The following are the therapeutic and evidence-based nursing interventions and actions (including their rationales) for patients at risk for falls: 1. Design an individualized plan of care for preventing falls. Provide a plan of care that is individualized to the patient’s unique needs. Planning an individualized fall prevention program is essential for nursing care in any healthcare environment and needs a multifaceted approach. Avoid relying too much on universal fall precautions as different individuals have different needs. Universal fall precautions are established for all patients to reduce their risk of falling. These standard strategies, in general, help develop a safe environment that reduces accidental falls and delineates core preventive measures for all patients. 2. Provide signs or secure wristband identification for patients at risk for falls to remind healthcare providers to implement fall precaution behaviors. Signs are vital for patients at risk for falls. Healthcare providers need to acknowledge who has the condition, for they are responsible for implementing actions to promote patient safety and prevent falls. When providing care, treatment, and services, use two patient identifiers. For example, wristbands should include the patient’s last and first name, date of birth, and NHS number in the UK. Details should be printed/written in black against a white background. Only red color should be used to signal special patient status. These recommendations are consistent with current developments in patient identification (Sevdalis et al., 2009). 3. Transfer the patient to a room near the nurses’ station. Determining which patients are most likely to fall is essential to prepare and anticipate nearby location and provide more constant observation and quick response to call needs. 4. Place items the patient uses within easy reach, such as call light, urinal, water, and telephone. Items that are too far may require the patient to reach out or ambulate unnecessarily and can potentially be a hazard or contribute to falls. 5. Respond to call light as soon as possible. Helps prevent the patient from going out of bed without any assistance. Nurses respond to fallers’ call lights more quickly than they do to lights initiated by non-fallers. The nurses’ responsiveness to call lights could be a compensatory mechanism in responding to the fall prevalence on the unit (Tzeng & Yin, 2010). Additional effort is required to reach the ideal or even a reasonable level of patient safety-first practice in current hospital environments. 6. Avoid the use of physical restraints to reduce falls. Studies demonstrate that regular use of restraints does not reduce the incidence of falls. The use of a trunk restraint is associated with a higher risk for falls and fractures among patients with either Alzheimer’s disease or dementia (Luo et al., 2011). 7. Inform the patient of the advantage of wearing eyeglasses and hearing aids. Encourage to have vision and hearing checked regularly. Hazard can be reduced if the patient uses appropriate aids to promote visual and auditory orientation to the environment. Visual impairment can greatly cause falls. 11 8. Provide high-risk patients with a hip pad. Hip pads, when worn properly, may reduce a hip fracture when fall happens. 9. Place beds are at the lowest possible position. Set the patient’s sleeping surface as near the floor as possible if needed. Keeping the beds closer to the floor reduces the risk of falls and serious injury. Placing the mattress on the floor significantly reduces fall risk in some healthcare settings. Low beds are designed to lessen the distance a patient falls after moving out of bed. Although these beds don’t prevent a fall, they reduce the distance of a fall, reducing trauma and injury (Quigley et al., 2015). 10. For tall patients, avoid keeping the bed in a low position at all times. Patients who are tall and with weak leg muscles who try to sit on the bed from a standing position are likely to fall onto the bed because it’s too low for them to lower themselves safely. Also, if a tall patient attempts to get up from a low bed without assistance, the patient is likely to fall back down onto the bed or miss the bed and fall onto the floor. 11. Secure bed and chair alarms when the patient gets up without support or assistance. Bed alarms serve as early-warning systems to warn nursing staff that a patient is about to get up from bed without assistance. They’re designed to promote timely rescue, not to prevent falls from bed. Audible alarms can also remind the patient not to get up alone. The use of alarms can also be a substitute for physical restraints. Aside from bed alarms, increased supervision for high-risk patients also may help prevent falls. 12. Raise side rails on beds, as needed. For beds with split side rails, leave at least one of the rails at the foot of the bed down. According to research, a disoriented or confused patient is less likely to fall when one of the four rails is left down. 13. Place a non-skid floor mat at the bedside. Floor mats can serve as a cushion that helps reduce the impact of a possible fall. 14. Encourage the patient to don shoes or slippers with nonskid soles when walking. As a person ages, gait becomes slower, and stride becomes shorter. Footwear influences balance and the subsequent risk of slips, trips, and falls by altering somatosensory feedback to the foot and ankle and modifying frictional conditions at the shoe/floor interface. Nonskid footwear provides sure footing for the patient with diminished foot and toe lift when walking. Shoes with low heels and a large contact area may aid older adults lessen the risk of a fall in everyday activities and settings (Tencer et al., 2004). A study likened slip resistance during mobilization, incline, and descent in patients with bare feet to patients wearing nonskid socks or compression stockings. Results showed bare feet provide better slip resistance than nonskid socks during mobilization and incline (Quigley et al., 2015; Chari et al., 2009). 15. For patients with shuffling gait or foot drop, avoid using nonskid socks. Patients with a shuffling gait increase fall chances dramatically. To reduce fall risk, shoes should be with a little to no heel, thin soles with slip-resistant tread, and support the ankles. 16. Have the patient wear proper footwear. Advise patient to use nonskid socks to prevent the feet from sliding upon standing. However, encourage patients to wear appropriate, well-fitting shoes—not nonskid socks for ambulation. 12 17. Improve home support. Many community service organizations provide financial assistance to make older adults make safe environments in their homes. 18. Familiarize the patient with the layout of the room. Discourage rearranging the furniture in the room. A fall is more likely to be experienced by an individual if the surrounding is not familiar, such as furniture and equipment placement in a certain area. The patient must get used to the room’s layout to avoid tripping over furniture or any large objects. 19. Teach patients how to safely ambulate at home, including using safety measures such as handrails in the bathroom. Helps relieve anxiety at home and eventually decreases the risk of falls during ambulation in their home setting. Raised toilet seats can facilitate safe transfer on and off the toilet. 