Policy: NPEOC: Adult Critical Care Standard Of Care

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OHSU Health Care System - Patient Care Services

NPEOC: Adult Critical Care Standard Of Care Effective Date: February 09, 2012 No: HC-PCS-ACC-S001

NURSING PRACTICE EXPECTATIONS OF CARE: START OF SHIFT Shift report 12 hour chart check (Kardex; eMAR; acknowledge all orders; POC; database; IV pump settings with LIP order, med concentration, use of Alaris Guardrails, and admit or dry weight) with RN at shift change. Check that IV fluid bags have time, date, and initials (correct fluid and medication concentration per order/condition) Review eMAR from previous shift Physical Exam Check lines and tubes (tubing to have date/time sticker: 4 days max, 1 day for TPN, IL; 12 hours for Propofol) Label IV tubing at hub w/ name of med infusing Replace field IV’s within 24 hours Zero and level all transducers (CVP, AL, PAP, EVD) Check pacer settings: document sensing threshold and capture threshold Check suction settings (ETT=) before DC central access Date, time, and initial all IV fluids when they are hung; New central lines require completely new drips and tubing (non-contaminated) Change EKG patches q 48 & prn Note spine precautions, C-collar on unless otherwise noted

THINGS TO CONSIDER Bowel program (when was last BM? Document on doc flowsheet) Nutritional status? Is patient receiving optimum calories? Dorsi-flexion boots/hand splints needed? Pulmonary bed needed? Skin care bed needed? Activity orders? PT/OT orders? Other referrals needed? Are they documented on plan of care? Is database complete? Orders for restraints need to be renewed q 24 hours. Vented patients in positive or negative isolation (requiring the doors to be closed) will have their vent alarms turned up to highest level as well as continuous end tidal CO2 monitoring. What have you done this shift to maximize safety for the patient and minimize risk of falls, pressure ulcers, nosocomial infections? Family concerns/issues Family spokesperson delegated? Is social worker needed? Aware of visiting protocol: (ICU visiting hours are 24 hours a day except for 06:30 to 08:30 and 18:30 to 20:30 (NSICU also has quiet time from 1400-1600 & 2400-0200; telephone at door; 2 persons at a time; family to select spokesperson). Does family have copy of ICU phone number, Waiting Room Guide, ICU/Pt information, Pt/ Family teaching forms appropriate to pt. diagnosis?

NEURO ICU SPECIFIC ISSUES: NSICU pager 17014, RT 17013

For the SAH patient or any patient who has had neurosurgery: FLUID BALANCE IS CRITIAL TO HELP PREVENT VASOSPASM AND FLUID OVERLOAD 1. Record weights and cumulative I/Os on the Fluid balance sheet found toward the back of the chart. 2. Euvolemia is the goal for most patients, parameters for fluid balance are usually written in daily NSICU team rounds. 3. Maintain hourly calculations of fluid balance. 4. Call the House Officer (HO) if the patients fluid balance is approaching or at parameters – do not wait until end of shift. Imbalances should be caught and corrected promptly. 5. Also HO if you notice sudden upward trend in UOP. (i.e. >300ml for 2-3 hours) as this could be a sign of Diabetes Insipidus or cerebral salt wasting syndrome. For the patient with an UNSECURED aneurysm: 1. 2. 3. 4. 5.

SBP should always be less than 160 Treat elevated SBP promptly, document in narrative note. Notify HO of elevated SBP especially if it is not responding to current PRN meds. Monitoring fluid balance is critical TCD’s should be ordered and done every day.

For the patient with a SECURED aneurysm: 1. SBP should be less than 180 unless otherwise specified. 2. Fluid balance is critical 3. TCD’s should be ordered and done every day.

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FOR NSICU ROUNDS PLEASE KNOW: 1. 2. 3. 4. 5. 6. 7.

