Skills Performance Checklists for Clinical Nursing Skills & Techniques 9th Edition

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i Brief Contents UNIT 9 Oxygenation UNNIITT 11 23 Oxygen Therapy, 627 Suppoorrttiinngg the Patient Through the Health 24 PPerforming Chest PPhysiotherapy, 660 Carree System 25 Airway MMaanagement, 672 11 Using Evidence in Nursing Practice, 1 26 Cardiac Care, 706 22 AAddmmitting,, TTransfer, and Discharge, 12 27 Closed CChest Drainage Systems, 714 33 Communication and Collaboration,, 31 28 Emergency Measures for Life Support,, 735 44 Documentation and Informatics, 51 UNIT 10 UNNIITT 22 Fluid Balance VVitall Siiggnnss and Physical Assessment 29 Intravenous and Vascular AAccess Therapy, 7751 55 VViittaal Signs,, 66 30 Blood Transfusions, 800 66 Health Assessment,, 105 UNIT 11 UNNIITT 33 Nutrition Sppeecciiaall Procedduurreess 31 Oral Nutrition, 819 77 Specimen Collection,, 166 32 Enteral Nutrition, 839 88 Diagnostic Procedures, 213 33 Parenteral Nutrition, 861 UNNIITT 44 UNIT 12 IInfection Control Elimination 9 Medical Asepsis,, 241 34 Urinary Elimination, 873 100 Sterile TTechnique, 256 35 Bowel Elimination and Gastric IInntubation, 9905 36 Ostomy Care, 931 UNNIITT 55 AActtiivityy and Mobility UNIT 13 1111 Safe Patient Handling,, TTransfer, and Positioning, 271 Care of the Surgical Patient 1122 Exercise and Mobilityy,, 292 37 PPreoperative and PPostoperative Care, 9945 133 Support Surfaces and Special Beds, 322 38 Ilntraoperative Care, 978 UUNNIITT 66 UUNNIITT 1144 Safetyy and Comfort DDressings and Wound Care 14 Patient Safetyy,, 339 39 Pressure IInjuryy Prevention and CCare, 990 155 DDisaster Preparedness,, 367 40 Wound Care and Irrigation, 1012 166 Pain Management,, 389 41 Dressings, Bandages, and BBiinders, 11039 17 Palliative Care,, 423 42 Therapeutic Use of HHeat and CCold, 10677 UNNIITT 77 UNNIITT 1155 Hyygiene Home Care 1188 Personal Hyygiene and Bed Making,, 441 43 HHome Care Safety, 1085 199 Care of the Eyye and Earr,, 484 44 HHome Care Teaching, 1108 UUNNIITT 88 AAPPPPEENNDDIIXXEESS Medicattiioonnss A NANDA Definitions from Nursing Diagnoses: Deffiinnitions 2200 Safe Medication Preparation, 501 2211 Nonparenteral Medications,, 521 and Classification 2015-2017, 10th Edition, 1147 2222 Parenteral Medications,, 575 B Common Prefixes and Sufffixes, 1153

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9th Edition Clinical Nursing Skills & Techniques Anne Griffin Perry, RN, MSN, EdD, FAAN Professor Emerita School of Nursing Southern Illinois University-—Edwardsville Edwardsville,, Illinois Patricia AA. Poottter, RN, MSN, PhD, FAAN Director of Research Patient Care Services Barnes--JJewish Hospital St.. Louis,, Missouri Wendy R. Ostendorf, RN, MS, EdD, CNE Professor of Nursing NNeumann University Aston,, Pennsylvania SSEECCTTIIOONN EEDDIITTOORR Nancy Laplante, PhD,, RN, AHN-BC Associate Professor of Nursing School of Nursing WWidener University Chester,, Pennsylvania ELSEVIER

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AAss aallwwaayyss,, tthhiiss bbooookk is ddeeddiiccaatteedd ttoo mmyy cchhiillddrreenn.. TToo bbee tthheeiirr mmootthheerr bbrriinnggss mmoorree jjooyy,, hhoonnoorr,, aanndd sseennssee ooff pprriiddee tthhaann II ccoouulldd hhaavvee eevveerr iimmaaggiinneedd.. TThheeyy aanndd tthheeiirr lloovveedd oonneess aarree ttrruullyy mmyy sshhiinniinngg ssttaarrss.. AAss tthheeyy ggrrooww,, tthhiinnggss cchhaannggee,, aanndd II nnooww ddeeddiiccaattee tthhiiss bbooookk ttoo:: MMyy ddaauugghhtteerr,, RReebbeeccccaa LLaacceeyy PPeerrrryy BBrryyaann;; hheerr hhuussbbaanndd,, RRoobbeerrtt DDoonnaalldd BBrryyaann;; tthheeiirr tthhrreeee ddaauugghhtteerrss,, CCoorraa EElliizzaabbeetthh BBrryyaann,, AAmalie MMaarry Bryann, aand NNoelle AAnne Bryan; aanndd tthheeiirr ssoonn,, SShheepphheerrdd CChhaarrllees Brryyaann;; AAnndd ttoo mmyy ssoonn,, MMiittcchh PPeerrrryy--CCooxx;; aanndd hhiiss hhuussbbaanndd,, SSaammuueell PPeerrrryy--CCooxx.. Anne Griffin Perry II wwiisshh ttoo ddeeddiiccaattee tthhiiss nneeww eeddiittioonn ooff oouurr tteexxttbbooookk tto tthhee eexxcceeppttiioonnaall prrooffeessssiioonnaall nurses at Barnes-Jewish Hospital.. It has been my privilege to have worked with so many talented people. TThheeyy ccoonnttiinnuuee ttoo iinnssppiirree mmee eeaacchh ddaayy.. Patricia AA.. Potter FFoorr TToobbaa aanndd HHaarrrriiss,, wwhhoo nneevveerr ssaaww tthhiiss aacchhiieevveemment buutt wouldd bbe proud of its influence onn todayy'’s aand tomorrow'’s nurses.. And,, as always, for my always supportive and patient husband. Wendy R. Ostendorff

vi About the Authors AANNEE GRIFFFFIN PPERRYY,, RN,, MSN,, EdD,, FFAAAN presented numerous papers at conferences across the United States and internationally. She was one of a few key consultants on DDrr.. AAnnnne GG.. Perryy,, Professor Emerita at Mosby’'s Nursing Video Skills and Mosby’'s Nursing Skills Online. SSoouutthhern Illinnois UUnniversityy-—Edwards­- vviillllee,, iis aa FFeelllloow in tthe AAmerican Academyy Dr. Perry is passionate about nursing education and has been ooff NNuurrssiinngg.. Shee received her BSN from the involved in education since 1973, ffiirst as an instructor and then UUnniivveerrssiittyy ooff MMiichigan, hher MSN from achieving the rank of Professor and assuming various leadership SSaaiinntt LLoouuiis UUnniversityy,, and her EdD from roles at Saint Louis University School of Nursing. She was a Profes-­ SSoouutthheerrnn Illliinnooiiss UUnniivversityy-—Edwards­- sor and Associate Dean and Interim Dean at Southern Illinois vviillllee.. DDrr.. PPeerryy iis a pprrolifiicc aanndd iinnfflluueennttiiaall University-—Edwardsville. As a clinician and researcher, Dr. Perry'’s authhoorr aannd sppeeaakkeerr.. AAn author for more contributions to pulmonary nursing and nursing language develop-­ thaann3355 yyeeaarrss,, hheer workk includes four major ment involve both research and policy making. She has investi-­ textbooks ((EEsssseennttiiaallss forr NNursinngg Practice,, gated and published ffiindings regarding topics that include weaning FFuunnddaammeennttaallss ooff NNuurrssing,, NNuurrssiinngg IInntteerrvveennttions & Clinical Skills,, and from mechanical ventilation, use of the therapeutic intervention CClliinniiccaall NNuurrssiinngg SSkkiillllss & TTechniqquueess)) and numerous journal articles,, scoring system, critical care, and validation of nursing diagnoses. abstraaccttss,, aanndd nnuurrssiinngg researchh and educatiioonn grants.. She has PPATRICIA A.. PPOTTER,, RN,, MMSN,, PPhhD,, FAAN School of Nursing and Saint Louis University. She entered into a DDrr.. PPaattrriicciiaa Potter received her BSN at the variety of managerial and administrative roles, ultimately becom-­ UUnniivveerrssiittyy ooff WWashington in Seattle and ing the director of nursing practice at Barnes-Jewish Hospital. In hheerr MSN and PhD at SSaint Louis Univer­- ssiittyy iinn St.. LLoouuiiss,, Missouurrii.. A groundbreak­- that capacity she sharpened her interest in the development of iinngg aauutthhoorrffoorr mmoorree tthhan 3300 yyears,, her work iinnccluuddees ffour mmaajjor tteexxttbbooookks ((EEssssentials for nursing practice standards and the measurement of ppatient oout-­ NNuurrssiinngg PPrraaccttiiccee,, Funddaammeennttaallss of NNursing,, comes in deffiining nursing practice. Her most recent passion has NNuurrssiinngg IInntteerrvveennttiioonnss & Clinical Skills,, and been in the area of nursing research, speciffiically cancer ffaamily CClliinniiccaall NNuurrssiinngg Skillss & TTechniques)) and caregiving, the cancer patient symptom experience, ffaall preven-­ publliiccaattiioonnss iin numerouuss professionall jour­- tion, and the effects of compassion fatigue on nurses. Recently Dr. nnaallss.. SShhee hhaas bbeeeenn an unceasing advocate ooff eevviiddeennccee--bbaasseedd practtiiccee and qualityy improvement in her roles Potter has worked with colleagues to develop an inpatient Innova-­ aass aaddmmiinniissttrraattoorr,, eedduuccaattoorr and,, more recentlyy,, director of research. tion Unit, which is designed to incorporate current evidence into DDrr.. Potter hhas devoted a lifetime to nursing education, practice, the selection and development of a unique work team and the aannd researchh.. SShhee ssppeenntt a decadee teaching at Barnes Hospital creation of a care delivery model and innovative care practices. Dr. Potter is currently a director of research for patient care services at Barnes-)Jewish Hospital. WENDYY RR.. OOSSTENDDOORRFF,, RN,, MS,, EdD,, CNE Skills and Clinical Nursing Skills & Techniques. She has presented more than 25 papers at conferences at the local, national, and DDrr.. WWenddyy RR.. Ostendorf received her BSN international levels. ffrroomm VViillllaannova UUniversityy,, hher MS from thee UUnniivversityy ooff Delaware,, and her EdD Professionally, Dr. Ostendorf has a diverse background in pedi-­ ffrroomm thhee UUnniiversityy of SSarasota.. She cur­- atric and adult critical care. She has taught at the undergraduate rentlyy sseerrvvees aas aa pprrooffeessor of nursing in the DDiivviissiioonn ooff NNuurrssiinngg aanndd HHeeaalltthh SScciieenncceess aatt aanndd ggrraadduuaattee lleevveellss ffoorr 3355 yyeeaarrss.. WWiitthh ddeeccaaddeess ooff pprraaccttiiccee aass aa cclliinnii-­ Neuummaannnn Univerrssiittyy iin AAsston,, Pennsylva­- cian, her educational experiences have infflluenced her teaching nniiaa.. SShhee hhaas ccoonntributed more than 30 philosophy and perceptions of the nursing profession. Dr. Osten-­ cchhaapptteers to mmuullttiipplle nursing textbooks dorf'’s current interests include the history and image of nursing as and hhaass sseerved as author for two major it has been represented in ffiilm.. Most recently she was a co-primary tteexxttbooks:: NNuurrsing IInntteerrventions & Clinical research investigator on this topic. vvii

vii Contributors Lori Klingman,,MSN,,RN Nurse Educator/Faculty Advisor Michelle Aeberssoolldd,, PhD,, RN,, CHSE,, FAAN Ohio Valley Hospital McKees Rocks, Pennsylvania Clinical Associate Professor DDiirreeccttoorr,, Simulation and Educational Innovations Stephen D. Krau,,PhD,,CNE UUniversity of MMiichigan School of Nursing Associate Professor Ann AArrbboorr,, MMiicchhigan School of Nursing Vanderbilt University Medical Center Marianne BBanas,, MSN,, RN,, CCTN,, CWCN Nashville, Tennessee SSttaafff NNurse UUniversity of Chicago Hospitals Carol Ann Liebold,,RN,,BSN,,CRNI CChhiiccaaggo,, Illinois President/Owner CarolAnn Liebold, Inc. Hope VV.. Bussenius,, DNNPP,, APRN,, FNP-BC Earlton, New York Assisttaanntt PPrrofessor Nelll Hoddgson WWoodruffff School of Nursing Nelda K. Martin,,RN,,ANP-BC,,CCNS EEmmoory UUnniivversity Adult Nurse Practitioner/Clinical Nurse Specialist Atlanta,, GGeeorgia Heart and Vascular Center Barnes-Jewish Hospital at Washington University Medical Janice C.. Colwell,, RN,, MS,, CWOCN,, FAAN Advanced Practice Nurse,, Ostomy and WWound Care Center DDeeppaartment of SSuurgery St. Louis, Missouri TThee UUnniivveersity of Chicago MMeedicine CChhiiccago,, Illinois Kristen L. Mauk,,PhD,,DNP,,RN,,CRRNN,,GGCNS-BC,, GNP-BC,,ACHPN,,FFAAN Jane FFeelllloowws,, MSN,, CWOCN WWound/Ostomy CNS Professor of Nursing Advanced Clinical PPrractice Director, RN-BSN and MSN programs DDuukke UUniversity HHealth System Colorado Christian University; Durham,, NNorth CCarolina President, International Rehabilitation Consultants/Senior Care Sussan JJaane Fetzer,, BA,, BSN,, MSN,, MBA,, PhD Central Profeessssoorr Ridgway, Colorado Department of Nursing Angela McConachie,,FNP,,DNP CCoolllleeggee of HHealth and Human Services Assistant Professor UUniversity of New Hampshire Faculty DDuurrham,, NNew Hammppsshhiirree Goldffaarb School of Nursing at Barnes-Jewish College St. Louis, Missouri Paula Grayy,, DNPP,, CRNPP,, NP-C DDiirreeccttoorr,, FFaammiily (Individual Across the Lifespan)) CRNP Jennifer Painter,,MSN,,APRN,,CNS,,RN-BC,, OCN,,AOCNS Program CCllinical Assistant Professor of Nursing Stafff Education Specialist WWiiddeener University School of Nursing Nursing School/Faculty Afffiiliations Coordinator CChheesstteerr,, Pennsylvania Student Nurse Extern Program Coordinator Nursing Development and Education Stepphhanie Jeffers,, PhD,, RN JIIonnhssttniittuuHttee. Affoomrr mLLeeoaanrrnnEiinndugg,,caLLteeiaoaddneeCrrsshehniippt,e, r&& DDeevveellooppmmeenntt ((iiLLeeaadd)) WAWAssiissddiisesettnnaaenenrttUPPrnrooifvfeeessrsssooirtry School of Nursing Newark, Delaware CChheesstteerr,, Pennsylvania Ann Petlin,,RN,,MSN,,CCNS,,CCCRNN--CCSC,, Alaine Kammm,, BSN,, MSN ACNS-BC,,PCCN Nurse Practitioner Clinical Nurse Specialist GGeneral Surgery Cardiothoracic Surgery TThee UUnniivveersity of CChhicago Medicine Barnes-)Jewish Hospital CChhicago,, Illinois St. Louis, Missouri vii

-viii CCOONNTTRRIIBBUUTTOORRSS Amyy Spencer, MSN, RN-BC Staff Development Specialist Therresa Pietsch,, PhD,, RNN,, CRRRNN,, CNE Christiana Care Health Systems Assssoocciiattee PPrrooffeessssoorr Newark,, Delaware NNeeuummaann Universsiittyy Asttoonn,, Pennsyllvaanniiaa C.J. Wright-Boon, RN, MSN Assistant Professor Diane Rudolphi,, MMSS,, RNN Saint Francis Medical Center College of Nursing Mastteerr Instructor Peoria,, Illinois UUnniiversity ooff DDelaware Scchool of Nursing NNeewark,, DDeellaware Rita Wunderlich, RN, PhD, CNE Associate Professor Jacqueline Rayybuck Saleebyy,, PhD,, RN,, BCCS Catherine McAuley School of Nursing AAssssoociate PPrrooffeessssoorr Maryville University CCaatthheerriine McAuley School of Nursing St. Louis, Missouri MMaarryyvviillllee Univveerrssiittyy SStt.. Louiss,, Missouri Felicia Schapss,, MMSSNN-Ed,, BSSNN,, RN,, CRNI,, OCCNN,, CNSC,, lIggCCNN Direeccttoorr oof NNuurrssiinngg OOperations BBioScrip,, IInncc.. WWashingttoonn,, D.C.. CCOONNTTRRIIBBUUTTOORRSS TTOO PPRREEVVIIOOUUSS EEDDIITTIIOONNSS WWee wwoouulld lliikkee tto acknnoowwledge the following ppeople who contributed to previous editions of Clinical Nursingg Skills & Techniques. JJeeaannnneettttee AAddaammss,, PhDD,, MSN,, APRN,, Deborah OOldenburg Erickson,, RN,,BSN, Mary Kay Macheca,,MSN(R),,RN,,CS,, CRNI MSN ANPP, CDE DDeellllaa AArriiddgee,, RN,, MSN Debra Farrell,, BSN,, CNOR Jill Feldman Malen,,RN,,MS,,NS,,ANP EElliizzaabeth A. AAyyeelllo,, PhD,, MS,, BSN,, RN,, Linda Fasciani,, RN,, BSN,, MSN Mary K. Mantese,,RN,,MSN CS,, CWWOOCN JJane Fellows,, RN,, MSN,,CWOCN Elizabeth Mantych,, RN,,MSN SSyyllvviiaa KK.. BBairdd,, BBSN,, MM Susan JJane FFetzer,, RN,, BA,, BSN,,MSN, Tina Marrelli, MSN,,MA,,RN NNiiccoollee BBaarrttooww,, RN,, MSN MBA,, PhD Nelda K. Martin,, APRN,, BC, CCNS,, Margaarreett BBennzz,, RN,, MSN,, CSANP Cathy FFllasar,, MSN,, APRN,, BC,,FNP ANP BBaarrbbaarraa JJ.. BBeerrggeerr,, MSN,, RN Marlene S.. Foreman,, BSN,, MN,,RNCS Kristin L. Mauk,,PhD,,DNPP,,RN,,CRRN,, LLynda!l GGuueenntthheerr Brand,, RN,, BSN,, MSN Carol PP.. Frayy,, RN,, MA GCNS-BC, GNP-BC,,FAAN Mary Mercer,,RN,,MSN Peggy BBrreecckkiinnrriidge,, RN,, BSN,, MSN,, FNP Leah WW.. Frederick,, RN,, MS,,CIC Rita Mertig,,MS,,BSN,,RNC,,CNS Kathleen Gerhart-Gibson,,MSN, RN, Norma Metheny, PhD,,MSN,,BSN, VVicttoorriiaa M.. Brownn,, RN,, BSN,, MSN,, PhD GGiinnaa Buffee,, RRNN,, BBSSN,, MSN(R)),, PhD,, CS CCRN FAAN Mary Dee Miller,,RN,,BSN,,MS,,CIC Gaallee Carllii,, MSNN,, MHedd,, BSNN,, RN Paula Goldberg,, RN,, MS,, MSN Sharon M.J. Muhs,,MSN,,RN Kathleen Mulryan,,RN,,BSN,,MSN EElllleenn CCaarrssoonn,, PhhDD Thelma HHalberstadt,,EdD, MS, BS, RN Lynne M. Murphy,,RN,,MSN MMaauurreeeenn CCaarrttyy,, MSNN,, OOCN Amy Hall,, PhD,, MS,, BSN,, RN Elaine K. Neel, RN, BSN,,MSN AAuurreellie CChhiinn,, RN,, MSN Roberta L.. Harrison,, PhD,,RN, CRRN Meghan G. Noble,,PhD,,RN MMaarryy FF.. CCllaarke,, MA,, RN Linda C.. Haynes,, PhD, RN Marsha Evans Orr, RN,,BS,,MS,,CS JJaanniice CC.. CCoollwwell,, RN,, MS,, CCWWOOCN Diane Hildwein, RN, BC,, MA Pamela L. Ostby,,RN,,MSN,,OCN® CChhaarrlene CCoommpphheerr,, PhD,, RD,, CNSC,, Maureen B.. Huhmann,, MS,, RD Dula FF. Pacquiao,,EdD,,RN,,CTN Nancy C.. JJackson,, RN, BSN,,MSN,, Jeanne Marie Papa, MBE,,MSN, ACNP- LLDN,, FFADA KKeellllyy JJoo CCoonnee,, RN,, BBSSNN,, MS,, PhD,, CNE CCRN BC,,CCRN Dorrootthhyy MMccDonnell Cooke,, RN,, PhD Ruth L.. JJilka,, RD,, CDE EEiilleeeenn CCostantinou,, RRN,, BBSN,, MSN Teresa M. JJohnson,, RN,, MSN,, CCRN Sharon Phelps, RN,BSN,MS SShheeiillaa A.. Cunnniingghhaamm,, RN,, BBSN,, MSN JJudith Ann Kilpatrick, RN,, DNSC SCChaaatthhroeenrriinnPeeheAAlp.. sRR, ooRbbNiinn,ssBoonSn,N, BB, AAM,,SRRNN Judith Roos,,RN,, MSN Pamela A. Cupec,RN,MS, ONC, CRRN, Carl Kirton,RN,BSN,MA,CCRN, Mary Janne RRuhlanndd,, MMSSNN,,RRNN,,BBCC PamAAeCClaMMA. Cupec, RN, MS, ONC, CRRN, CarAAl CCKRiRrtNNo,n, A,ARNNNPP, BSN, MA, CCRN, JJaann RRuummffeelltt,,RRNNCC,, MMSSNN,,EEddDD RRuutthh CCuurrcchhoe,, RRNN,, MSN,, CIC Lori Klingman, MSN,, RN Jacqueline Raybuck Saleeby,,PhD,,RN,,CS RRiicckk DDaanniieellss,, RNN,, BBSN,, MSN,, PhD Marilee Kuhrik, RN, MSN,, PhDD Linetttte MM.. SSaarrttii,,RRNN,,BBSSNN,, CCNORR MMaarrddeellll DDaavviiss,, RRNN,, MMSSNN,, CCEETTNN NNaannccyy SS.. KKuuhhrriikk,, RRNN,, MMSSNN,, PPhhDD PPhhyylllliiss AAnnnn SScchhiiaavvoonnee,,MMSSNN,,CCRRNNPP CCaarroollyynn RRuuppppeell d'’AAvis,, RN,, BSN,, MSN Diane M.. Kyle,, RN,, BSN,, MS LLooiiss SScchhiicckk,,MMNN,,MMBBAA,,CCPPAANN,,CCAAPPAA PPaattrriicciiaa A.. DDeetttteennmmeeiieerr,, RN,, BSN,, Nancy Laplante, PhD,, RN,, AAHHNN--BC KKeellllyy MM.. SScchhwwaarrttzz,,RRNN,,BBSSNN LLoouuiissee KK.. LLeeiittaaoo,, RRNN((cc)),, BBSSNN,, MMAA AApprriill SSiieehh,, RRNN,, BBSSNN,, MMSSNN MMSSNN((RR)),, CCCCRRNN GGaaiill BB.. LLeewwiiss,, RRNN,, MMSSNN WWaannddaa CClleevveellaanndd DDuubbuuiissssoonn,, BBSSNN,, MMNN RRuutthh LLuuddwwiicckk,, PPhhDD,, MMSSNN,, BBSSNN,,RRNNCC,, SShhaarroonn JJ.. EEddwwaarrddss,, RRNN,, MMSSNN,, PPhhDD MMaarrtthhaa EE.. EEllkkiinn,, RRNN,, MMSSNN CCNNSS

CCOONNTTRRIIBBUUTTOORRSS -ix Marlene Smith,, RN, BSN, MEd Lynn TTier, RN, MSN, LNC Pamela E. Windle, MS, RN, NE-BC, JJulie S. Snyderr,, MSN, RNC Nancyy Tomaselli,, RN, MSN, CS, CRNPP, CPAAN, CAPA, FAAN Laura Sofiieelldd,, MMSSN,, AAPPRN,, BC Sharon Souterr, MSN, BSN CWWOCN, CLNC Terry L. Wood, PhD, RN Marrtha AA. Spies, RN, MSN Riva TTougerr-Decker, PhD, RD, FADA PPaattricia H. Worthington, MSN, RN, Paula Ann Stangeland, PhD, RN, CRRN Anne Falsone VVaughan, MSN, BSN, Patricia AA. Stockert, RN, BSN, MS, PhD CNSC E. Bradleyy Strecker, RN, PhD CCRN Rita Wunderlich, PhD(C), MSN(R), VVirrgginia Strootman,, RN MS CRNI Cynthia VVishyy, RN, BSN Sandra Ann Szekely, RN, BSN Pamela Becker Weilitz, MSN(R), RN, CS, CCRN DDonna L.. TThompson, MSN, CRNPP, ANP Rhonda Yancey, BSN, RN FNP-BC, CCCN JJoan Domigan Wentz, MSN, RN Laurel Wiersema,, RN, MSN Valerie Yancey, PhD, RN, HNC, CHPN

x Reviewers Yvette Egan,, RN,,BSN,, MS CClliinniiccaall AAssssiissttaanntt PPrrooffeessssoorr Michelle Aebbeerrssoolldd,, PhD,, RN,, CHSE,, FFAAN UUnniivveerrssiittyy ooff WWiissccoonnssiinn MMaaddiissoonn SScchhooooll ooff NNuurrssiinngg CClliinniiccaall AAssssoocciiaattee PPrrooffeessssoorr UUnniversity of WWiissccoonsin DDiirreeccttoorr,, SSiimmuullaattiioonn aanndd EEdduuccaattiioonnaall IInnnnoovvaattiioonnss MMaaddiissoonn,, WWiissccoonnssiinn UUnniivveerrssiittyy ooff MMiicchhiiggaann SScchhooooll ooff NNuurrssiinngg AAnnnn AArrbboorr,, MMiicchhiiggaann Amber Essman,,DNP,,MSN,,FNP-BC,,CNE VViissiittiinngg PPrrooffeessssoorr,, RRNN ttoo BBSSNN OOnnlliinnee PPoossttlliicceennssuurree PPrrooggrraamm Margarrett Barrnness,, DNPP,, MSN,, RN CChhaammbbeerrllaaiinn CCoolllleeggee ooff NNuurrssiinngg AAssssiissttaanntt PPrrooffeessssoorr GGrroovvee CCiittyy,, OOhhiioo IInnddiiaannaa WWeesslleeyyaann UUnniivveerrssiittyy MMaarriioonn,, IInnddiiaannaa Margaret M. Gingrich,,RN,,MSN,,CRNP Professor of Nursing Karreenn BBeennjjaamin,, RN,, MSN Harrisburg Community College RRNN EEdduuccaattoorr Harrisburg, Pennsylvania UUnniivversityy ooff WWyyoommiinngg LLaarraammiiee,, WWyyoommiinngg Karen FF. Gonzol,,BSN,,MSN,,RN RReettiirreedd Nakkiia Best,, MSN,, RN EElleeaannoorr WWade Custer Scchhoool of Nursing PPhhDD SSttuuddeent/TTeeaching Fellow Shenandoah University UUnniivversityy ooff NNoorrth CCaarroolliinna CChhaappel Hill School of Nursing Winchester, Virginia CChhaappeell HHiillll,, NNoorrtthh CCaarroolliinnaa TTeresa J. Green,,MSN,,RN,,FNP-BC AAnnnnaa M.. BBrruucchh,, RNN,, MSSNN AAssssoocciate Professor of Nuurrssiinng Nuurrssiinngg PPrrooffeessssoorr Moorrehead SSttate UUniversity IIlllliinnooiiss VValley CCoommmmuunnity CCoolllleege Morehead, Kentucky OOgglleessbbyy,, IIlllliinnooiiss Jacqueline Guhde,,MSN,,RN,,CNS JJeennnniifferr AA.. BBrruunnwwoorrtth,, MSN,, RN Senior Instructor CCoooorrddiinnaattoorr,, NNuurrssiing LLeeaamrniinng LLaabb University of Akron CClliinniiccaall AAssssiissttaanntt PPrrooffeessor of Nursing Akron, Ohio MMaarryyvviillllee UUnniivveerrssiittyy SStt.. Loouuiiss,, MMiissssoouri Kandi Hudson,,EdD,,RN,,CMSRN,,CNE Associate Professor Paattrriicciia C.. Buchseell,, RN,, MSN,, OCN,, FFAAN TT he Community College of Baltimore County—-Essex Campus CClliinniiccaall IInnssttrruuccttoorr Baltimore, Maryland SSeeaattttllee UUnivveerrssiittyy ooff Nursiinngg SSeeaattttllee,, WWaasshhiinnggttoonn Vickey Keathleyy,, BSN,,MSN,,RN ABSN Clinical Nurse Educator Kimberlyy CClleevveennggeerr,, EdD,, MSN,, RN,, BC Duke School of Nursing AAssssoocciiaattee PPrrooffeessssoorr off NNuurrssiinngg Durham, North Carolina MMoorreehheeaadd SSttaatte UUnniivveerrssiittyy MMoorreehheeaadd,, KKeennttuucckkyy Christina D. Keller,,RN,,MSN,,CHSE Instructor Eileeeenn CCoossttaantinou,, MSN,, RN,, BC Radford University Clinical Simulation Center PPrraaccttiiccee SSppeecciiaalliisstt//SSeenniioorr CCoooorddiinnaattoorr Radford University BBaarrnneess--JJeewwiisshh HHoossppiittaall RRaaddffoorrdd,, VViirrggiinniiaa St. Louis, Missouri Lori L. Kellyy,, BSN,, MSN,,MBA St. Louis, Missouri Associate Professor of Nursing Aquinas College School of Nursing HHoolllyy Diesell,, BAA,, BSN,, MSN,, PhD Nashville, TTennessee AAssssoocciiate PPrrooffeessssoorr GGoollddffaarrbb SScchhooooll ooff Nursiinngg aat BBaarrnnes--JJewish College PPaattrriicciiaa TT.. KKeettcchhuumm,,MMSSNN SStt.. Loouuiiss,, MMiissssoouri Director of Nursing Laboratories and Lecturer in Nursing Oakland University School of Nursing JJuulliiee EEddddiinnss,, MMSSNN,, AAGG--AACCNNPP--BBCC,, CCRRNNII Rochester, Michigan OOrrtthhooppeeddic RReeccoonnssttrruuccttiioon NNuurrssee Practitioner BBaarrnneess--JJeewwiisshh HHoossppiittaall SStt.. Loouuiiss,, Missssoouurrii Xx

