I-D - Documentation

1. Documentation:

       Critical care documentation requires a basic understanding of the nursing process
and how to utilize a care plan. All nurses learn how to complete focus notes (FDAR,
SOAPIE). However, some hospitals, including their critical care units, now use
computerized documentation.

1. Electronic Medical Record (EMR)

        An electronic (digital) collection of medical information about a person that is stored
on a computer. An electronic medical record includes information about a patient’s
health history, such as diagnoses, medicines, tests, allergies, immunizations, and
treatment plans. Electronic medical records can be seen by all healthcare providers who
are taking care of a patient and can be used by them to help make recommendations
about the patient’s care. A blank box is offered where additional documentation can be
entered, such as details and other items pertaining to tasks performed.
        A nurse must remember the nursing process, liability, safety, and patient care when
documenting. It is always necessary to “save,” or store.
Note: “If it was not documented, it was not done”
 

1. Withdrawal Medical Treatment Forms:

2. Do not Resuscitate (DNR) - DNR orders are only in effect if the patient does
not have a heartbeat or has stop breathing altogether. This is not applied
when the person is still breathing or undergoing treatment. This is a legal and
ethical bind where written consent is a must

 
A DNR order is not the same as a "do not treat" order. Instead, it simply means that CPR
will not be attempted. Other treatments (such as antibiotics, transfusions, dialysis, or the
use of a ventilator) that may prolong life are still available. These additional procedures
are usually more likely to be successful than CPR, depending on the person's health.
Treatment that maintains the person pain-free for as long as possible.

1. Do not Intubate (DNI) - A DNI or “Do Not Intubate” order means that chest
compressions and cardiac drugs may be used, but no breathing tube will be
placed through mouth into the trachea (windpe0 to help with breathing.
 2. c. Palliative Care - Palliative care is an approach that improves the quality of
life of patients (adults and children) and their families who are facing problems
associated with life-threatening illness.

                Palliative care is explicitly recognized under the human right to health. It should
be  
           provided through person-centered and integrated health services that pay special
attention
             to the specific needs and preferences of individuals
           
GUIDELINES FOR EFFECTIVE COMMUNICATION TO FACILITATE END-OF-LIFE
CARE
 

 Present a clear and consistent message to the family. Mixed messages confuse
families and patients, as do unfamiliar medical terms. The multi professional
team needs to

communicate and strive to reach agreement on goals of care

and prognosis.

 Allow ample time for family members to express themselves during family
conferences. This increases their level of satisfaction and decreases
dysfunctional bereavement patterns after the patient’s death.
 Aim for all (healthcare providers, patients, and families) to agree on the plan of
treatment. The plan should be based on the known or perceived preferences
of the patient. Arriving at such a plan through communication minimizes legal
actions against providers, relieves patient and family anxiety, and provides an
environment in which the patient is the focus of concern.
 Emphasize that the patient will not be abandoned if the goals of care shift
from aggressive therapy to “comfort” care (palliation) Let the patient and
family know who is

responsible for their care and that they can rely on those individuals to be present and
available when needed.

 Facilitate continuity of care. If a transfer to an alternative level of care, such as

a hospice unit or ventilator unit, is required, ensure that all pertinent
information is conveyed to the new providers. Details of the history,
prognosis, care requirements, palliative interventions, and psychosocial needs
should be part of the information transfer.
 1. Collaboration:

     International Patient Safety Goals: (IPSG) - The International Patient Safety Goals
(IPSG) were developed in 2006 by the Joint Commission International (JCI). Health care
professionals have been challenged to reduce medical errors and promote an
environment that facilitates safe practices.

 
 

1. IPSG1 - Identify Patients Correctly

 Using 2 identifiers (Name and ID band)

 Before administering medications, blood, or blood products
 Before providing treatments and procedures
 Policies and procedures support consistent practice in all situations

2. IPSG 2 – Improve Effective Communication

 Complete verbal and telephone order were written down by the receiver
 Read back by the receiver of the order
 Confirmed by the individual who gave the order

3. ISG 3 – Improve the Safety of High Alert Medications

 Medications involved in a high percentage of error and sentinel events

 Medications that carry a higher risk for adverse outcomes
 Look-a like /sounds -a like medications
 Policies and procedures are developed to address the identification, location,
labeling and storage of high alert medications
 The policies and procedures are implemented

4. IPSG 4 -Ensure Correct Site, Correct -Procedure, Correct Patient Surgery

 Uses an instantly recognized mark for surgical site, identification and involves
the patient in the marking process
 Uses a checklist to verify preoperatively the correct site, correct procedure,
and correct patient and that all documents and equipment needed are on
hand, correct, and functional
 The full surgical team conducts and documents a time-out procedure just
before starting a surgical procedure
 Policies and procedures are developed that support uniform process to ensure
the correct site, correct procedures, and correct patient
5. IPSG 5 – Reduce the Risk of Health Care -Associated Infections

 Follow and adapted hand hygiene guideline

 Implements an effective hand hygiene program
 Policies and procedures are developed that support continued reduction of
health care – associated infections (HCAI)

6. IPSG 6 – Reduce the Risk of Patient Harm resulting from Falls

 Implements a process for the initial assessment of patients for fall risk and
reassessment of patients when indicated by a change in condition or
medications
 Measures are implemented to reduce fall risk for those assessed to be at risk.
 Measured are monitored for results, both successful fall injury reduction and
any unintended related consequences.