20. Use heavy furniture that will not tip over when used as support when ambulating. Make the primary path clear and as straight as possible. Avoid clutter on the floor surface. Patients having difficulty balancing are not skilled at walking around certain objects that obstruct a straight path. Recognizing and fixing potential hazards and establishing assistive devices are effective fall prevention approaches that make the home environment safer for older adults. Safety experts and design engineers can collaborate with healthcare providers, homecare workers, and the older people to improve the home environment (Rogers et al., 2004). 21. Provide the patient with a chair with a firm seat and arms on both sides. Consider locked wheels as appropriate. Chairs with firm seats and armrests are easier to get out of, especially for patients who experience weakness and impaired balance. 22. Provide appropriate room lighting, especially at night. Patients, especially older adults, have reduced visual capacity. Lighting an unfamiliar environment helps increase visibility if the patient must get up at night. In a study, homes with adequate lighting report fewer falls (Ramulu et al., 2021). Improvement in lighting at home may reduce fall rates in older adults. 23. Provide the patient with assistive devices for transfer and ambulation. The use of gait belts by all health care providers can promote safety when assisting patients with transfers from bed to chair. Assistive aids such as canes, walkers, and wheelchairs can improve patient stability and balance when ambulating. 24. Consider physical and occupational therapy sessions to assist with gait techniques. Occupational therapy is defined as the therapeutic application of activities of daily living ADL (occupation) in an individual or group to develop and enhance participation in roles, habits, and routines at home, at school, in the workplace, in the community, and in other settings. These interventions enable individuals to integrate exercise into their day-to-day routine. Group exercises can be incredibly helpful for older people. Observing their peers when performing the exercises can attain progress in their reactions and behavior (Samardzic et al., 2020). 25. Acknowledge that when the patient attends to another task while walking, such as holding a cup of water, clothing, or supplies, they are more likely to fall. Patients should avoid carrying different objects that could cause a higher risk for subsequent falls. 13 26. Limit use of wheelchairs as much as possible because they can serve as a restraint device. Most people in wheelchairs do not move. Wheelchairs, unfortunately, serve as a restraint device 27. If the patient has a new onset of confusion (delirium), provide reality orientation when interacting. Have family bring in familiar items, clocks, and watches from home to maintain orientation. Reality orientation can help prevent or decrease the confusion that increases the risk of falling for patients with delirium. 28. Ask the family to stay with the patient. Helps prevent the patient from accidentally falling or pulling out tubes. 29. Consider using sitters for patients with impaired ability to follow directions. Sitters are effective for guaranteeing a secure, protected, and safe environment. However, studies demonstrated very low-certainty evidence that sitters reduce fall risk in acute care hospitals and only moderate-certainty that alternatives like video monitoring can reduce sitter use without increasing fall risk, suggesting that sitters are not as useful as initially believed (Greely et al., 2020). 30. Refer the patient with musculoskeletal problems for diagnostic evaluation. Patients with musculoskeletal problems such as osteoporosis are at increased risk for serious injury from falls. Musculoskeletal pain, explicitly general pain, is a fundamental risk factor for falls in older women with disabilities. The risk for recurrent falls and self-reported fractures due to falls was also heightened in women with musculoskeletal pain, almost invariably in women with general pain (Leveille et al., 2002). Bone mineral density testing will help identify the risk for fractures from falls. Physical therapy evaluation can identify problems with balance and gait that can increase a person’s fall risk. 31. Collaborate with other health care team members to assess and evaluate patients’ medications that contribute to falling. Examine peak effects for prescribed medications that affect the level of consciousness. A review of the patient’s medications by the prescribing health care provider and the pharmacist can identify side effects and drug interactions that increase the patient’s fall risk. The more medications a patient takes, the greater the risk for side effects and interactions such as dizziness, orthostatic hypotension, drowsiness, and incontinence. Polypharmacy in older adults is a significant risk factor for falls. Fall Risk-Increasing Drugs (FRID) refers to the medications well-recorded to be associated with heightened fall risk. These comprise but are not limited to anti-hypertensives, anti-psychotics, narcotics, sedatives, and anticholinergics. For example, recent studies have revealed that long-term use of proton pump inhibitors (PPIs) increased the risk of falls (Lapumnuaypol et al., 2019). 32. Allow the patient to participate in a program of regular exercise and gait training. Studies recommend exercises to strengthen the muscles, improve balance, and increase bone density. Increased physical conditioning reduces the risk for falls and limits injury that is sustained when fall transpires. Land and water-based exercise programs may be similarly beneficial on balance and gait and thereby reduce the risk for falls. Water exercise may contribute a positive benefit on balance and gait for women 65 years and older. Water-based exercise could be regarded as an alternate exercise activity for older people, significantly if land-based exercise is challenging due to chronic musculoskeletal conditions (Booth, 2004). 33. Encourage patient to do Chair Rise Exercise or Sit-to-Stand Exercise. Chair Rise Exercise is a simple sit-to-stand exercise that helps strengthen the muscles in the thighs and buttocks and improves mobility and independence. The goal is to do Chair Rise exercises without using 14 hands as the client becomes stronger. See resources section for a detailed instruction on how to perform Chair Rise exercise. 34. Explain the use of vitamin D supplements. Vitamin D helps in maintaining postural balance, propulsion and improves executive functions and navigation abilities among older adults. Vitamin D supplementation determines gait performance and prevents the occurrence of falls and their complications among older adults (Annweiler et al., 2010). The prescription of at least 800 IU of vitamin D daily for older patients is a simple intervention that should be integrated into new methods for postural rehabilitation, primary and secondary fall prevention, strength training, integration of body schema, automation of gait, and adaptation to the environment 15  FIRE DRILLS AND SAFETY A fire drill is an evacuation simulation that helps prepare participants for a real fire emergency response. Running drills lets people know what to expect and how to respond safely. During a fire drill, everyone will evacuate the building upon hearing an alarm or announcement and follow the fire evacuation plan that has already been communicated. A hospital fire response plan will include a general plan to move patients and staff to safety as well as specific information that is directly related to the facility structure, staff roles, and more. Every hospital should have a written fire response plan that includes when and how to sound and report fire alarms, how to contain smoke and fire, how to use a fire extinguisher, and how to evacuate areas of refuge. Staff should be trained in each of these areas, and have their knowledge tested with regular but varied fire drills. 