Vicky J.. King,, RRN,, MS,, CNE RREEVVIIEEWWEERRSS -xi NNursing FFaculty Lynette Tanaka, MSN, RN Cochise College Assistant Teaching Professor SSierra VVista,, Arizona College of Nursing University of Missouri—-SSt. Louis Jean LaFollette,, RN, BSN,, MSN SSt. Louis, Missouri Instruccttoorr,, Familyy Health and Communityy Health Nursing SSouthern Illinois Universityy-—Edwardsville Lynne L. Tier, MSN, RN Assistant Director ofSSimulation Edwardsville, Illinois Adventist University of HealthSSciences Orlando, Florida Diana R.. Magerr,, RN,, BSN, MSN, DNPP, Board Certified Home Healthh Nursing Heidi Tymkew, PT, DPT, MHS, CCS ClinicalSSpecialist Assistant Professor Barnes-J)ewish Hospital, Department of Rehabilitation Fairfiieelldd UUnniivveerrssiittyySScchhooooll oof NNuurrssiinngg SSt. Louis, Missouri Fairfiieelldd,, CCoonnnneeccttiiccuutt Susan A. Wheaton,, RN, BSN, MSN Shheila Matye,, DNPP, CNE Lecture/Learning Resource Director WWeb Developer and Manager of Curriculum & Instruction University of Maine Orono, Maine Chamberlain College of Nursing Downers Grove,, Illinois Paige D. Wimberley, PhD, APRN, CNNSS-BC, CNE Associate Professor of Nursing Janis Longfield McMillan,, RN,, MSN,, CNE ArkansasSState University Assistanntt Clinical Professor Jonesboro, Arkansas Northern Arizona Universityy Flagstaff,, Arizona Aimee Woda, PhD, RN, MSC Assistant Professor Sarahh Newwtton,, PPhhD,, RN Marquette University Milwaukee, Wisconsin Director of Undergraduate Programs SSchool of Nursing Lea Wood, DNNP, MS(N)}, BSN-RN Director ofSSimulation/Assistant Teaching Professor Oakland Universityy University of Missouri RRoochester, Michigan Columbia, Missouri Rebecca Otten,, EdD, MSN, BAHA,, RN Jean Yockey, MSN, FNP, CNE Associate Professors,, Coordinator Pre-Licensure Programs Assistant Professor CaliforniaSState Universityy, Fullerton University ofSSouth Dakota Vermillion,SSouth Dakota Fullerton, California Melody Ziobro, RN, MS PPatrricia PPence,, BSN, MSN, PPhhD Assistant Professor of Nursing MorrisvilleSState College Nursing Professor Morrisville, New York Illinois VValleyy Communityy College Oglesbyy,, Illinois CLINICAL REVIEWERS Jill R.. Reed,, PPhhD, APPRRN-NPP Keithh D. Lamb, RRT AAssistant Professor SSpecialist,SSurgical Critical Care/Trauma UMNC College of Nursing-—KKearney Division Christiana Care HealthSSystems KKearneyy,, Nebraska Newark, Delaware Diane Rudolpphhi,, MS,, RN Manju Maliakal, MSN, CMSRN AMdamnijnuistMraativlieaSSkuaple,rMvisSorN, CMSRN Master Instructor BaylorSScott and White Health Universityy of DelawareSSchool of Nursing Carrollton, Texas Newark,, Delaware Marion FF. Winkler, PhD, RD, LDON, CNSC Suussan Scchholtz,, RN,, PPhhD, Schhool Nursing SSurgical NutritionSSpecialist and Associate Professor ofSSurgery CCeerrttiiffiiccaattee Rhode Island Hospital, Department ofSSurgery NutritionalSSupportSService and Alpert MedicalSSchool of Associate Professor of Nursing Moravian College Brown University Bethlehem, Pennsylvania Providence, Rhode Island Benjamin A.. Smallhheerr,, PPhhD, RN, ACNPP-BC, CCRN Assistant Professor of Nursing VVanderbilt UniversityySSchool of Nursing Nashville, TTennessee

xii Preface to the Student NNuummeerroouuss ffeeaattuurreess aaree bbuuiilt inttoo this ttext to help you identify 2222 Parenteral Medications kkeeyy ppiieecces ooff iinnffoorrmmaation aandd studdy more effiicciieennttllyy.. AAdddii­- I ttiioonnaal ssttuddyy ttooollss aand review qquueesstions may be found on the ccoommppaanniioonn Evoollvvee ssiittee:: htttpp://evolve.elsevier.com/Perry/skills ►4SK\\iIiL!LS-S-PA·iN¢iD•lP#ihRO•iCriE¥iD■iU11R·1E¥S Objectives highlight the Skill 22.11 Preparing Injections: Ampules and Vials, p. 5580 primary aims of chapter PProcedurall GGuuideline 22.11 MMixing PPaarenteral Medications in OOnne SSyyrringe, p. 58866 content.. Skill 22.2 Administering Ilntradermal Injectionss,, p. 589 Skill 22.3 Administering Subcutaneous Injections, pp. 5593 Evolve media resources are Skill 22.4 Administering Intramuscularr Injections, p. 600 available for everyy chapter. Skill 22.5 Administering Medications by Intravenous BBolus, p. 607 Skill 22.6 Administering Intravenous MMedications by PPigggyback, Intermittent Infusion Sets, anndd Mini-Infusion Pumps, p. 614 Skill 22.7 Administering Continuouss Subcutaneouus Medications, p. 62200 OBJECTIVES • Discuss ways to promote patient comfort while Mastery of content in this chapter will enable the nurse to: administering an injection. • Correctly prepare injectable medications from a vial and an • Correctly administer intradermal, subcutaneous, and ampule. intramuscular injections. • Identify advantages, disadvantages, and risks of • Compare the risks of three different intravenous administering medications by each parenteral route. routes. • Evaluate the effectiveness and outcomes of administering • Correctly administer an intravenous medication by medications by each parenteral route. intravenous piggyback, intermittent infusion, or bolus. • Explain the importance of selecting the proper-size syringe • Initiate, maintain, and discontinue a continuous and needle for an injection. subcutaneous infusion. • Discuss factors to consider when selecting injection sites. MEDIA RESOURCES •• AAuuddiiooGGlloossssaarryy • �NSO Nursing Skiilllss Online •• evolve hhttttpp::////eevvool�vee..eellsseevviieerr..ccoomm//PPeerrrryy//sskkiillllss • Clinical Debrriieff anndd Revviiew Queessttiioonnss Answerrss • ReviewQQuueessttiioonnss • Video Clips SKILL 22.3 AADDMMIINNIISSTERING SUBCUTANEOUS INJECTIONS 599 PURPOSE STANDARDS OFF CARE 'S,lTlEIP' / RH/A\\JTIIOOfNJ/A\\LLlE Medications administered by the parenteral route enter body tissues • Centers for Medicare & Medicaid Services (CMS), 2015— and the circulatory system by injection. Injected medications are Preparation and Administration of Drugs Clinical Decision Point Aspiration after injecting a subcutaneous medication is not necessary. Piercing a blood vessel in a subcutumasnoeedroeuwqs uhiniecjnekcltpyioaantbiesonrtbseadrethvaonmoirtainl mg eodriccaatnionnost. Parenteral routes are • Infusion Nurses Society, 2016—Infusion Nursing Standards of is very rare. Aspiration after injecting heparin and insulin is not recommended (Lilley et al., 2012). swallow, when rapid Practice onset of a medication is needed, and/or when patients are restricted • Institute for Safe Medication Practices (ISMP), 2011; 2012; 2015—Safe Medication Preparation e. Withdraw needle quickly while placing antiseptic swab Supddpuisorcriontimgngfnoetrietsdsaulseesoswcaiitrahoteuddnradwwiiantlh.jeDacltrciyoonghaosuliztoeenmmnainoynimminiiztneaiscmfwdtrduioisiztrsmkehecisonpatama.dartmkefioeiiinrnnntgtvisaotseriravilnegfallunnuidioddnsts.hp. uaTTrshehpneeostseseeermamglreemdaeticedarictriaiostkniosnathsdma(nsientehisCotrshaeatiapostnseorcp2ira1ot)ce.ed- or gauze gently over site. Aids absorption. Massage can damage underlying tissuEea.cThimtyepe of injection requires a certain set of skills to ensure • The Joint Commission, 2016—Patient Identification that the medication reaches the proper location. There are four 17. Apply gentle pressure to site. Do not massage site. (If interval prevents bleeding at site. routes for parenteral administration: PPRRIINNCCIIPPLLEESS FFOORR PPRRAACCTTIICCEE heparin is given, hold alcohol swab or gauze to site for 30 to 60 seconds.) Gives patient sense of well-being. 1. Subcutaneous injection: IInnjection into tiss. ues just under the • When managing a patient’s medications, communicate clearly with the interprofessional team, assess and incorpo- 18. Help patient to comfortable position. Prevents injury to patients and health care personnel. dermis of the skin rate the patient’s priorities of care and preferences, and 19. Discard uncapped needle or needle enclosed in safety Recapping needles increases risk for needlestick in2ju.ryIntramuscular (IM) injection: Injection into the lbxox:dly off a use the best evidence when making decisions about patient muscle care. shield (see illustrations) and attached syringe into (OSHA, n.d.). 3. Intradermal (ID) injjeeccttiioonn:, IInnjjeeccttiioonn iinnttoo t1hhee ddeerrmmiiss jjuusstt puncture- and leak-proof receptacle. • Use technology (e.g., bar scanning, electronic medication administration record [MAR]) that is available in your agency under the epidermis when preparing and giving medications. 4. Intravenous (IV) injection or infusion: Injection into a vein 575 AB Clinical Decision Points highlight points to consider when performing skillss to ensure STEP 19 Needle with plastic guard to prevent needlesticks. A, Position of guard before injection. effective outcomes and promote safety. B, After injection guard locks in place, covering needle. Extensive illustrations demonstrate step-­ 2200.. Remove gloves and perform hand hygiene. Reduces transmission of microorganisms. by-step procedures for more thorough 2211.. Stay with patient for several minutes and observe for any Dyspnea, wheezing, and circulatory collapse are signs of severe understanding. allergic reactions. anaphylactic reaction. Quick Response codes may be scanned to link to video clips directly from the text EVALUATION CCoonnttiinnuueedd ddiissccoommffoorrtt mmaayy iinnddiiccaattee iinnjjuurryy ttoo uunnddeerrllyyiinngg bboonneess oorr page.. nerves. 1. Return to room in 15 to 30 minutes and ask if patient feels any acute pain, burning, numbness, or tingling at injection site. Bruising or induration indicates complication associated with injection. 2. Inspect site, noting bruising or induration. Provide warm compress to site. Adverse effects of parenteral medications develop rapidly. Evaluate effect of medication on basis of onset, peak, and 3. Observe patient’s response to medication at times that duration of action. correlate with onset, peak, and duration of medication. Review laboratory results as appropriate (e.g., blood glucose, Determines patient’s and family caregiver’s level of understanding partial thromboplastin). of instructional topic. 4. Use Teach-Back: “I want to be sure I explained to you the reason for this subcutaneous injection. Tell me why you are receiving this injection.” Revise your instruction now or develop a plan for revised patient or family caregiver teaching if patient or family caregiver is not able to teach back correctly. xxiiii

PPRREEFFAACCEE TTOO TTHHEE SSTTUUDDEENNTT xiii SSKKIILLLL 2222..S5 AADDMMIINNIISSTTEERRIINNGG MMEEDDIICCAATTIIOONNSS BBYY IINNTTRRAAVVEENNOOUUSS BBOOLLUUSS 613 SSITLEiP' / HRAAJTIONALlE Unexpected Outcomes/Related Interventions help yyou anticipate problleems 44.. UU,s..e, TTueaccbh--BBaacclkr.:: \"“[I w••anntt ttoo bbee 1suu�re II oe:xppll1aiinn.e-,dd ttoo �y-oouu 1w1.'h111y Determines patient’s and family caregiver’s level of understanding and respond appropriately. ryoouu aarrce rrceccceiivviin1g 1thhii1s IIVV bboolluu1s mmreddiiccaattiioonn.. CC■ann yyoou uexppll■ain of instructional topic. ttoo mmee wwhh■att tthh..e, mmeeddiiccaattiioonn iiis ifoorr ■anndd wwhheenn ttoo cc■allll tthhee nnuurrswe??'\"” Recording and Reporting guuiiddeelliinnes for RRcevviiis,ee yyoouurr iinn1sttrruuccttiioonn nnoo•w• oorr ddcevv<le'lloopp Ia ppll1a1n ffoorr rrce\\vlii-s,ed each skill detail what to docuument and report. ppuatiicenntt oorr\"f-ammiillyy ccuarce1giivvuer ute,1a1cchhiinn1g iiff pp■attiicemnt oorr ff1a1mmiillyy ccuarce1giivvuerii1s nnoott ■ahbilee 1t0o ttueacchh bbaacckk ccoorrrreeccttllyy. Special Considerations indicate special teaching considdeerations, as welll as Unexpected Outcomes R•• eSlSattootppedOdOeIIHlnnivvteeeelriirnnrvggeemmnneetddiiooiiccnnaattsiioonn iimmmmeeddiiaatteellyy aanndd ffoollllooww aaggeennccyy�poliiccyyoorr procedure modifications needed ffor pediiatric, 1. Patient develops adverse reaction to medication. guuiiddeellines ffor apppprroopprriiaattee rresponse tto allergCfic rereaaccttiioonn((ee.g.,, adminis­- gerontological, and home care populattiions. •• NtrtNrereoraopptttoiioiiofofrytryntiinpnpoogagaffttieoaioaefnfnnnUattati'’dhsdsivvsheheteaerrssamaeellttihnhddeerrccuuasasggrurueecrreehppaarcarcootstvvKiioliddldnleiespsr.rhoeoeffnaahddyyvdveerrarrsmseeineeeeffffeeoccrtteesspiiimmnneemppehld! riiinar tetee))llyay.nd 22.. rvIV mmeedication is incompatibblle wwith IV fluids (e.g.,, rI.VJ fflluid bbeeccomees •• AAdddd aallllergyy innffoorrmmaatiKollnltto ppaattiieenntt'’ss rrecord. ccllooouddyy iinn ttuubbiinngg))((sseeee aaggeennccyy ppoolliiccyy)). •• SStooprI.VJflluuiiddss aaondd ccllamprI.VJline . •• FFllusshhrIV.Jlliinneewwith 1100 mlL of00..99%% sodium chlor1irdlee or steriille wateer. 33.. r.IJV ssiittee sshhoowwss syympptoms of infilltrration or phlebitiis (see Chaapptteerr 229). •• GGivee lIVVbboollus overr appproopprriaatee amount of timee. •• FFlluusshh wrwraaitttehe aaaasnsommtheeeddriicc11aa00ttiioomnnlLwwoafs00ai.9:dlmm%iinnsiiossdtteeiurreemdd.chl0o<riide o rr steerir le water at ssaammee •• RReessttaarrtt IIVV fflluuiiddss wwiitthh nnew tuubbiinngg aatt pprreessccrriibbeedd rraattee. •• IIff uunnaabbllee ttoo ssltoopp IVininffuussiioonn,, ssttaarrtt nneeww r.IVJ ssiittee((sseeee CChhaapptteerr 2299)) aaondd aaddmmiinniissteerr medication using lIVV push(r(I.VJlock))methOoOd. • SStopp rI.VJ ·inufusion immeediatelyy orr discontinue access deevice anid:l reestart in anotheerr site. • Deetteerrmrniinnee hhooww mmuucchh id:laammaaggee rI.VJ mmeeddiiccaattiioonn ccaann pprrOoOduuccee iin subbccuuttaa-- nneeooouss ttiissssuuee. •• PiiPnnrrffooiillvtvtrirdaatetkilornIn.VJsseiitxtxeett))rraaavssasiinnaddtiioiioccnaattceeaddrbeb(yy(eaa.gggee.,,nncicnyyjjeeppcootliliniccgyy,ppuhseeenaatolmmameeddiniiceceaattaiiooronnurrneedffeeIrV-r­ eennccee,, aanndd ccoonnssuulltt pphhaarrmmaacciissttttoo ddeetteerrmmiine apppprroopprriiaattee ffoollllooww--uuppccaarree. RReeccoorrddiinngg aanndd RReeppoorrttiinngg oovveerrllooaadd (Hoodck.rennbbrerrrrry ■anndd WWiillasoonn,, 22001155)).. TToo mm1aiinntt1aiinn ppreddii-- •• lImmmmre<dlii•attrellyy rrreccoorrdd mmreddiiccaattiioonn 1addmmiinnii1sttrraattiioonn., iinncclluuddiinnig ddrruu1g,, aartrriicc p.a1ttiieenn1t mumsareMfde,d1tiiycyc,,laltcicimo■arnrureslfu\\uvIlilil■layyIIVVffooll,bll.oool=wu•�s.a\"=gen=\" c-\"y 'p=oilicciie'\"s= �w•h=\"e'�n\"-�-------------------- adm1iinnii1sttrerriinn1g ���� ddoosre,, rroouuttre,, ttiimmre iimnsttiillllredd., ■anndd dduatre ■anndd ltiimmre 1addmmiinnii1s1trerrredd oonn MMAARR iin nnuunrsnes\"’ nnootnes iinn rellrectrroonic hhueallth rreccoorrdd((EEHHR) or Gerontological SSKKIILLLL 2222..33 AADDMMIINNIISSTTEERRIINNGG SSUUBBCCULTJTAANNEEOOUUSS IINNJJEECCTTIIOONNSS 593 cchh■arrtt.. lInncclluuddre iinniittii1all1soorr 1siijgnnuatuurrte. •• RRreccoorrdd pp■altiirenntt ttueacchhiinnig,, vv•alliidd■attiioonn ooff uunnddeerrssttaannddiinngg,, and •• TThhee rreennaall aanndd mmeettaabboolliicc ssyysstteemmss cdo not function as efficiently ppuat·irenntt'’s rrre1sppoonnsre ttoo mm,•e,d:l\"icc•att\"ioonn ·inn nnuurrssee'’s nnootteess ·inn EHR or bbeemcauussee ooff tthhee aaggiinngg pprroocceers.ss.. 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xiv Preface to the Instructor TThhee eevvoolluution ooff tteecchhnnoologyy and kknnowledge inflluueenncceess the wayy we ••  DDeelleeggaattiioonn aanndd CCoollllaabboorraattiioonn sections deffiine communication tteeaacchh cclliinniiccaal skkiillllss ttoo nursing ssttudents and improves the qualityy within the patient care team and the nurse’'s responsibility when ooff ccaare ppoossssiible ffoorr everyy patieenntt.. Howweevveerr,, the foundation for delegating to assistive personnel. ssuucccceesss iinn ppeerrffoorming nursing skills remains a competent, well­- inffoorrmmeedd nnuurrssee whhoo tthinkks criticallyy,, asks the right questions at the ••  CClliinniiccaall DDeecciissiioonn PPooiinnttss alert students to key steps that affect rriigghhttttiimmee,, aand mmaakkees timelyy ddecisions.. TThat outcome is the driving patient outcomes and help them modify care as needed to meet ffaaccttoorr bbeehhiinndd thiiss neeww eeddition.. individual patient needs. IIn thiiss ninth edition of CClliinniiccaall NNuurrssiinngg SSkkiillllss & TTeecchhnniiqquueess,, we ••  EEvvaalluuaattiioonn sections highlight steps students must take to evalu-­ hhaavvee ccrreeaatteed aa vveryy diffffeerreenntt ffoormat for our textbook.. Each chapter ate the outcomes of the skills performed. ooppeens bbyy introducingg students to kkeyy concepts:: SStandards of PPrraaccttiiccee,, Princciipplleess ffoorr Practicee,, Evidence-Based Practice,, Patient­- ••  TTeeaacchh--BBaacckk is included in each evaluation section, where we CCeenntteerreedd CCaarree,, andd SSafetyy Guidelineess.. TThese have been stream­- demonstrate to students how to phrase a Teach-Back question lliinneedd iinnttoo a qquuiicckk,, eeaasyy--ttoo--rreeaadd bulleted fformat.. Our new approach appropriately. eemmpphhaassiizzeess yyeett ssiimmplifiieess tthheessee iimmppoorrttaanntt ccoonncceeppttss.. ••  RReeccoorrddiinng aannd RReeporting sections follow the evaluation discus-­ IInn additioonn,, tthese concepts align with the QQuuaalliittyy aanndd SSaaffeettyy sion and alert students to what information should be docu-­ EEdduuccaattiioonnffoorrNNuurrsseess ((QQSSEEN) initiative.. Chapter 1,, Using Evidence mented in each situation. iinn NNuurrssiinngg Practiccee,, prepares students to understand and use the eevviiddeennccee--bbased pprractice inffoormation included in everyy chapter. ••  UUnneexppected Outcomes and RReelated Interventions sections inform students to be alert for potential problems and help them AAll ttopics and skills,, including sample documentation,, have determine appropriate nursing interventions. bbeeeenn uuppddaatteedd ttoo thhee mmoost recent standardss in nursing practice. ••  Special Considerations sections include additional consider-­ YYoouurr students will fiinndd tthhaatt tthhiiss eeddiittiioonn ooff CClliinniiccaall NNuurrssiinngg SSkkiillllss ations when performing the skill for speciffiic populations of && TTeecchhnniiqquueess pprroovviides aa comprehensive resource that will serve patients or in speciffiic settings and may include: tthheemm wweellll tthhrroouugghh tthheeiirr nursing education and right into their ••  TTeaching Considerations cclliinniiccaall pprraaccttiice ccaarreeers.. ••  Pediatric Considerations ••  Gerontological Considerations CCLLAASSSSIICC FFEEAATTUURREESS ••  Home Care Considerations •• OOvveerr220000 bbaassiicc,, iinntteerrmmeeddiiaatte,, and advanced nursing skills and ••  Quick Response codes (scan with smartphone or tablet with pprroocceedduurreess are ccovered.. camera to view video clips) on the text pages link video clips to the appropriate skill or procedure, allowing students to view •• FFiivvee--sstteepp nursinngg pprrooccesss ffoorrmmaatt provides a consistent presen­- the video immediately after reading the implementation section ttaation thhaatt hheellps students applyy the process while learning each of the skill. sskkiillll.. ••  Glossary (on Evolve) deffiines all key terms. •• SSkkiillllss aanndd PPrroocceeduurreess listt and Objectives open each chapter. ••  Additional review questions (on Evolve) include a brand new •• OOvveerr 112200 ffuullll--ccoolloorr photos and drawings help students set of unique questions for every chapter. mmaasstteerr thee mmaterial covered.. ••  TTEEACH for RN instructor manual helps you capitalize on the •• EEvideenccee--BBaasseedd Practiiccee sections in each chapter present stu­- new clinical material in the text, skills video series, and online denttss with the newest scientiffiicc eevviiddeennccee ffoorr tthe procedures course. Additional case studies and discussion questions unique pprreesseenntteed.. Recent research ffiinnddiinnggss aarree ddiissccuusssseedd,, aand their to the TEACH manual expand the in-class material available iimmpplliiccaattiioonnss fforr ppaatient care are explored.. to you. •• PPaattiieenntt--CCeenntered CCaarree sections prepare students to recognize ••  AAss wwiitthh tthhee eeiigghhtthheeddiittiioonn,, aann Image Collection is available tthhee iimmppoorrttaannccee oof having patients partner in performing skills with Clinical Nursing Skills & Techniques. iinn aa ccoommppaassionate and coordinated wayy based on respect for a ppaatient'’s cultural preferences,, values,, and needs (QSEN core NNEEWW TTOO TTHHIISS EEDDIITTIIOONN:: ccompetencyy)).. •• SSaaffeettyy GGuuiiddeelliinneess sseeccttiioonnss ccoovveerr gglloobbaall rreeccoommmmeennddaattiioonnss oonn ••  Standards of Care sections summarize the most recent evi-­ tthhee saaffee execution of the particular skill set covered in each dence-based standards and/or the professional clinical standards cchhaapptteerr (QQSSEN core competency).. •• NNSSOO iiccoonn linkkss text content with the new edition of Nursing rreeccoommmmeennddeedd ffoorr tthhee sskkiillllss wwiitthhiinn eeaacchh cchhaapptteerr.. SSkkiillllss OOnliinnee,, which hhas been simultaneouslyy revised with the ••  Principles for Practice sections highlight the key nursing prin-­ tteexxttbbooookk ttoo pprroovide completelyy ccoooordinated information. •• RRaattiioonnaalleess aarree ggiivveen ffoorr sstteeps within skills so students learn the ciples that apply to all skills within a chapter. wwhhyy aas well aas the how of each skill.. RRaationales include citations ••  EExpanded and improved end-of-chapter exercises include a ffrroomm tthhee ccuurrrreenntt lliitteerraattuurree.. Clinical Debrief case study, examples of SBAR communication, and review questions. xxiivv

xv Contents UUNNIITT 11 SSkkiillll 66..77 MMuussccuulloosskkeelleettaall aanndd NNeeuurroollooggiiccaall AAsssseessssmmeenntt,, 115544 Supporrtting the Patient Through the Health PPrroocceedduurraall GGuuiiddeelliinnee 66..11 MMoonniittoorriinngg IInnttaakkee aanndd OOuuttppuutt,, 116622 Carre Syssttem UUNNIITT 33 1 Usingg Evidence in Nursing Practice,, 11 Special Procedures PPaattrriicciiaa AA.. Potttteerr,, RN,, MSN,, PhD,, FMAAN 7 Specimen Collection, 166 PPuurrppoossee,, 11 Rita Wunderlich,, RN, PhD, CNE SSttaannddaarrddss ooff CCaarree,, 11 PPrriinncciipplleess ffoorr PPrraaccttiiccee,, 11 SSkkiillll 77..11 UUrriinnee SSppeecciimmeenn CCoolllleeccttiioonn:: MMiiddssttrreeaamm ((CClleeaann--VVooiiddeedd)) UUrriinnee;; SSuussttaaiinniinngg EEvviiddeennccee--BBaasseedd PPrraaccttiiccee CChhaannggeess,, 1100 SStteerriillee UUrriinnaarryy CCaatthheetteerr,, 116677 22 AAdmitting,, TTransfer,, and Discharge,, 12 PPrroocceedduurraall GGuuiiddeelliinnee 77..11 CCoolllleeccttiinngg aa TTiimmeedd UUrriinnee SSppeecciimmeenn,, 117733 MMiicchheelllee Aeberssooldd,, PPhhDD,, RN,, CHSE,, FFAMAN PPrroocceedduurraall GGuuiiddeelliinnee 77..22 UUrriinnee SSccrreeeenniinngg ffoorr GGlluuccoossee,, KKeettoonneess,, PPrrootteeiinn,, SSkkiillll 22..11 AAddmmiittttiinngg PPaattiieennttss,, 1133 BBlloooodd,, aanndd ppHH,, 117744 SSkkiillll 22..22 TTrraannssffeerrrriinngg PPaattiieennttss,, 2200 SSkkiillll 77..22 MMeeaassuurriinngg OOccccuulltt BBlloooodd iinn SSttooooll,, 117755 SSkkiillll 22..33 DDiisscchhaarrggiinngg PPaattiieennttss,, 2244 SSkkiillll 77..33 MMeeaassuurriinngg OOccccuulltt BBlloooodd iinn GGaassttrriicc SSeeccrreettiioonnss 33 Commuunication and Collaboration, 31 ((GGaassttrrooccccuulltt)),, 117788 SSkkiillll 77..44 CCoolllleeccttiinngg NNoossee aanndd TThhrrooaatt SSppeecciimmeennss ffoorr CCuullttuurree,, 118800 JJaaccqquueelline Raybuck SSaaleebyy,, PhD,, RN,, BCCS SSkkiillll 77..55 OObbttaaiinniinngg VVaaggiinnaall oorr UUrreetthhrraall DDiisscchhaarrggee SSppeecciimmeennss,, 118833 PPrroocceedduurraall GGuuiiddeelliinnee 77..33 CCoolllleeccttiinngg aa SSppuuttuumm SSppeecciimmeenn bbyy SSkkiillll 33..11 EEssttaabblliisshhiinngg tthhee NNuurrssee--PPaattiieenntt RReellaattiioonnsshhiipp,, 3333 SSkkiillll 33..22 CCoommmmuunniiccaattiinngg WWiitthh PPaattiieennttss WWhhoo HHaavvee DDiiffffiiccuullttyy EExxppeeccttoorraattiioonn,, 118866 SSkkiillll 77..66 CCoolllleeccttiinngg aa SSppuuttuumm SSppeecciimmeenn bbyy SSuuccttiioonn,, 118877 CCooppiinngg,, 3399 SSkkiillll 77..77 OObbttaaiinniinngg WWoouunndd DDrraaiinnaaggee SSppeecciimmeennss,, 119900 SSkkiillll 33..33 CCoommmmuunniiccaattiinngg WWiitthh aa CCooggnniittiivveellyy IImmppaaiirreedd PPaattiieenntt,, 4444 SSkkiillll 77..88 CCoolllleeccttiinngg BBlloooodd SSppeecciimmeennss aanndd CCuullttuurree bbyy VVeenniippuunnccttuurree SSkkiillll 33..44 CCoommmmuunniiccaattiinngg WWiitthh CCoolllleeaagguueess,, 4477 ((SSyyrriinnggee aanndd VVaaccuuttaaiinneerr MMeetthhoodd)),, 119933 44 Docuummeenntation and Informatics,, 511 SSkkiillll 77..99 BBlloooodd GGlluuccoossee MMoonniittoorriinngg,, 220022 SSkkiillll 77..1100 OObbttaaiinniinngg aann AArrtteerriiaall SSppeecciimmeenn ffoorr BBlloooodd GGaass TThheerreessaa Pietscchh,, PhD,, RN,, CRRRN,, CNE MMeeaassuurreemmeenntt,, 220066 PPrroocceedduurraall GGuuiiddeelliinnee 44..11 GGiivviinngg aa HHaanndd--OOffff RReeppoorrtt,, 5588 PPrroocceedduurraall GGuuiiddeelliinnee 44..22 DDooccuummeennttiinngg NNuurrsseess'’ PPrrooggrreessss NNootteess,, 6611 88 Diagnostic Procedures, 213 PPrroocceedduurraall GGuuiiddeelliinnee 44..33 AAddvveerrssee EEvveenntt RReeppoorrttiinngg,, 6622 PPrroocceedduurraall GGuuiiddeelliinnee 44..44 GGuuiiddeelliinneess ffoorr MMeeaanniinnggffuull UUssee ooff aann EElleeccttrroonniicc Nancy Laplante,, PhD,, RN, AHN-BC,, and Stephen D0. Krau,, PhD,, CNE HHeeaalltthh RReeccoorrdd ((EEHHRR)),, 6633 SSkkiillll 88..11 IInnttrraavveennoouuss MMooddeerraattee SSeeddaattiioonn,, 221155 UUNNIITT 22 SSkkiillll 88..22 CCoonnttrraasstt MMeeddiiaa SSttuuddiieess:: AArrtteerriiooggrraamm ((AAnnggiiooggrraamm)),, CCaarrddiiaacc Vital Signs and Physical Assessment CCaatthheetteerriizzaattiioonn,, aanndd IInnttrraavveennoouuss PPyyeellooggrraamm,, 221199 55 Vital Siggns, 666 SSkkiillll 88..33 AAssssiissttiinngg WWiitthh AAssppiirraattiioonnss:: BBoonnee MMaarrrrooww AAssppiirraattiioonn//BBiiooppssyy,, Suussaann JJannee Fettzzeerr,, BA,, BSN,, MSN,, MBA,, PhD LLuummbbaarr PPuunnccttuurree,, PPaarraacceenntteessiiss,, aanndd TThhoorraacceenntteessiiss,, 222255 SSkkiillll 55..11 MMeeaassuurriinngg BBooddyy TTeemmppeerraattuurree,, 6688 SSkkiillll 88..44 CCaarree ooff aa PPaattiieenntt UUnnddeerrggooiinngg BBrroonncchhoossccooppyy,, 223322 SSkkiillll 55..22 AAsssseessssiinngg RRaaddiiaall PPuullssee,, 7788 SSkkiillll 88..55 CCaarree ooff aa PPaattiieenntt UUnnddeerrggooiinngg EEnnddoossccooppyy,, 223366 SSkkiillll 55..33AAsssseessssiinngg AAppiiccaall PPuullssee,, 8822 SSkkiillll 55..44 AAsssseessssiinngg RReessppiirraattiioonnss,, 8877 UUNNIITT 44 SSkkiillll 55..55 AAsssseessssiinngg AArrtteerriiaall BBlloooodd PPrreessssuurree,, 9911 Infection Control PPrroocceedduurraall GGuuiiddeelliinnee 55..11 NNoonniinnvvaassiivvee EElleeccttrroonniicc BBlloooodd PPrreessssuurree 99 Medical Asepsis, 2411 MMeeaassuurreemmeenntt,, 110000 Angela McConachie, FNPP, DONP Procedural Guideline 5.2 Measuring Oxygen Saturation (Pulse ProcOOexxdiimmureeattlrryyG)),u, 1i1d00e2l2ine 5.2 Measuring Oxygen Saturation (Pulse Skill 9.1 Hand Hygiene, 243 SSSkkkiiillllll 999...122 CCHaaarnriidnnggHffyoogrriePPnaaett,iiee2nn4ttss3UUnnddeerr IIssoollaattiioonn PPrreeccaauuttiioonnss,, 224477 66 Healthh AAssessment,, 1105 PPrroocceedduurraall GGuuiiddeelliinnee 99..11 CCaarriinngg ffoorr PPaattiieennttss WWiitthh MMuullttiiddrruugg--RReessiissttaanntt Paauullaa GGrraayy,, ODNPP,, CRNPP,, NP--CC OOrrggaanniissmmss ((MMDDRROOss)) aanndd CClossttrriiddiiuum ddiiffffiicciillee,, 225544 1100 Sterile Technique, 256 SSkkiillll 66..11 GGeenneerraall SSuurrvveeyy,, 111122 SSkkiillll 66..22 HHeeaadd aanndd NNeecckk AAsssseessssmmeenntt,, 112200 Angela McConachie, FNPP,, DONP SSkkiillll 66..33 TThhoorraaxx aanndd LLuunngg AAsssseessssmmeenntt,, 112255 Skill 66.4 CCardiovascular Assessment,, 132 SSkkiillll 1100..11 AAppppllyyiinngg aanndd RReemmoovviinngg CCaapp,, MMaasskk,, aanndd PPrrootteeccttiivvee Skill 66..55 Abddoomminal Assessment,, 143 Eyewear,, 225577 Skill 66..66 Genittaallia and Rectum Assessment,, 149 SSkkill 100..22 PPrreeppaarriinngg aa SStteerriillee FFiieelldd,, 226611 SSkkill 10.33 SStteerriillee GGlloovviinngg,, 226666 xvv