Neuro exam OFF sedation/kind of sedation/pain med Current shift total I/O, past 24hr I/O and admit cumulative I/O. Cumulative I/O should be on “Fluid Balance Sheet”. total hourly fluid intake: IVF+PO+TF+NGT MEDS+IVPB+pressure lines Current Na Level and if pt is on any 3% Na and/or salt tabs or Florinef Seizure history/On SZ meds/recent Dilantin level Invasive lines, dates inserted, site assessments On antibiotics/ which ones/ when started

NA LEVELS 1. 2. 3. 4.

Na+ parameters are usually written in daily rounds normal range is 135-145, and may be maintained on high end of normal of Neuro patients Call HO for NA145 or a significant change from last NA level Pt.s on 3% NaCL should have frequent labs, usually q6 hour Na and K.

CAMINO MONITORS 1. Camino monitors do not need to be leveled or zeroed after insertion 2. Record ICP hourly, calculate and record CPP hourly. Notify HO for CPP 20, Drainage of >20ml/hr, Sudden increase in blood in drainage or frank flood No drainage from EVD for hour. Check patency by lifting drain off holder and briefly lowering to watch for drip. 6. Clamp Ventric prior to suctioning or repositioning patient. 7. Monitor ICP on transport, clamp drain only when actually moving patient from bed. Leave open and leveled when transporting.

Parameters

Policies

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Policy: NPEOC: Adult Critical Care Standard Of Care

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ICU vital signs (Temp, BP, Pulse, RR, SpO2) are monitored and documented Q 2 hours or more frequently as indicated by patient condition. Vital signs post procedure/post surgical will be Q 15 minutes x 4, Q 30 minutes x 2, Q 1 hour x 4 or until baseline is achieved.

VITAL SIGNS

Temperature Source, BP Location, Document Q shift and PRN changes BP Position OXYGEN THERAPY

Document all applicable parameters Q 2 hours and PRN changes

PAIN

Patients must be assessed for the presence of pain within 4 hours of admission. Presence of pain should be assessed and documented Q 2 hours. Document the numeric pain score using the applicable pain scale (Numeric, Faces, Noverbal, PAINAD). Document Pain Location with pain score. Add additional locations if necessary. Pain Interventions If pain level is a 4/10 or greater, interventions should be documented as performed Response To Document within 1 hour of intervention

MAAS Sedation Assessment

Document Q 2 hours

CBG

Document CBG as resulted per insulin protocol; Document CBG Intervention when performed

PRESSURE LINES

Document applicable parameters Q 2 hours or more frequently as indicated by patient condition

HEMODYNAMICS

Perform PA catheter and PiCCO hemodynamic measurements Q 4 hours or more often as ordered or as determined by patient condition. Document pertinent hemodynamic parameters Q 4 hours or more often as patient condition dictates. Calibrate PiCCO Q shift. Do not perform PAWP on CTS patient--use the PAD

PERFUSION & VENTILATION ETCO2 Document Q 1 hour; calibrate Q shift SVO2 Document Q 4 hours; calibrate Q 24 hours with a co-oximeter panel ScVO2 Document Q 4 hours Apnea Duration Document as occurs IABP

Document all IABP parameters Q 1 hour

RN VENT SETTINGS

Document applicable RN vent settings Q4 hours and PRN changes Document when occurs; consider Q 2 hours depending on assessment of presence of abnormal breath sounds; irregular respiratory pattern; presence of secretions; Sx unable to clear secretions; increased coughing; or change in patient appearance. Document sputum color and sputum consistency with suctioning Document Mode, Rate, Stroke Volume, and Flow Q 1 hour then Q 2 hours when stable

Heartmate

Self Test Perform and document Q AM Dressing Change Perform and document as ordered (usually BID at first, then Q day) Filter Change Perform Q week on Monday and document Filter Change Due on Q week on Monday Alarm Document as occurs Action Document as occurs THORATEC