16  RESTRAINTS Three general categories of restraints exist—physical restraint, chemical restraint, and seclusion. 1. Physical restraint Physical restraint, the most frequently used type, is a specific intervention or device that prevents the patient from moving freely or restricts normal access to the patient’s own body. Physical restraint may involve: applying a wrist, ankle, or waist restraint tucking in a sheet very tightly so the patient can’t move keeping all side rails up to prevent the patient from getting out of bed using an enclosure bed. Typically, if the patient can easily remove the device, it doesn’t qualify as a physical restraint. Also, holding a patient in a manner that restricts movement (such as when giving an intramuscular injection against the patient’s will) is considered a physical restraint. A physical restraint may be used for either nonviolent, nonself-destructive behavior or violent, self-destructive behavior. (See What isn’t a restraint?) A. Restraints for nonviolent, nonself-destructive behavior: Typically, these types of physical restraints are nursing interventions to keep the patient from pulling at tubes, drains, and lines or to prevent the patient from ambulating when it’s unsafe to do so—in other words, to enhance patient care. For example, a restraint used for nonviolent behavior may be appropriate for a patient with an unsteady gait, increasing confusion, agitation, restlessness, and a known history of dementia, who now has a urinary tract infection and keeps pulling out his I.V. line. B. Restraints for violent, self-destructive behavior: These restraints are devices or interventions for patients who are violent or aggressive, threatening to hit or striking staff, or banging their head on the wall, who need to be stopped from causing further injury to themselves or others. The goal of using such restraints is to keep the patient and staff safe in an emergency situation. For example, a patient responding to hallucinations that commands him or her to hurt staff and lunge aggressively may need a physical restraint to protect everyone involved. 2. Chemical restraint Chemical restraint involves use of a drug to restrict a patient’s movement or behavior, where the drug or dosage used isn’t an approved standard of treatment for the patient’s condition. For example, a provider may order haloperidol in a high dosage for a postsurgical patient who won’t go to sleep. (If the drug is a standard treatment for the patient’s condition, such as an antipsychotic for a patient with psychosis or a benzodiazepine for a patient with alcohol-withdrawal delirium, and the ordered dosage is appropriate, it’s not considered a chemical restraint.) Many healthcare facilities prohibit use of medications for chemical restraint. 17 3. Seclusion With seclusion, a patient is held in a room involuntarily and prevented from leaving. Many emergency departments and psychiatric units have a seclusion room. Typically, medical-surgical units don’t have such a room, so this restraint option isn’t available. Seclusion is used only for patients who are behaving violently. Use of a physical restraint together with seclusion for a patient who’s behaving in a violent or self-destructive manner requires continuous nursing monitoring. Determining when to use a restraint The patient’s current behavior determines if and when a restraint is needed. A history of violence or a previous fall alone isn’t enough to support using a restraint. The decision must be based on a current thorough medical and psychosocial nursing assessment. Sometimes, addressing the issue that’s underlying a patient’s disruptive behavior may eliminate the need for a restraint. Also, caregivers must weigh the risks of using a restraint, which could cause physical or psychological trauma, against the risk of not using it, which could potentially result in the patient harming him- or herself or others. Input from the entire care team can help the provider decide whether to use a restraint. Alternatives to restraints Use restraints only as a last resort, after attempting or exploring alternatives. Alternatives include having staff or a family member sit with the patient, using distraction or de-escalation strategies, offering reassurance, using bed or chair alarms, and administering certain medications. If appropriate alternatives have been attempted or considered but have proven insufficient or ineffective or are deemed potentially unsuccessful, restraint may be appropriate. A provider order must be obtained for patient restraint. Be sure to update and revise the care plan for a restrained patient to help find ways to reduce the restraint period and prevent further restraint episodes. Reducing restraint risks Restraints can cause injury and even death. In 1998, TJC issued a sentinel event alert on preventing restraint deaths, which identified the following risks: Placing a restrained patient in a supine position could increase aspiration risk. Placing a restrained patient in a prone position could increase suffocation risk. Using an above-the-neck vest that’s not secured properly may increase strangulation risk if the patient slips through the side rails. A restraint may cause further psychological trauma or resurfacing of traumatic memories. To help reduce these risks, make sure a physical restraint is applied safely and appropriately. With all types of restraints, monitor and assess the patient frequently. To relieve the patient’s fear of the restraint, provide gentle reassurance, support, and frequent contact. Monitor vital signs (pulse, respiration, blood pressure, and oxygen saturation) to help determine how the patient is responding to the restraint. 18 Restraint orders must include: Date and time of restraint order Expiration date and time of order What type of restraint Circumstances under which a restraint is to be discontinued What restraint device should be use Duration The following are limitations to the duration of restraint use: Time is specified by the physician but is not to exceed 24 hours. The patient is to be re-evaluated face-to-face by the physician at least every 24 hours to determine if restraints need to be continued. A new restraint order must be written every 24 hours if restraints are still needed. Restraints and seclusion may not be used simultaneously unless the patient is continually monitored face-to-face by an assigned staff member. The patient should be frequently evaluated for possible restraint removal or possible reduction in the level of restraint used. Restraint removal or reduction should be implemented when the patient demonstrates an improvement or reduction in the behavior that led to restraint use. Restraints should be released every 2 hours to perform a skin assessment, and complete range of motion exercises. When done, the restraints should be safely and properly reapplied. Documentation and Assessment Every episode of restraint use is to be thoroughly assessed and documented. This should include: All alternative measures attempted Type of restraint used Behaviors requiring restraint usage Vital signs Skin assessment Circulation checks Hydration/elimination needs Nourishment offered Level of distress/agitation, mental status, and cognitive functioning Need for continued restraint, if applicable Individualized needs assessed Changing the culture The American Psychiatric Nurses Association’s position statement on the use of restraint suggests a unit’s philosophy on restraint use can influence how many patients are placed in restraints. Interacting with patients in a positive, calm, respectful, and collaborative manner and intervening early when conflict arises can diminish the need for restraint. Facility leaders should focus on reducing restraint use by supporting ongoing monitoring and quality-improvement projects. 