-xvi CCOONNTTEENNTTSS UUNNIITT 77 UUNNIITT 55 Hygiene AAccttiivviittyy aannd MMoobbiilliittyy 1188 Personal Hygiene and Bed Making, 4411 Jennifer Painter, MSN, APRN, CNS, RN-BC, 1111 Saffee Patient Handlingg,, TTrraannssffeerr,, and OCN, AOCNS Positioning,, 2711 Rita WWuunnderlich,, RN,, PhD,, CNE Skill 18.1 Complete or PPartial Bed Bath, 445 Procedural Guideline 18.1 Perineal! Care, 454 Skill 1111..11 Using Safe and Effective TTransfer TTechniques, 272 Procedural Guideline 18.2 Use of Disposable Bed Bath, Tub, orr Procedduural Guideline 1111..11 Wheelchair TTransfer TTechniques,, 282 Skill 1111..22 Movviing and Positioniinngg Patients in Bed,, 283 Shower, 456 Skill 18.2 Oral Hygiene, 457 1122 EExxeerrcciissee aannd MMoobbiilliittyy,, 229922 Procedural Guideline 18.3 Care of Dentures, 463 PPaattricia AA.. Potterr,, RN,, MSN,, PhD,, FFMAAN Skill 18.3 Performing MMouth Care for an Unconscious or Debilitated Skill 1122..11 PPrromoting Early Activity and EExxercise, 294 Patient, 464 Procedduural Guideline 1122..11 Perfforming Range-of-Motion Procedural Guideline 18.4 Hair Care—-Combing anndd Shaving, 467 Procedural Guideline 18.5 Hair Care—-Shampooing, 470 EExxeerrcciisseess,, 229988 Skill 18.4 Performing Nail and Foot Care, 471 Procedduural Guideline 112..2 MMoonniitoring a Patient on a Continuous Procedural Guideline 18.6 Making an OOccupied Bed, 477 Procedural Guideline 18.7 Making an Unoccupied Bed, 481 PPaassssiivvee MMoottiioonn MMaacchhiinnee,, 330044 Procedduurraall Guideline 112..3 AApplying Graduated Compression (Elastic) 1199 Care of the Eye and Ear, 484 Anne Griffin Perryy, RN, MSN, EdD, FAMAN SSttoocckkiinnggss aanndd SSeeqquueennttiiaal CCoommpprreessssiioonn DDeevviice,, 330055 Procedduural Guideline 112..4 Assisting With Ambulation (Without Assist Procedural Guideline 19.1 Eye Care ffor Comatose PPaattiieenntts, 485 Procedural Guideline 19.2 Takinngg Care of Contact LLeenses, 486 Deviicceess)),, 330088 Skill 19.1 Eye Irrigation, 489 Skill 1122..22 AAssisting With Use of Canes,, Walkers,, and Skill 19.2 Ear IIrrigation, 492 Skill 19.3 Care of Hearing Aiids, 495 CCrruuttcchhees,, 331111 UUNNIITT 88 1133 Suppppoorrtt SSuurrffaaces anndd Special Beds,, 3222 Kristteenn L.. Mauk,, PhD,, DNPP,, RN,, CRRN,, GCNS-BC,, Medications GNP--BBCC,, AACHPN,, FFMAAN 2200 Safe Medication Preparation, 5011 Procedduural Guideline 1133..11 Selectiion of a Pressure-Redistribution Wendyy R. Ostendorf, RN, MS, EdD, CNE SSuuppppoorrtt SSuurrffaaccee,, 332255 Purpose, 501 Skill 1133..11 Placing a PPatient on a Support Surface,, 327 Skill 1133..22 Placing a PPatient on Special Bed,, 332 Standards of Care, 501 Principles for PPractice, 502 UUNNIITT 66 SSaaffeettyy aanndd Coommffoorrtt Pharmacological CConcepts,, 502 Types of Medication Action, 502 1144 PPaattiieenntt SSaafety,, 333399 Routes of Administration, 505 Patricia AA.. Potterr,, RN,, MSN,, PhD,, FFMAAN Meeddiiccaatiioonn DDiistrriibuuttiion, 550066 SSyysstteemmss ooff MMeeddiiccaattiioonn MMeeaassuurreemmeenntt,, 550088 SSkkiillll 1144..11 FFaallll PPrreevveennttiioonn iinn HHeeaalltthh CCaarree AAggeenncciieess,, 334411 PPaattiieenntt--CCeenntteerreedd CCaarree,, 550099 SSkkiillll 1144..22 DDeessiiggnniinngg aa RReessttrraaiinntt--FFrreeee EEnnvviirroonnmmeenntt,, 334488 Safe Medication Administration, 509 SSkkiillll 1144..33 AAppppllyyiinngg PPhhyyssiiccaall RReessttrraaiinnttss,, 335522 MMeeddiiccaattiioonn PPrreeppaarraattiioonn,, 551144 PPrroocceedduurraall GGuuiiddeelliinnee 1144..11 FFiirree,, EElleeccttrriiccaall,, aanndd CChheemmiiccaall EEvviiddeennccee--BBaasseedd PPrraaccttiiccee,, 551166 NNuurrssiinngg PPrroocceessss,, 551166 SSaaffeettyy,, 335588 RReeppoorrttiinngg MMeeddiiccaattiioonn EErrrroorrss,, 551188 SSkkiillll 1144..44 SSeeiizzuurree PPrreeccaauuttiioonnss,, 336611 PPaattiieenntt aanndd FFaammiillyy TTeeaacchhiinngg,, 551188 1155 DDiissaasstteerr PPrreppaarrednneessss,, 367 2211 Nonparenteral Medications, 5211 NNancy Lappllaannttee,, PhD,, RN,, AAHN--BBCC Anne Griffin Perryy, RN, MSN, EdD, FAMAN SSkkiillll 1155..11 CCaarree ooff aa PPaattiieenntt AAfftteerr BBiioollooggiiccaall EExxppoossuurree,, 337733 Skill 1155..22 Care of a Patient After Chemical Exposure,, 379 SSkkiillll 2211..11 AAddmmiinniisstteerriinngg OOrraall MMeeddiiccaattiioonnss,, 552233 Skill 1155..33 Care of a Patient After Radiation Exposure,, 384 SSkkiillll 2211..22 AAddmmiinniisstteerriinngg MMeeddiiccaattiioonnss TThhrroouugghh aa FFeeeeddiinngg TTuubbee,, 553300 Skill 21.3 Applying Topical Medications too the Skin, 536 1166 Paiinn Managemenntt,, 38899 SSkkiillll 2211..44 AAddmmiinniisstteerriinngg OOpphhtthhaallmmiicc MMeeddiiccaattiioonnss,, 554411 Patricia AA.. Potterr,, RN,, MSN,, PhD,, FFMAAN SSkkiillll 2211..55 AAddmmiinniisstteerriinngg EEaarr MMeeddiiccaattiioonnss,, 554477 SSkkiillll 2211..66 AAddmmiinniisstteerriinngg NNaassaall IInnssttiillllaattiioonnss,, 555500 SSSkkkiiillllll 11116666....2121 PPPaaaitinnieAnAtss-ssCeeossnsstmmroeellnnettdaaAnnnddaBlBgaaesssiiicca,,CC3oo9mm8ffoorrtt MMeeaassuurreess,, 339922 SSkkiillll 2211..77 UUssiinngg MMeetteerreedd--DDoossee IInnhhaalleerrss ((MMDDIlss)),, 555544 SSkkiillll 1166..33 EEppiidduurraall AAnnaallggeessiiaa,, 440033 PPrroocceedduurraall GGuuiiddeelliinnee 2211..11 UUssiinngg DDrryy PPoowwddeerr–-IInnhhaalleedd ((DDPPII)) SSkkiillll 1166..44 LLooccaall AAnneesstthheettiicc IInnffuussiioonn PPuummpp ffoorr AAnnaallggeessiiaa,, 440099 SSkkiillll 1166..55 NNoonnpphhaarrmmaaccoollooggiiccaall PPaaiinn MMaannaaggeemmeenntt,, 441122 MMeeddiiccaattiioonnss,, 556600 SSkkiillll 2211..88 UUssiinngg SSmmaallll--VVoolluummee NNeebbuulliizzeerrss,, 556611 1177 PPaalllliiaattiivvee CCaarree,, 442233 SSkkiillll 2211..99 AAddmmiinniisstteerriinngg VVaaggiinnaall IInnssttiillllaattiioonnss,, 556655 SSteepphhaanie JJeeffers,, PhD,, RN SSkkiillll 2211..1100 AAddmmiinniisstteerriinngg RReeccttaall SSuuppppoossiittoorriieess,, 556699 SSkkiillll 1177..11 SSuuppppoorrttiinngg PPaattiieennttss aanndd FFaammiilliieess iinn GGrriieeff,, 442255 SSkkiillll 1177..22 SSyymmppttoomm MMaannaaggeemmeenntt aatt tthhee EEnndd ooff LLiiffee,, 442288 SSkkiillll 1177..33 CCaarree ooff aa BBooddyy AAfftteerr DDeeaatthh,, 443344

22 Parenteral Medications, 575 CCOONNTTEENNTTSS -xvii Wendy R.. Ostendorf,, RN,, MS,, EdD,, CNE UUNNIITT 1100 Skill 22.1 Preparing Injections:: Ampules and Vials,, 580 Fluid Balance Procedural Guideline 22.1 Mixing Parenteral Medications in One 29 Intravenous and Vascular Access TTherapy, 751 Syringe, 586 Carol Ann Liebold,, RN,, BSN,, CRNI Skill 22.2 AAdministering lIntradermal Injections,, 589 Skill 29.1 Insertion of a Short-Peripheral Intravenous Device, 754 Skill 22.3 AAdministering Subcutaneous Injections,, 593 Skill 29.2 Regulating Intravenous Flow Rates, 768 Skill 22.4 AAdministering Intramuscular Injections,, 600 Skill 29.3 Changing Intravenous Solutions,, 774 Skill 22.5 AAdministering Medications by Intravenous Skill 29.4 Changing Infusion Tubing, 777 Skill 29.5 Changing a Short-Peripheral Intravenous Dressing, 781 Bolus,, 607 Procedural Guideline 29.1 Discontinuing a Short-Peripheral Intravenous Skill 22.6 AAdministering IInnttravenous Medications by Piggyback,, Device, 784 Skill 29.6 Managing Central Vascular Access Devices, 785 Intermittent Infusion Sets,, and Mini-Infusion Pumps, 614 Skill 22.7 AAddmministering Continuous Subcutaneous 3300 Blood Transfusions, 800 Carol Ann Liebold,, RN,, BSN,, CRNI Medications,, 620 Skill 30.1 Initiating Blood Therapy, 805 Skill 30.2 Monitoring for Adverse Transfusion Reactions, 814 UUNNIITT 99 Oxygenation UUNNIITT 1111 Nutrition 23 Oxyygen TTherapyy, 627 CC..JJ.. WWrriight-Boon,, RN,, MSN 3311 Oral Nutrition, 819 Hope VV.. Bussenius,, DNPP,, APRN,, FNP-BC Skill 23.1 AApplying an Oxygen-Delivery Device,, 629 Skill 31.1 Performing a Nutritional Screening and Physical Skill 23.2 AAddmmiinistering Oxygen TThherapy to a Patient With an Artificial Examination, 821 Skill 31.2 Assisting an Adult Patient With Oral Nutrition, 826 AAiirrwaayy,, 636 Skill 31.3 Aspiration Precautions, 832 Skill 23.3 Using Incentive Spiroommeettryy,, 639 Skill 23.4 Care of a Patienntt Receivinngg Noninvasive Positive-Pressure 3322 Enteral Nutrition, 839 Amy Spencerr,, MSN,, RN-BC Ventilation,, 642 Skill 32.1 Inserting and Removing a Small-Bore Nasogastric or Procedural Guideline 23.1 Use of a Peak Flowmeter, 647 Nasoenteric Feeding Tube, 840 Skill 23.5 Care of a Patient on a Mechanical VVentilator, 649 Skill 32.2 Verifying Feeding Tube Placement, 847 Skill 32.3 Irrigating a Feeding Tube, 850 2244 Performing Chest Physiotherapyy, 660 Skill 32.4 Administering Enteral Nutrition: Nasoenteric, Gastrostomy, or AAnnnnee GGrriiffin Perryy,, RN,, MSN,, EdD,, FFAMAN JJeejjuunnoossttoommyy TTuubbee,, 885522 PPrroocceedduurraall GGuuiiddeelliinnee 3322..11 CCaarree ooff aa GGaassttrroossttoommyy oorr JJeejjuunnoossttoommyy SSkkiillll 2244..11 PPeerrffoorrmmiinngg PPoossttuurraall DDrraaiinnaaggee,, 666622 Tube, 858 PPrroocceedduurraall GGuuiiddeelliinnee 2244..11 UUssiinngg aann AAccaappeellllaa DDeevviiccee,, 666688 Procedural Guideline 24.2 Performing Percussion and 3333 Parenteral Nutrition, 8611 Felicia Schaps,, MSN-Ed,, BSN,, RN,, CRNI, OCN, VViibbrraattiioonn,, 666699 CNSC,, IlgCN SSkkiillll 3333..11 AAddmmiinniisstteerriinngg CCeennttrraall PPaarreenntteerraall NNuuttrriittiioonn,, 886644 2255 Airwayy Management, 672 SSkkiillll 3333..22 AAddmmiinniisstteerriinngg PPeerriipphheerraall PPaarreenntteerraall NNuuttrriittiioonn WWiitthh CC..JJ.. WWrriight-Boon,, RN,, MSN LLiippiidd ((FFaatt)) EEmmuullssiioonn,, 886699 SSkkiillll 2255..11 PPeerrffoorrmmiinngg OOrroopphhaarryynnggeeaall SSuuccttiioonniinngg,, 667744 SSkkiillll 2255..22 AAiirrwwaayy SSuuccttiioonniinngg,, 667777 UUNNIITT 1122 PPrroocceedduurraall GGuuiiddeelliinnee 2255..11 CClloosseedd ((IInn--LLiinnee)) SSuuccttiioonn,, 668877 Elimination SSkkiillll 2255..33 PPeerrffoorrmmiinngg EEnnddoottrraacchheeaall TTuubbee CCaarree,, 668899 SSkkiillll 2255..44 PPeerrffoorrmmiinngg TTrraacchheeoossttoommyy CCaarree,, 669966 3344 UUrriinnaarryy EElliimmiinnaattiioonn,, 887733 Wendy R.. Ostendorf,, RN,, MS,, EdD,, CNE 2266 Cardiac Care, 706 PPrroocceedduurraall GGuuiiddeelliinnee 3344..11 AAssssiissttiinngg WWiitthh UUssee ooff aa UUrriinnaall,, 887755 NNeelda K.. Martin,, RN,, AANP-BC,, CCNS SSkkiillll 3344..11 IInnsseerrttiioonn ooff aa SSttrraaiigghhtt oorr aann IInnddwweelllliinngg UUrriinnaarryy CCaatthheetteerr,, 887766 SSkkiillll 2266..11 OObbttaaiinniinngg aa 1122--LLeeaadd EElleeccttrrooccaarrddiiooggrraamm,, 770077 SSkkiillll 3344..22 CCaarree aanndd RReemmoovvaall ooff aann IInnddwweelllliinngg CCaatthheetteerr,, 888877 SSkkiillll 2266..22 AAppppllyyiinngg aa CCaarrddiiaacc MMoonniittoorr,, 771100 PPrroocceedduurraall GGuuiiddeelliinnee 3344..22 BBllaaddddeerr SSccaann aanndd CCaatthheetteerriizzaattiioonn ttoo DDeetteerrmmiinnee RReessiidduuaall UUrriinnee,, 889922 2277 CClloosseedd CChheesstt DDrraaiinnaaggee SSyysstteemmss,, 771144 SSkkiillll 3344..33 PPeerrffoorrmmiinngg CClloosseedd UUrriinnaarryy CCaatthheetteerr IIrrrriiggaattiioonn,, 889933 Ann Pet/in, RN, MSN, CCNS, CCRN-CSC, SSkkiillll 3344..44 AAppppllyyiinngg aa CCoonnddoomm--TTyyppee EExxtteerrnnaall CCaatthheetteerr,, 889977 AAACnnNSP-eBtlCin,,, PRCNC, MN SN, CCNS, CCRN-CSC, SSkkiillll 3344..55 SSuupprraappuubbiicc CCaatthheetteerr CCaarree,, 990000 SSkkiillll 2277..11 MMaannaaggiinngg CClloosseedd CChheesstt DDrraaiinnaaggee SSyysstteemmss,, 771188 SSkkiillll 2277..22 AAssssiissttiinngg WWiitthh RReemmoovvaall ooff CChheesstt TTuubbeess,, 772288 SSkkiillll 2277..33 AAuuttoottrraannssffuussiioonn ooff CChheesstt TTuubbee DDrraaiinnaaggee,, 773311 2288 EEmmeerrggeennccyy MMeeaassuurreess ffoorr LLiiffee SSuuppppoorrtt,, 773355 Neellda K.. Martin,, RN,, AANP-BC,, CCNS SSkkiillll 2288..11 IInnsseerrttiinngg aann OOrroopphhaarryynnggeeaall AAiirrwwaayy,, 773366 SSkkiillll 2288..22 UUssiinngg aann AAuuttoommaatteedd EExxtteerrnnaall DDeeffiibbrriillllaattoorr,, 773399 SSkkiillll 2288..33 CCooddee MMaannaaggeemmeenntt,, 774422

-xviii CCOONNTTEENNTTSS 355 Bowell Elimination and Gastric Intubation,, 905 441 Dressings, Bandages, and Binders, 1039 Lorii Klingman,, MSN,, RN Alaine Kamm, BSN, MSN; and Marianne Banass, MSN, RN, CCTN, CWCN SSkkiillll 3355..11 PPrroovviiddiinngg aa BBeeddppaann,, 990077 SSkkiillll 3355..22 RReemmoovviinngg FFeeccaall IImmppaaccttiioonn DDiiggiittaallllyy,, 991122 SSkkiillll 4411..11 AAppppllyyiinngg aa DDrreessssiinngg ((DDrryy aanndd DDaammpp--ttoo--DDrryy)),, 11004422 SSkkiillll 3355..33 AAddmmiinniisstteerriinngg aann EEnneemmaa,, 991155 SSkkiillll 4411..22 AAppppllyyiinngg aa PPrreessssuurree BBaannddaaggee,, 11005500 PPrroocceedduurraall GGuuiiddeelliinnee 3355..11 AAppppllyyiinngg aa FFeeccaall MMaannaaggeemmeenntt SSyysstteemm,, 992211 SSkkiillll 4411..33 AAppppllyyiinngg aa TTrraannssppaarreenntt DDrreessssiinngg,, 11005533 SSkkiillll 3355..44 IInnsseerrttiioonn,, MMaaiinntteennaannccee,, aanndd RReemmoovvaall ooff aa NNaassooggaassttrriicc TTuubbee SSkkiillll 4411..44 AAppppllyyiinngg aa HHyyddrrooccoollllooiidd,, HHyyddrrooggeell,, FFooaamm,, oorr AAllggiinnaattee ffoorr GGaassttrriicc DDeeccoommpprreessssiioonn,, 992222 DDrreessssiinngg,, 11005566 PPrroocceedduurraall GGuuiiddeelliinnee 4411..11 AAppppllyyiinngg GGaauuzzee aanndd EEllaassttiicc BBaannddaaggeess,, 11006622 3366 Ostomyy Care,, 931 PPrroocceedduurraall GGuuiiddeelliinnee 4411..22 AAppppllyyiinngg aann AAbbddoommiinnaall BBiinnddeerr,, 11006655 Jane Fellows,, MSN,, CWOCN 4422 Therapeutic Use of Heat and Cold, 1067 Anne Griffin Perryy, RN, MSN, EdD, FAMAN SSkkiillll 3366..11 PPoouucchhiinngg aa CCoolloossttoommyy oorr aann lIlleeoossttoommyy,, 993333 SSkkiillll 3366..22 PPoouucchhiinngg aa UUrroossttoommyy,, 993388 SSkkiillll 4422..11 AApppplliiccaattiioonn ooff MMooiisstt HHeeaatt ((CCoommpprreessss aanndd SSiittzz BBaatthh)),, 11006699 SSkkiillll 3366..33 CCaatthheetteerriizziinngg aa UUrriinnaarryy DDiivveerrssiioonn,, 994422 SSkkiillll 4422..22 AAppppllyyiinngg AAqquuaatthheerrmmiiaa aanndd DDrryy HHeeaatt,, 11007744 SSkkiillll 4422..33 AApppplliiccaattiioonn ooff CCoolldd,, 11007777 UUNNIITT 1133 SSkkiillll 4422..44 CCaarriinngg ffoorr PPaattiieennttss RReeqquuiirriinngg HHyyppootthheerrmmiiaa oorr HHyyppeerrtthheerrmmiiaa CCare of the SSuurrgical Patient BBllaannkkeettss,, 11008811 3377 Preoperative and Postoperative Care,, 945 UUNNIITT 1155 Diane Rudo/lphi,, MS,, RN Home Care 4433 Home Care Safety,, 1085 SSkkiillll 3377..11 PPrreeooppeerraattiivvee AAsssseessssmmeenntt,, 994477 SSkkiillll 3377..22 PPrreeooppeerraattiivvee TTeeaacchhiinngg,, 995511 Nancy Laplante,, PhD, RN, AHN-BC SSkkiillll 3377..33 PPhhyyssiiccaall PPrreeppaarraattiioonn ffoorr SSuurrggeerryy,, 996600 SSkkiillll 3377..44 PPrroovviiddiinngg IImmmmeeddiiaattee AAnneesstthheessiiaa RReeccoovveerryy iinn tthhee SSkkiillll 4433..11 HHoommee EEnnvviirroonnmmeenntt AAsssseessssmmeenntt aanndd SSaaffeettyy,, 11008866 SSkkiillll 4433..22 AAddaappttiinngg tthhee HHoommee SSeettttiinngg ffoorr CClliieennttss WWiitthh CCooggnniittiivvee PPoossttaanneesstthheessiiaa CCaarree UUnniitt,, 996644 SSkkiillll 3377..55 PPrroovviiddiinngg EEaarrllyy PPoossttooppeerraattiivvee aanndd CCoonnvvaalleesscceenntt PPhhaassee DDeeffiicciittss,, 11009966 SSkkiillll 4433..33 MMeeddiiccaattiioonn aanndd MMeeddiiccaall DDeevviiccee SSaaffeettyy,, 11110022 RReeccoovveerryy,, 997722 4444 Home Care Teaching, 1108 3388 Ilntraoperaattiivvee Care, 978 Theresa Pietsch, PhD, RN, CRRN, CNE Diane Rudo/lphi,, MS,, RN SSkkiillll 4444..11 TTeeaacchhiinngg CClliieennttss ttoo MMeeaassuurree BBooddyy TTeemmppeerraattuurree,, 11110099 SSkkiillll 3388..11 SSuurrggiiccaall HHaanndd AAnnttiisseeppssiiss,, 998811 SSkkiillll 4444..22 TTeeaacchhiinngg BBlloooodd PPrreessssuurree aanndd PPuullssee MMeeaassuurreemmeenntt,, 11111133 SSkkiillll 3388..22 DDoonnnniinngg aa SStteerriillee GGoowwnn aanndd CClloosseedd GGlloovviinngg,, 998855 SSkkiillll 4444..33 TTeeaacchhiinngg IInntteerrmmiitttteenntt SSeellff--CCaatthheetteerriizzaattiioonn,, 11111188 SSkkiillll 4444..44 UUssiinngg HHoommee OOxxyyggeenn EEqquuiippmmeenntt,, 11112211 UUNNIITT 1144 SSkkiillll 4444..55 TTeeaacchhiinngg HHoommee TTrraacchheeoossttoommyy CCaarree aanndd SSuuccttiioonniinngg,, 11112288 Drressings aanndd Woundd Care SSkkiillll 4444..66 TTeeaacchhiinngg MMeeddiiccaattiioonn SSeellff--AAddmmiinniissttrraattiioonn,, 11113333 SSkkiillll 4444..77 MMaannaaggiinngg FFeeeeddiinngg TTuubbeess iinn tthhee HHoommee,, 11113388 3399 PPrressure IInnjury Prevention and Care, 990 SSkkiillll 4444..88 MMaannaaggiinngg PPaarreenntteerraall NNuuttrriittiioonn iinn tthhee HHoommee,, 11114411 JJanice CC.. CColwell,, RN,, MS,, CWOCN,, FAMAN SSkkiillll 3399..11 RRiisskk AAsssseessssmmeenntt,, SSkkiinn AAsssseessssmmeenntt,, aanndd PPrreevveennttiioonn AAPPPPEENNDDIIXXEESS SSttrraatteeggiieess,, 999955 SSkkiillll 3399..22 TTrreeaattmmeenntt ooff PPrreessssuurree IInnjjuurriieess,, 11000033 AA NANDA Definitions from Nursing Diagnoses: Definitions and Classification 2015-2017, 4400 WWound Care and Irrigation,, 1012 10th Edition, 1147 Janice CC.. Colwell,, RN,, MS,, CWOCN,, FAMAN BB Common Prefixes and Suffixes, 1153 PPrroocceedduurraall GGuuiiddeelliinnee 4400..11 PPeerrffoorrmmiinngg aa WWoouunndd AAsssseessssmmeenntt,, 11001166 SSkkiillll 4400..11 PPeerrffoorrmmiinngg aa WWoouunndd IIrrrriiggaattiioonn,, 11001177 SSkkiillll 4400..22 RReemmoovviinngg SSuuttuurreess aanndd SSttaapplleess,, 11002222 SSkkiillll 4400..33 MMaannaaggiinngg WWoouunndd DDrraaiinnaaggee EEvvaaccuuaattiioonn,, 11002277 SSkkiillll 4400..44 NNeeggaattiivvee--PPrreessssuurree WWoouunndd TThheerraappyy,, 11003322

1I Using Evidence in Nursing Practice OOUUTTLLIINNEE PPuurrppoossee,, pp.. 11 SSttaannddaarrddss ooff CCaarree,, pp.. 11 PPrriinncciipplleess ffoorr PPrraaccttiiccee,, pp.. 11 SSuussttaaiinniinngg EEvviiddeennccee--BBaasseedd PPrraaccttiiccee CChhaannggeess,, pp.. 1100 OOBBJJEECCTTIIVVEESS • Discusstheprocessforcritiquingevidenceintheliterature. • Identifytheelementstoreviewwhencritiquingascientifiic MMaasstteerryy ooff ccoonntteenntt iinn tthhiiss cchhaapptteerr wwiillll eennaabbllee tthhee nnuurrssee to:: • Discusshowscientiffiicevidenceimprovestherelevance article. • Discusswaystoapplyevidenceinnursingpractice. andefffiicacyofnursingskills. • Explaintheimportanceofidentifyingoutcomesinthe • Explainthedifferencesbetweenresearch-andnon­ evaluationofanevidence-basedpracticechange. research-basedevidence. • Describethesixstepsofevidence-basedpractice. • ExplainthecomponentsofaPICO(T)question. MMEEDDIIAA RREESSOOUURRCCEESS • ClinicalDebriefandReviewQuestionsAnswers • CaseStudies evolve. http://evolve.elsevier.com/Perry/skills • ReviewQuestions • AudioGlossary PURPOSE PPRRIINNCCIIPPLLEESS FFOORR PPRRAACCTTIICCEE OOne off the kkeyy messages in the 2010 report of the Institute of Cathy works on a medical oncology unit wheree patiieennttss underrggoo Medicciinnee (IOMM)),, TThe Future of Nursing:: Leading Change, chemotherapy and radiation for leukemiaa,, lymphoma, andd ootther AAdvancing Health,, is ffor nurses to be full partners with physicians forms of cancer.. Because of their chemotherapy, manyyppaattiieents eexxpe-­ andd other hheealth care professionals in redesigning health care in rience a drop in their platelet count and clotting factors, iinnccreasing the UUnited SStates (IOM,, 2010).. TTo achieve better patient out-­ their risk for bleeding. Cathy recently cared for a 422--yyeeaarr--old wwooman ccoommees,, new knowledge must bbe transformed into clinically useful who fell while trying to get to the bathroom andd hit hher heaaddaaggaaiinnsstt aapppproaches and then ssuucccessfully iimplemented across the entire the bedframe, resulting in a serious intracranial bleeedd. Caatthhyy ddiiss-­ hhealth care team and mmeasured in terms of meaningful impact on cusses the situation with two nurse colleagues aanndd asks, “\"Hooww ccaann perffoormance and hhealth outcomes (Stevens, 20133). Nursing is posi­- we reduce the number of falls and injuuriieess to our patients on thhee tionedd to lead change and advance health through the use of oncology unit?”\" The nurse specialist for the unit tteells CCathy, “\"I heaarrdd eevidence-based practiccee (EBP),, a processs that makes nurses more about an approacchh to fall preventiioonn onn one off the surgiiccaall fflloors; it autonommoouuss in changiinngg healthh care practices.. EBP is a problem­- involves hourly rounding. Let’'s ask this qquueestion, “\"Inn adult oncologyy solving approach to clinical practice that combines the best avail­- patients, will the use of hourly rounding compared with thee current able eevidence in combination with a clinician'’s expertise, patient fall prevention protocol affeecctt the incidence of ffaalls duringg hospital-­ preferences and values,, and available health care resources in ization?”\" Feeling frustrated that their eexxissttiinngg fall prevveennttiioonn prooto-­ mmaakkiinngg ddeecciissiioonnss aabboouutt ppaattiieenntt ccaarree (MMeellnykk aanndd FFiinneeoouutt­- qccooulleswwtiaaossnnnisootttheeeffffreeicgcthtiitvveeoniinen trroeedsdeuuaccriicnnhgginffnaallttllhss,,e ttlhihteeergagrtrououruepp. aaggrreeeess tthhaatt tthhee Overholt,, 20144).. Through the use of current and relevant scientiffiic eeviddeence,, nurses ensure that the skills and procedures performed This clinical case study highlights how professional nurses address on patients incorporate best practices for effiicciieennccyy,, patient safetyy,, problems in their practice. andd cllinical effectiveness.. EBP is a process of making informed decisions about the wwaayy SSTTAANNDDAARRDDSS OOFF CCAARREE nurses care ffoor patients. It all begins with asking clinicall questions. Clinical questions lead nurses such as Cathy and her colleagues to QQuuaalliittyy aanndd SSaaffeettyy EEdduuccaattiioonn ffoorr NNuurrsseess (QQSSEENN)) IInnssttiittuute: Pre­- ffiinndd eevviiddeennccee ffrroomm tthhee rreesseeaarch literatuurree,, clinical papers, quality LLiicceennssuree KSSAA'’ss,, 22001144-—EEvviiddeennccee--bbaasseedd pprraaccttiiccee ccoommppeetteennccyy improvement data, risk-management trends, and the opinions of nnuurrssee eexxppeerrttss.. NNuurrsseess tthheenn aappppllyy tthhee eevviiddeennccee ttoo mmaakkee rreelleevvaanntt 1