Document all applicable parameters Q 1hour then Q 2 hours when stable. Perform and document all dressing changes as ordered

CARDIAC RHYTHM & INTERVALS

Provide continuous ECG monitoring for all critical care patients unless otherwise noted. Identify and document Cardiac Rhythm Q shift and PRN changes. Continue to post dual lead EKG rhythm strips with interval measurements (PR, QRS, QT, and QTc if applicable) in the Nurse Progress Note Q shift and prn changes

HEIGHT & WEIGHT Ht. Document once on admission

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Wt. Document admission weight and daily weight here Wt Source Document with each weight performed BSA Calculated by EPIC BMI Calculated by EPIC Dosing Weight Document the patient's weight based medication weight Q shift

CRITICAL LAB VALUES LOG

Health care staff will report, read back, and verify results of critical tests or critical results of routine tests in a timely manner, in order to promote patient safety and reduce communication errors. Document all critical lab values and parameters when recieved/reported

KARDEX INFO Unit Draw

Document on admission to ICU--ensure it is answered "YES" to properly print lab labels

Transport-Mobility Document on admission and update PRN changes Transport Needs

Document on admission and update PRN changes--this is how CT, MRI, and other areas determine and order transportation for your patient for road trips

HYGIENE Baths should be performed per unit standards and documented when completed; perineal care should be performed and documented Q shift; catheter care should be Hygiene care performed and documented daily, with stooling and PRN; all other hygiene items should be documented as performed Oral Care

Oral care performed and documented Q 4 hours on intubated/trached patients; oral care performed and documented Q shift for all other patients

Tube care performed and documented Q 24 hours and PRN; brace/cast care performed and documented Q shift and PRN; collar care performed and Site Care documented Q shift and PRN; foley care performed and documented daily, with stooling and PRN; Pin site care performed and documented Q 8 hours the first 72 hours, then Q day; trach care performed and documented Q 4 hours; Activity should be performed per MD order. Document applicable parameters as it occurs.

ACTIVITY

Devices Devices are documented Q 8 hours HOB Documented Q 1 hour if patient is vented/trached; documented Q 4 hours otherwise SAFETY & PRECAUTIONS

All parameters documented Q shift and PRN changes

Room safety check includes monitor alarms (limits, volumes). A comment must be added if alarms are disengaged for an extended period of time; emergency meds; Room Safety Check bag valve mask with face mask; oral airway; 2 suction setups; 2 oxygen flowmeters; BP cuff Bed Alarm Document Q shift and PRN changes Intraabdominal Pressure

Document Q 4 hours or more often as patient condition warrants

INTAKE

Document PO intake as it occurs Nutrition Type Document Q shift and prn changes Meal % Consumed Document prn meals

MAINTENANCE IV Rate Document Q 4 hours and PRN changes Volume Document Q 1 hour to populate I/O IV PIGGYBACK/BOLUS VOLUMES IVPB Document volume as administered to populate I/O IV Bolus Volume Document volume as administered to populate I/O

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BLOOD COMPONENT VALUES

Document all blood component volumes (RBC, Plasma, Plt, Cryo, Granulocytes, Albumin, Humate) as they are administered to populate I/O

OUTPUT

Document all measurable output volumes (urine voided, emesis, measured stoll, blood measured, measured lochia, stool/urine mix, diaper, irrigation out, other) when they occur to populate I/O

OUTPUT ASSESSMENT

Assess and document all outputs (stool consistency, stool color, emesis color/consistency, sputum color/consistency) as they occur

Urine Characteristics

Assess and document as voided OR assess and document Q shift and prn changes if a catheter is in place

UNMEASURABLE OUTPUT

Document all output volumes (lochia, menstruation, incidental loss, blood loss, urine, stool, emesis) as they occur if unmeasurable