19 To help ensure a restraint is applied safely, nurses should receive hands-on training on safe, appropriate application of each type of restraint before they’re required to apply it. Such training also should occur during orientation and should be reinforced periodically. The goal is to use the least restrictive type of restraint possible, and only as a last resort when the risk of injury to the patient or others is unacceptably high. Consider using restraint only after unsuccessful use of alternatives, and only as long as the unsafe situation occurs. Remember—restraint use is an exceptional event and shouldn’t be a part of a routine protocol. 20  MEDICATION SAFETY 10 Rights of Medication Administration Whether you are a nurse giving medication or a patient receiving medication, it is important to understand the 10 rights of medication administration. You may be giving medications to a family member or taking them yourself. Safety should be the first thing on your mind with medications. There is always a risk of giving the wrong pill, the wrong dose, or the wrong person’s medication. If this happens, harm to the person can occur and some reactions can be deadly. While there has always been protocol for giving drugs in the hospital, it is important for everyone to know the safety rules for medications. In the past, you may have heard of the “5 Rights of Medication Administration: right patient, right drug, right route, right time, and right dose.” Medical practices have changed to include a few more rights. 1. Right Patient Make sure you are giving the right medication to the right person.If you are at home and giving medication to a family member, make sure you check the bottle and giving the right prescription to the right person. If you work in the medical field, always ask the patients name, check an ID band, and check the medication bottles to compare before giving a medication. 2. Right Medication When your doctor prescribes a medication, there will be a prescription label on the bottle. It isn’t safe to just grab any bottle and take any pill. Even pharmacies can make mistakes. Check your pills and your prescription label carefully to make sure you have the right medication. Check the label every time you grab your bottle to take a dose. Most pill bottles are easily mixed up because they look so much alike. Also, never store a different medication in an empty pill bottle that was used for something else. In a healthcare setting, check the medication supply and compare it to the doctor’s orders to make sure it is the right one. Some medications have “sound alike” names. These include the drugs Inderal (Heart Medication)/Adderall (ADHD Stimulant), Celexa (Anti-depressant)/Celebrex (Anti- Inflammatory), Paxil (Anti-depressant)/Plavix (Blood Thinner), and many others that could be dangerous medication errors if mixed up. 3. Right Dosage This is one of the most important in the 10 rights of medication administration. Before you leave the doctor’s office, ask how much of the medication you should take. Then if you are unsure after you leave, talk to the pharmacist. When you get home do not “play” with dosages. Do not break pills in half or take more or less than the doctor wants you to. Check to see if it takes more than one pill to make your right dosage. For example; you may need two 25mg tabs to make a 50mg dosage. In the healthcare setting, check the doctor’s orders to your supply of the medication on hand. Calculate the dosage yourself to make sure it is right. Be aware of the difference of a pediatric dose and an adult dose. 21 4. Right Route If your doctor gives you pill form and you can’t swallow, you may need to ask for liquid form of the medication. This is especially important for children that cannot swallow pills yet. Check to see if the medication is given by suppositories (rectal or vaginal) and only use topical creams and lotions on the skin. Nurses should always make sure their patients can swallow pills okay and make sure the medication is given the right route. Some injections can either be IM (In the Muscle) or Sub-Q (In the fatty tissue). 5. Right Time If your doctor orders a medication at HS, this means take it at bedtime. Some bedtime medications can make you sleepy. If you see the letters, QAM that means take the medication in the morning. 6. Right Documentation Athome you should keep a journal of the meds you take, what time you took them and how much you took. If you give yourself injections, write down the injection site since most injection sites should be rotated. Nurses need to write down a medication that is given after they give the actual dose. Nurses should also document injection sites. Any medication documentation needs to be initialed yourself, never let anyone document for you. 7. Right Client Education Know the side-effects of the medications you and your loved ones are taking. Let them know what they are and have them tell you if they feel an unwanted reaction to the medication. The same thing goes for nurses in the hospital, let your patients know what to expect from the medication: side-effects, benefits, and reactions that might happen. 8. Right to Refuse At home or in the hospital, people taking medications have the right to refuse medications. If someone tells you they don’t want to take something, simply dispose of the medication and call the doctor to let them know. Nurses must legally document a refusal of medication. 9. Right Assessment Have a copy of the patient’s medical history. Medications like blood pressure medications always warrant a quick blood pressure check before giving a blood pressure medication. Ask the doctor what number is too low to give the medication. 10. Right Evaluation Make sure you check for drug allergies and interactions between different medications. Doctors and pharmacists don’t always catch them and we need to be a third set of eyes. At home, it is important to keep a drug guide so you can check prescriptions against each other. 22  After learning about the 10 rights of medication administration, here are the guidelines for medication administration. Whenever a medication is given, follow these guidelines for medication safety: 1. Let them know what they are taking and answer questions. 2. Give them responsibilities. Hand them their meds and let them take them. 3. Give them privacy. 4. Don’t get distracted while giving medications. 5. Use a quiet place for medication administration. 6. Don’t leave bottles open or leave them out on a counter. Keep small children in mind. 7. Wash your hands with soap and water before giving someone medicine. 