-2 CHAAPTTEERR 11 USINGEVIDENCEINNURSINGPRACTICE aanndd iinnffoorrmmeedd cchhaannges in practicee such as fall prevention in the practice. IV care was based on tradition. Recent research has ccaassee ssttuuddyy.. shown that topical antibiotics offer no beneffiit and daily dressing changes are not beneffiicial unless a dressing becomes soiled or TThheerreeaarree elemennttssof all nursinngg procedurreess withinn this textbook compromised. Today the current standard of care is to cleanse an tthhaatt aarree eevviiddeennce bbaasseedd. FFoorr example,, the length of time necessary adult'’s IV site with chlorhexidine antiseptic solution, not antibi-­ ttoo wwaasshh hhaannddss,, thee technique ffoorr determining the position of a otic ointment,, and to change dressings on peripheral catheters if ffeeeeddiinngg ttuubbee iinn thhee ssttoomach,, and the technique for giving an intra­- the dressing is damp, loosened, and/or visibly soiled and at least mmuussccuullaarr injection aarre bbaased on evidence. Clinical research led to every 5 to 7 days (INS, 2011). The challenge is to obtain the very tthhee answweerrss ffoorr hhoow thessee nursiinngg procedurreess should be performed. best, most current inffoormation at the right time, when you need it TThhee uussee ooff ssuucchh eevviiddeennce in pprractice enables clinicians to provide for patient care. tthhee hhiigghheesstt qualityy off care to their patients and families. The best evidence comes from well-designed, systematically Quaalliittyy Healtthh Care conducted research studies that are reported in scientiffiic journals. Unfortunately many health care settings do not have a process to TThhee AANNAA rreeppoorrttss thatt the emphasis in health care today for help staff adopt new evidence in practice. Nurses in practice set-­ eevviiddeennccee--bbaasseedd qquality impprrovement and health care transforma­- ttiioonn uunnddeerrssccoores thhee nneeeedd foorr redesigning care that is effective, safe, tings, unlike educational settings, may not have easy access to aanndd eefffiicciieenntt ((SStteevveennss,, 22001133)).. TThhee uussee ooff EEBBPP iiss kkeeyy ttoo aacchhiieevviinngg qquuaalliittyy hheeaalltthh ccaarree,, ddeeffiinneedd aass tthhee ddeeggrreeee ttoo wwhhiicchh hheeaalltthh sseerrvviicceess databases ffoor scientiffiic literature. Instead they often care for ffoorr iinnddiivviidduuaallss aanndd ppooppuullaattiioonns increase the likelihood of desired hheeaalltthh oouuttccoommeess aannd are consistent with current professional patients on the basis of tradition, preferences, or convenience. kknnoowwlleeddggee (IOOM,, 22013).. Implementing health care processes or Because there are often obstacles to research-based practice in pprraaccttiicceess thhaatt aarree knowwnn too work (evidence basedd)) in a reliable wwaayy iiss aa ffeeaattuurree oof \"“quality ccaare.\"” IImmplleementing new knowledge clinical settings, it is important for administrators to provide a inttoo pprraaccttiicce rreeqquuiirreess aa ssyysstteemmatic approach that applies evidence ttoo cclliinniiccaall,, eedducational,, and administrative practices. EBP is one supportive environment and adequate facilitation of change. ooff tthhee QSEENN competeenncciieess,, with the goal for the QSEN project bbeeiinngg ttoo prepare nurses too hhaavve the kknowledge,, skills,, and attitudes Researchers have found that leadership within health care institu-­ ttoo ccoonnttiinuously improvve thee qquality and safety of the health care tions is vital for the process of implementing EBP in nursing (Sand-­ ssyysstteemmss wwiitthhiinn which theyy wwork (QSEN Institute,, 2014). Perhaps strom et al., 2011). Some hospitals have created councils of nurses wwhhaatt iiss mmoosst iimmppoorrttaannt aabboout EEBP is that the process encourages to lead initiatives to implement and study measures that promote aallll hheeaalltthh ccaarree pprroviders to question pprractices and to use evidence the best standards of care. Hospital-based nursing research centers inn ddeecciiddiinngg whiicchh iinntterventions prodduce the best outcomes and have also helped sustain a culture of EBPP, something that hospitals whhiicchh ddoo nnoott.. Nurrsseess playy a kkey rrole at the bedsiiddee in questioning are focusing on as they move to apply for Magnet designation or oouuttddaatteedd,, iillllooggiiccaall,, oorr unsafe pprractices and then adopting evidence­- redesignation (Ingersoll et al., 2010). bbaasseedd iinntteerrvveennttiioonnss tthhaat wwill change patients'’ health status and aacchhiieevvee ddeessiirreedd oouuttccoommes. One thing that is unique about EBP is that it includes multiple AA Case ffoor Evviiddeenncce sources of evidence. When there is no research evidence for a practice question or issue, nurses have a range of non–-research-­ EEBBPP iss aa gguuiiddee ffoorr mmaakkiinngg accurate,, ttiimmeellyy, and appropriate clinical based evidence available (Dearholt et al., 2012). Examples of non–­ ddeecciissiioonnss.. IItt iiss aan interprofessional process for applying the newest research-based evidence includes consensus or position statements, kknnoowwlleeddggee availlaabbllee iin hheealth care sciences to the patient'’s bedside. general literature reviews, quality improvement and risk manage-­ FFoorr eexxaammppllee,, uussiinngg aa sliding bboard to transfer a patient from bed ment data, retrospective or concurrent chart review, and clinicians’' ttoo ssttrreettcchheerr iinnsstteeaadd of lifting and using the research-based Braden expertise. Non-–research-based evidence is valuable in informing SSccaallee ttoo rroouuttiinneellyy assess aa patient'’s risk for skin breakdown are you about practice issues in your setting (e.g., fall or infection eexxaamples ooff using evidencee at the bbedside. This textbook demon­- rates). But remember, it is important that you nnoott rely on non–­ ssttrraattees hhooww ttoo use evidence in nursing procedures or skills and research-based evidence alone. Research-based evidence is more pprroovviiddes thhee sscciientifiicc gguuiiddeelliinneess ttoo ppeerrffoorrmm sskkiillllss mmoorree eeffffeeccttiivvelyy likely to be timely, accurate, and relevant. When you face a clinical aannd iimmpprrove ppaattiieenntt oouuttccoomes. problem, seek out all sources of evidence to ffiind the best solution in caring for patients. AAs a professional nurse you need to stay informed and be aware ooff thhee moosstt ccuurrrrent eevvidence. Typically new students diligently Even when you use the best evidence available, application and rreeaadd thheeiirr textbooks and aassigned scientifiicc aarrttiicclleess.. AA ggoooodd tteexxtt­- outcomes will differ on the basis of your patients’' values, prefer-­ bbooookk iinnccoorporates ccuurrent evidence into the practice guidelines ences, concerns, and/or expectations. Apply critical thinking com-­ aand nnursing sskkills att the time it is published. Howeveerr,, because a petencies to determine whether evidence is relevant and appropriate teexxttbbooookk rreelliies oonn the scientifiicc lliitteerraattuurree,, ssoommee iinnffoorrmmaattiioonn ccaan to your patients and to a clinical situation. For example, some bbeeccoommee oouuttddaatteedd bbyy tthhee ttiimmee iitt iiss ppuubblliisshheedd.. AArrttiicclleess ffrroomm nnuurrssiinngg research suggests that spirituality positively affects and enhances and tthhee hheeaalltthh care lliitterature are aavailable on almost any topic patients'’ physical and psychological health and health promotion iinnvvolving nursing pprraactice. New research is reported every dayy. behaviors (Conway-Phillips and Janusek, 2014; White, 2013). AAlltthhoouugghh tthe sscientifiicc bbaassiiss ooff nurrssiinngg pprraaccttiiccee hhaass groowwnn,, tthheerre However, if a patient is reluctant to discuss his or her spirituality are practices tthat are still not \"“research based\"” (based on ffiindinggss and you are unsure of his or her beliefs, an attempt to use spiritual ffrroomm well-ddeessiiggnneedd rresearch studies) because fiinnddiinnggss aarree innccoonncclluu­- health interventions is inappropriate. Using your clinical expertise ssiivvee oorr rreesseeaarrcchheerrss hhaavvee nnoott yyeett ssttuuddiieedd tthhee pprraaccttiicceess.. FFoorr eexxaammppllee,, and considering patients’' cultures, values, and preferences, ensure iinn tthhee ppaasstt nnuurrsseess cchhaannggeedd iinnttrraavveennoouuss ((IIVV)) ssiittee ddrreessssiinnggss ddaaiillyy aanndd that you apply new evidence in practice both ethically and appro-­ aapppplliieedd aannttiibbiioottiicc ooiinnttmmeenntt ttoo rreedduuccee tthhee iinncciiddeennccee ooff iinnffeeccttiioonn aatt priately. EBP requires good nursing judgment; it is not ffiinding aa ssiittee.. HHoowweevveerr,, tthheerree wwaass nnoo eevviiddeennccee aatt tthhee ttiimmee ttoo ssuuppppoorrtt tthhiiss research evidence and applying it blindly. SStteepps ooff Evviiddeennccee--BBaaseedd Practice TThheerree aarree ddiiffffeerreenntt mmooddeellss ffoor using EEBPP.. TThe JJohns Hopkins MMooddeell iinncclludes three pphhaasseess ddeessccrriibbeedd as ppractice question, eevviiddeennccee,, aanndd ttrraannssllaattiioonn ((PPEETT)) ((DDeeaarrhhoolltt aanndd DDaanngg,, 22001122)).. AAllttoo-­ ggeetthheerr tthhee PPEETT mmooddeell iinncclluuddeess 1188 sstteeppss.. AA ssiimmpplleerr mmooddeell iiss oonnee

CHAAPTER 1  USINGEVIDENCEINNURSINGPRACTICE -3 ddeessccrriibbeedd bbyy MMeellnnyykk aanndd FFiinneeoouutt--OOvveerrhhoolltt ((22001144)) tthhaatt iinncclluuddeess .B: OX 1.1 ssiixx sstteeppss:: Developing a PICO Question 11.. AAsskk aa cclliinniiccaall qquueessttiioonn.. 22.. SSeeaarrcchh ffoorr tthhee mmoosstt rreelleevvaanntt aanndd bbeesstt eevviiddeennccee tthhaatt aapppplliieess P Patient, population or problem Besuccinct.Identifyyourpatientsbyage,gender,ethnicity, ttoo tthhee qquueessttiioonn.. disease,orsymptoms. 33.. CCrriittiiccaallllyy aapppprraaiissee tthhee eevviiddeennccee.. 44.. AAppppllyy oorr iinntteeggrraattee eevviiddeennccee aalloonngg wwiitthh yyoouurr cclliinniiccaall eexxppeerr-­ I Intervention or issue of interest Whichinterventiondoyouthinkisworthwhiletousein ttiissee,, ppaattiieenntt pprreeffeerreenncceess,, aanndd vvaalluueess iinn mmaakkiinngg aa pprraaccttiiccee practice?Itcanbeatreatment;aclinical,educational,or ddeecciissiioonn oorr cchhaannggee.. administrativeintervention;aprocessofcare;aneducation 55.. EEvvaalluuaattee tthhee pprraaccttiiccee ddeecciissiioonn oorr cchhaannggee.. strategy;oranassessmentapproach. 66.. CCoommmmuunniiccaattee aanndd ddiisssseemmiinnaattee rreessuullttss.. C Comparison with the intervention Ask aa Clinical Question Doesacomparisoninterventionexist?Whichstandardofcare AAsskkiinngg aa cclliinniiccaall qquueessttiioonn iiss mmoosstt iimmppoorrttaanntt bbeeccaauussee hhooww aa pprroobblleemm orcurrentinterventiondoyouusuallyusenowinpractice? iiss ppoosseedd ddrriivveess tthhee rreemmaaiinniinngg sstteeppss ooff tthhee EEBBPP pprroocceessss ((DDeeaarrhhoolltt aanndd DDaanngg,, 22001122)).. EEvveerryy ddaayy nnuurrsseess ppeerrffoorrmm iinntteerrvventions (e.g., O0 Outcome (that is measurable) pprroovviiddiinngg ccoommffoorrtt mmeeaassuurreess,, ccaarriinngg ffoorr wwoouunnddss,, aanndd ooffffeerriinngg ggrriieeff Whichresultdoyouwishtoachieveorobserveasaresultof ssuuppppoorrtt)) tthhaatt ssttiimmuullaattee qquueessttiioonnss ssuucchh aass,, \"“WWhhyy ddoo wwee uussee tthhiiss anintervention(e.g.,changeinpatient'sbehavior,qualityof aapppprrooaacchh??\"” aanndd \"“lIss tthheerree aa bbeetttteer wwaayy??\"” oorr \"“TThhiiss sstteepp ccaauusses ppaattiients life,physicalfiinding;changeinpatient'sperception,rate ddiissttrreessss.. WWhhaatt ootthheerr ooppttiioonnss aarree aavvaaiillaabblle?”\" AAllwwaayyss tthhiinnkk aabbout ofadverseevents,costs)? your practice when caring for patients. Question what does not make sense to you and what you think needs clariffiication. Include T Time (an optional component for a clinical question) colleagues from other disciplines whose perceptions might help to clarify or examine the clinical problem or issue. As shown in the Adapted from Dearholt SL, Dang D: Johns Hopkins nurrssing eevviiddeennccee-based previous case studyy, think about a patient care problem or an area practice: model and guidelines, ed 2, Indianapolis, 2012, Sigma Theta Tau of interest that is time consuming, costly, or not logical. Often TJC International; Purdue Libraries: Evidence-based prraactice, http://guides.lib sstandards (e.g., the annual patient safety goals) spark questions for .purdue.edu/content.php?pid=296535&sid=2435417, 2014. Accessed July 6, 2015; and University of Illinois at Chicago: Evidence-based mmeeddiicciine, PICO, you to pose about your patients. 2015, http://researchguides.uic.edu/c.php?g=252338&p=1683349. Accessed July6,2015. Clinical questions often arise as a result of either a problem- or a knowledge-focused triggerr. A problem-focused trigger develops as practice it helps to be able to identify foreground questions so the you care for a patient or notice a trend on a nursing unit. For extent of literature to review is limited. example,, a problem-focused trigger might arise while caring for an unconscious ppaatient: \"“Which is the best anti-infective solution to A well-stated foreground question is clearly worded whenn you use when giving oral care to unconscious patients?\"” Examples of use a PICO format. Box 1.1 summarizes the elements off a PIICCO question. Using key words in a PICO question make it easier to problem-focused trends include the increase in the number of pres­- search for evidence in the scientiffiic literature because it restricts a sure injuries to patients'’ skin or tissues or the incidence of urinary search to only articles pertinent to the PICO terms. The words used in the PICO question are the key terms for your literature tract infections on a nursing unit. A knowledge-focused trigger search. Examples of PICO questions follow: In abdominal surgery patients (P),, does epidural analgesia (I) compared with patient-controlled arises when you ask a question regarding new information about a analgesia (C) affect pain severity (O0)? In medical patients ((P) does the topic. For example,, \"“What is the current evidence to reduce blood­- use off a case-management model (I) compared with a telephone call-­ stream infection in central venous catheters?\"” Important knowl­- back system (C) improve patient medication adherence (O0)? edge sources often include standards and practice guidelines An option used in PICO questions involves use of an additioonnaall available from national agencies such as the Agency for Healthcare term, “\"T”\" for timing. The addition of a Timing ffaactor in aa PICOT question allows you to further narrow your question. For example, Research and Quality (AHRQ), the INS, the American Associa-­ timing might refer to when an intervention is to be used or a timee frame for outcome achievement. Here is an example: In abdominal tion of Critical Care Nurses (AACN), and National Pressure Ulcer surgery patients (P), does epidural analgesia ((I) compared with patient-­ controlled analgesia (C) affect pain severity (O0) in the first 48 hours Advisory Panel (NPUAPP, 2016). after surgery (T)? There are two types of clinical questions:: background and ffoore­- Well-designed PICO questions do not have tto include all four ground (Dearholt and Dang, 2012; Straus,, 2011). Think of a forest and the trees. A background question gives us a view of a forest. It is broad and general about a condition or idea. For example, \"“Which interventions reduce falls in oncology patients?\"” The answer to the question provides general knowledge about the problem,, concepts or topic of interest (e.g.,, falls, fall occurrence among oncology patients,, reasons oncology patients fall). In con-­ elements. For example, a comparison intervention is not pertinent ttrraasstt,, aa ffoorreeggrroouunndd qquueessttiioonn ggiivveess uuss aa cclloosseerr llooookk aatt tthhee ttrreeeess iinn aa wwhheenn aa PPIICCOO qquueessttiioonn iiss aabboouutt mmeeaanniinngg ssuucchh aass,, DDoo ffaammiillyy ccaarreeggiivv-­ forest. It is a more specifiicc and ffoocused question that includes ers (P) of hospice patients feel anxiety (O0) when providing hands-on specifiicc ccoommppaarriissoons (DDearholt and Dang,, 2012). A foreground care (I)? Also, if there is no comparison intervention, only thee question asks which of two interventions is likely the more effec-­ standard of care, a ((C) is not required. The elements off Population, tive in addressing a practice issue. For example, \"“Does hourly an Intervention or issue of interest, and Outcome are essential for rounding compared with a standard fall prevention protocol affect a well-designed PICO question involving an intervention. the incidence of falls?”\" A background question allows you to A clearly stated PICO qquestion helps to identify kknnoowwledge gappss explore a vast array of options in the literature; whereas a for a speciffiic clinical, educational, or managerial problem or situ-­ foreground question produces a reffiined and limited body of evi­- ation. When you form well–-thought-out questions, thee type of dence speciffiic tto your areaa of interest. In day-to-day clinical evidence you lack for clinical practicee becomeess clearerr whenn youu

-4 CCHHAAPPTTEERR 11 USINGEVIDENCEINNURSINGPRACTICE searrcchh the literature. Examples of different knowledge gaps include .B: OX 1.2 tthhe ffoollowing:: Searchable Scientific Literature DDatabases ••  DDiiaaggnnoossiiss:: Questions about the selection and interpretation and Sources of diagnostic tests. EExxaammppllee:: Does the use of a disposable oral CINAHL CumulativeIndexofNursingandAlliedHealth tthhermometer compared with an electronic oral thermometer Literature;databaseforEBSCOnursing resources;includesstudiesinnursing,allied measure body temperature accurately in a patient with an health,andbiomedicine endotracheal tube? http://www.cinahl.com ••  PPrrooggnnoossiiss:: Questions about a patient'’s likely clinical outcome. MEDLINE USNationalLibraryofMedicine®;bibliographical Example:: Is there a difference in the incidence of deep vein databasethatcontainsmorethan22million referencestojournalarticlesinlifescienceswith thrombosis in surgical patients wearing sequential com-­ aconcentrationonbiomedicine pression stockings compared to those who wear elastic http://www.nlm.nih.gov/bsd/pmresources.html stockings? EMBASE Biomedicalandpharmaceuticalstudiesand ••  Therapy:: Questions about the selection of the most beneffiicial abstractsandarticlesfrombiomedical,drug, andmedicaldeviceconferences treatments. Example:: Which bowel regimen is most effective http://www.embase.com in relieving constipation caused by the administration of PsyclNFO lnterprofessionalbibliographicalresourcesin opioid therapy in oncology patients with chronic pain? psychologyandthebehavioralandsocial ••  Prevention:: Questions about screening and prevention sciences methods to reduce the risk of disease. Example:: Does the use http://www.apa.org/psycinfo of social media with education messages compared with Cochrane Fulltextofregularlyupdatedsystematicreviews Community­ preparedbytheCochraneCollaboration; informational brochures improve male adolescent’'s adher-­ Databaseof includescompletedreviewsandprotocols Systematic ence to the human papillomavirus vaccine series? Reviews http://community.cochrane.org/cochrane-reviews ••  EEdducation:: Questions about best teaching strategies for National Publicresourceforevidence-basedclinical colleagues, patients, or family members. Example:: Is the use Guidelines practiceguidelines.Availablethroughthe of motivational interviewing compared with low-literacy Clearinghouse AgencyforHealthcareResearchandQuality; teaching booklets more effective to educate low-literacy adults about therapeutic diets? ••  MMeaanniinng:: Questions that seek understanding of a phenom­- enon. Example:: How do patients with cervical cancer per-­ ceive their quality of life? Searrcchh for the Best EEvidence containsstructuredabstracts(summaries)about clinicalguidelinesandtheirdevelopment;also Once you have a clear and concise PICO question, you are ready PubMed includescondensedversionofguidelinesfor to search ffoor evidence. NNumerous research and non-research viewing rreesources are available to aid in your search, including government http://www.guideline.gov/index.aspx and professional websites,, agency procedure manuals,, performance HealthsciencelibraryattheUSNationalLibraryof improvement reports, and computerized bibliographical databases. Medicine;freeaccesstomorethan24million Do nnot hesitate to ask ffoor help to fiinndd aapppprroopprriiaattee eevviiddeennccee. AA citationsforbiomedicalliteraturefromMEDLINE, rreeffeerreennccee librarian is an excellent resource with whom to collabo­- lifesciencejournals,andonlinebooks rrate to conduct a literature search. If one is not available, go to your facullttyy member or an advanced practice nurse within the http://www.nlm.nih.gov health care institution. oncology might be entered instead as cancer to ffiit the database AA reference librarian knows the relevant databases available to language; whereas adherence might be also entered as compliance. you foor a literattuurree search about your PICO question (Box 1.2). When you work within a database you enter key words to search TThhe databases are repositories of published scientiffiic studies, for articles. Because the vocabulary within published articles is including peer-reviewed research. A peer-reviewed article is prefer­- able ffoor retrievvaall becaussee it has been evaluatedd by a panel of experts often vague, the words that you select sometimes have one meaning ffamiliar with the topic or subject matter of the article.. Working with the lliibbrarian,, you translate the elements of your PICO (T) to one author and a very different meaning to another. Each key qquuestion into the llanguage or key words that will yield the best word generates a set of articles. For example, in the PubMed data-­ articles ffoor your evidence search. For example, consider this PICO base oncology patient generates over 196,000 articles, adherence gen-­ question:: \"“Does motivational interviewing (I) compared with erates 99,631 articles, and chemotherapy generates over 2,600,000 media instruction (C) improve oncology patients'’ (P) adherence to cchemotherapy medications (O)?”\" The key words include oncol­- articles. That’'s a lot of reading! In this example you want to read only articles that address all three of the topics in the same article. There are several ways to reduce those thousands of articles to a oogy patient, motivational interviewing, media instruction, chemo­- more manageable number. One is by using Boolean operators or tthheerraappyy, and adherence.. A good librarian will recommend using the function of Search Limits. You narrow a search by combining the iinndexing language or controlled vocabulary of the database key terms from your PICO question using the Boolean connector and.. For example, by entering the combination of “\"oncology thatt you are searching.. The controlled vocabulary known as patient and chemotherapy and adherence”\" into the literature data-­ MMeeddical Subject HHeadings (MeSH®) is updated annually from the UUSS NNational Library of Medicine and contains over 220,000 terms base, you will only obtain a listing of the articles that contain all ((UUSS NNaattiioonnaall LLiibbrraarryy ooff MMeeddiicciinnee,, 2001155)).. PPrrooppeerr uussee ooff MMeeSSHH®® tteerrmmss ffaacciilliittaatteess aa mmoorree tthhoorroouugghh aanndd ffooccuusseedd lliitteerraattuurree sseeaarrcchh tthhaann tthhrreeee tteerrmmss;; iinn tthhiiss ccaassee iitt iiss 666611 aarrttiicclleess,, wwhhiicchh iiss ssttiillll qquuiittee aa ffeeww.. oonnee yyoouu mmiigghhtt ggeett ffrroomm ssiimmppllyy ttrryyiinngg ttoo sseeaarrcchh ccoommbbiinnaattiioonnss ooff AA lliibbrraarriiaann ccaann aallssoo sshhooww yyoouu hhooww ttoo uussee tthhee SSeeaarrcchh LLiimmiittss ffuunncc-­ kkeeyy wwoorrddss oonn GGooooggllee oorr YYaahhoooo.. IInn tthhee pprreevviioouuss eexxaammppllee tthhee wwoorrdd ttiioonn.. YYoouurr sseeaarrcchh ccaann bbee ffuurrtthheerr nnaarrrroowweedd bbyy lliimmiittiinngg iitt bbyy cceerrttaaiinn ccaatteeggoorriieess ssuucchh aass tthhee ttiimmee ffrraammee dduurriinngg wwhhiicchh tthhee aarrttiiccllee wwaass

CCHHAAPPTTEERR 11 USINGEVIDENCEINNURSINGPRACTICE -5 Systematic reviews and meta-­ an equal chance of being assigned to either group. In that way it I analyses of RCTs is not likely ffoor the two groups to be highly different. The treat-­ ment group receives the experimental intervention at the same II One properly designed RCT time the control group receives the usual standard of care. Both groups are measured ffoor the same outcomes to determine if the Strength of evidence III Controlled trials without experimental intervention made a difference. Following comple-­ randomization tion of an RCT, the researcher knows if the intervention leads to better outcomes than the standard of care. An RCT is an example IV Case control and cohort studies of a clinical trial, a research study in which one or more human subjects are prospectively assigned to one or more interventions to Systematic reviews of descriptive evaluate the effects of those interventions on health-related bio-­ V and qualitative studies medical or behavioral outcomes (NIH, 2014). VI Single descriptive or qualitative More often you ffiind articles in the nursing literature that study involve controlled trialss without randomization (i.e., quasi-­ experimental studies) or descriptive studies. Even though these VII Quality improvement,, risk types of studies represent a lower level of evidence than RCTss,, a management data study with relevant results helps you decide if your PICO question can be answered. For example if a quasi-experimental study resulted VIII Opinion of expert clinicians in a positive clinical improvement, even though it was not a sta-­ tistically signiffiicant change, the clinical change might be worth FIGG 11..11 TThhe evidence pyramid. RCTT,, Randomized controlled trial. strong consideration for reliable evidence. written,, typess of studies, English language publications, or age of The use of clinical experts is at the bottom of the evidence patients. In this example, using limits of humans,, 5 years,, English, pyramid, but do not consider clinical experts a poor source of and clinical trial,, the search now yields 73 articles. Use of Boolean evidence. Expert clinicians frequently use evidence as they build their own practice, and they are rich sources of information for connectors and Search Limits reduces the number of articles to a clinical problems. manageable number to review for a PICO question. Critique the Evidence The pyramid in Fig. 1.1 represents a hierarchy for rating avail-­ In the case study the nurses on the oncology unit conduct their unit practice committee (UPC) meeting. During the meeting Cathy and able scientifiicc eevvidence tthat you oobtain iin your search. It is impor­- her colleagues decide that it is important to include key members tant to learn about the types of studies to help you know which of their interprofessional team (pharmacy and physical therapy).. ones have the best scientiffiicc evideennccee and thus which ones you The UPC then reviews the articles careffuully, using a rapid-appraisal choose to revieeww. The strongest level of evidence is at the top of checklist. After the group evaluates the articles ffoor the strength of the pyramid; the weakest is at the bottom. YYou can use the rating evidence and synthesizes the findings, they decide that there is evidence for implementing hourly rounding with focused patient scale of I to VIII when you later critique each article that you assessment to prevent falls. The stafff notes that one off the articles recommends hourly rounding during daytime hours and rounding obtain in your search of the literature. Table 1.1 describes types of every 2 hours during evening and night hours. Another article sum-­ and provides examples of studies in the evidence hierarchy, begin­- marizes fall risks for patients in an acute care hospital and highlights ning with the study at the top of the hierarchy, a systematic review. factors to include in a nursing assessment such as medications ((e.g..,, antihistamines, sedatives, analgesics, and antiemetics). If your PICO question leads you to an article that is a systematic Critically reviewing and analyzing the available evidence requires revieeww,, celebrate!! A systematic review is the perfect answer to a a systematic approach. Each source of evidence (e.g., journal article, PICO question. Basically a researcher has asked the same PICO clinical guideline, expert summary) must be reviewed to determine question you have asked and then examined all of the well-designed its value, feasibility, and utility of evidence ffoor making a practice change. Your review should allow you to determine if there is evi-­ relevant research studies that ask the same question. The researcher dence that answers your question. It is important to use an approach creates a detailed and comprehensive plan and search strategy with that does not bog you down by reviewing every single element of the goal of reducing bias in any ffiindings by identifying, appraising, each article. The use of critical appraisal checklists allows you to and synthesizing all relevant studies on the topic (Uman, 2011). rapidly review each article from your search and answer four impor-­ The researcher sets criteria for the type of studies to review in the tant questions (Centre for Evidence-Based Medicine, 2014): search. A systematic review explains if the evidence for which you are searching about a speciffiic qquestion exists and whether it sup­- 1. Does this study address a clearly focused question? ports a change in practice. A systematic review of well-designed 2. Did the study use valid methods to address this question? research studies provides the best evidence of the effectiveness of 3. Are the results of the study valid and important? different interventions. A meta-analysis involves using statistical 4. Will these valid, important results help you provide better techniques to analyze the data from the studies in the systematic review to determine statistically the strength of the evidence. care for your patients? Many organizations use appraisal checklists (Fig. 1.2) for recording A randomized controlled trial (RCT) is a formal experiment for article reviews. You begin an article review by determining if the testing therapies and establishing cause and effect. A researcher qquueessttiioonn ppoosseedd bbyy tthhee rreesseeaarrcchheerr iiss cclleeaarr aanndd ccoonncciissee.. DDooeess tthhee tteessttss aann iinntteerrvveennttiioonn ((ee..gg..,, aa mmoobbiilliittyy pprrooggrraamm oorr nneeww ttyyppee ooff aarrttiiccllee cclleeaarrllyy eexxppllaaiinn tthhee ppuurrppoossee,, tthhee rreesseeaarrcchh qquueessttiioonnss aaddddrreesssseedd,, wwoouunndd ccoovveerriinngg)) aaggaaiinnsstt tthhee uussuuaall ssttaannddaarrdd ooff ccaarree.. RReesseeaarrcchheerrss oorr aaiimmss ooff tthhee ssttuuddyy?? Ilss tthhee ppuurrppoossee ooff tthhee aarrttiiccllee rreelleevvaanntt ttoo yyoouurr rraannddoommllyy aassssiiggnn ssuubbjjeeccttss iinn aann RRCCTT ttoo eeiitthheerr aa ccoonnttrrooll oorr aa ttrreeaatt-­ PPIICCOO qquueessttiioonn?? NNeexxtt,, iiss tthhee rreesseeaarrcchh ssttuuddyy wweellll--ddeessiiggnneedd?? TThhiiss mmeenntt ggrroouupp.. IInn ootthheerr wwoorrddss,, aallll ooff tthhee ssuubbjjeeccttss iinn tthhee ssttuuddyy hhaavvee

-6 CHHAAPTTER 11 USINGEVIDENCEINNURSINGPRACTICE TTABBLLEE 11..11 TTyyppeess ooff SSttuuddiieess inn thee Evidence HHiieerrarchy SSttuuddyy TTyyppee DDeessccrriippttiioonn EExxaammple Systematic Anauthororpanelofexpertsreviewsthe ThisstudyaimedtoexaminethevalidityofusingtheBradenScalein reviewor evidencefromrandomizedcontrolledtrials long-termcare(LTC)settings.Elevendatasetsfromninepublished meta-analysis (RCTs)(andotherdeffiinedtypesofresearch studiesdescribing40,361residentswereanalyzed.Theappropriateness studies)aboutaspeciffiicclinical questionand oftheBradenScaleinLTCisquestionablegivenitslowspecifiicityand summarizesthestateofthescience.Ina positivepredictivevalue.Thismeansthatthescalehashighprobability meta-analysisthereistheadditionofa thatsubjectswithapositivescreeningtesttrulyhaveariskforapressure injury;however,iftheresultontheBradenScaleispositive,thecertainty statisticalanalysisthatcombinesdatafrom ofthepersonactuallyhavingapressureinjuryislow(Wilcheskyand Lungu,2015). allstudies. RCT Aresearchertestsaninterventionagainstthe Thisstudy,focusingonpatientsatisfaction,evaluatedtheimpactof usualstandardofcare.Participantsare providingclinicianphotographsoninpatients'recall.TheRCTinvolved randomlyassignedtoeitheracontrolgroup threegroups.Acontrolgroupreceivedthecurrentstandardofcare;the (receivesstandardcare)oratreatmentgroup secondgroupreceivedhandoutswiththenamesandrolesoftheirclinical (receivestheexperimentalintervention),with careteam;andthethirdgroupreceivedhandoutswiththenames,roles, bothmeasuredonthesameoutcomestosee ifthereisadifference. andphotographsoftheirclinicalcareteam.Patientscompletedasurvey beforedischargeontheirabilitytorecalltheircliniciansandratedthe qualityofcommunicationwiththecareteam.Thosewhoreceivedphotos inthehandoutcorrectlyidentifiiedsigniffiicantlymorecliniciansby photographandidentifiiedmorecliniciannames.Therewasnodifference inqualityofcommunication(Appeletal.,2015). Quasi­ Thisresearchapproachtriestoshowthatan Hospitalsroutinelyconductregularsurveillanceontheincidenceof experimental interventioncausesaparticularoutcome.This ventilator-associatedpneumonia(VAP)inintensivecareunits(ICUs).This study typeofstudyisdonewhenitisnotpractical, studyaskedwhatwouldhappentotheincidenceofVAPifsurveillance ethical,orpossibletorandomlyassign stopped.SurveillancewasinterruptedforayearinoneICU(A)and subjectstoexperimentalandcontrolgroups continuedinasecond(B).TheincidenceofVAP,mortality,andpatient (Dearholtetal.,2012). lengthofstayincreasedintheAunit.Surveillanceprovidesimportantdata feedbackforongoingperformanceimprovement(Benetetal.,2012). Casecontrolor Researchersstudyonegroupofsubjectswitha Thisstudyexaminednursepractitioner(NP)andphysicianassistant(PA) cohortstudy certaincondition(e.g.,obesity)atthesame timeasanothergroupofsubjectswhodonot participationindirectpatientcarewithICUs.PatientsinICUswithNPs/ havetheconditiontodetermineifthereisan PAshadlowermeanAcutePhysiologyScoresandmechanicalventilation associationbetweentheconditionand ratesthanICUswithoutNPs/PAs).ResultssupportthatNPs/PAsarea predictorvariables(e.g.,exercisepattern, safeadjuncttotheICUteam.TheffiindingssupportNP/PAmanagement familyhistory,historyofdepression). ofcriticallyillpatients(Costaetal.,2014). Descriptive Studydescribestheconceptsunderstudy.It Thisstudyassessedtheriskfactorsforinfectionincancerpatientsreceiving study sometimesexaminestheprevalence, chemotherapy.Datawerecollectedfrompatientmedicalrecords.Risk magnitude,and/orcharacteristicsofa factorsforinfectionincancerpatientsreceivingchemotherapyincluded concept. alkylatingagentsandunderlyingdiabetesmellitus(Parketal.,2015). Qualitative Studyexaminesindividuals'perceptionsof Researchersanalyzedinterviewsfrompatientsandtheirhealthcare study experienceswithhealthproblemsorlifeevents providersfollowingabdominalsurgerytodevelopaconceptualframework andthecontextsinwhichtheexperiences occur.Aqualitativestudyprovidesnarrative forrecoveryafterabdominalsurgery.Themostimportantconcepts datafromextensiveinterviewswithsubjects.A identiffiiedwere\"Energylevel,\"\"Sensationofpain,\"\"Generalphysical qualitativeresearcherencouragessubjectsto endurance,\"and\"Carryingoutdailyroutine.\"Researchersfoundthatno telltheirstoryaboutaneventorconditionto currentinstrumentsformeasuringrecoveryincludealloftheseconcepts obtainafullandrichdescription. (Leeetal.,2015). Clinicalexperts Accessingclinicalexpertsonanursingunitisan Thisarticledescribeshowusingresearchandpersonalexperienceledto excellentwaytolearnaboutcurrentevidence. developmentofanapproachtohelpapreceptorandnewnursemake Clinicalexpertsoftenwriteclinicalarticleson themostofthepreceptorexperience(NooeandKautz,2015). topicsthatrequireapplicationofevidencein theliterature. qquueessttiioon rreeqquuiirrees knowing thee type of study,, using thee evidence for a thorough and objective review of ffiindings? Studies that are ppyyrraammiidd.. FFoor example,, if you have an article on an RCT to review, not designed well cannot provide deffiinitive support for the evi­- wweerree subbjjeeccttss randomized in the study? WWas the sample of subjects dence they aim to produce. larggee eennoouugghh ttoo test the intervention effectively? WWhhat approach As you read each article, you ask the next question: What are wwaass usseedd inn delivering the intervention and measuring the effects? the results and were they important? Do the ffiindings apply to your WWeerree aallll ssuubbjjeeccttss mmeeaassuurreedd fforr tthhee ssaammee oouuttccoommeess?? IInn ccoonnttrraasstt,, iiff ppaattiieennttss aanndd ppractice ssetting? If yyou hhave an RCT,, you want to yyoouu rreeaadd aa qquuaalliittaattiivvee ssttuuddyy,, ddiidd tthhee rreesseeaarrcchheerr ssttuuddyy aa ssuuffffiicciieenntt kknnooww iiff aann iinntteerrvveennttiioonn wwoorrkkeedd oorr nnoott ttoo hheellpp ddeecciiddee iiff iitt ppootteenn-­ nnuummbbeerr aanndd rreepprreesseennttaattiioonn ooff ssuubbjjeeccttss,, aanndd ddiidd tthhee aapppprrooaacchh aallllooww ttiiaallllyy mmaakkeess sseennssee ttoo uussee iitt iinn yyoouurr pprraaccttiiccee.. YYoouurr aannaallyyssiiss ooff