CRRT

Document Access P, Filter P, Effluent P, and Return P Q 1 hour Mode Document Q shift and prn changes BFR Document Q shift and prn changes Replacement Rate Document Q shift and prn changes Dialysate Rate Document Q shift and prn changes CRRT Input Document Q 1 hour CRRT Output Document Q 1 hour to populate the I/O

CALORIE COUNT

If calorie count is ordered, document any food item eaten and % eaten PRN

CHEST TUBE

Includes Standard, Pleurx, Wayne, Mini, Blake, Furman CT Status Documented Q 4 hours and PRN changes Cm H2O Suction Documented Q shift and prn changes Fluid Assessment Documented Q 4 hours

Skin/Site Assessment Documented Q 4 hours Dressing Type Documented Q shift and prn changes I/O CT Output Document Q 2 hours or more often as patient condition warrants to populate I/O CSF CATHETER

Includes ICP, Lumbar, EVD. Document all parameters Q 1 hour.

ETT/ORAL AIRWAY

ETT, LMA, Oral, Nasal, HI/LO ETT

Placement (cm) Document Q shift and prn changes Site/Skin Assessment Document Q 4 hours; Retape Q 24 hours; Reposition ETT Q 24 hours Airway Document Q 4 hours If a new epidural, document all parameters Q 1 hour x 4, then Q 2 hours x 4, then Q 4 hours until D/C'd; clear cumulative dose history Q AM at 0600

EPIDURA LDA

Site/Skin Assessment Document catheter entrance site Q 8 hours I/O Volume Infused Document hourly to populate I/O Verification Independent RN verfication Q shift and prn changes, new bag, new concentration GASTRIC/FEEDING TUBE

NG, OG, PEG, DHT, G Tube, J Tube

Site/Skin Assessment Document Q 4 hours Status

Document Q 4 hours and prn changes; confirm placement of NG, OG, DHT prior to each use

I/O Tube Feed (mL) Document Q 1 hour to populate the I/O Tube Feed Rate

Document Q 4 hours and prn changes; change Lopez valve, tubing, and open tube feeding bag Q 24 hours; change closed tube feeding bag Q 48 hours

Tube Feed Bolus (mL) Document as given; flush tubes Q 4 hours and after every use I/O Free Water (mL) Document as given Tube Feed Residuals Document Q 4 hours

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Residuals Refed? Document as occurs Gastric Output Document Q 4 hours to populate I/O Output Quality Document Q 4 hours D/C Reason Document on D/C OSTOMY

Colostomy, ileostomy, ileal conduit Stoma Assessment Document Q 4 hours

Peristomal Skin Assessment Document Q 4 hours Appliance Assessment Change pouch and wafer Q 3 days or PRN leakage Stoma Size Document Q shift Ostomy Output Document Q 4 hours or more often as patient condition warrants. Output Quality Document Q 4 hours Flexiseal--DO NOT discard Flexiseal--it can be rinsed and reused for 29 days from date of original insertion

RECTAL TUBE

Assessment Document Q 4 hours Interventions Irrigate PRN to maintain patency; Change collection bag PRN Skin/Site Assessment DocumentQ 4 hours D/C Reason Document on D/C Rectal Tube Output Document Q 2 hours Output Quality Document Q shift and prn changes SURGICAL WOUND/DRAINS

Blake, Hemovac, JP, Penrose, T Tube, Wound Vac

Skin/Site Assessment document Q 4 hours Drain Assessment Document Q 4 hours Drain Appearance Document Q 4 hours Dressing/Site Care Document Q 4 hours Bag/Cannister Change Document when performed D/C Reason Document on D/C Wound Irrigation Input Document PRN Drain Ouput Document Q 2 hours or more often as patient condition warrants to populate I/O Jackson, Shiley, Bivona, Stoma, Laryngeal trach. Assess and document all parameters Q 4 hours

TRACH Interventions

Trach care performed documented Q 4 hours; change inner cannula Q 4 hours and PRN; change trach ties PRN but do not change the first 72 hours post trach Foley, Temp probe Foley, Tieman, Rob-Nel, Condom, 3-way Irrigation, Nephrostomy, Suprapubic, ureter stent, urostomy