8. Wash your hands after you give someone medicine, especially if there are multiple sick people in your home. SOFTWARE GUARDRAILS Guardrails safety software is a medication safety and quality auditing system designed specifically for infusions. This smart-pump technology empowers healthcare professionals to identify, track, and ultimately prevent many of the most harmful IV medication errors. These errors can occur at any stage of the medication delivery process, from prescription to administration, with those occurring during administration being particularly challenging to intercept. LOCKED MEDICATIONS Double-locking cabinets (requiring two keys on one door or two keys for double doors) are still used, especially in smaller facilities, such as long-term care facilities. Only authorized personnel are allowed access to the keys, and this type of cabinet is usually contained in a locked room to further limit access. Note that this type of cabinet is not refrigerated, so some controlled substances will need to be stored in a securely locked refrigerator or refrigerated cabinet or container. Controlled substances are now usually provided in individual dose containers rather than bulk (such as 30 mL vials or 100 tablet bottles). With this system, some form of record (written, computerized) is kept each time a drug is removed from the storage cabinet because this system requires a manual narcotics count. The usual information recorded when medication is removed includes the date, time, drug, patient for whom the drug is intended (name, ID, room number), the name of the prescriber, and the name of the healthcare provider procuring the drug. With this type of storage, the traditional end-of-shift narcotics count with the oncoming nurse counting and the outgoing nurse verifying is usually conducted. 23 Minimizing Interruptions and Distractions A distraction occurs when an individual’s attention is drawn away from one task to a different task, or when they are trying to work on multiple tasks at the same time. An interruption occurs when an individual is engaged in a task and stops or performs another task with the intention of returning to the initial task. In today’s healthcare environment, practitioners are expected to multitask, and distractions and interruptions are generally accepted as the norm. In fact, a study showed that pharmacists, technicians, and nurses can be distracted or interrupted as frequently as once every 2 minutes. Distractions and interruptions in healthcare environments are a threat to human performance and patient safety. Interruptions can be necessary and appropriate when crucial information, such as holding a patient’s medication due to a critical laboratory value or speaking up about a potential medication error, must be conveyed to prevent patient harm. This could include the use of well-designed alerts, clinical decision support, and person-to-person communication to bring someone's attention to a potential safety issue. However, researchers have shown that interruptions can also lead to an increase in errors when performing clinical tasks such as medication prescribing, dispensing, and administration. When interrupted, practitioners do not remember where they left off with the task when they return to it. Minimizing unnecessary distractions and interruptions is essential for ensuring patient safety, quality of care, and the healthcare practitioner’s well-being. Sources of Distractions and Interruptions Understanding the types of distractions and interruptions is important to drive appropriate risk-reduction strategies. Distractions may be voluntary, such as scrolling through emails, text messages, social media; multitasking; or socializing. Or they may be involuntary (e.g., hunger, thirst, fatigue). However, interruptions are generally involuntary, such as taking phone calls, answering patient questions, colleagues having a conversation nearby, or responding to electronic health record [EHR] alerts or healthcare device alarms. These contribute to diversion of attention, stress, fatigue, and forgetfulness, and can lead to medication errors. Safe Practice Recommendations: 1. While distractions and interruptions cannot be fully eliminated, organizations should consider the following recommendations to limit them. 2. Define critical tasks. Determine a list of critical tasks that require dedicated time without interruptions. These may include activities such as entering or verifying a medication order, preparing a medication dose, removing medication from an ADC, programming a smart infusion pump, or administering a medication. 3. Improve systems and processes. Identify the sources of common distractions and interruptions and remedy any system issues. Establish systems for the electronic communication of information (e.g., used between nursing and pharmacy) that do not require immediate phone contact. Evaluate the environment where critical tasks are performed and rectify poor environmental conditions (e.g., unnecessary noise, dim lighting). For example, place ADCs in locations with limited foot traffic to reduce distractions. Provide medications to patient care units in ready-to-administer formulations to remove the risk of interruptions while mixing or diluting medications. 4. Limit alerts, alarms, and noise. Reduce the frequency of invalid, insignificant, or overly sensitive computer alerts and device alarms to promote the delivery of necessary critical notifications. Minimize the 24 noise of overhead pages and other unnecessary chatter in areas where medication tasks are being performed. For more information about the impact of sound and noise during the medication-use process, review USP General Chapter Physical Environments that Promote Safe Medication Use. 5. Optimize the phone tree. Establish a triaging system for incoming phone calls to avoid interruptions in designated areas (e.g., sterile compounding room). When possible, have designated ancillary staff (e.g., front desk staff, technician) screen out non-emergent calls in the patient care units and in the pharmacy. 6. Be prepared. To minimize task disruption, ensure that all the supplies that practitioners will need are organized together in medication preparation areas prior to preparing or administering medications. 7. Develop a checklist. Create a checklist of important information for lengthy critical tasks as a reference. When available, utilize guided technologies (e.g., IVWMS with step-by-step procedural capabilities) to ensure staff follow approved medication preparation procedures, and can return to the appropriate step if an interruption occurs. 8. Find the best time. Practitioners should establish set times to address non-urgent questions. If urgent notifications are necessary when practitioners are prescribing, dispensing, or administering medications, others should attempt to intervene during transitions between subtasks, such as between patients or doses being prescribed, prepared, or administered. 9. Manage the use of mobile devices. Educate staff about the risks associated with distractions from the use of mobile devices, and obtain input from stakeholders regarding their appropriate and inappropriate use. Implement a strategy to address appropriate use while minimizing the distraction risks. Any inattentive behavior related to personal use of mobile devices should be treated as an at-risk behavior that requires coaching to promote safe behavioral choices. 10. Educate staff. Warn practitioners not to disturb colleagues completing critical tasks unless significant alteration in a patient’s therapy must be communicated immediately. Embed distractions and interruptions into annual simulation training when practitioners are practicing critical tasks. This targeted training can make staff aware of how distractions and interruptions impact their processes. In one school of nursing where students participated in simulations with high noise levels and varied background noises (e.g., music, conversations), the students found that distractions decreased accuracy in medication preparation and administration.2 For suggestions on how to use simulations, see our May 4, 2023, feature article, The role of simulation when onboarding healthcare professionals—Part II. 11. Manage patient questions. Conduct regularly scheduled bedside rounds to facilitate appropriate times for patients/caregivers to ask questions. Before performing a critical task in front of a patient, practitioners should explain to the patient/caregiver what they plan to do, and provide them with time to ask any questions before initiating the task, when possible. 