CCHHAAPPTTEERR 11 USINGEVIDENCEINNURSINGPRACTICE -7 Example of a Rapid Critical Appraisal Form • Why was the study done? (Is there a clear explanation of the study purpose?) • Are the study findings valid? How were study participants chosen? How many were chosen? Are the study instruments valid and reliable? Does the research approach fit the purpose of the study? How were accuracy and completeness of data ensured? Do the study findings fit the data that were generated? • What are the results of the study, and are they important? Yes No Unknown • Is the finding from the study clearly identified? • Are the results logical, consistent, and easy to follow? • Are the results plausible and believable? • How do the results fit with previous research in the area? • Will the results help me in caring for my patients? • Do the results apply to my patients? • How would I use the findings in my practice? • How would patient and family values be considered in applying these results? • Do we have the resources to apply this in our practice setting? FIG 1.2 Example of a rapid critical appraisal form. (Adapted from Melnyk B, et al: Evidence-based practice in nursing and health care: a guide to best practice, ed 3, Philadelphia, 2014, Wolters Kluwer; and Fineout-Overholt E,, et al: Evidence-based practice step by step: critical appraisal off the evidence, Part 1,, Am)J Nurs 110(7):47,, 2010.) statistics will help. For example, if an intervention was shown to After reading the abstract and introduction, decide if you want to continue to read the entire article. You will know if the topic of be \"“statistically signifiiccaanntt,,\"” tthe iinntteerrvention shows bbenefiitt.. IIff the article is similar to your PICO question or related closely instead there was no statistically signiffiicant difference,, you may rejecctt the value of the intervention. Howeverr, if the intervention enough to provide you useful information. Remember that the led to improvement even though not statistically signiffiicant, you research question does not need to be the same as yours but close might still consider it to have clinical value. If you have a descrip­- enough to offer useful information. If this is the case, continue to tive ssttuuddyy, you will decide if the information is relevant to your PICO question. For example, were characteristics of the patients read the next elements of the article: in the study similar to those of your own patients? ••  Literature review or backggrround: A good author offers a detailed background of the level of scientiffiic or clinical infor­- YYou might also choose to review a clinical article that explains mation that exists about the topic of the article. The review a clinical practice topic relevant to your PICO question. A clinical explains what led the author to conduct a study or report on article is not rated for its level of evidence; but it can offer useful a clinical topic. Perhaps the article itself does not address information, especially if you decide to implement a change related your PICO question the way you desire but possibly leads to the practice topic. To learn how to read research and clinical you to other more useful articles. The literature review gives articles, know each of the common elements. This will help you you a good idea of how past research led to the researcher’'s decide if an article is complete and well explained. Articles should question. include the following elements: ••  AArrttiiccllee nnaarrrraattiivvee:: The “\"middle section”\" or narrative of an ••  Abstract:: A brief summary of the article that tells you if the article is research or clinically based.. An abstract summarizes article differs, depending on whether it is clinical or research based (Melnyk and Fineout-Overholt, 2014). A clinical the purpose of the study or clinical topic, the major themes article describes a clinical topic, which often includes a or fiinnddiinnggss,, aanndd tthhee iimmpplliiccaations ffoorr pprraaccttiicce.. description of a patient population, the nature of a certain ••  Introduction:: Contains information about the purpose of the disease or health problem, how it affects patients, and impli-­ aarrttiiccllee aanndd tthhee iimmppoorrttaannccee ooff tthhee ttooppiicc ffoorr tthhee aauuddiieennccee wwhhoo ccaattiioonnss ffoorr nnuurrssiinngg ccaarree.. CClliinniiccaall aarrttiicclleess oofftteenn ddeessccrriibbee hhooww rreeaaddss iitt.. TThheerree iiss uussuuaallllyy aa bbrriieeff ddiissccuussssiioonn ooff ssuuppppoorrttiinngg ttoo uussee aa tthheerraappyy oorr nneeww tteecchhnnoollooggyy.. AA rreesseeaarrcchh aarrttiiccllee eevviiddeennccee aabboouutt wwhhyy tthhee ttooppiicc iiss iimmppoorrttaanntt ffrroomm tthhee aauutthhoorr'’ss ddeessccrriibbeess tthhee ccoonndduucctt ooff aa rreesseeaarrcchh ssttuuddyy,, iinncclluuddiinngg iittss ppooiinntt ooff vviieeww.. ppuurrppoossee,, hhooww tthhee ssttuuddyy wwaass ddeessiiggnneedd,, aanndd tthhee rreessuullttss.. AA

-8 CHHAAPTTER 11 USINGEVIDENCEINNURSINGPRACTICE narrative of a research article contains several standard of evidence, using the scale of I to VIII from the evidence pyramid subsections: (see Fig. 1.1). It also helps to review multiple articles with a group ••  PPuurrppoossee ssttaatteemmeenntt:: Explains the focus or intent of a study. of colleagues involved in the EBP process. Each person can review a single article; then you can come together as a group to review IIt identifiieess wwhhiicchh coonncceeppttss wwiillll bbee rreesseeaarrcchheedd.. your total ffiindings. Rememberr,, when reviewing evidence, a recom­- ••  MMeetthhooddss oorr ddeessiiggnn:: Explains how a research study is orga­- mendation to change practice should not rely solely on a single study or the opinion of a single expert (Poe and White, 2010). nnized and ccoonducted to answer the research question(s). Once all evidence has been reviewed, it is time to discuss the third TThhiiss iss wwhheerree you learn the type of study (i.e.,, RCTT,, case important question: Will the results help you care for your patients? ccoonnttrrool,, oor qualitative). YYou also learn how many subjects oor peooppllee aare in a ssttuuddyy. In health care studies subjects Use critical thinking to consider the scientiffiic rigor of the evi-­ ssoometimes iinncclude patients,, family members,, or health dence and how well it answers your area of interest. Scientiffiic rigor ccaarree sstaffff.. TThe language in the methods section is some­- is the extent to which the ffiindings of a study are valid, reliable, and ttiimmeess ccoonnffuussiinngg iff it explains details about how the relevant to a patient population of interest. Consider the evidence rreesseeaarrcchheerr ddesigns the study to minimize bias so as to in light of your patients'’ concerns and preferences. Your review of obtaiinn the most accuratee results possible. Use your faculty articles offers a snapshot conclusion based on combined evidence mmeemmbbeerr as a resource to help interpret this section. about one focused topical area. As a clinician, judge whether to use ••  RReessuullttss oorr FFiinnddiinnggss:: Clinical and research articles have a the evidence for a particular patient or group of patients who usually ssuummmmaary sseecction. In a clinical article the author explains have complex medical histories and patterns of responses (Melnyk tthhee cclliinical implications for the topic. In a research and Fineout-Overholt, 2014). Ethically always consider evidence aarrtticle thhee author explains the results and how the that will beneffiit patients and do no harm. Decide if the evidence is rreesseeaarrcch question was answered. For example,, in a quali­- relevant, is easily applicable in your setting of practice, and has the ttaattiivvee ssttuuddyy there iis a thorough summary of subject nar­- potential for improving patient outcomes. rraattiivveess,, which provide a ddescription of themes and ideas tthhaatt arise from the rreessearcher'’s analysis of data. There is There will be times when you ffiind that there is insufffiicient or nno statisticall analysis of the data collected. A quantita­- no evidence to answer a PICO question. This ffiinding warrants no ttiivve ssttudy includes a full description of the study subjects change in practice because the evidence is weak and inconsistent aanndd a ssttaattiisstical analysis of fiinnddiinnggss.. IItt iiss iimmppoorrttaanntt ttoo or absent. llearn some off the common statisticaall terms (Box 1.3). A ggooodd author discusses limitations to a study in the results Apply the Evidence—- Project Management sseection. TThe inffoormation on limitations helps you decide If a literature review and critique yield evidence that answers your iiff yyoou wwaanntt too use the evidence from the article with your PICO question and offer evidence that can be applied to practice, ppaattients. the next step is to implement an EBP project. An EBP team must ••  Clinical implications:: A research article includes a section be able to manage an EBP project (such as a new fall prevention tthhaatt eexxplains iff the fiinnddiinnggss ffrroomm tthhee ssttuuddyy hhaavvee cclliinniiccaall protocol) to ensure completion of project tasks and translation of iimmpplliiccaattiioons.. TThe researcher explains how to apply ffinndd­- the evidence ffiindings into daily practice (Poe and White, 2010). iinnggss in a practice setting for the type of subjects studied. In other words, a team must introduce practice changes success-­ AAs yyoouu critique each article,, complete your critical appraisal check­- fully. A successful EBP project involves the following: list. YYoou mmaayy choose to rate each article by its level and strength 1. A sponsor (e.g., an advanced practice nurse, nurse manager, .B: OX 1.3 or senior staff nurse) who has the commitment and expertise to make the project succeed. CCoommmmoonn SSttaattiissttiiccaall TTermms 2. Sufffiicient resources to accomplish the project, including time SSaammppllee SSiizzee::Number(n)ofindividualsinastudy. (e.g., staff having time to attend meetings, collect data), SSiiggnniiffiiccaannccee::Ameasurethatgivesthelikelihoodthataffiindingora support of all team members, infrastructure of the unit where change will occur (e.g., how procedures are performed, unit resultofastudyiscausedbytheinterventionbeingtestedandnot setting), and equipment and supplies ((ddepending on project). simplybychance.Mostresearcherssetthelevelofsigniffiicanceat aa ppvalueof0.05or0.01.Forexample,iftheeffectsofan 3. Clear identiffiication of outcomes to be measured to deter-­ intervention(e.g.,hourlyrounding)aresigniffiicantatpp<<0.05,it mine if the EBP practice change is a success (outcomes are meansthatthelikelihoodoftheeffect(fewerfalls)occurringby a component of the PICO question, but a team must kknow chanceislessthan5%;thusitis95%morelikelythatthe how to measure them consistently). NOOTTEE: Outcomes should be measured before the pilot to have a baseline to interventiontrulyhadaneffectinreducingfalls.Whenastudy determine if the intervention leads to a change. resulthasappvalue(0.61)greaterthanthatset(e.g.,pvalue0.05), 4. Time schedule for project. It is recommended you pilot test theresearcherhastoconcludethattheresultswerepossiblyby a practice change a minimum of 3 months and gather chanceandtheinterventionhadnoeffect. outcome measures throughout this time. CCoownnhffiiicddheencnclcineeiciiinantnteesrrcvvaaalnl((eCCxlIp))::eTchtetoragnegtere(esu.glt.s,rifanthgeeyopfreasmenetaannscore)in 55.. CCoommmmuunniiccaattiioonn aanndd oorriieennttaattiioonn ppllaann.. IItt iiss ccrriittiiccaall ttoo bbee ssuurree that all staff involved in any EBP change are inffoormed and interventioninthesamewayasitwasinastudy(Fineout-Overholt educated (if necessary) to be able to perform the practice etal.,2010).TheCltellsyoutheprecisionofastudy.A95%Cl change. meansthatclinicianscanbe95%conffiidentthattheirffinidingswill bewithintherangegiveninthestudy. In the case study, the oncology UPC has completed the literature rreevviieeww.. TThhee nnuurrssee ssppeecciiaalliisstt ttaakkeess tthhee lleeaadd ffoorr tthhee tteeaamm.. OOnn tthhee bbaassiiss EEffffeecctt ssiizzee::Whentheeffectofaninterventionisstatistically of tthhee eevviiddence, the committtee members’' eexxpperiences, a review off tthhee uunniitt ffaallll rraattee rreeppoorrttss,, aanndd kknnoowwlleeddggee oofftthheeiirr ppaattiieennttss’' rriisskk ffaaccttoorrss,, signifficiant,itdoesnotnecessarilymeanthatitisbig,important,or tthhee UUPPCC rreeccoommmmeennddss aa nneeww ffaallll pprreevveennttiioonn pprrooggrraamm ffoorr tthhee uunniitt.. helpfulindecisionmaking.Itsimplymeansthatyoucanbe conffiidentthatthereisadifference.Aneffectsizegreaterthan0.05 isconsideredalargeeffect.

CCHHAAPPTTEERR 11 USINGEVIDENCEINNURSINGPRACTICE -9 TThe UPC alsoo recommends piloting the new program for 3 months. .B: OX 1.4 TThe evidence-based program includes several features. The patients Outcome Measurements on the unit fall during all hours of the day and night; therefore hourly rounding will be implemented around-the-clock. The evidence OOuuttccoommee OOuuttccoommee MMeeaassuurree review revealed iinffoormation allowing the team to develop a focused Falloccurrence Fallindex,fallswithinjuries ffaall screening tool and nursing assessments for key fall risk factors. Medicationadherence Pillcounts,patientself-report,number RRegistered nurses ((RRNs)) will round on patients on all even hours and offiilledprescriptions conduct the focused assessments of fall risk factors for oncology Learningdischarge patients identifiieedd ffrrom tthhee lliitteerrature ssuucch as lloowweerr-extremity weak­- instructions(topic Patientsurveys,includingquestionson ness,, impaired gait,, general fatigue, and use of antihistamines. The specifiic) topic;nurseobservationsofpatients nurses will infform each patient of their personal fall risks. performingskills(usingaratingscale) Infectionoccurrence AA pprroojjeecctt sshhoouulldd aappppllyy eevviiddeennccee iinn aa mmaannnneerr tthhaatt iinntteeggrraatteess weellll Monthlyinfectioncontrolreportsof wwiitthh eexxiissttiinngg pprraaccttiiccee ffoorr aallll aaffffeecctteedd ddiisscciipplliinneess.. laboratorytestsoninfectionincidence Inn the case ssttuuddyy, if an oncology patient is found to be at high fall e. Limit the number of staff who ccollect dattaa to ensure bbetter risk,, the physical therapists will be asked to consult and assess the accuracy and consistency in measurement. Be sure that each person collects data the same way, at the same time or fre-­ patient'’s lloowweerr-extremity strength and overall balance and make quency, and accurately. tthheerrapy recommendations.. The pharmacy will place alerts on medi-­ f. Establish a way to record all data. cation administratiioonn records so nurses can monitor patients receiv­- The goal of any EBP change is to ensure the highest quality of care ing antihistamines before blood transfusions.. Nursing assistive by using evidence that promotes the best outcomes ((Poe and White, 2010). Proper planning is essential before and as you imple-­ ppersonnel ((NNAP)) will round on odd hours and do follow-up obser-­ ment your practice change. Once you implement your interven-­ vations to be sure that patients have their toileting needs met, are tion, monitor the project closely and consider how staff and comffoortable, and have no further needs. Patients will be told that patients are responding. every hour someone will return to their room for another check. Evaluate the Practice Decision or Change TThhee nnuurrssee ssppeecciiaalliisstt hhaass ttaallkkeedd wwith the unit manaaggeerr,, presented After implementing a practice change, your next step is to evaluate the pilot plan,, and obtained commitment from the manager to move the outcomes. You do this by analyzing the outcome data that you ffoorward with the project.. The UPC works with the manager to create collectedd before and during the pilot project. Outcome evaluation a staff orientation schedule and sets a date for the start of the hourly tells you if your practice change improved conditions, created no rounding program pilot. Before the start date the nurse specialist change, or worsened conditions. Here are some eexxamples. After using a new, transparent IV dressing, the staff analyzed their audits, gathers the ffaall rate data and falls with injuries from the last 3 months which included the incidence of dislodged IVs and thee incidence and rating of phlebitis. Their ffiindings showed reduction in the ffoor baseline measures.. To evaluate the process for program piloting, number of catheters that became dislodged and iin the onset and severity of phlebitis. The recommendation for this project would tthe team will also collect short surveys from all staff members to continue use of the new dressing. After using a new aapppproach to educating clinic patients aboutt medications and administration determine their reactions to and acceptance of the program. schedules, ffoollow-up phone calls to patients found an improved understanding of doses and times to administer. However, patients IItt is important to have a well-organized EBP project management plan. IIf the bbarriers to practice change are excessive, adopting a were not able to explain which side effects to expect. The staff practice change can be diffiiccuulltt,, iiff nnoott iimmppoossssiibbllee.. FFoorr example,, if involved with this EBP project created single-page bulleett points the oncology unit'’s fall program is too diffiiccuulltt ffoorr ssttaaffff ttoo complete,, about common side effects of medications and continued to evalu-­ if tthere iis inadequate stafffiinngg,, oorr iiff nnoott aallll ssttaaffff aarree aable to attend ate the pilot an additional 3 months. orientation sessions,, the program may not be successful. Once an evaluation is complete, you must decide to continue Outcome Measurement the EBPP, make a revision, or discontinue the practice change. Duriinngg an EBP pilot project,, collection of outcome measures is Consider not only if the outcomes were met but also whether or critical.. TThis involves knowing the measures to collect and having not patients, families, or staff were affectedd in other ways by the a processs for consistent reliable data collection.. change. Analysis of an EBP change may require assistannccee from 1.. PPlan hhow to collect baseline data on the outcomes that will statisticians if you or your team members collect extensive data. Be sure to use reliable rresources and be tthorough in eexxaamining all ddata. evaluate the effect of your practice change (e.g., the oncology nurse specialist will be able to use the unit'’s monthly quality On the ooncology unit the UPC made sure that oouutcome measurreess performance report that includes fall rate and fall with injuries. were in place before implementing the fall prevention program.. The TThe nurse specialist collects values for 3 months before imple-­ fall rate and falls with injuries were collected from monntthhllyy qquuaalliittyy mentation of the program. The nurse specialist will continue to performance reports and included each of the 3 months beeffoorree collect the fall rate and the fall-related injury rate each month, implementation and then for 3 months after tthhee program bbeeggaann.. once the new program pilot begins. The UPC designated three stafff members to also ccoollect ssuurrvveeyyss a. Know which outcomes to measure and how to collect the ffrroomm ssttaaffff aatt 11 mmoonntthh aanndd 33 mmoonntthhss ttoo sseeee hhooww tthheeiirr ccoolllleeaagguueesswweerree rreeaaccttiinngg ttoo tthhee nneeww pprrooggrraamm.. TThhrreeee mmoonntthhss aafftteerr iimmpplleemmeennttiinngg tthhee mmeeaassuures ccoonnssiisstently (e.g.,, to measure pain acuity use a self­- pprrooggrraamm,, tthhee oonnccoollooggyy uunniitt wwaass ccaauuttiioouussllyy ooppttiimmiissttiicc.. TThhee aavveerraaggee rreeppoorrtt ppaaiinn ssccaallee;; ttoo mmeeaassuurree aammbbuullaattiioonn ddeetteerrmmiinnee tthhee ddiiss­- ffaallll rraattee ffoorr tthhee uunniitt ddrrooppppeedd ffrroomm 55..11 ttoo 33..99;; aanndd tthhee iinnjjuurryy rraattee ttaannccee aa ppatient wwalks each time). b. Be sure that the outcomes are measurable (Box 1.4). Use ssccaalleess (e.g.,, pain and Braden Scales),, physiological measures ((ee..gg.,, tteemmperature,, blood pressure, pulse oximetry), survey ttooools,, aand performance improvement reports.. c. Choose ooutcomes that are not costly to collect. Use existing eeqquuiippment if you can. d. Educate team members on the approach to use to collect and rreeccoorrdd outcomes.

10 CHAAPTTEERR 11 USINGEVIDENCEINNURSINGPRACTICE aallssoo ddrrooppppeedd,, ffrroomm 22 dduurriinngg tthhee ffiirrsstt 33 mmoonntthhss ttoo oonnllyy 11 aafftteerr tthhee presenting in workshops or seminars, submitting an abstract for a ppiilloott bbeeggaann.. AAlltthhoouugghh iitt wwaass nnoott aann oouuttccoommee mmeeaassuurree,, tthhee nnuurrsseess poster presentation, and publishing an article. As a professional oobbsseerrvveedd aa ddeecclliinnee iinn ppaattiieennttss'’ uussee ooff ccaallll lliigghhttss,, wwhhiicchh wwaass aattttrriibb­- you are responsible for communicating important information uutteedd ttoo tthheeiirr kknnoowwiinngg tthhaatt nnuurrsseess aanndd aassssiissttiivvee ppeerrssoonnnneell wwoouulldd vviissiitt about nursing practice. Sharing evidence and the effects of any ffrreeqquueennttllyy.. TThhee nnuurrssiinngg aanndd pphhyyssiiccaall tthheerraappyy ssttaaffff ssuurrvveeyyss rreevveeaalleedd practice change motivates others within a health care setting and tthhaatt tthhee mmaajjoorriittyy wweerree eenntthhuusseedd aanndd aaggrreeeedd tthhaatt hhoouurrllyy rroouunnddiinngg makes them excited about potential practice improvements on nneeeeddeedd ttoo bbee aa rroouuttiinnee ppaarrtt ooff tthheeiirr uunniitt pprraaccttiiccee.. TThhee nnuurrssiinngg ssttaaffff their work units. When you successfully adopt an EBP way of wwaass aabbllee ttoo sseeee tthhaatt tthhee ffaallll pprreevveennttiioonn pprrooggrraamm iimmpprroovveedd ppaattiieenntt thinking, it becomes very natural to talk about available evidence oouuttccoommeess aanndd ggaavvee tthheemm mmoorree ttiimmee ttoo ccoooorrddiinnaattee ccaarree bbeeccaauussee ooff and continue seeking solutions ffoor problems in patient care. ffeewweerr ddiissttrraaccttiioonnss ffrroomm ppaattiieenntt ccaallllss.. SUSTAINING EVIDENCE-BBASED Commuunniiccaatte aanndd Diisssemiinnaatte PRACTICE CHANGES aa Prraaccttiicce Chaannge Implementing EBP changes in a health care setting takes time SSiixx mmoonntthhs aafftteerr ssttaarrttiing the nnew fall prevention protocol,, the fall and commitment to do it well. What is even more difffiicult is iinnddeexx ooff tthhee oonnccoollooggyy uunniitt ccoonnttiinnuueess ttoo rreemmaaiinn llooww.. AAnn aaddddeedd sustaining the changes over time. Chambers et al. (2013) oouuttccoommee iiss aann iimmpprroovveemmeenntt iinn ppaattiieenntt ssaattiissffaaccttiioonn ssccoorreess.. CCaatthhyy describe an important process, dynamic sustainability. The ssuubbmmiittss tthhee pprroottooccooll ffoorr aann aabbssttrraacctt iinn tthhee hhoossppiittaall ppuubblliiccaattiioonn,, process involves continued learning and problem solving and NNuurrssiinngg PPrraaccttiiccee.. TThhee oouuttccoommeess ooff tthhee oonnccoollooggyy UUPPCC pprroojjeecctt rreessuulltt ongoing adaptation of interventions so they continue to ffiit the iinn tthhee ddeevveellooppmmeenntt ooff hhoossppiittaall--wwiiddee hhoouurrllyy rroouunnddiinngg pprroottooccoollss.. practice environments and needs of patients and expectations for OOtthheerr uunniitts rreevviieewweedd tthhee literature to ccustommize the nursing assess­- ongoing improvement as opposed to diminishing outcomes over mmeenntt ttoo tthheeiirr ppaarrtticular ppaattient needs.. The methodical and well­- time. Competency in EBP requires a commitment to learning ddeessiiggnneedd EEBBPP pprroojjeecct lleedd bby the oncology UPC resulted in new scientiffiic knowledge,, working with teams to appropriately eessttaabblliisshhmmeenntt ooff aann eevviiddeennccee--bbaasseedd ssttaannddaarrdd ffoorr ootthheerr nnuurrssiinngg uunniittss apply and later adapt new interventions in practice, and then iinn tthhee hhoossppiittaall.. ffiinding ways to maintain and continue interventions that are consistently effective. Patients expect nursing professionals to be AAfftteerr aappppllyyiinngg evidence,, itt iis iimmppoorrttaanntt to communicate the informed and to use the safest and most appropriate interven-­ cchhaannggee iin pprraactice and tthe results to nursing and other health care tions. Use of evidence enhances nursing practice and improves ccoolllleeaagguues.. TThhiiss iiss truuee wwhhether the results are successful or unsuc­- patients’' outcomes. cceessssffuull.. TThheere aarree manyy ways to ccoommunicate the outcomes of EEBBPP:: ttaallkkiinngg wwiitthh aa colleaagguuee,, sharing results in staff meetings, CLINICAL DEBRIEF theirfamilycaregiversparticipated.Theresearchercomparedthetwo groupsforthedischargeoutcomesoflengthofstayandpostopera­ Anorthopedicinterprofessionalteamcomposedofstaffnurses,aphys­ tiveambulation. icaltherapist,andanorthopedicsurgeonhasbeendiscussingthecare a. Whichtypeofstudywasreviewedbythephysicaltherapist? ofpatientsundergoingtotalhipreplacements.Thesurgeonbelievesthat b. Listtworeasonswhythisstudymightbeusefultotheinterprofes­ thepatientsshouldbereachingahigher levelofmobility before being discharged.Thephysicaltherapistsharesconcernsaboutnotbeingable sional team in planning their evidence-based practice (EBP) tosee allpatients ina timely manner since the number of surgeries project. performed has increased.The staff nurses have noted that patients' c. Listtworeasonswhythisstudymightnotbeusefultotheteam familymembersalwaysseeminterestedintheirpatients'progress.One inplanningtheirEBPproject. registerednursesharesastoryaboutadaughterofapatientwhospent 44.. Identifytwowaysmembersoftheinterprofessionalteammightdecide timecoachingherfathertowalkabitfurther,anditseemedtohelp.The to measure mobility and how might they reach that decision in the teamwondersifthefamilycouldbeamoreinvolvedresource.Theywant contextofwhoisontheteam? touseanevidence-basedapproachtoimprovepatientcare. 11..Write a PICO question for the orthopedic team's area of clinical ♦ REVIEW QUESTIOONS interest. 11.. Placethestepsofevidence-basedpracticeinthecorrectorder: 2.Thestaffnursewhochairstheunitpracticecommitteecontactsthe 1 ____SearchtheliteratureusingMeSH®termsandlimitsto gatherevidence. hospitallibrariantocollaborateonaliteraturesearchtoffiindarticles 2____Evaluateoutcomesofthepracticechange. pertinenttothePICOquestion.Thenursetellsthe librarianthat the 3____Reporttheffiindingsinanewslettertostaff. teamwantstoseeifthereisevidencefortheirapproachtoimproving 4____Applytheevidencebychangingapracticeprotocol. patientmobility.Thelibrarianhelpsthenurseselectindexinglanguage 5____Identify a problem in practice and ask a PICO question. fromthedatabasethatwillbesearched.Whichalternative MeSH® 6____ Review the articles obtained from the literature review termsmightyougivethelibrarianforthetermmmoobbiilittyy? andcritiquetheavailableevidence. 33..Thestaff meetstoreview the articles obtained from the literature review.Eachmemberselectsanarticletoreview.Thephysicalthera­ 22.. Anursespecialistisreviewingtheoutcomemeasurescollectedduring pistreviewsandpresentsastudyinvolvingtestingofaneducational anevidence-basedpractice(EBP)projectonasurgicalunit.TheEBP approach for patients who underwent knee-replacement surgery. Patientswererandomlyassignedtooneoftwogroups: one group receivedstandardpatienteducationbrochures about their surgery,  andtheothergroupattendedapreoperativeteachingclassinwhich