URINARY DRAINS

Site/Skin Assessment Document Q 4 hours I/O Bladder Irrigation In Document PRN Drain Output Document hourly to populate I/O PERIPHERAL LINE Line Status Document Q shift and prn changes IV Assessment Document Q shift and prn changes IV Interventions

Document when performed; change dressings Q 72 hours, gauze dressings Q 48 hours

I/O Saline Flush Volume Document when flushed Q 8 hours and prn Phlebitis Scale Document Q 8 hours Infiltration Scale Document Q 8 hours

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IV D/C Reason Document on D/C CVC, PICC (valved and open), Tunneled CVC (valved and open), Portacath, Arterial Port, PiCCO, Introducer, IO, HD cath, IABP

CENTRAL LINE LDA

Line Status Documented Q shift and prn changes IV Assessment Documented Q shift and prn changes Interventions Documented as performed; zero and level transducer Q shift and PRN I/O Saline Flush Volume

10 mL NS pulsatile flush followed with 3-5 mL 10 units/mL heparin lock Q 8 hours and after each use, documented each time

IV D/C Reason Documented as performed D/C Tip Intact Documented on D/C SUBCUTANEOUS LINE

Pain pump, Pain ball, Insulin pump, PCA, Remodulin Site check Document Q 4 hours

ART LINE Assessment Document Q 4 hours Interventions Document PRN BP correlates with cuff? Document PRN Flush Volume Document Q 1 hour to populate I/O D/C Reason Document on D/C D/C Tip Intact Document on D/C PA CATHETER Assessment Document Q 4 hours Interventions Document as performed cm to Hub Document Q 8 hours Air to Wedge Document Q shift Flush Volume Document Q 1 hour (for I/O) Output Volume Drawn Document Q CO performance D/C Reason Document on D/C Tip Intact? Document on D/C SHEATH LDA

Arterial, Venous Assessment

Document Q 4 hours; when D/C'd, assess and document Q 15 minutes x 4, Q 30 minutes x 2, then Q 1 hour x 2

Interventions Document as performed Flush Volume Document PRN Volume Drawn Out Document PRN D/C Method Document on D/C Tip Intact? Document on D/C EXTERNAL PACEMAKER

Permanent, Transthoracic, Epicardial, Transvenous, Transecho, Transcutaneous

Wire Insertion Point Document Q 8 hours Interventions Document as performed; perform and document threshold testing Q shift and PRN Pace Mode Document Q 4 hours and prn changes Pace Rate Document Q 4 hours and prn changes Atrial mA ouptut Document Q shift Atrial mV Sensitivity Document Q shift Vent mA output Document Q shift

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Vent mV Sensistivity Document Q shift A/V Delay mS Document Q shift Document Q shift - this parameter doesn't make sense CONTINUOUS MEDICATIONS

Check for accurate doses, rates, guardrail programming, and weight

Infusion Dose Document hourly Infusion Rate Document hourly I/O Infusion Volume (mL) Document hourly to populate I/O WOUND

All wounds that are NOT incisions should be included under this heading; Document all parameters Q 4 hours or PRN as patient condition warrants; Document wound care/dressing changes as performed

INCISION

All surgical incisions should be included under this LDA heading; Document all parameters Q 4 hours or PRN as patient condition warrants; document incision care/dressing changes as performed

BURNS

All burns should be included under this LDA heading; Document all parameters Q 4 hours or PRN as patient condition warrants; document burn care/dressing changes as performed

Bibliography: none

Related Forms: none

Supersedes: February 2008

Reviewed: 36 Months

Author: Undeclared

Review Committee: Adult Critical Care Cluster, April 2009

Approved By: Practice Council

Document History: Updated: • February 09, 2012 • July 11, 2010

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