12. Reassess. After implementing interventions to address distractions and interruptions, directly observe practitioners completing critical tasks, gather feedback from end-users, and provide coaching as needed. Also monitor error reports and reevaluate if additional strategies are needed. 25  DEMENTIA Dementia is a progressive neurological disorder that impairs cognitive function, affecting an individual’s memory, thinking, reasoning, and daily functioning. It is not a single disease but rather an umbrella term that encompasses a range of conditions characterized by the decline of cognitive abilities beyond what is considered normal aging. The condition exerts a great impact not only on individuals but also on their families, caregivers, and society at large. As the global population ages, understanding dementia becomes increasingly essential for nurses. This nursing note discusses into the various aspects of dementia, highlighting its causes, symptoms, diagnosis, medical management, and nursing interventions. What As the patient’s care provider, you need to examine the behavior objectively. The patient may be exhibiting an embarrassing, disruptive or uncomfortable behavior. It is your role as the caregiver to ask yourself, can the actions lead to adverse outcomes? Will the patient’s behavior lead to self-harm or harm to others? You must be able to know what behaviors to let go of, and should avoid correcting, intervening, or escalating the current situation. When Care providers should be aware and continuously assess for patterns or situations, such time of day or certain times of year, that trigger the difficult behavior. If you begin to notice a trigger pattern, make sure to discuss and communicate your findings to the other care team members. You should attempt to avoid topics that can trigger your patient, quickly changing topics when your patient becomes agitated. Where The environmental condition or changes to the environment can bring about difficult behavior. Care providers should be aware of what the patient sees in their environment and try to see from the patient’s perspective. A new smell or unexpected noise, although not noticeable to you, can increase stress and cause agitation to your patient. Why It is important to keep your focus on why the patient is behaving this way and not the actual behavior. Patient behaviors most often are reactions to stressful situations or a sense of loss of control, which as an adult is challenging. Think of yourself in situations where you have no control or lack the ability to communicate or even make your own decisions. How would you react? As humans, regardless of cognitive or physical decline, still have basic needs that need to be met. Remember Maslow’s Hierarchy of needs? Your patient could just be tired, hungry or thirsty, and is unable to communicate his or her needs to you. Meeting an unmet need can resolve the difficult behavior. 26 Clinical Manifestations The following symptoms have been identified with the syndrome of dementia: Memory impairment. Impaired ability to learn new information or to recall previously learned information. Impairment in abstract thinking, judgment, and impulse control. Impairment in language ability, such as difficulty naming objects. In some instances, the individual may not speak at all (aphasia). Personality changes are common. Impaired ability to perform motor activities despite intact motor abilities (apraxia). Disorientation. Patients may feel disoriented regarding their current place, time, o names of persons they are close with. Wandering. Because of disorientation, patients with dementia may often wander from one place to another. Delusions are common (particularly delusions of persecution). The nursing interventions for a dementia client are: Orient client. Frequently orient the client to reality and surroundings. Allow the client to have familiar objects around him or her; use other items, such as a clock, a calendar, and daily schedules, to assist in maintaining reality orientation. Encourage caregivers about patient reorientation. Teach prospective caregivers how to orient clients to time, person, place, and circumstances, as required. These caregivers will be responsible for client safety after discharge from the hospital. Enforce positive feedback. Give positive feedback when thinking and behavior are appropriate, or when the client verbalizes that certain ideas expressed are not based in reality. Positive feedback increases self-esteem and enhances the desire to repeat appropriate behavior. Explain simply. Use simple explanations and face-to-face interaction when communicating with clients. Do not shout messages into the client’s ear. Speaking slowly and in a face-to-face position is most effective when communicating with an elderly individual experiencing hearing loss. Discourage suspiciousness of others. Express reasonable doubt if the client relays suspicious beliefs in response to delusional thinking. Discuss with the client the potential personal negative effects of continued suspiciousness of others. Avoid the cultivation of false ideas. Do not permit the rumination of false ideas. When this begins, talk to the client about real people and real events. Observe the client closely. Close observation of the client’s behavior is indicated if delusional thinking reveals an intention for violence. Client safety is a nursing priority. 27  END OF LIFE CARE Palliative care is specialized medical care for people living with a serious illness, such as cancer or heart failure. Patients in palliative care may receive medical care for their symptoms, or palliative care, along with treatment intended to cure their serious illness. Palliative care is meant to enhance a person's current care by focusing on quality of life for them and their family. Increasingly, people are choosing hospice care at the end of life. Hospice care focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life. At some point, it may not be possible to cure a serious illness, or a patient may choose not to undergo certain treatments. Hospice is designed for this situation. The patient beginning hospice care understands that his or her illness is not responding to medical attempts to cure it or to slow the disease's progress. Like palliative care, hospice provides comprehensive comfort care as well as support for the family, but, in hospice, attempts to cure the person's illness are stopped. Hospice is provided for a person with a terminal illness whose doctor believes he or she has six months or less to live if the illness runs its natural course. Advance Directives A living will is a written, legal document that spells out medical treatments you would and would not want to be used to keep you alive, as well as your preferences for other medical decisions, for example, in the event of brain death or terminal illness. Durable Power of Attorney for healthcare, on the other hand, covers all health care decisions, and lasts only as long as the patient is incapable of making decisions for themselves. However, specific provisions can be declared in the Power of Attorney outlining how the patient wants the agent to act regarding deathbed issues. Type of Advance Directives 1. The Living Will A living will be a written, legal document that spells out medical treatments you would and would not want to be used to keep you alive, as well