11111CHAAPTEER 1  USINGEVIDENCEINNURSINGPRACTICE 11 teamappliedevidenceaboutgivingaround-the-clock (ATC) analge­ Dearholt SL, et al: JJoohhnnss HHooppkkiinnss nnuurrssiinngg eevviiddeennccee--bbaasseedd prraaccttiiccee: mmooddeell aanndd gguuiiddee-­ sicstopostoperativepatientsinsteadoftraditionalprn (as needed) lliinneess,, ed 2, Inndianapolliiss,, 2012, Sigma TTheta Tau Internatioonnaall.. medications.TheuseofATCanalgesicsstartedinSeptember. a. Reviewthegraphanddescribethechangeinanalgesicdosesand FFiinneeoouutt--OOvveerrhhoolltt EE,, eett aall:: EEvviiddeennccee--bbaasseedd pprraaccttiiccee,, sstteepp bbyy sstteepp:: ccrriittiiccaall aapppprraaiissaall of the evidence, Part II, Amm JJ NNuurrss 110(9):41, 2010. painscores. b. ExplainifthechangesweretobeexpectedasaresultoftheEBP Infusion Nurses Society (INS): Infusion nursing standards of practice, J IInnffuuss NNuurrss 3344((11SS))::2200111l.. change. Ingersoll GI, et al: Meeting Magnet research and evidence-based practice expeccttaa-­ JJuunnee July Augg Sept Oct Nov tions through hospitall--bbaasseedd research centers, NNuurrss EEccoon 28((44):222266,, 2201100.. 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Averagepainscores IInnssttiittuuttee ooff MMeeddiicciinnee ((I!OOMM)):: AAnnnnoouunncceemmeenntt:: ccrroossssiinngg tthhee qquuaalliittyy cchhaassmm:: tthhee I!OM health care quality initiative, 2013, www.iiom.eedduu//GGloobbaall//NNeewwss%%2200 24hpostop 5.4 5.1 4.8 4.1 3.7 3.5 Announcements/Crossing-the-Quualitty-Chasm--TThhe-IIOM--HHeeaaltth--CCaarree-­ QQuuaalliittyy--Ilnniittiiaattiivvee..aassppxx.. AAcccceesssseedd JJuullyy 66,, 22001155.. 48hpostop 4.9 4.2 4.6 3.9 4.1 3.3 Lee L, et al: How well are we measuring postoperative “\"recovery”\" after aabbddoommiinnaall 33.. Anevidence-basedpractice(EBP)committeeonamedicineunithas surgery? QQuuaall LLiiffee RReess 24:2583, 2015. selectedaPICOquestionandreviewedandcritiqued the literature andisnowreadytoproceedwithan EBP project.Which of the fol­ Melnyk BM, Fineout-Overholt E: Evidence-bassed pprractice in nnuursing and healthcare:: lowingfactorsareessentialforsuccessfulEBPprojectmanagement? aa gguuiiddee ttoo bbeesstt pprraaccttiiccee,, ed 3,, Philadelphia, 2014, Woolltterrss Kluwer. (Selectallthatapply.) 1. A sufffiicientnumberofarticlesprovidingevidenceforthePICO National Institute of Health (NIH): NNoottiiccee ooff rreevviisseedd NIH ddeeffiinniittiioonn ooff “\"cclliinniiccaall ttrriiaall,, question 2014. https://grants.nih.gov/grants/guide/notice-files/NOT--OD-15-015.html. 2. Asponsorwhohasthecommitmentandexpertise to make the Accessed October 24, 2015. projectsucceed National Pressure Ulcer Advisory Panel: Nationaall Pressure Ulcer Advisory Panel 3. Resourcestoaccomplishtheproject 4. Timescheduleforapilotproject (NPUAP) announces a change in terminology ffoorm pressure ullcceerr tto prreessssuurree 5. Sufffiicientnumberofoutcomestobemeasuredtodeterminethat injury and updates the stages of pressure injury, Press Release, AApprriill 1133,, 22001166,, http://www.npuap.org/natioonal-pressure--uulcer--aadvissoorryy-paanneell-npuuaapp--annoouunncceess-­ theEBPpracticechangeisasuccess. a-change-in-terminology-from-pressure-ulcer-to-pprreessssuuree--injjuurryy--aanndd--uuppddaatteess-­ VViissiitt tthhee EEvvoollvvee ssiittee ffoor a ccommpplleettee lisstt off Clinical DDebrief and Review the-stages-of-pressure-injury/. QQuueessttiioonnss aannswweerrs.. Nooe A, Kautz DD: Preceptorship: combining experience with research, DDiimmeennss RREEFFEERREENNCCEESS CGritt Care Nurs 34(2):81, 2015. Park JH, et al: A retrospective analysis to identify the ffaactors aaffffeecctting infection AAppppeell LL,, eett aall:: PPuutt aa ffaaccee ttoo aa namee:: aa randomizeedd controlled trial evaluating the iimmppaacctt ooff pprroovviiddiinngg clinicciiaann pphhootographs on inpatients'’ recall, Am JJ Med in patients undergoing chemotherapy, Eur J Onceoall Nurs 2015.. ii::S1l446622((1155)) 112288((11))::8822,, 22001155.. 00052-6. [Epub ahead off print]. Poe SS, White KM: JJoohhnnss HHooppkkiinnss nnuurrssiinngg eevviiddeennccee--bbaasseedd pprraaccttiiccee:: iimmpplleemmeennttaattiioonn BBeénneettTT,, eett aall:: IImmppaacctt ooff ssuurrvveeiillllaannccee ooff hhoossppiittaall--acquuiirreedd infections on the inci­- and translantion, Indianapolis, 2010, Sigma Thetaa Tau Internatioonnaall.. ddeennccee ooff vveennttiillaattoorr�-aassssoocciiaatteedd pneumonia in intensive care units: a quasi-� QSEN Institute: Pre-Licensure KSA’s' , 2014, http://qsen.org/commpetenciies/pre-­ eexxppeerriimmeennttaall ssttuuddyy,, GCrrit CCaarree 116(4):RRl161,, 2012. licensure-ksas/. Accessed June 20, 2015. CCeennttrree ffoorr EEvviiddeennccee--BBaasseedd MMeeddiicciinnee:: CCrriittiiccaall aapppprraisal tools, 2014, http:// Sandstrom B, et al: Promoting the implementation of evidence-based practice: aa wwwwww.cebm..nneett//ccrriittiiccaall--aappraiisaall//. AAccessed JJuly 8,, 2015. literature review ffoocusing on the role of nursinngg leadership, WWoorrllddvviieewwss EEvviidd CChhaammbbeerrss DDAA,, eett aall:: TThhee ddyynnaammiicc ssuussttaaiinnaabbilliittyy framework: addressing the ppaarraaddooxx ooff sustainmeenntt amidd oonnggooing cchhange,, Impplement SScci 8:117, 2013. Based Nurs 8(4):212, 2011. Stevens K: The impact of evidence-based practice in nursingg and the nnext big CCoonnwwaayy--PPhhiilllliipps RR,, JJaannuusseekk LL:: IInnfflluueennccee ooff sseennssee ooff ccoohheerreennccee,, ssppiirriittuuaalliittyy, ssoocciial ssuuppppoorrtt aanndd hheeaalltthh ppeerrcceeppttion on bbrreeaasstt cancer screening mmotivation and ideas, Online J Issues Nurs 18(2):2013. bbeehhaavviioorss iinn AAffrriccaann--AAmerican women,, AABNF JJ 25(3):72,, 2014. Straus SE: Evidence-based medicine: how to practice and teach EEBBM, ed 4, Edinbbuurrgghh,, CCoossttaa DDKK,, eett aall:: NNuurrssee pprraaccttiittiioonneerr//physician assistant stafffiinngg aanndd ccrritical ccaarree mmoorrttaalliittyy,, CChheesst 114466((66))::11556666,, 2014.. 2011, Elsevier/Churchiillll Livingstone.. Uman LS: Systematic reviews and meta-analyses, J Can Acad Childd Adolesc Psy-­ chiatry 20(1):57, 2011. US National Library of Medicine: Fact Sheet: Medical Subject HHeeaaddiinngs ((MMeeSSHH®®)), 2015, http://www.nlm.nih.ggoovv/pubs/factsheetss//mmeesh..hhttmmll.. AAcccceesssseedd JJuullyy 66,, 2015. White ML: Spirituality self-care effects on quality of life ffoor patients diagnoosseedd with chronic illness, Self Care Dependd Care Nurs 20((1):2233,, 201133.. Wilchesky M, Lungu O0: Predictive and concurrent validity of the Braden SSccale inn long-term care: a meta-anaallyysiss,, Wound Repair Reggeenn 223(1):44, 2015.

22 Admitting, Transfer, and Discharge SSKKIILLLLSS AANNDD PPRROOCCEEDDUURREESS • Identifytheongoingneedsofpatientsinthedischarge Skill2.1 AAddmmiittttiinngg PPaattiieennttss,, pp.. 1133 planningprocess. Skill2.2 TTrraannssffeerrrriinngg PPaattiieennttss,, pp.. 2200 Skill2.3 DDiisscchhaarrggiinngg PPaattiieennttss,, pp.. 2244 • Explaintheroleofapatient'sfamilyintheadmission, transfer,ordischargeprocess. OOBBJJEECCTTIIVVEESS • AudioGlossary MMaasstteerryy ooff ccoonntteenntt iinn tthhiiss cchhaapptteerr wwiillll eennaabbllee tthhee nnuurrssee ttoo:: • ClinicalDebriefandReviewQuestionsAnswers • Describetherolecommunicationplaysinmaintaining continuityofcarethroughapatient'sadmission, transfer,  anddischargefromanacutecareagency. • Explainthepurposeandimportanceofdischargeplanning. MMEEDDIIAA RREESSOOUURRCCEESS . evolve http://evolve.elsevier.com/Perry/skills • ReviewQuestions PURPOSE ••  Dischargeplanningbeginsatthetimeofadmissiontoahospi-­ tal, or even earlier when a patient uses an outpatient clinic or TThhee coorrddiinnaattiioonn of resources and planning a patient'’s care from testing center to begin his or her care journey. aaddmmiissssiioonn ttoo ddiisscchhaarrggee oorr ffrroom oone level of care to the next is aa kkeeyy rroollee of aa nurssee.. Nursseess identtiiffyy patienttss'’ ongoing health PPAATTIIEENNTT--CCEENNTTEERREEDD CCAARREE ccaarree nneeeeddss aanndd anticipate pphhyyssiical,, psychological, and social ddeeffiicciittss tthhaatt hhaavvee iimmpplliiccaattiioonnss ffoorr ppaattiieennttss ttoo rreessuumme nnoorrmmall ••  IInntthheeUUnniitteeddSSttaatteessmmaannyyiinnddiivviidduuaallssffaacceeggrreeaatteerroobbssttaacclleessttoo aaccttiivviittiieess.. AA nurssee iinnvvolves appropriate ffamily members in a good health on the basis of one or more of the following factors: ppllaann ooff ccaarre;; pprroovviides iinntteerventions,, including health educa­- racial or ethnic group; religion; socioeconomic status; gender; ttiioonn;; aanndd assisttss iin mmaking hheeaalth care resources available to age; mental health; cognitive, sensory, or physical disability; ppaattiieennttss.. sexual orientation or gender identity; geographical location; or other characteristics historically linked to discrimination or SSTTAANNDDAARRDDSS OOFF CCAARREE eexxcclluussiioonn ((UUSSDDHHHHSS,, 22001155)).. YYoouurr aaddmmiissssiioonn aasssseessssmmeenntt mmuusstt incorporate patients’' cultural beliefs and practices so you can •• TThheeJJooiinnttCCoommmmiissssiioonn((TTJJCC)),,22001166-—PPaattiieennttiiddeennttiiffiiccaattiioonnaanndd provide a patient-centered approach to care. medication rreeccoonnciliation ••  BBeeaawwaarreeooffhhoowwccuullttuurraallvvaarriiaabblleesswwiillllaaffffeeccttyyoouurrppaattiieennttaanndd •• TThheeJJooiinnttCCoommmmiissssiioonn ((TTJJCC)),, 22001166-—AAddmmiissssiioonn aasssseessssmmeenntt,, family assessment, approach to nursing care, and teaching during rreessttrraaiinnttss,, andd effective communication aaddmmiissssiioonnoorrddiisscchhaarrggee..IIttiisseesssseennttiiaallttooiinnvvoollvveetthheeppaattiieennttaanndd family caregiver in making decisions about care activities. •• QQSSEENN,,22001144-—PPaattiieenntt--cceenntteerreeddccaarreesskkiillllss ••  AAsskk tthhee ppaattiieenntt tthheeiirr pprreeffeerrrreedd ccoommmmuunniiccaattiioonn ssttyyllee oorr llaann-­ PPRRIINNCCIIPPLLEESS FFOORR PPRRAACCTTIICCEE guage and modify your approach to meet his or her needs as aapppprroopprriiaattee..IInnaaddeeqquuaatteeaacccceessssttoollaanngguuaaggeesseerrvviicceessccoommpprroommiissee •• PPaattiieennttssaannddffaammiilliieesssshhoouullddbbeeppaarrttnneerrssiinnccaarree,,sshhaarriinnggiinntthhee ppaattiieennttoouuttccoommeess((NNQQFF,,22001122)).. pprroocceessss ooff ddeeccision mmaaking. EEVVIIDDEENNCCEE--BBAASSEEDD PPRRAACCTTIICCEE •• PPaattiieenntt ccaarree mmuusstt bbee iinntteeggrraatteedd aaccrroossss aa vvaarriieettyy ooff sseettttiinnggss,, sseerrvviicceess,, hhealth ccare practitioners,, and care levels to maintain NNuurrssee--ttoo--nnuurrsseehhaanndd--ooffffssdduurriinnggccaarreettrraannssiittiioonnss((ee..gg..,,sshhiifftt--ttoo--sshhiifftt a continuum oof care. oorrttrraannssffeerrttooddiiffffeerreennttsseerrvviicceesseettttiinngg))ccaannccrreeaatteeiimmppoorrttaannttiinnffoorr-­ mmaattiioonn ggaappss,, oommiissssiioonnss,, aanndd eerrrroorrss iinn ppaattiieenntt ccaarree ((SSttaaggggeerrss aanndd •• TTrraannssiittiioonnaall ccaarree iinnvvoollvveess nnuurrssiinngg aaccttiioonnss iimmpplleemmeenntteedd ttoo BBllaazz,,22001133)).. eennssuurree coordination and continuity of care for patients who ttrraannssffeerr bbeettwweeeenn ddiiffffeerreenntt sseettttiinnggss oorr lleevveellss ooff ccaarree.. •• VVeerrbbaallhhaanndd--ooffffsssseerrvveeiimmppoorrttaannttffuunnccttiioonnssbbeeyyoonnddiinnffoorrmmaa-­ ttiioonn ttrraannssffeerr aanndd sshhoouulldd bbee rreettaaiinneedd iinn pprraaccttiiccee.. GGrreeaatteerr •• TTrraannssiittiioonnssooffccaarreerreeqquuiirreeccaarreeffuullaatttteennttiioonnttooccoommmmuunniiccaattiioonn ttoo eennssuurree ppaattiieenntt ssaaffeettyy.. 1122

SSKKIILLLL 22..11 ADMITTINGPATIENTS 13 consideration is needed on analyzing hand-offs from a •• Asystematicreviewoftheliteraturedemonstratesthatmed-­ patient-centeredperspective. Hand-off methods should be iiccaattiioonn rreeccoonncciilliiaattiioonn pprrooggrraammss ttaarrggeetteedd aatt hhiigghh--rriisskk ppooppuullaa-­ hhiigghhllyy ttaaiilloorreedd ttoo nnuurrsseess aanndd tthheeiirr ccoonntteexxttuuaall nneeeeddss iinn tthhee ttiioonnss ssuucchh aass tthhee eellddeerrllyy,, ppaattiieennttss wwiitthh ccoo--mmoorrbbiiddiittiieess,, aanndd sseettttings in which they work  (StaggersandBlaz, 2013). ppaattiieennttss oon mmuullttiiple mmeeddications can have the greatest ••  The use of hhaand-offs performed effectively can result in impact on reducing adverse drug events (Mueller etal., bbeetttteerr ccoommmmuunniiccaattiioonn ooff ppaattiieenntt ffaallll rriisskk oorr ppootteennttiiaall ffoorr 2012). iimmppaaiirreedd sskkiinn iinntteeggrriittyy aanndd hheellpp ttoo pprreevveenntt ppaattiieenntt iinnjjuurryy resultingfromfallsorpressureinjuries.Inaddition,aneffec­- •• Successful medication reconciliation interventions include tive hhand-off can improve communication about patients'’ intensive pphhaarrmmaaccyy staaffff iinvolvement. medications and reduce medication errors (VVandenberg, 2013). SAFFETYY GGUIDEELLIINEESS ••  Theuseof a standardized hand-off form can reduce hand­- ••  Identifywhetherapatienthasasensoryorcommunicationneed off-f–related errors and help to ensure that critical information (e.g.,hearingaid,glasses,needforaninterpreter). is communicated  (Zou andZhang, 2016) ••  Identifyifapatientusesanyassistivedevicesandbesurethat Medication reconciliation involves the process of creating the each is provided and deemed safe to use. most accurate list possible of all medications a patient is taking, includingdrug name, dosage, frequency,androute;andcomparing ••  Screen all patients on admission to a health care setting for that list against a physician'’s admission, transfer, and/or discharge possible discharge needs to ensure that appropriate teaching is orders,, with the goal of providing correct medications to the completed to ensure a safe discharge. patient at all transitionpoints withinahospital (IHI,  2016). ••  Includethepatient,familycaregiver,andrelevanthealthcare ••  Medicationreconciliationavoidsmedicationerrorssuchas professionals early in planning care to promote successful transi-­ omissions,, duplicationss,, dosing errors, or drug interactions tion through the health care system. ••  Consider a patient’'s educational background, health literacy (Kwan et al.,,2013; TJC,,2016a). level, and ability to understand instructions. ••  Medicationssneedtobereviewedwiththepatientonadmis­- ••  Coordinate the health care providers who contribute to a sion by eitherr nursing staff or pharmaccyy. They need to be patient’'s care needs to develop a plan of care for discharge to ensure a safe transition to home or an alternate care ffaacility. reviewed once again at discharge and shared with the post­- ••  Helpotherhealthcarepersonnel(e.g.,dietitian,socialworker, pharmacist, physical therapist) assess appropriate resources ddiischarge pprroviders to ensure that they uunderstand any needed as patients transition through the health care system. cchhanges that were made. This is necessary to reduce adverse drug events and improvepatient outcomes (TJC,  2016a). ♦ SKILL 2.11 Admitting Patients pertinent information for the hospital records while the staff are caringforthepatient.Incontrast,anolder-adultpatientwithself-­ Patients enter health care systems inavarietyofways(e.g., hospi­- care limitations undergoes extensive screening before being tal,, clinic,, or physician'’s or health care provider’'s offfiices). The accepted as a nursing home resident. admission process is typically the ffiirsstt experience a patient has with a health care aaggency. There are common procedures for admitting Admission offfiicers, secretaries, and technicians are the person-­ patients to these settings (Box  2.1). Most patients enter a health nel involved in the preliminary admission process such as inter-­ care system through a scheduled admission process that often viewing patients and reviewing information about insurance, requiresanextensiveregistration.However,somepatientsrequire demographic data, and agency procedures. Technicians usually emergency admissions. A patient admitted through the emergency collect routine specimens and perffoorm screening procedures such department(ED)isoftennotabletoundergothesameregistration aselectrocardiograms(ECGs).Anurseperformsthenursingadmis-­ process that takes place in a hospital admission offfiice. Level of sionassessment(seeChapter6). consciousness,, pain,, or other symptoms may prevent the patient from being a reliable resource. Family members usually provide Role of the Admission Personnel .B: OX 2.1 The admission personnel initiate and maintain a courteous and professional relationship with patients while providing inffoormation Commonn Procedures for Admission to a Health about their safety, legal rights, and privacy. A private interview area Care System gives patients and families a place to reveal important identifying information, including a patient’'s full legal name, age, birth date, •• EPxlapclaenmaetniotnooffppaatiteienntti'nsraigphptrsop(CriaMteS,re2c0e0iv9in)ganadreealementsof aaddddrreessss,, nneexxtt ooff kkiinn,, hheeaalltthh ccaarree pprroovviiddeerr,, rreelliiggiioouuss pprreeffeerreennccee,, advancedirectives occupation, and type of insurance. When a patient has severe hearing impairment, the family or a speech and language patholo-­ • Orientationtorelevanthealthcareagencypoliciesandprocedures gist may assist. If a patient does not speak English, a professional androomenvironment interpreter helps during the admission procedure. • Assessmentofpatient'shealthcareproblemsandneeds(including The admission personnel secures an identiffiication (ID) band riskforfalls,pressureinjuries,andallergies) legibly stating a patient’'s full legal name, hospital or agency number, healthcareprovider,andbirthdatetothepatient’'swrist.Health • Preliminarytestingandscreening(speciffiicforeachagencyand care providers use information from the ID band to identify a patient'scondition) patient when performing treatments or procedures. In many • Developmentofapatient-centeredplanofcare • Determinationofpatient'spaymentsourceforhealthcare

1111111114 CCHHAAPPTTEERR 22 ADMITTING,TRANSFER,ANDDISCHARGE agenciieessannIIDDbbannd coonnttaaiinnssa patient'’s unique bar code that then  that information be available in multiple languages and alternate mmaakkees iitteeaassyytto iiddeennttiiffyyaappatient fforrall ordered proocedures. Bar-­ formats (e.g.,  audio,  visual,  or written). Other regulatory agencies such as The Joint Commission (TJC) also require agencies to ccooddee wwrriissttbbaannddss aarree ttyypically created att tthe poiinntt of admission, and provide forspeciffiic patient rights (Box 2.3) . Each agencyhaspoli-­ ssppeecciiffiiccppaattiieenntt iinnffoorrmmaattiioonn iiss ccoonnttiinnuuaallllyy uuppddaatteedd oonn tthhee bbaassiiss ooff cies and procedures describing a patient’'s rights and the role of ppaattiieenntts'’ neeeddss (TTorress,, 20122)).. If a patient is unconscious,, you ccaannnnoottppeerrffoorrmmIIDDunttiillffaamily members arrive or unless you have  nurses in ensuring those rights. a bbaarr--ccooddeessyyssttem. HHoossppiittal staff proovide a ppaatientwhohas been a  The Patient Self-Determination Act, effective December 1, vviiccttiimmooffccrriimme witthhaann anonymoouussnnaame on his  or her  ID band  1991, requires all Medicare- and Medicaid-recipient hospitals to uunnddeerr tthhee aaggeennccyy'’ss \"“bbllaacckkouutt\"” orr \"“do noott publish\"” procedure.. provide patients with information about their right to accept or AA ppatient'’s legal rriights are met by instructing the patient or reject medical treatment. At the time of registration patients receive leggaall gguuaarrddiiaann tto rread tthhee ggeneral coonnsseenntt form for treatment. The CCeenntteerrssffoorrMMeeddiiccaarreaannd MMedicaid (CMS) (2012a) require all information about advance directives and are referred to appropriate ppaattiieennttss ttoo rreecceeiivvee information regarding their rights related to resources if they want to discuss advance directives or receive help incompletinganadvancedirectivedocument(Box2.4). hheeaalltthh ccaarree sseerrvviicceess att admissioonn;; ootthheerrwwise the hospital will not rreecceeiivveerreeiimmbbuurrsseemmeennttffoorrsseerrvices  (Box 2.2)..The  CMS  requires  Onadmissionpatientsmustalsoreceiveinformationaboutthe HealthInsurancePortabilityandAccountabilityAct(HIPAAAA),a BOX 2.2 PPaattiieennts'’ Righhtts Provided forr by CMS CCooddee off FFeeddeerraall RReegguullaattiionnss TTitle 42,, Chapter IVV,, • Thepatienthastherighttobefreefromrestraintsorseclusionof PPaarrtt 448822,, SSeecc.. 44822..1133 CCoonnddiittiionn oof Particippation:: PPaattiieennttss'’ RRiigghhttss anyformthatisnotmedicallynecessaryorisusedasameansof SSttaannddaarrdd 11:: Noottiiccee ooff RRiigghhttss coercion,discipline,convenience,orretaliationbystaff.Arestraintis anymanualmethod,physicalormechanicaldevice,material,or •Ahospitalmustprotectandpromoteeachpatient'srights. equipmentthatimmobilizesorreducestheabilityofapatientto •Ahospitalmustinformeachpatientwheneverpossibleor,when movehisorherarms,legs,body,orheadfreely.Adrugusedasa restraintisamedicationusedtomanagethepatient'sbehaviororto appropriate,thepatient'srepresentativeofthepatient'srightsin advanceoffurnishingordiscontinuingpatientcare. restrictthepatient'sfreedomofmovementandisnotastandard •Thehospitalmusthaveaprocessforpromptresolutionofpatient treatmentordosageforthepatient'smedicalorpsychiatric grievancesandmustinformeachpatientwhomtocontacttofiilea condition.Seclusionistheinvoluntaryconfiinementofapatientalone grievance. inaroomorareafromwhichthepatientisphysicallypreventedfrom leaving. SSttaannddaarrdd 22:: EExxeerrcciisse ooff RRiigghhttss • Arestraintdoesnotincludedevicessuchasorthopedically prescribeddevices,surgicaldressingorbandages,protective •Thepatienthastherighttoparticipateinthedevelopmentand helmets,orothermethodsthatinvolvethephysicalholdingofa implementationofhisorherplanofcare. patientforthepurposeofconductingroutinephysicalexaminations •Thepatientorhisorherrepresentativehastherighttomake ortests,toprotectthepatientfromfallingoutofbed,ortopermit informeddecisionsregardinghisorhercare. thepatienttoparticipateinactivitieswithouttheriskofphysicalharm (thisdoesnotincludeaphysicalescort). •Thepatient'srightsincludebeinginformedofhisorherhealth • Arestraintorseclusioncanonlybeusedifneededtoimprovethe status,involvedincareplanningandtreatment,andabletorequest patient'swell-beingandlessrestrictiveinterventionshavebeen orrefusetreatment.Thisrightmustnotbeconstruedasa mechanismtodemandtheprovisionoftreatmentorservices determinedtobeineffective. deemedmedicallyunnecessaryorinappropriate. • Theuseofarestraintorseclusionmustbeselectedonlywhenother •Thepatienthastherighttoformulateadvancedirectivesandhave lessrestrictivemeasureshavebeenfoundtobeineffectivetoprotect hospitalstaffandpractitionerswhoprovidecareinthehospital complywiththesedirectives. thepatientorothersfromharmandinaccordancewiththeorderof •Thepatienthastherighttohaveafamilymemberorrepresentative aphysicianorotherlicensedindependentpractitioner. ofhisorherchoiceandhisorherownhealthcareprovidernotifiied • Thisordermustneverbewrittenasastandingorderoronan promptlyofhisorheradmissiontothehospital. as-neededbasis(i.e.,prn).Theordermustbefollowedby SSttaannddaarrdd 33:: PPrriivvaaccyy aanndd SSaaffety consultationwiththepatient'streatingphysicianassoonaspossible •Thepatienthastherighttopersonalprivacy. ifsomeoneotherthanthepatient'streatingphysicianorhealthcare •Thepatienthastherighttoreceivecareinasafesetting. providerorderedtherestraintorseclusion. •Thepatienthastherighttobefreefromallformsofabuseor • Theuseofarestraintorseclusionmustbe: • Inaccordancewithawrittenmodifiicationtothepatient'splanof harassment. care. SSttaannddaarrdd 44:: CCoonnffiiddeennttiiaallittyy ooff PPaattiieent Recoorrd • Implementedintheleastrestrictivemannerpossible. • Inaccordancewithsafeandappropriaterestrainingtechniques. •Thepatienthastherighttotheconffiidentialityofhisorherclinical • Endedattheearliestpossibletime. records. • Theconditionoftherestrainedorsecludedpatientmustbe assessed,monitored,andreevaluatedcontinually. •Thepatienthastherighttoaccessinformationcontainedinhisor • Allstaffwhohavedirectpatientcontactmusthaveongoing herclinicalrecordswithinareasonabletimeframe. educationandtrainingintheproperandsafeuseofrestraintsand seclusion. SSttaannddaarrdd 55:: Resttrraaiinntt oorr Seclluussiioonn •Thepatienthastherighttobefreefromphysicalormentalabuse andcorporalpunishment. ModiffiiedfromCentersforMedicareandMedicaidServices:MedicareandMedicaidprograms,hospitalconditionsofparticipation:patients'rights;ffiinalrule,FFeedd RReegg71(236):71426,2009. CCMMSS,,CentersforMedicareandMedicaidServices.

SSKKIILLLL 22..11 ADMITTINGPATIENTS 15 federal law fiinnaalliizzeed inn200033ddeessiiggnned to protect the privacy of agencywillhandletheirPHI;((2)theagencyandthehealthcaree patient healthh informationn and referred to as pprrootteecctteedd hheeaalltthh iinnffoorr­- providersaretouseordiscloseapatient’'sPHIonlyforthepurposseess mmaattiioonn ((PPHHII)) (US DDepartment of Health and Human Services of treatment, payment, or health care operationss;; and ((3) health [UUSSDDHHHS],,2003). Health information refers to any information care providers disclose only the minimum amount of PHI neces-­ (oral or recorded) in any form that is created or received by a health care provider, health plan, public health authority, employer, sary, on a need-to-know basis, to accomplish the purpose of the life insureerr,, school or university, or health care clearinghouse and use. In addition to existing laws, new proposals include allowingg relatess to the past, present,, or future physical or mental health or patientstoknowwhohasaccessedtheirinffoormattiioonn((USDHHS, condition of any individual;; the provision of health care to an 2011). Know your agency-speciffiic policies and procedures related individual;; or the past,, present,, or future payment for the provision toHIPAA. of health care to an individual (HHIPPAA, 2009).Individuallyiden-­ tifiiaabbllee hheeaalltthh iinnffoormation iis inffoormation that is a subset of health Role of the Nurse information, including demographic infformation (e.g.,  age, social securitynnumber,electronic mailaddress)collectedfromanindi­- On admission to a patient care area, nurses complete a thorough vidual. Three key conceptsofHHIPPAAare: (1)agenciesarerequired to inffoorm patients of the privacy rights they have and how the nursing assessment, review any advance directives, and ensure that necessarydiagnostictestingiscompleted.Ifpatientswerereceiving B: OI X 2.3 health care before admission (e.g., home health care, long-term care),anursefromthesendingareaprovidesappropriateinforma-­ TThhee Jointt Commission Patients'’ Rights Standards tiontothereceivingnurseforcontinuityofcare.Inthissituation • Righttoanappropriatelevelofcare the nurse from the sending agency should explain to thee nurse • Righttoreceivesafecare • Respectforculturalvaluesandreligiousbeliefs receiving the hand-off report information about the patient’'s con-­ • Privacy • Consentobtainedforrecordingorfiilmingforpurposesotherthan dition and why he or she is being sent to the acute care setting (Tolesetal.,2012). theidentiffiication,diagnosis, ortreatmentofpatients • Conffiidentialityofinformation Admitting personnel collaborate with rreecceiving nnuursing staffftto • Recognitionandpreventionofpotentialabusesituation • Notiffiicationofunanticipatedoutcomes ensure that a patient’'s room assignment is based on the patient’'s • Involvementincaredecisions condition, health care needs, developmental level, activity level, • Informationonrisksandbeneffiitsofinvestigationalstudies expectedlengthofstay,andpersonalpreferences.Forexample,the • End-of-lifecare • Advancedirectives best room for an older patient who is acutely ill, at risk for ffaalls,, • Organprocurement and receiving multiple treatmentss is one close to the nurses’' • Righttohaveadvancedirectivesandtohavethemfollowed station. The nurse identiffiies if a patient has any known allergies • Freedomfromunnecessaryrestraints and, if any exist, places an allergy band on the patient and properly • Informedconsentforvariousprocedures • Righttorefusecare documents the known allergies in the medical record. • Righttohavepainbelievedandrelieved WhenapatientisadmittedthroughtheED,thenursenotiffiies • Communicationwithadministration • Education the nursing division and reports on the patient’'s admission infor-­ mation, including his or her name; admitting physician or health FromTheJoint Commission (TJC): Comprehensive accreditation manual for hhoossppittals,,Chicago,IL,2016,TheCommission. care provider; chief complaint; and any treatments or testing com-­ pleted and the outcome, diagnosis, and pertinent information B: OI X 2.4 relatedtothepatient’'scondition(e.g.,initialvitalsigns,allergies, lleevveell ooff ccoonnsscciioouussnneessss,, aanndd iinnttrraavveennoouuss [[IIVV]] fflluuiidd iinnffuussiinngg)).. AAnn AAdvance Directives escort takes the patient and ffaamily members to the nnursing ddivision and introduces them to the nurse assuming the patient’'s care. The • Anadvancedirectiveisadocumentthatgivesapatientdirections EEDDnnuurrsseesshhaarreessppeerrttiinneennttoobbsseerrvvaattiioonnssaabboouutttthheeppaattiieenntt’'ssbbeehhaavv-­ aboutfuturemedicalcareordesignatesanotherperson(s)tomake iioorr ((ee..gg..,, aannxxiieettyy,, ffeeaarr,, oorr lleevveell ooff kknnoowwlleeddggee rreeggaarrddiinngg nneeeedd ffoorr medicaldecisionsiftheindividuallosesdecision-makingcapacity. hheeaalltthhccaarree))wwiitthhtthheennuurrssiinnggssttaaffffttooffoosstteerrccoonnttiinnuuiittyyooffccaarreeaanndd help the patient and family cope with a new environment. • Anadvancedirectiveconveysthepatient'schoiceincontinuing medicalcarewhenthepatientisunabletospeakormake MMaannyyppaattiieennttssggoottooaahhoossppiittaallsseevveerraallddaayyssiinnaaddvvaanncceeffoorrnneecceess-­ decisions. ssaarryy pprreeooppeerraattiivvee ddiiaaggnnoossttiicc tteessttiinngg.. IInn ssoommee ccaasseess tthheessee ppaattiieennttss and their ffaamily members also attend preoperative educationn • Advancedirectivesmayincludealivingwill,powerofattorneyfor ccllaasssseess..OOtthheerrppaattiieennttsshhaavveeccoonnttaaccttwwiitthhhheeaalltthhccaarreepprroovviiddeerrssffoorr healthcare,ornotarizedhandwrittendocument. tthheeffiirrssttttiimmeewwhheenntthheeyyaarrrriivveeaattaahhoossppiittaalloorrssuurrggii--cceenntteerr..PPaattiieennttss admitted on the morning of a surgical procedure or treatment are • Amecdoipcaylorefcthoerdd.oIfcnuomteanvtasilhaboulel,dthbeesauvbaislatabnleceinotfhethepaatdievnatn'sc e directiveshouldbedocumentedinthemedicalrecord,anda family  “\"same-day”\" admissions. A nurse provides basic instructions about membershouldbeaskedtobringtheadvancedirectivetothe the purpose of the surgery or treatment, preparatory procedures, hospital. and postsurgical or posttreatment care. Admission and consent • Theattendinghealthcareproviderisnotiffiiedofthepatient's ffoorrmmss,,ddiiaaggnnoossttiicctteessttss,,pprreeooppeerraattiivveeppaattiieenntttteeaacchhiinngg((sseeeeCChhaapptteerr advancedirective. 3377)),, aanndd iinnssttrruuccttiioonnss aarree uussuuaallllyy ccoommpplleetteedd bbeeffoorree tthhee aaccttuuaall ddaayy of surgery. When nurses are able to see patients several days in • Witnessesforanadvancedirectivedocumentshouldnotbe medicalpersonnel,norshouldtheyberelatedtothepatientor advance, they use a variety of resources such as classess,, videotapes, heirstothepatient'sestate.Asocialworkeroftenfulffiillsthis information booklets, and calls to home ffoor patient teaching. requirement. Nurses actively coordinate the initial admission pprocess for aallll ppaattiieennttss.. AA ppaattiieenntt’'ss ccoonnddiittiioonn iinnfflluueenncceess tthhee eexxtteenntt aanndd ttyyppee ooff admission activities. AAlways note the ppatientt’'ss levell off faatiguuee andd ccoommffoorrtt.. FFoorr eexxaammppllee,, wwhheenn aa ccrriittiiccaallllyy iillll ppaattiieenntt rreeaacchheess aa hhooss-­ ppiittaall nnuurrssiinngg ddiivviissiioonn,, hhee oorr sshhee uunnddeerrggooeess eexxtteennssiivvee eexxaammiinnaattiioonn aanndd ttrreeaattmmeenntt pprroocceedduurreess iimmmmeeddiiaatteellyy.. TThheerree mmaayy bbee lliittttllee ttiimmee

16 CCHHAAPPTTEERR 22 ADMITTING,TRANSFER,ANDDISCHARGE aavvaaiillaabbllee ffoorr yyoou to orienntt the patient and family to the division Equipment oorr lleeaarrnn ooff tthhee ppaattiieenntt'’ss ffeeaarrs oor concerns. WWhheen a patient enters aa hhoossppiittaall ffoorr electivvee ttreatment,, you hhaave more time to prepare ••  Hospitalgown hhiimmoorrhheerrppssyycchhoollooggically forrhhoossppiittaalization. EEarly psychological  ••  Bedpanandurinal(ifneeded) pprreeppaarraattiioonn wwhheenn aa ppaattient iss still at hhoome better prepares patients ••  Washbasin,bathtowel,andwashcloth ffoorrhhoossppiittaalliizzaattiioonn.. ••  Toiletry items (e.g., soap, toothpaste, hand lotion; optional in DDeelegatiioon andd Collaboration somehospitals) ••  Facialtissues TThhee sskkiillll ooff ccoommpplleettiinngg the nursinngg assessment during admission ••  Waterpitcheranddrinkingcup ttoo aa hheeaalltthh ccaarree aaggeency cannnoott be delegated to nursing assistive ••  Kidneyoremesisbasin ppeerrssoonnnneell((NNAAPP))..TThheennuurrse ddiirrects tthe NAP to:: ••  Disposablethermometer(seeagencypolicy) •• PPrreeppaarree tthe ppaattiieenntt'’ss rroom with equipment needed before ••  Sphygmomanometer ••  Stethoscope admission.. ••  CCleangloves •• GGaatthheerrandsseeccuuretheepatient'’spersonalcareitems. ••  Pulseoximeter(optional) •• EEssccoorrttaannddoorriieenntttthepatientandfamilytothenursingunit. ••  Documentationforms(seeagencypolicy) •• CCoollllectorderedssppecimens. SSTTEEPP/ RRAATTIIOONNAALLEE RROOOOMM PPRREEPPAARRAATTIIOONN Promotespatient'’scomfortbypreventingdelaysduring admissiioonn..Properpositionofbedlessenslikelihoodofpatient 11.. PPeerformhhaannddhhyyggiieenneeaannddprepareroomequipmentand fall during transfer and also reduces risk of back injuries to ffuurrnniittuurree..PPrreeppaarreebbeeddbbyyaaddjjuussttiinnggiittttootthheelloowweesstthhoorriizzoonnttaall stafff helping patient into bed. ppoossiittiioonniiffppaattiieennttiissaammbbuullaattoorryy..PPllaacceebbeeddiinnhhiigghhppoossiittiioonniiff ppatient is arriving by ssttrreettcchher. Turn down top sheet and Preventsdelaysindeliveringimmediatetreatmentandprovides bbeeddspread. Arrange room furniture for easy access to bed. for smooth transition between caregivers. Adjust lliights,, temperature,, and ventilation. 22.. BBeessuuretthhaatteeqquuiippmmeenntisinwwoorkingordeerr.Assembleany sspecial equipment (e.g.,,suction,,oxygen supplies,,or  IV pole) inn patient'’s room. AASSSSEESSSSMMEENNTT EEnnssuurreessccoorrrreeccttppaattiieenntt..CCoommpplliieesswwiitthhTThheeJJooiinnttCCoommmmiissssiioonn ssttaannddaarrddssaannddiimmpprroovveessppaattiieennttssaaffeettyy((TTJJCC,,22001166aa)).. 11.. IIddeennttiiffyyppaattiieennttuussiinnggaattlleeaassttttwwooiiddeennttiiffiieerrss((ee..gg..,,nnaammeeaanndd bbiirrtthhddaayyoorrnnaammeeaannddmmeeddiiccaallrreeccoorrddnnuummbbeerr))aaccccoorrddiinnggttoo PPrroovviiddiinnggppeerrssoonnaalliizzeeddccaarreerreedduucceessaannxxiieettyyaabboouuttaaddmmiissssiioonn,, aaggeennccyy ppoolliiccyy.. ccllaarriiffiieessssttaaffffrroolleess,,aannddeexxppeeddiitteessppaattiieennttrreeqquueessttss.. 2.. GGrreeeettppaattiieennttaannddffaammiillyyccoorrddiiaallllyybbyynnaammee..IInnttrroodduuccee TTranslation services are preferable to using family members to yyoouurrsseellff bbyy nnaammee aanndd jjoob ttitle;; explain your rreesspponsibilities promote effective communication. iinn ppaattiieenntt'’ss ccaarree.. A speech and language pathologist may have augmented hearing 33.. IIffppaattiieennttddooeessnnoottssppeeaakk,,rreeaadd,,oorruunnddeerrssttaannddEEnngglliisshh,, devices or resources to facilitate communication of assessment aarrrraannge ffoorr aa pprroffeessional ttrraannssllaattoor to hheelp with the nursing data. aasssseessssmmeenntt..UUsseetteelleepphhoonneeiinntteerrpprreetteerrsseerrvviicceessaassaa ssuupppplleemmeennttaall ssyysstteemm when ann iinntteerrpreter iis needed instantly PPrroovviiddeessbbaasseelliinneeaasssseessssmmeenntt.. oorrwwhheennsseerrvviicceessaarreenneeeeddeeddiinnaannuunnuussuuaalloorriinnffrreeqquueennttllyy eennccoouunntteerreeddllaanngguuaaggee((UUSSDDHHHHSS,,OOPPHHSS,,22000011)).. 44.. WWhheen a ppaattient hhas a ssevere hheearing impairment,, a speech aanndd laanngguuaaggee ppaatthhoollooggiisstt mmay bbe of hheelp. 5.. AAsssseess patient'’s general appearance. Note signs or symptoms ooffpphhyyssiiccaallddiissttrreessss((sseeeeCChhaapptteerr66)).. CClliinniiccaall DDeecciissiioonn PPooiinntt IIff ppatieenntt iiss hhaavviinng acute pphyysical problems,, postpone routine admission procedures and nursing history until his or her needs aarree mmeett.. CCoommpplleettee aa ffooccuusseedd aasssseessssmmeenntt aatt tthhiiss ppooiinntt.. 6.. AAssssess patient'’s ability to understand and implement health This helps you determine at what reading level a patient can iinnffoorrmmaattiioonnbbyyaasskkiinnggaahheeaalltthhlliitteerraaccyyqquueessttiioonn,,ssuucchhaass read, allowing you to select appropriate level of educational \"“HHoowwccoonnffiiddeennttaarreeyyoouuffiilllliinnggoouuttmmeeddiiccaallffoorrmmssbbyy mmaatteerriiaallaannddtteeaacchhiinnggmmeetthhooddssssuucchhaassTTeeaacchh--BBaacckk((AAHHRRQQ,, yyoouurrsseellff??\"”((WWaallllaacceeeettaall..,,22000066))..TThheeRREEAALLMM--SSFFiissaa 22001155aa)).. rreelliiaabbllee aanndd vvaalliidd ttooooll wwiitthh aa lliisstt ooff sseevveenn wwoorrddss yyoouu aasskk aa ppaattiieenntt ttoo rreeaadd ttoo ddeetteerrmmiinnee tthheeiirr lleevveell ooff hheeaalltthh lliitteerraaccyy oonn ggrraaddeessccaallee((ee..gg..,,tthhiirrddggrraaddee,,ffoouurrtthhttoossiixxtthhggrraaddee,,sseevveenntthh aannddeeiigghhtthhggrraaddeeaannddhhiigghhsscchhooooll))((AAHHRRQQ,,22001155aa))..

11111SSKKIILLLL 22..11 ADMITTINGPATIENTS17 SSTTEEPP/ RRAATTIIOONNAALLEE 77.. Assess patient'’s and family'’s psychological status by noting Anxietyinfflluenceshowwellpatientadaptstoahealthcare environment and retains instruction. verbal and nonverbal behaviors and responses to greetings Providesbaselinemeasurementtocomparefutureffiindings. and explanations. Determinesalterationsfromnormalrange. 88.. Assessvviittalsigns(seeChapter5),,heightandweight(see Havingapatientwalkallowsyoutomoreobjectivelyassesshis Chapter 6),,and patient'’slevelof discomfort  (usingaO0to 10 or her gait and level of strength rather than asking the sscale)(seeChapter16). patient if he or she has walking limitations. 99.. AAssess ffoorr ffaall risk using scale with grading criteria agency Providesdatatodeterminepatient’'sriskforinjuryandwhether policyy. Ask patient to walk at end of bed and note gait and heorsheneedstobeplacedonfallprecautions.Foracute movement. Considerr patient'’ssriskfactors (e.g., individual care hospital inpatients, the maximum time frame for intrinsicfactors::co-morbidities(neurologicaldisorders), completingfallriskadmissionnassessmentssis24h((TJC, 2016b6). muscle weakness, unsteady gait, and urinary incontinence (de JJong et al.,, 2013;;Spoelstra etal.,  201ll1); transient Providesforprivacyandpreparespatientforexamination. factors:: postural hypotension, polypharmacy, and use of high--rriisskkmedications  (e.g.,  analgesics,,antihypertensives) EEaacchhpatieenttiissttoohhaaveanadmissionassessmentpreparedbya (Changetal.,,20l1l1). registteerednurse(RN)(TJC,2016a).Eachagencysetsatime 1100.. Havefamilyyorfriendsleaveroomunlesspatientwishesto ffrraammeeffoorrccoommpplleettiioonnooffaaddmmiissssiioonnaasssseessssmmeenntt((mmaaxxiimmuummttiimmee hhaave them help with changing into a hospital gown or 2244hhoouurrss)).. pajamas.Close door and curtains.Helppatientundressand Esttaabblliisshheessabbaasseelliinneeofpatient’'sclinicalstatus. into comfortable position. 1111.. OObbttaaiinnnnuurrssiinngghhiissttoorryyaasssoooonnaassppoossssiibblleeaafftterppaattiieent’'s IIddeennttiiffiieessssiiggnnssaannddssyymmppttoommssiinnccaasseeppaattiieenntt’'ssccoonnddiittiioonn deteriorates. arrival to nursing division. Apply standards of nursing care aaddoopptteeddbbyyhhoossppiittaall((ee..gg..,,ffuunnccttiioonnaallhheeaalltthhppaatttteerrnnss))..DDaattaa Prroovviiddeessaahhoolliisstticviewofpatient’'shealthproblemsandresponse include the following:: to those problems. a.. PPaattiieenntt'’ssppeerrcceeppttiioonnooffiillllnneessssaannddhheeaalltthhcarreenneeeds b.. Pastmedicalhistory Allows you to institute preventive care measures and educate c.. PPrreesseennttiinnggssiiggnnssaannddssyymmppttoommssaannddrreeaassoonnffoorr patient about health promotion behaviors. hhoossppiittaalliizzaattiioonn PPaattiieennttssoofftteennhhaavveesseennssiittiivviittyyttooaaddrruuggoorrssuubbssttaanncceerraatthheerrtthhaann d.. CCoommpplleettiioonnooffaarreevviieewwooffhheeaalltthhssttaattuussbbaasseeddoonn aattrruueeaalllleerrggyy;;tthhiissnneeeeddssttoobbeeccllaarriiffiieedd..SSppeecciiffyyaallllaalllleerrggeennss to prevent accidental exposure. ssttandards ssuch as elimination,, respiration,, nutrition and metabolissmm,, activiittyy and exercisee,, self-concept,, values andd beliefs,, cultural factors, social support, and cognitive function e.. RRiisskkffaaccttoorrssffoorriillllnneessss ff.. HHiissttoorryyooffaalllleerrggiieess,,iinncclluuddiinnggttyyppeeooffssuubbssttaanncceeaannddaa description of the reaction that patient has previously eexxppeerriieenced CClliinniiccaall DDeecciissiioonn Pooiinntt Provide ppatient with allergy arm band listing allergies to foods, drugs, latex, or other substances;; document allergies according ttoo agency ppolicy.. g.. DDeettaaiilleeddmmeeddiiccaattiioonnhhiissttoorryy,,iinncclluuddiinnggpprreessccrriibbeedd,, Assesses potential for drug interactions, and information often oovveerr--tthhee--ccoouunntteerr((OOTTCC)),,aannddaalltteerrnnaattiivveetthheerraappiieessssuucchh explains patient’'s presenting signs and symptoms. ass hheerrbs and hhoorrmones EEnnaabblleessyyoouuttoorreeccooggnniizzeeaannddmmeeeettppaattiieenntteexxppeeccttaattiioonnsswwhheenn hh.. PPaattiieenntt'’sskknnoowwlleeddggeeooffhheeaalltthhpprroobblleemmssaannddeexxppeeccttaattiioonnss possible. off care PPrroovviiddeessoobbjjeeccttiivveeddaattaaffoorriiddeennttiiffyyiinngghheeaalltthhpprroobblleemmss.. 1122.. AAppppllyycclleeaanngglloovveess..CCoonndduuccttpphhyyssiiccaallaasssseessssmmeennttooff UUnnaannnnoouunncceeddpprroocceedduurreessccaannmmaakkeeppaattiieennttssaannxxiioouuss.. aapppprroopprriiaatteebbooddyyssyysstteemmss((sseeeeCChhaapptteerr66))..IIffnnoottoobbttaaiinneeddiinn PPrreeppaarraattiioonnooffppaattiieennttrreelliieevveessaannxxiieettyy.. aadmitting, instruct patient to provide a urine specimen. IInnffoorrmmppaattiieennttiiffccoolllleeccttiinnggbbllooooddssppeecciimmeennssoorrppeerrffoorrmmiinngg PPrroovviiddeessbbaasseelliinneeddaattaaffoorrpprreessssuurreeiinnjjuurryypprreevveennttiioonnaanndd iiddeennttiiffiieesstthheepprreesseenncceeooffaannyyccoommmmuunniittyy--aaccqquuiirreeddpprreessssuurree tteessttss.. iinnjjuurriieesswwhheennppaattiieennttiissaaddmmiitttteedd..EExxiissttiinnggpprreessssuurreeiinnjjuurriieess aa.. A priority is to assess a patient'’s skin integrity and any mmuussttbbeeddooccuummeenntteeddwwiitthhiinn2244hhoouurrssooffaaddmmiissssiioonn((CCMMSS,, 22000088))..PPrreessssuurreeiinnjjuurriieesstthhaattddeevveellooppwwhhiilleeaappaattiieennttiiss ccuurrrreennttsskkiinnbbrreeaakkddoowwnnaattaaddmmiissssiioonn..UUsseeaarriisskkffoorr hhoossppiittaalliizzeeddaarreeccoonnssiiddeerreeddaannaaddvveerrsseeeevveennttaannddbbeeccoommeetthhee pprreessssuurreeiinnjjuurryyddeevveellooppmmeennttssccaalleessuucchhaasstthheeBBrraaddeenn ffiinnaanncciiaall rreessppoonnssiibbiilliittyy ooff tthhee aaggeennccyy rreessppoonnssiibbllee ffoorr tthheeiirr ccaarree SSccaalleettooaasssseessssrriisskkffoorrppootteennttiiaallsskkiinnbbrreeaakkddoowwnn..AAfftteerr ((CCMMSS,,22000088)).. assessment is complete,, remove and dispose of gloves and ppeerrffoorrmm hhaanndd hhyyggiieennee..

18 CCHHAAPPTTEERR 22 ADMITTING,TRANSFER,ANDDISCHARGE SSTEEPP/ RATIONALLE bb.. SSoommeehhoossppiittaallssaarreenowrreeqquuiirriinnggaasssseessssmmeennttofriskfor STTOOP-Bangscorewasvalidatedinobeseandmorbidlyobese oobbssttrruuctive sslleep apnea(OOSA) in ssurgicalppatients (see surgicalpatients.ForidentifyingsevereOSA,aSTOP-Bang CChhaapptter 337)). See agency policy. UUse the STTOOP-Bang  scoreof4hashighsensitivityof88%.Forconffiirmingsevere insttrruummeenntt iif available. OOSA,ascoreof6ismorespeciffiic(Chungetal.,2013). Allows you to institute appropriate postoperative 1133.. CChheecckkhheeaalltthhccaarreepprroovviiddeerrss'’ordersffoorrtreatmentmeasures observations.OOSAisapotentiallyserioussleepdisorderin ttoo iinniittiiaattee iimmmmeeddiiaatteellyy.. which breathing repeatedly stops and starts during sleep. SurgicalpatientswithOSAareconsideredatriskfor 1144.. AAsskk ppaattiieenntt ttoo identify hhiiss orr hheer vvalues regardingg health relaxation of their throat muscles and blockage of the ccaarree aanndd nneeds oorr expecttaattiioonnss of care:: \"“TTo what extent do airway during recovery from anesthesia and sedation yyoouu bbeelliieevve bbeeiinng iinn tthhee hhoossppiital wwillll hheellp you? TTell me (D'’Arcy,2013). wwhhaatt yyoouu hhooppee wwiillll hhaappppeenn duurriinngg yyoouurr hospitall stay? TTell mmee wwhhaatt iiss iimmppoorrttaanntt ttoo yyoou ffoorr yyoouurr care hheere to be Delaycausesdeteriorationofpatient’'scondition. ssaattiissffaaccttoorryy..\"” NNOOTTEE::IInnccoorrppoorratetthheesseeqquueessttionsdduurriinnggthe pphhyyssiiccaall eexxaammiinnaattiioonn.. Patient-centeredcarerequiresincorporationofpatientneeds, preferences,andvalues(QSEN,2014). 1155..OOrriieennttppaattiieennttttoopattiieennttccaarreeunit. aa.. IInnttrroodduucceessttaaffffmmeemmbbeerrsswwhhooeenntteerrroom.AAlways Helpspatientrecognizecaregivers.Showsrespectforpatient. introdduuce ppaattiient bbyy last name unless patient indicates ootthheerrwwiissee.. Providesmeansforpatientandfamilytocommunicateproblems. bb.. TTeellll ppaattiieenntt aanndd ffaammiillyy tthhee namee off tthhee nurse manager in cchhaarrggee of thee division and explain that person'’s role in Providesknowledgeandincreaseswillingnesstoobservepolicy ssoollvviing pprroobbllems. for visiting hours. cc.. EExxppllaaiinnvviissiittiinngghhoouurrssaannddtthheeiirrppuurrpose(i.e.,,toprovide timmee ttoo administeer needed procedures and give patient A hospital-wide smoking policy that prohibits the use of smoking timmeettoorest)).. materialsthroughoutthehospitalisrequired.Somehospitals dd.. DDiissccuussssssmmookkiinnggppoolliiccyyannddiiddeennttiiffyysmokingareasfor may have a designated smoking area. ppaattiieenntt and ffaamily if available. Patient'’ssafetydependsonpatientunderstandingcorrectuseof ee.. DDeemmoonnssttrraatteeuusseeooffeeqquuiippmmeenntt((ee..gg.,,bbed,,over-bedtable,, equipment. lliigghhttiinngg)).. Ensuresthatpatientknowswhyandhowtocallforassistance. ff.. SShhoowwppaattiieenntthhoowwttoouusseennuursecalllliigghhttandpositionit innaaccoonnvveenniieent place.Have patient demonstrateuse of  PPaattiieenntt'’ssssaaffeetyddeeppendsinpartonunderstandinghowtouse lliigghhtt..DDiissccuss wwith patient hhis or herspecifiiccffaallllrriisskkssand  toilet facilities. eennccoouurraaggee hhiim or hheerr to ask for help when getting out ooff bed. gg.. EEssccoorrttppaattiieennttttoobbaatthhrroooomm((iiffaabblleettooaammbbuullaattee)).. CClliinniiccaall DDeecciissiioonn PPooiinntt EEnnssuurree tthhaatt ppaattiieenntt kknnoowwss hhooww ttoo ccaallll ffoorr hheellpp wwhhiillee in bbaatthhrroooomm.. ((AAnn eemmeerrggeennccyy ccaallll lliigghhtt iiss uussuuaallllyy in bbaatthhrroooommss..)) hh.. EExxppllaaiinnhhoouurrssffoorrmmeeaallttiimmeeaannddnnoouurriisshhmmeennttssttooppaattiieenntt FFaammiillyyoofftteennwisheessttoovisitduringeveningtohelpwithmeals. anndd ffaammiillyy. OOffffeerrssppaattiieennttooppttiioonnssffoorrmmaakkiinnggddeecciissiioonnss.. ii.. DDeessccrriibbeesseerrvviicceessaavvaaiillaabbllee((ee..gg..,,cchhaappllaaiinn,,bbeeaauuttyysshhoopp,, aaccttiivviittyytthheerraappyy)).. NNUURRSSIINNGG DDIIAAGGNNOOSSEESS •• AAnnxxiieettyy ••  FFeeaarr •• Riskforinjury •• AAccuutteeppaaiinn ••  IInneeffffeeccttiivveeccooppiinngg,,iinnddiivviidduuaalloorrffaammiillyy •• RRiisskkffoorrffaallllss •• CChhrroonniiccppaaiinn ••  PPoowweerrlleessssnneessss •• DDeeffiicciieennttkknnoowwlleeddggeerreeggaarrddiinngghhoossppiittaall proocceedduurreess andd planned tthherapies RReellaatteeddffaaccttoorrss//RRiisskk ffaaccttoorrss aarree iinnddiivviidduuaalliizzeedd bbaasseedd oonn ppaattiieenntt'’s condition or needs..

SSKKIILLLL 22..11 ADMITTINGPATIENTS 19 SSTTEEPP/ RRAATTIIOONNAALLEE PPLLAANNNNIINNGG Understandingtreatmentplangivespatientabettersenseof control and reduces anxiety about the uunknown. 11.. EExxppeectedoutcomesfollowingcompletionofprocedure: •• PPaattiieennttiissaabbletooeexxppllaainpurposeandscheduleofplanned Fallscommonlyoccurwhenpatientsattempttogetoutofbed treatments and procedures.. without help. •• PPaattiieennttddeemmoonnssttrrateshhoowwtocallfornursewhenhelpis Ensurespatientsafetyandmobilityinroom. needeedd.. •• PPaattiieennttiissaabbletooambulate(ifconditionpermits)inroom Equipmentusedincareofpatientfrequentlyposeshazards;helps to reduce some anxiety. free oof obstacles. •• PPaattiieennttccaannsafeellyyandeffiicciieennttllyyuusseeeeqquuiippmmeennttiinthhee Knowledgeofhospitalpolicieshelpspatientadapttothehealth care environment. room.. •• PPaattiieennttvveerbalizesunderstandingofsmokingpolicyy,visiting Basicpainandcomfortmeasuresareeffective. hhoouurrss,, mmealtimes,, and services available. •• PPaattiieennttsseellff--rreportsimprovedcomfort. IIMMPPLLEEMMEENNTTAATTIIOONN Medicationreconciliationonadmissionhelpstomakesuretthhaatt patient is taking the correct medicationnss and avoids 11.. PPeerrffoorrmhhandhhyyggiieennee.CCompleteppatientmedication medicationerrors((TJC,2016a). rreeccoonnciliation byy checking home medication list for Patienthasrighttobeinformedofanyscheduledpproceduresor treatments.Beingabletoanticipateplannnneeddtherapies duplication,, omission,, or potential drug interactions with minimizesanxiety. newlyyordered medications. Update medicationlist on the basis of hhealth care provider'’s orders for treatment.Follow Enablespatienttoparticipateinplannedtherapiesand education. agencyy ppolicyy. 22.. IInformppaattiientaboutpprrooceduresortreatmentsscheduledfor Identiffiiespatient'’sandfamilycaregiver’'seducationalneedsand learning preferences. the next shift or dayy(e.g., visitsbyyhealth careprovider or dietitian). These varyybaseddonnature of patient'’scondition. Providesopportunitytoclarifyexpectationnssand 33.. PPeerrffoormbasiccomfortmeasures(positioning,temperatureof misconceptions.Providesforshareddecisionmaking. rroom) and administer analgesic  (if ordered). Removeand Accounts for placement of valuables and prevents loss. ddiisspose of gloves. 44.. CCoommpplleete lleeaarrnniinnggreadiness and learning needsassessment Admission is often stressful and fatiguing. Allows time for decision making. for patient and familyy caregiver. 55.. GGiivveeppaattiieentandfamilyycaregiverachancetoaskquestions PPrroovviiddeessffoorrppaattiieennttssaaffeettyy.. about procedures or therapies and to share their personal RReedduucceesssspprreeaaddooffmmiiccrroooorrggaanniissmmss.. goals of care.  (If patient is unresponsive or unable to understand,,review with familyy.) 66.. CCoolllleeccttvvaalluuaabblleesstthhaattppaattiieennttcchhoooosseessttookkeeeeppaattbbeeddssiiddee.. CCoommpplleetteeccllootthhiinnggaannddvvaalluuaabblleesslliissttiinnggsshheeeett((sseeeeaaggeennccyy ppoolliiccyy));;hhaavveeppaattiieennttssiiggnn..PPllaacceevvaalluuaabblleessiinnaaggeennccyyssaaffeeoorr send home with familyy. 77.. EEnnssuurreetthhaattppaattiieennttaannddffaammiillyyhhaavveettiimmeettooggeetthheerraalloonneeiiff desired. 88.. BBeessuurreetthhaattccaalllllliigghhttiisswwiitthhiinneeaassyyrreeaacchhaannddbbeeddiissiinnllooww position. 99.. PPeerrffoorrmmhhaannddhhyyggiieennee.. EEVVAALLUUAATTIIOONN PPaattiieennttddeemmoonnssttrraatteesslleeaarrnniinnggaanndduunnddeerrssttaannddiinnggtthhrroouugghh 11.. HHaavveeppaattiieenntteexxppllaaiinnoowwnnffaallllrriisskkss,,hhoossppiittaallppoolliicciieess,,tteessttss,, feedback. aannddpprroocceedduurreesstthhrroouugghhddiissccuussssiioonnaannddqquueessttiioonnss.. DDeetteerrmmiinneessiiffppaaiinnsseevveerriittyyhhaassddeeccrreeaasseedd.. 2.. AAsskkppaattiieennttttoorraatteesseevveerriittyyooffppaaiinnoonnssccaalleeooffO0ttoo1100.. RPRPrreeoottvvuuiirrddnneesdsdeeddmmaattooaannttssoottrrjajauuttdidiooggnneecpcpooaantntiiffeeiinrrnmmtt’'ssssssllaeeafaafeerrtntnyyiinniinngg..aammbbuullaattiinnggwwiitthhoouutt 343.... MHHMaaoovvnneeiittppooaarrttpipieeaannttititeedndneett'm’mssoaoabnbniissllttiirtrtayayttetetoouuaassememobobffuulclcaaaattlleellliliininggddhheettpp.. eennddeennttllyy.. injury. 5.. CChheecckkppaattiieenntt'’ssrroooommsseettuupprreegguullaarrllyy.. DDeetteerrmmiinneessiiffccaarreeaarreeaaiissffrreeeeooffoobbssttaacclleess.. 6.. Use TTeacchh--BBacckk::\"“IIwwaannttttoobbeessuurreeyyoouuuunnddeerrssttaannddhhoowwttoo DDeetteerrmmiinneessppaattiieenntt’'ssaannddffaammiillyyccaarreeggiivveerr’'sslleevveellooffuunnddeerrssttaannddiinngg uussee yyoouurr ccaallll llight too ccoonnttaacctt the nurses if you need assistance of instructional topic. ggeettttiinnggoouuttooffbbeedd..CCaannyyoouusshhoowwmmeehhoowwttoouusseeiittaannddtteellllmmee wwhheennyyoouusshhoouulldduusseeiitt??\"”RReevviisseeyyoouurriinnssttrruuccttiioonnnnoowwoorr ddeevveelloopp aa ppllaann ffoorr rreevviisseedd ppaattiieenntt oorr ffaammiillyy ccaarreeggiivveerr tteeaacchhiinngg iiff ppaattiieenntt oorr ffaammiillyy ccaarreeggiivveerr iiss nnoott aabbllee ttoo tteeaacchh bbaacckk ccoorrrreeccttllyy..