as your preferences for other medical decisions. The Living Will should address a number of possible end-of-life care decisions, such as: The type of medical treatment a person would accept or refuse Under what conditions an attempt to prolong life should begin or end Pain management Comfort or palliative care Dialysis Organ and tissue donation Donating your body to science Feeding tube, IV fluids, and TPN Mechanical Ventilation Do Not Resuscitate and do not intubate 28 If a person can’t speak for themselves a living will help the attending physician and family understand what interventions the person does or doesn’t want done to prolong life in the event of a terminal illness. If so, stated it can allow doctors to discontinue life prolonging treatment in the case of an incurable illness or a permanent vegetative state (permanent brain damage). If a person has hope of recovery the living will generally does not apply. The living will is a formal legal document that must be in writing. Each state has different forms and requirements for creating legal documents. Depending on where the patient lives, the form may need to be signed by a witness or notarized. Spouses, potential heirs, doctors caring for the patient, or employees of the healthcare facility are usually not allowed to witness the living will, check facility policies. Patients may revoke (end or take back) a living will at any time. A few states will automatically void the living will after a certain number of years. The living will generally applies only when a person is unable to speak for themselves and is terminally ill or permanently brain dead. It also only gives written instructions about certain things that might happen, but it does not cover every healthcare situation that could arise. A living will does not include choosing an agent or proxy to make decisions or ensure that wishes are carried out. 2. Durable Power of Attorney for Healthcare A durable power of attorney for healthcare is a legal document, signed by a competent adult (the principal), designating a proxy (agent) to make healthcare decisions for them ONLY if the principal becomes unable to do so. The proxy can speak with doctors and other caregivers on behalf of the patient and make decisions according to what the patient would want if the patient is unable to do so for themselves. The agent chosen would decide which treatments or procedures the patient would want only in the event that the patient becomes unable to make health care decisions the family, or next of kin, become the health care proxy. 3. “Do Not Resuscitate” Orders A hospitalized patient can add a Do Not Resuscitate (DNR) order to their medical record. This is done when the patient does not want the hospital staff to try to revive them if their heart or breathing stops. A hospitalized patient can also add a Do Not Intubate order. This is done when the patient wants cardio pulmonary resuscitation if their heart stops beating but does not want to be intubated and placed on a ventilator. A patient can have a DNR or DNI order without making a living will or appointing a medial power of attorney. Some hospitals require a new DNR/DNI order each time a patient is admitted. An In- patient DNR/DNI order is only good while the patient is in the hospital. A DNR or DNI order can be revoked by the patient at any time. Even if a patient has a living will which include preferences regarding resuscitation and intubation, it is still a good idea to establish DNR or DNI orders each time patients are admitted to a new hospital or health care facility. An Out of Hospital Do Not Resuscitate (DNR) order is used outside of the hospital. The Out of Hospital DNR is intended for Emergency Medical Service (EMS) teams who answer 911 calls. Even though families expecting a death are advised to call other sources for help, when the patient worsens, a moment of uncertainty sometimes results in a 911 call which can result in unwanted measures that prolong life. The Out of Hospital DNR must be signed by the patient and physician for it to be valid. The order offers a way for patients to refuse the full resuscitation effort in advance, even if EMS is called. 29 Patient Self-Determination Act (PSDA)e Patient Self- The 1990 Patient Self-Determination Act (PSDA) encourages every competent adult of sound mind to decide what type of medical care they want in case they become incompetent and are unable to voice their health care decisions. These preconceived decisions are called advanced directives. The PSDA requires any health care facility receiving funding from Medicare or Medicaid to: Give patients information on their state laws about their rights to make decisions about their care Find out if patients have an advance directive Recognize the advance directive and honor the patient's wishes Never discriminate against patients based on whether they have filled out an advance directive or not The PSDA recommends that everyone create an advanced directive, but no person is required to create an advanced directive. In the event that no advanced directive was made, and a patient becomes unable to make health care decisions the family, or next of kin, become the health care proxy. 30  CULTURAL AND RELIGIOUS CONSIDERATION The health care provider should never make religious and cultural assumptions when providing care. Most religions have a prayer schedule or like to pray with their spiritual leader, Pastor or Priest. It is important to ask the patient what their spiritual beliefs are and if you can contact their spiritual leader, Pastor or Priest to come for prayer. Also ask if they have any special cultural or religious items that they want by their side. Common religious practices include, but are not limited to: Catholics like to have their rosary beads for prayer and participate in mass Baptist might have a cross they like to wear or hold during prayer, and listen to sermons on Sunday Orthodox Jews pray three times a day Muslims pray five times a day facing Mecca Buddhist like time to meditate and chant Some religions require followers to adhere to dietary restrictions. Some common dietary restrictions include: Hindus are often vegetarians Jews adhere to a Kosher Diet t Muslims will refrain from eating pork and some shell fish, and fast during the month of Ramadan Eastern Orthodox will have a yearly 40 day fast when they refrain from eating any meat, dairy, and oil Jehovah’s Witness will not eat any food that contains blood in it Catholics avoid eating meat during Lent Mormons might fast every month for 24 hours Religions and cultures vary on what is acceptable care. Some examples include: Jehovah’s Witness will refuse any blood product Muslims forbid any contact between the opposite gender therefore require same gender care givers Hindus must have a bath every day Proper social interactions and family dynamics varies between cultures. Examples include: Members of Hispanic Ethnicity are very modest. The eldest male makes important decisions in the family, and family and extended family like to remain by the patient to support and help. Members of African American Ethnicity will make eye contact as a sign of respect, and display silence as a sign of distrust. Matriarchs are the leaders of many African American families. Members of Native American Ethnicity usually avoid eye contact as a sign of respect. Individuals will make medical decisions for themselves and speaking loud indicates aggression. Members of Chinese ethnicity will avoid eye contact and be silent to show respect. Questions are disrespectful. Involve the eldest male in decisions. 31  Health Insurance Portability and Accountability Act of 1996 (HIPAA) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA. The HIPAA Security Rule protects a subset of information covered by the Privacy Rule. HIPAA Privacy Rule The Privacy Rule standards address the use and disclosure of individuals’ health information (known as protected health information or PHI) by entities subject to the Privacy Rule. These individuals and organizations are called “covered entities.” The Privacy Rule also contains standards for individuals’ rights to understand and control how their health information is used. A major goal of the Privacy Rule is to make sure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high- quality healthcare, and to protect the public’s health and well-being. The Privacy Rule permits important uses of information while protecting the privacy of people who seek care and healing. Covered Entities The following types of individuals and organizations are subject to the Privacy Rule and considered covered entities: 1. Healthcare providers: Every healthcare provider, regardless of size of practice, who electronically transmits health information in connection with certain transactions. These transactions include: Claims Benefit eligibility inquiries Referral authorization requests Other transactions for which HHS has established standards under the HIPAA Transactions Rule. 2. Health plans: Health, dental, vision, and prescription drug insurers Health maintenance organizations (HMOs) Medicare, Medicaid, Medicare+Choice, and Medicare supplement insurers Long-term care insurers (excluding nursing home fixed-indemnity policies) Employer-sponsored group health plans Government- and church-sponsored health plans Multi-employer health plans 32 Exception: A group health plan with fewer than 50 participants that is administered solely by the employer that established and maintains the plan is not a covered entity. 3. Healthcare clearing houses: Entities that process nonstandard information they receive from another entity into a standard (i.e., standard format or data content), or vice versa. In most instances, healthcare clearinghouses will receive individually identifiable health information only when they are providing these processing services to a health plan or healthcare provider as a business associate. 4. Business associates: A person or organization (other than a member of a covered entity’s workforce) using or disclosing individually identifiable health information to perform or provide functions, activities, or services for a covered entity.These functions, activities, or services include: Claims processing Data analysis Utilization review Billing HIPAA Security Rule While the HIPAA Privacy Rule safeguards PHI, the Security Rule protects a subset of information covered by the Privacy Rule. This subset is all individually identifiable health information a covered entity creates, receives, maintains, or transmits in electronic form. This information is called electronic protected health information, or e-PHI. The Security Rule does not apply to PHI transmitted orally or in writing. To comply with the HIPAA Security Rule, all covered entities must: Ensure the confidentiality, integrity, and availability of all e-PHI Detect and safeguard against anticipated threats to the security of the information Protect against anticipated impermissible uses or disclosures that are not allowed by the rule Certify compliance by their workforce Covered entities should rely on professional ethics and best judgment when considering requests for these permissive uses and disclosures. The HHS Office for Civil Rights enforces HIPAA rules, and all complaints should be reported to that office. HIPAA violations may result in civil monetary or criminal penalties. For more information, visit HHS’s HIPAA website. 33  COMMON MEDICAL EQUIPMENTS USED Please do some research and review some common medical machines being used. Alaris IV Infusion Pump / primary and secondary tubing Kangaroo Enteral Feeding Pump / Nasogastric Tube, Salem Sump PCA Pump Vacutainer for blood collection for lab test Covidien Closed Chest Drainage system (used with chest tubes) Implanted IV access device-Portacath and Huber needle Single, double, and triple lumen central catheters PICC line with StatLock Crash Cart Drugs (Emergency or Bristojet Syringes) EpiPen Closed/Inline suction system used with ventilators Trach Care Kit and Disposable Inner Cannula Finger Pulse Oximeter Jackson Pratt Drain Hemovac Suction Drainage Foley Catheter to Bedside Bag, with StatLock Blood Administration set (including review of procedure) Central Line Dressing Kit Venous Doppler Ultrasound Welch Allyn Connex Vital Signs Monitor HillRom Hospital Bed 34  VIDEO LINKS https://www.youtube.com/watch?v=gG8kh8MfnGY Head to Toe https://www.youtube.com/watch?v=ue96cuS-lNs Starting and IV https://www.youtube.com/watch?v=chEzTAA7a2k Central line dressing change https://www.youtube.com/watch?v=22EYsZiH9WE Kangaroo Pump https://www.youtube.com/watch?v=xe7i999O4_8 Starting a Feeding https://www.youtube.com/watch?v=v4PHCwvkH24 Blood Transfusion https://www.youtube.com/watch?v=DCDYXY9LpSU Bladder Scan for Urinary Retention https://www.youtube.com/watch?v=Td5GV8O75PE Foley Catheter Insertion https://www.youtube.com/watch?v=9pRyoBXAYl0 Foley Catheter Removal https://www.youtube.com/watch?v=_NvNypTKYJE Linen Change https://www.youtube.com/watch?v=iwvnA_b9Q8Y PPE Donning and Doffing 35  POINTERS FOR RETURN DEMONSTRATION 1. Hand Hygiene 2. Introduce yourself to the patient 3. Two patient identifiers 4. Explain procedure (obtain consent if needed) Head-to-Toe Assessment (Discuss and explain normal and abnormal findings using inspection, auscultation, palpation, and percussion) NEURO State of Awareness Eyes (PERRLA) Cranial Nerves CARDIO Chest and Heart Sounds (landmarks to identify some murmurs) EKG Leads placements Point of Maximum Impulse Pulses Capillary Refill Edema Grading RESPI Chest Inspection (shapes) Respiration rate, rhythm, and pattern Normal and Abnormal Breath sounds GI Inspect Shape and Color Auscultate bowel sounds in all 4 quadrants SKIN Discuss staging of Decubitus Ulcer and Common Locations Identify skin color, hygiene, odors. MUSCULOSKELETAL Resistance IV Insertion and Foley Catheter Insertion and Removal (discuss the steps and rationale) SBAR Charting 1. Identify a scenario directly from your own nursing experience in which you had to contact a physician or other healthcare provider to provide optimum care to your patient. 2. Write out an efficient and effective script for communication, using the SBAR technique. 3. Present the script during the feedback meeting. 36  REFERENCES http://www.cancer.org/treatment/findingandpayingfortreatment/understandingfinancialandlegalmatters/advancedirectives /index https://www.americannursetoday.com/assessing-patients-risk-falling/ https://www.ncbi.nlm.nih.gov/books/NBK235613/ https://www.morx.com/assets/docs/FallsAwareness/high%20risk%20med%20list.pdf https://www.jointcommissioninternational.org/6th-edition-in-depth-preventing-falls-in-inpatient-and-outpatient-settings/ http://www.cms.gov/Regulations-and-Guidance/HIPAA- AdministrativeSimplification/HIPAAGenInfo/index.html?redirect=/HIPAAgeninfo/ http://www.HIPAA-101.com/HIPAA-security.htm http://procedures.lww.com. http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdf https://www.cms.gov/Regulations-andGuidance/ http://www.disabilityrightsca.org/pubs/545701.pdf http://www.medscape.com/viewarticle/838521_4 https://www.firstalert.com/us/en/safetycorner/p-a-s-s-the-fire-extinguisher/ https://health.usnews.com/senior-care/articles/dementia-stages 37