20 CCHHAAPPTTEERR 22 ADMITTING,TRANSFER,ANDDISCHARGE STEP / RRAATTIIOONNAALLEE Unexpeccteedd Outcomes Related Interventions 11.. PPaattiieenntt iss unable to eexplain hospital policies (e.g.,, visitation,, smoking)) • Schedulefollow-upsessionwithpatient. or does not know purpose or schedule for tests and procedures.. • Keep information focused and specific to patient’'s situation. Include 22.. Paattiieenntt bbeeccoommeess restless,, expresses concerns,, or displays tension in family if helpful. body movements. • Givepatienttimetodiscussfearsandconcerns. • Showcaringandcompassionsopatientbecomeswillingtocommuni- 33.. Paattiieenntt falls or is injured.. cate openly. • Attendtopatient'’simmediatephysicalneeds. • Informhealthcareprovideroftheinjuryorfall. • Reassesspatient'’senvironment,altercareplanasneeded,ensurethat the environment is free of safety hazards. • Completeincident/adverseeventreport. Recordingg and Reporting anxiety is most common from middle infancy throughout the toddleryears,especiallyages16to30months.Preschoolersare ••  RReeccoorrdhistory and assessment fiinnddiingsiinappropriateffoorms/ better able to tolerate brief periods of separation, but their screensof electronichealth record (EHR) or chart. Begin to protest behaviors are more subtle than those in younger chil-­ develop nursing plan of care. ddrreen (ee..gg..,, rreeffussaal ttoo eat, difffiiccuullttyy sslleeeeppiinngg,, wwiitthhddrraawwiinngg from others). School-age children are able to cope with separation ••  DDooccuummeenntt yyoouurr eevvaalluuaattiioonn ooff ppaattiieenntt aanndd ffaammiillyy ccaarreeggiivveerr but have an increased need for parental security and guidance learning. (HHoocckkeennbbeerrrryyaandWWilson,22015). ••  EExxppllaaiinn tthhe rroooommiinngg--iinn aand visiting policies of the agenccyy. ••  Iffpatienthhasanadvancedirective,placecopyinthemedical Allow and encourage parental involvement in the child’'s care. rreeccoorrdd..IInntthheeaabbsseenncceeooffaannaaccttuuaallaaddvvaanncceeddiirreeccttiivvee,,ddooccuummeenntt AAlllloowwppaarreennttssttoohheellppwwiitthhrroouuttiinneeccaarreeaaccttiivviittiieess((ee..gg..,,bbaatthhiinngg,, tthhee ssuubbssttaannccee ooff tthhee ddiirreeccttiivvee iinn tthhee mmeeddiiccaal reccoorrdd (TTJJC,, eeaattiinngg)) aanndd,, when possible, to remain with the child during 22001166aa)).. procedures. ••  PPaarreennttaalliinnppuuttdduurriinnggaaddmmiissssiioonnaasssseessssmmeennttiisseesssseennttiiaallbbeeccaauussee ••  NNoottiiffyyhheeaalltthhccaarreepprroovviiddeerrooffppaattiieenntt'’ssaarrrriivvaall;;rreeppoorrttaannyyuunnuussuuaall they can provide input on the child’'s normal behavior and ffiinnddiinnggss..SSeeccuurreeaaddmmiissssiioonnoorrddeerrssiiffnnoottpprreevviioouussllyypprroovviiddeedd.. deviations caused by illness. Speciaall Considerations Gerontological TTeachhiingg ••  HHoossppiittaalliizzeeddoollddeerraadduullttsseexxppeerriieenncceeffuunnccttiioonnaallddeecclliinneessssuucchhaass ••  EExxppllaaiinnttooppaattiieenntttthhaattaaddiiffffeerreennttnnuurrsseepprroovviiddeessccaarreeoonneeaacchh new-onset incontinence, malnutrition, deconditioning, pressure sshhiifftt..EExxppllaaiinnttiimmeeffrraammeeffoorrhhoowwaassssiiggnnmmeennttssaarreemmaaddee.. iinnjjuurriieess,, aanndd ffaallllss.. IInntteerrvveennttiioonnss tthhaatt rreettaaiinn ffuunnccttiioonnaall ssttaattuuss ((ee..gg..,,pphhyyssiiccaalltthheerraappyy,,nnuuttrriittiioonnccoonnssuullttaattiioonn))rreeqquuiirreepprroovviiddiinngg ••  TTeeaacchhiinngg ooccccuurrss tthhrroouugghhoouutt tthhee aaddmmiissssiioonn pprroocceessss.. PPrroovviiddee ccoooorrddiinnaatteeddiinntteerrddiisscciipplliinnaarryyccaarree((TToouuhhyyaannddJJeetttt,,22001144)).. information regarding physical assessment ffiindings,, risks for ••  PPaattiieennttsswwhhoottyyppiiccaallllyyffaalllliinntthheehhoossppiittaallaarreetthhoosseewwhhoohhaavvee falling,, nature of patient'’s illness, planned diagnostic and treat­- been admitted recently and are unfamiliar with surroundings, ment procedures,, medications, goals of care, and hospital have acute illness, take ffoour or more medications, or have been routines. rreellooccaatteeddrreecceennttllyy.. VViissuuaall cchhaannggeess tthhaatt ooccccuurr wwiitthh aaggiinngg oofftteenn lleeaaddttooffaallllssiinnhhoossppiittaalliizzeeddoollddeerr--aadduullttppaattiieennttss((TToouuhhyyaannddJJeetttt,, ••  IInnaanneemmeerrggeennccyy ssiittuuaattiioonn oorr iiff ppaattiieenntt iiss uunnaabbllee ttoo ppeerrffoorrmm 22001144)).. aspects of his or her care,, teach family caregivers about the ratio­- nale for any procedures and routines to be used in patient'’s care. Peddiiatrriic ••  HHoossppiittaalliizzaattiioonniissaammaajjoorrccrriissiissffoorrcchhiillddrreennwwhhooffeeeellssttrreessssffrroomm sseeppaarraattiioonn,,lloossssooff ccoonnttrrooll,, bbooddiillyyiinnjjuurryy,, aanndd ppaaiinn.. SSeeppaarraattiioonn ♦ SSKKIILLLL 22..22 Transferring Patients particularly for patients with complex physiological, psychological, PPaattiieennttss ttrraannssffeerr ttoo ddiiffffeerreenntt ppaattiieenntt ccaarree uunniittss aanndd aaggeenncciieess ttoo aannddssoocciiaallnneeeeddss((TToossccaanneettaall..,,22001122)).. rreecceeiivvee alternate forms and levels of therapy and services and to When patients move between units or agencies for diagnosis, hhave eessential care continued closer to home. When patients trans­- ferr,, you need to ensure continuity of nursing care by improving treatment, and ongoing care, there is a safety risk at each interval. transitions across the continuum of care. The goal of a transfer of TThheehhaanndd--oovveerr((oorrhhaanndd--ooffff))ccoommmmuunniiccaattiioonntthhaattooccccuurrssbbeettwweeeenn care is to continuuee health care to avoid therapeutic interruptions staff on different units and between and among care teams might oorroommiissssiioonnsstthhaattmmaayyhhiinnddeerrpprrooggrreessssttoowwaarrddrreeccoovveerryy..CCoollllaabboorraattee not include all the essential information, or information may be eeaarrllyy wwiitthh hheeaalltthh ccaarree pprroovviiddeerrss aanndd mmeemmbbeerrss ooff tthhee iinntteerrddiisscciipplliinn­- mmiissuunnddeerrssttoooodd.. HHaanndd--ooffffss sseerrvvee mmaannyy ffuunnccttiioonnss,, ffrroomm ccooaacchhiinngg aarryy tteeaamm ttoo eennssuurree eeffffiicciieenntt ppaattiieenntt ttrraannssffeerr wwiitthh ooppttiimmaall ppaattiieenntt aanndd tteeaacchhiinngg ttoo tteeaamm bbuuiillddiinngg;; bbuutt tthheeiirr mmoosstt iimmppoorrttaanntt ffuunnccttiioonn oouuttccoommeess.. EEvviiddeenncceesshhoowwss tthhaatt mmuullttiippllee pprrooffeessssiioonnaallss  aarree nneecceess­- iiss iinnffoorrmmaattiioonn pprroocceessssiinngg:: mmaakkiinngg ssuurree tthhaatt eesssseennttiiaall ddaattaa aarree ttrraannss-­ ssaarryy ttoo pprroovviiddee mmoorree iinntteeggrraatteedd ccaarree tthhaann iinnddiivviidduuaall pprroovviiddeerrss,, ffeerrrreedd ffoorr ppaattiieenntt ssaaffeettyy ((HHaallmm,, 22001133)).. SSuubbssttaannddaarrdd oorr vvaarriiaabbllee

SSKKIILLLL 22..22 TRANSFERRINGPATIENTS 21 hand-offs have contributed to errors, care omissions, treatment transfer is accomplished. AAn appropriate transfer includes the fol-­ delays, ineffiicciieenncciieess fromm rreeppeeated work,, inappropriate treatment, lowing steps: •• Informing the patient of the risks and beneffiits of the adverse events with minor or major harm, increased length of stay, transfer avoidablereadmissions,andincreasedcosts(Blouin,20l1l1;Riesen­- •• Obtainingthepatient’'swrittenconsentfortransfeerr berg et al.,,2010). •• Havingthetransferringghospitalprovidemedicaltreatment within its capacity When providing a hand-off of a ppatient to another unit, it is •• Havingavailablespaceandqualiffiiedpersonnelfortreatment of the patient at the receiving agency and an agreement to essential to cclearly communicate information about the patient'’s accept transfer of the patient and provide treatment •• Making copies of all relevant medical records, includinngg aa care, treatment, services, and current condition and any recent or transfer ffoorm, sent by the transferring agency to the receiving anticipated changes in order to meet patient safety goals (TJC, agency 2016a). PPolicies and procedures areusually similar throughout an •• Transportingthepatientusingqualiffiiedpersonnelandtrans-­ agennccyy. PPreventing communicationffailuresbeginswithstructured portationequipment(e.g.,ambulancewithadvancedcardiac lifesupport[[AACLS]versusbasiclifesupport[BBLLS]). communication, which is often achieved through the use of stan­- AAlthoughthislawprimarilyaffectstheED,itisimportanttoknow dard protocols that identify necessary information for reliable EMTAALA and the transfer policies for inpatient transfeerrss within hand-offs.Highlyreliablehand-offsincorporatethreekeyelements the agency itself. Many agencies follow the same policiess for aalll (Halm, 2013):: patient transfers. 1. Face-to-face,two-waycommunicationbetweenhealthcare Delegation and Collaboration team members The skill of assessment and decision making conducted during 2. Structuredwrittenforms,templates,orcheckliststhatallow transferscannotbedelegatedtonursingassistivepersonnel((NNAAP). ThenursedirectstheNNAAPto: clinicians to agree on minimum essential data that create a •• Helpthepatientwithdressing. •• Gather and secure the patient’'s personal belongings and any shared mental model of a patient'’s situation 3. Contentthat\"“capturesintention,\"”meaningthatclinicians equipmentthatgoeswiththepatient. •• EEscortthepatienttothenursingunitortransportarea. share problems and hypotheses with a predictive diagnosis off the patient'’s clinical situation (foresight), rather than Equipment listing eventsandcompleted tasks (hindsight), which has ••  Transferforms been associated with hand-off errors ••  Copies of documents such as medical records, radiology ffiilms, Mnemonics such as SBAR (Situation, Background, Assessment, Recommendation) or \"“I PASS the BATONN”\" (Introduction, llaabboorraattoorryytteessttrreessuullttss((aassaapppprroopprriiaattee)) ••  SSppeecciiaall eeqquuiippmmeenntt aass nneeeeddeedd:: wwhheeeellcchhaaiirr oorr ssttrreettcchheerr,, eemmeessiiss Patient, Assessment,, Situation, Safety concerns, Background, Actions, Timing, Ownership,, Neexxtt))aarreeexampplleessooffffoorrmmaattsstouse basin, bedpan and urinal, oxygen tank and tubinngg,, intravenouuss ((IIVV))ppoollee,,ccaarrddiiaaccmmoonniittoorr,,aannddeemmeerrggeennccyymmeeddiiccaattiioonnss during communication of transfers that can be tailored for different clinical areas and/or purposes. IInntthheeeemmeerrggeennccyy ddeeppaarrttmmeenntt (EEDD)), whheen a ppaattiieennt is trans-­ ferred from one agency to another, a nurse completes the transfer iinnccoommpplliiaanncceewwiitthhtthheeEEmmeerrggeennccyyMMeeddiiccaallTTrreeaattmmeennttaannddLLaabboorr AAcctt ((EEMMTTAALLAA)) ((CCMMSS,, 220011226b)).. EEMMTTAALLAA iiss aa ffeeddeerraall llaaww intended to protect patients from being transferred against their wishes and thus deffiinneess hhoow aan appropriate agency-to-agency SSTTEEPP/ RRAATTIIOONNAALLEE AASSSSEESSSSMMEENNTT EEnnssuurreessccoorrrreeccttppaattiieenntt..CCoommpplliieesswwiitthhTThheeJJooiinnttCCoommmmiissssiioonn ssttaannddaarrddssaannddiimmpprroovveessppaattiieennttssaaffeettyy((TTJJCC,,22001166aa)).. 1. IIddeennttiiffyyppaattiieennttuussiinnggaattlleeaassttttwwooiiddeennttiiffiieerrss((ee..gg..,,nnaammee aannddbbiirrtthhddaayyoorrnnaammeeaannddmmeeddiiccaallrreeccoorrddnnuummbbeerr)) HHeeaalltthhccaarreepprroovviiddeerriisslleeggaallllyyrreessppoonnssiibblleeffoorrrreelleeaassiinnggppaattiieennttffrroomm accordingg to agency poliiccyy. medical care and arranging for receiving health care provider. PPaattiieenntthhaasslleeggaallrriigghhttttoorreeffuusseettrraannssffeerraaggaaiinnssttmmeeddiiccaallaaddvviiccee.. 2. OObbttaaiinnaannddrreevviieewwttrraannssffeerroorrddeerrffrroommsseennddiinngghheeaalltthhccaarree pprroovviiddeerr..OOrrddeerriinncclluuddeessnnaammeeoofftthheerreecceeiivviinnggaaggeennccyy PPaatthhiieeeennaattllttnnhheecceeaaddrrsseettnnooeehheeaaddvvss..eeHHaacceeccaaeellttsshhssttccooaarraaeeggeeppnnrrooccvyvyiiwdwdeeiitrrthhddebbetteeeessrrttmmrreieinnssooeeususrrppccaaeettssiieettnonottmm’'sseeeett ((wwhheennaapppplliiccaabbllee)),,rreecceeiivviinngghheeaalltthhccaarreepprroovviiddeerr'’ssnnaammee,, physical stability for transfer. and statement of patient's stability for transfer. IIddeennttiiffyyiinnggppaattiieennttssaattrriisskkffoorrttrraannssiittiioonnaallccaarreepprroobblleemmssaalllloowwssffoorr 33.. IIannndccooslltllaaatbbeoomrraaettniiotonnofwwpiiatththiehhneetaa’sllttshhtaccbaairlrieetypprrfooorvviitddreaernrsaafnnerdd.mmeemmbbeerrssooff bbeetttteerrccoonnttiinnuuiittyyooffccaarreeaannddiimmpprroovveeddppaattiieennttoouuttccoommeess((TToouuhhyy the interdisciplinary team, assess reason for patient'’s aannddJJeetttt,,22001144))..PPaattiieennttssmmaayyrreeqquuiirreeccoonnssuullttaattiioonnwwiitthhnneeeeddeedd ttrraannssffeerr((ee..gg..,,cchhaannggeeiinnccoonnddiittiioonn,,sseerrvviicceessaavvaaiillaabblleeaatttthhee rreessoouurrcceess((ee..gg..,,ccaarreemmaannaaggeerr,,ppssyycchhoollooggiisstt))wwhheennaarrrriivviinnggaatt ageennccyy,, patient or family preferences regarding patient'’s destination. llooccaattiioonn)).. 4. Assess individuals at high risk for transitional care problems ((ee..gg..,,oollddeerraadduullttsswwiitthhmmuullttiipplleehheeaalltthhiissssuueess,,ddeepprreessssiioonn,, nnoonn--EEnngglliisshhssppeeaakkeerrss,,ppaattiieennttsswwiitthhsseennssoorryyiimmppaaiirrmmeennttss,, aannddllooww--iinnccoommeeppaattiieennttss))..

22 CCHHAAPPTTEERR 22 ADMITTING,TRANSFER,ANDDISCHARGE SSTTEEPP/ RRAATTIIOONNAALLEE 55.. EExxppllaaiinppuurrppoosseeooftransferrthoroughlyandprovidetimeto Patientsneedtobeinformedoftransferplansinatimelymanner discuussss patient'’s and family'’s feelings about the cchange in (TTJJC, 20166b).Apatient requires adequate psychological ccaare sseettting. As necceessssaarryy,, oobtain patient'’s written consent preparation.Intheeventofaclinicalemergencyinwhich to ttrraannssffeerr. If patient is unable to consent, patient'’s family provides this consent. patient and patient'’s family are unable to consent, this consent 66.. AAsssseessss ppaattiieenntt'’ss ccuurrrreent pphhyysical condition and determine is waived,, and patient is transferred to a higher level of care on method for transport. When transferring to a new agency, assess method of transport to transferring vehicle the basis of the clinical judgment of the health care provider ((ee..g.,,wwhheeelchair or stretcher) (consult agency  requestingthetransfer. policy). Determineslevelofpatientstability.Patient’'sconditionoften changes quickly and infflluences stability for transfer andtypeof support needed during transport. CClliinniiccaall DDeecciissiioonn PPooiinntt DDeetteerrmmiinnee iiff ppaattiieenntt'’ss ssttaattuuss aanndd ssaaffeettyy rreeqquuiirree lliiffee--ssuuppppoorrtt eeqquuiippmmeenntt.. SSttaaffff aassssiissttiinngg wwiitthh ttrraannssffeerr nneeeedd ttrraaiinniinngg iinn lliiffee-­ ssuuppppoorrtt mmeeaassuurreess.. WWhheenn ttrraannssppoorrttiing tto nnew aaggeennccyy,, a vehicle equipped with life-support equipment is necessary.. 77.. AAsssseessssifppaattiieennttrreeqquuiirrespainrelieforothermedications Ensurespatient’'scomfortduringtransfer. for symptom management. Providesadequatecommunicationwithffaamilyorsigniffiicantothers 88.. EEnnssuurreetthhaattstaaffffhhaavveennoottiifiieeddppaattiieenntt'’ssffaammiillyyoorrssiiggnniiffiiccaanntt to help with patient'’s emotional and psychological adjustment ootthers of transfer as desired by patient. ttootthheettrraannssffeerr(TTJJC,2001666b)). NNUURRSSIINNGG DDIIAAGGNNOOSSEESS •• AAnnxxiieettyy ••  FFeeaarr ••  Relocationstresssyndrome •• DDeeffiicciieennttkknnoowwlleeddggeerreeggaarrddiinngg ••  PPoowweerrlleessssnneessss ttrraansfer procedure RReellaatteedd ffaaccttoorrss aarree iinnddiivviidduuaalliizzeedd onn tthhee bbaassiiss off ppaattiieenntt'’ss ccondition oor needs.. PPLLAANNNNIINNGG TTreatments are planned so as not to interrupt physical support of patient during transfer. 11.. EExxppeecctteeddouttccoomesffoolllloowingcompletionofprocedure:: ••  PPaattiieenntt'’ssvviittaallssiiggnnssaannddpphhyyssiioollooggiiccaallssttaattuussrreemmaaiinntthhee SSaaffeettyymmeeaassuurreessaarreessuucccceessssffuulliinnttrraannssffeerrrriinnggppaattiieennttffrroomm ssaammee ffoolllloowwiinngg ttrraannssffeerr.. wheelchair or stretcher to transport vehicle. ••  PPaattiieennttiinnccuurrssnnooiinnjjuurryydduurriinnggttrraannssppoorrttpprroocceedduurreess.. UUnnddeerrssttaannddiinnggpprroovviiddeessppaattiieennttwwiitthhsseennsseeooffccoonnttrrooll.. •• PPaattiieennttoorrffaammiillyyeexxppllaaiinnssppuurrppoosseeooffttrraannssffeerraanndd pprroocceedduurree ffoorr ttrraannssppoorrtt.. EEnnssuurreessccoonnttiinnuuiittyyooffccaarree.. •• RReecceeiivviinnggnnuurrssiinnggssttaaffffaaccqquuiirreeaannddccoonnffiirrmmwwrriitttteennppllaann TTransfer needs to occur without delays so patient has access to all ooff ccaarree.. needed resources at all times. 22.. AArrrraannggee ffoorr ppaattiieenntt'’ss transport to the agency by PPrreevveennttssddeellaayysswwhheennppaattiieennttaarrrriivveessaattddeessttiinnaattiioonn..RReecceeiivviinngg cchhoosseennvveehhiiccllee((ssoocciiaallwwoorrkkeerriinnvvoollvveemmeennttmmaayybbee hhoossppiittaalleennssuurreesstthhaattssppaacceeaannddqquuaalliiffiieeddppeerrssoonnnneellaarreeaavvaaiillaabbllee nneecceessssaarryy)).. ttoottrreeaattppaattiieennttss..HHoossppiittaallaallssooaaggrreeeessiinnaaddvvaanncceettoottrraannssffeerr.. 33.. WWhheen ttrraansfer is tto aa new agency,, contact the agency and aarrrraannggeeffoorrbbeeddiinnaapppprroopprriiaatteesseettttiinngg..CCoonnffiirrmmwwiilllliinnggnneessss oofftthheeaaggeennccyyttooaacccceeppttppaattiieenntt((uussuuaallllyyssoocciiaallwwoorrkkeerroorr ddiisscchhaarrggeeccoooorrddiinnaattoorrccoommpplleetteess)).. IIMMPPLLEEMMEENNTTAATTIIOONN Accurate information is necessary for receiving agency to assume patient'’s care. 11.. MMaakkeessuurreetthhaattddooccuummeennttaattiioonniinnppaattiieenntt'’ssrreeccoorrddiiss ccoommpplleettee,,wwiitthhccaarreeppllaanntthhaatthhaassiinnddiivviidduuaalliizzeeddnnuurrssiinngg FFoorrmmssuummmmaarriizzeessppaattiieenntt’'ssppeerrttiinneennttnnuurrssiinnggccaarreenneeeeddssttooeennssuurree ccaarree meeaassuurreess.. continuity of care and prevent unnecessary duplication of services. 22.. CCoommpplleetteennuurrssiinnggccaarreettrraannssffeerrffoorrmmaaccccoorrddiinnggttooaaggeennccyy ppoolliiccyy..((WWhheennttrraannssffeerriissttooaaddiiffffeerreennttnnuurrssiinngguunniitt,,eennttiirree mmeeddiiccaallrreeccoorrddaaccccoommppaanniieessppaattiieenntt..))

SSKKIILLLL 22..22 TRANSFERRINGPATIENTS 23 SSTTEEPP/ RRAATTIIOONNAALLEE 3.. CCompletemedicationreconciliationperagencypolicy. The new medication regimen prescribed at the time of transfer Check  patient'’s  currentt ordersfor transfer against the may omit needed medications, unnecessarily duplicate existing therapies,orcontainincorrectdosages(AHRQ,2015b6). most recent medication administration record and the Ensuresthatpatientreceivescorrectmedicationsatnew original homemedication list. CCommunicate updated agencyanddecreasesmedicationerrors(TJC,2016a). medication list to next provider of care. Preventslossofarticlesduringtransfer. 44.. HaveNNAPgatherpatient'’spersonalcareitems,clothing, Ensurespatient'’scomfortandsafetyduringtransport. and valuables. CChecktheentireroomandallstorage areas..Secureinsuitcaseorcontainer. Itiseasiertomovepatienttransportedtooutsideagencyby 55.. Anticipateproblemsthatpatientfrequentlydevelopsjust stretcher into transport vehicle. before or during transfer.Performnecessarynursing Minimizesriskofpatientdevelopingcomplicationsduring therapies such as suctioning or changing a dressing. transfer. 66.. Helptotransferpatienttostretcherorwheelchairusing safepatient-handlingtechniques(seeChapter11). 77.. Performanddocumentfiinnaallaasssseessssmmeennttoffppaattiieent'’s physical stabiliittyy.. CClliinniiccaall DDeecciissiioonn PPooiinntt Priorityy assessmentt includes vital siggnnss,, clear airway,, patency of IV lines and accuracy of infusion rate, and ppaatient’'s level off consciousness.. 8.. When transfer occurs to an outside agency, accompany Ensuresthatmedicallyqualiffiiedpersonnelareinattendanceuntil patient to transport vehicle. patient leaves agency/unit. 9.. CCaallllrreecceeiivviinnggaaggeennccyy//uunniittaannddnnoottiiffyyooffiimmppeennddiinngg Notiffiication of nurse in charge or nurse assuming care of patient transferandpatient'’sstatus(checkagencypolicy). ensures better continuity of care at time of patient’'s arrival. EEVVAALLUUAATTIIOONN Determinesifpatient'’sconditionischanging. 1.. Duringtheffiinnaallassessmentccoommpparedatawiththeprevious Properalignmentandpositioningreduceriskofaninjuryoccurring fiinnddiinnggss.. during transport. 2.. Inspectpatient'’salignmentandpositioningonstretcher/ EEqquuiippmmeennttssuucchhaassooxxyyggeennmmuussttllaasstttthhrroouugghhttrraannssppoorrttffoorrppaattiieenntt wheelcchhaaiirr.. safety. 3.. EEnnssuurreetthhaatteeqquuiippmmeennttnneeeeddeeddffoorrttrraannssffeerriissffuunnccttiioonniinngg.. FFeeeeddbbaacckkhheellppssttooeennssuurreelleeaarrnniinngg.. 44.. CCoonnffiirrmmtthhaattppaattiieennttuunnddeerrssttaannddssttrraannssffeerraannddpprroocceedduurreess PPrroovviiddeessffoorrcclleeaarrccoommmmuunniiccaattiioonndduurriinngghhaanndd--ooffffaannddccoonnttiinnuuiittyy tthhrroouugghhddiissccuussssiioonnaannddqquueessttiioonnss.. of care. 5.. DDeetteerrmmiinneeiiffrreecceeiivviinnggaaggeennccyy//nnuurrsseehhaassqquueessttiioonnssaabboouutt DDeetteerrmmiinneessppaattiieenntt'’ssaannddffaammiillyyccaarreeggiivveerr'’sslleevveellooffuunnddeerrssttaannddiinngg patient'’s care.. of instructional topic. 6.. Use TTeacchh-Bacckk::\"“IIwwaannttttoobbeessuurreeyyoouuuunnddeerrssttaannddwwhhyy yyoouuaarreebbeeiinnggttrraannssffeerrrreeddttooyyoouurrnneewwuunniitt..CCaannyyoouutteellllmmee why you aree bbeeing transferred and what the name of your nneewwuunniittiiss??\"”RReevviisseeyyoouurriinnssttrruuccttiioonnnnoowwoorrddeevveellooppaappllaann ffor rreevised patient or ffamily caregiver teaching if patient or ffaamily ccaarreegiver is not able to teach back correctly. UUnneexxppeecctteedd OOuuttccoommeess RReellaatteedd IInntteerrvveennttiioonnss 11.. PPaattiieenntt'’sspphhyyssiiccaallssttaattuussddeetteerriioorraatteessdduurriinnggpprreeppaarraattiioonn.. •• CCaallllhheeaalltthhccaarreepprroovviiddeerriimmmmeeddiiaatteellyy.. 2.. Patient is confused or uncertain about transfer. •• IInniittiiaatteeiinntteerrvveennttiioonnssttoossttaabbiilliizzeeppaattiieenntt’'ssccoonnddiittiioonn.. 33.. RReecceeiivviinnggssttaaffffmmiissiinntteerrpprreettddiirreeccttiioonnssffoorrppaattiieenntt'’ssccaarree.. • Provideclarificationoradditionalexplanation. •• SSeennddiinnggaaggeennccyyhhaassnnuurrsseeoorrhheeaalltthhccaarreepprroovviiddeerrccaallllttooccoonnffiirrmmtthhaatt tthheerreeaarreennooqquueessttiioonnssrreeggaarrddiinnggppaattiieenntt’'ssccaarree.. RReeccoorrddiinngg aanndd RReeppoorrttiinngg of transport, patient’'s condition, and care provided at time of arrival. ••  TThhee nnuurrssee sseennddiinngg tthhee ppaattiieenntt ddooccuummeennttss ppaattiieenntt'’ss ssttaattuuss,, including vital signs and other assessment ffiindings regarding SSppeecciiaall CCoonnssiiddeerraattiioonnss patient'’s condition, nursing plan of care, date and time of trans-­ TTeeaacchhiinngg fer, and method of transport on appropriate transfer form. ••  AA ttrraannssffeerr ffrreeqquueennttllyy ccrreeaatteess aannxxiieettyy ffoorr aa ppaattiieenntt aanndd ffaammiillyy ••  DDooccuummeenntt yyoouurr eevvaalluuaattiioonn ooff ppaattiieenntt aanndd ffaammiillyy ccaarreeggiivveerr mmeemmbbeerrss..CCaarreeffuullllyyrreeppeeaattiinnssttrruuccttiioonnssaabboouutttthheettrraannssffeerrwwhheenn lleeaarrnniinngg.. ppaattiieenntt aanndd ffaammiillyy ccaarreeggiivveerr aarree bbeetttteerr aabbllee ttoo uunnddeerrssttaanndd yyoouurr ••  NNuurrsseerreecceeiivviinnggppaattiieenntt ddooccuummeennttssppaattiieenntt'’ss aarrrriivvaall aatt aaggeennccyy bbyy rreeccoorrddiinngg ddaattee aanndd ttiimmee ooff aarrrriivvaall,, rreeaassoonn ffoorr ttrraannssffeerr,, mmeetthhoodd

24 CCHHAAPPTTEERR 22 ADMITTING,TRANSFER,ANDDISCHARGE explanation.Inthis situation be sure to have patient restate Long-Term Care aannyy ccrriittiiccaall iinnffoorrmmaattiioonn.. ••  Itisimportantthatpatientsreceivethelevelofservicesappro-­ Pediatric priatetotheirphysicalandmentalhealthneeds.Participation ••  CChhiillddrenneedtheirparents'’comfortandsecurityy;;thusmake ooff ssoocciiaall wwoorrkkeerr oorr ddiisscchhaarrggee ppllaannnneerr iinn ttrraannssffeerr pprroocceessss eennssuurreess tthhaatt ttrraannssffeerr ttoo aa lloonngg--tteerrmm ccaarree ffaacciilliittyy iiss aapppprroopprriiaattee.. surethat parents are well  informed. Involve older children in ••  Onpatient’'sarrivalatlong-termcarefacility,completeaResi-­ aannyy ddiissccuussssiioonn rreeggaarrddiinngg ttrraannssffeerrss.. AAllllooww aa ppaarreenntt ttoo aaccccoommppaannyy dent Assessment Instrument (RAI). The RAI consists of the tthhee cchhiilldd iinn tthhee ttrraannssffeerr.. minimum data set (MDS), resident assessment protocols, and utilization guidelines speciffiied in state operations guidelines Gerontologiiccal (TouhyandJett,2014). ••  WWhentransferringanolder-adultpatienttoanewagencyy,relo­- ••  Essentialcomponentsofsuccessfultransfertoalong-termcare ffaacciilliittyy aarree aaccccuurraattee ccoommmmuunniiccaattiioonn ooff mmeeddiiccaattiioonn lliissttss aanndd cation is stressful. Ensure thatsignifiiccaannttssuuppppoorrttpeople are still  advancedirectives.Possibleuseofastandardizedtransferform aacccceessssiibbllee aanndd tthhaatt ppaattiieenntt iiss tthhoorroouugghhllyy oorriieenntteedd ttoo nneeww ssuurr­- can help in accurate communication (Mueller etal., 22012; rroouunnddiinnggss.. AAllssoo mmaakkee ssuurree tthhaatt ppaattiieenntt iiss aabbllee ttoo ttaakkee iimmppoorrttaanntt Tolesetal.,2012). mmeemmoorraabbiilliiaa aanndd hhaass aann ooppppoorrttuunniittyy ttoo mmaakkee ddeecciissiioonnss aabboouutt care (Touhyyand JJett,,2014). ♦ SSKILL 2.3 Discharging Patients effective (AHRQ, 2013). When team members communicate during end-of-shift hand-offs, consultations, or huddle sessions, a EEaarrlyyand comprehensive ddischargepplanningfacilitates the transi­- patient'’sdischargereadinessshouldbeacentraltopic.Communi-­ tion of a patient or resident from a health care agencyy to the most cation is enhanced if an organization has a discharge coordinator indepennddenntt level of care,, whether that is home or another agencyy. or case manager. Stafff members in these roles thoroughly assess TThhe overall goal of discharge planning is to provide the most what each patient’'s needs will be at discharge, identify available appropriate level and qualityy of care throughout all stages of a and needed resources, and link patients and families to these patient'’s illness. The US Department  of Health  andHumanSer­- resources(e.g.,communityagencies,MealsonWheels,rehabilita-­ vices (USDHHS) (2014) explainssthat discharge planning involves: tionsites). The staff also coordinate services (e.g., home health) as appropriate and follow up on patients’' progress after discharge. ••  Determining theappropriate posthospital/agencyy discharge destination for a patient. Discharge from an agency is stressful for a patient and family. Before a patient is discharged, the patient and family need to be ••  Identifyiinng what a patient requires for a smooth and safe prepared with the knowledge and skills to manage care in the transition from the acute care hospital/ post-–acute care home. They also need to know what to expect in regard to any agencyy to his or her discharge destination. continuing physical problems.Without the necessary equipment and professional resources, a patient risks loss of rehabilitation ••  Beginningtheprocessofmeetingapatient'’sidentiffiiedpre- gains made before discharge. Failure to understand restrictions or discharge and postdischarge needs. .B: OX 2.5 TThhe discharge planning process is comprehensive and interdisci­- plinaryy,, including all caregiverss who are involved in the care of the The Joint Commission Recommendations for ppaattient. EEveryy hhoossppitalized patient requires patient-entered dis­- Discharge Planning PProcess ccharge planning,,and it is equallyyessential for anyypatient perma­- nenntlyy moving to a different health care agencyy. The trend toward • Addresspatientcommunicationneeds,includingpatient'spreferred shorter lengths of stayy in acute care settings makes discharge plan­- language and any  sensory  or communication impairments. nning increasinglyydiffiiccuulltt,,bbuuttaalllltthheemmoorreeessential.TTheJJoint CCommission (TJC) identifiieess tthhe eleemmeennttss ooff a comprehensive • Ensurethatlanguageservicesareavailableforpatientandfamily discharge planning model  (Box 2.5). members. Development of a ddischarge plan with outcomes mutually • Engagepatientsandfamiliesactivelyindischargeplanningand accepted byya patient and health care providers isessential (TJC,  instruction. 20115). Effective discharge planning prepares patients to assume self-care or prepares familyy caregivers to provide needed support • Providedischargeinstructionthatmeetspatientneeds. andd thus can decrease hospital readmission and promote optimal • Instructionmayinvolveuseofpictures,diagrams,ormodelsto patieennttoutcomes (RRutherford et al.,,2013).The dischargeprocess illustrateinstruction. is simple or complex and occurs in three phases:: acute, transitional, anddcontinuingcare.Intheacutephasemedicalattentiondomi­- • UMsaetedriiaslcshsahrgoeuldinsbteruacttioffiifnththgartadmeeeotrslohweearlthrelaitderinagcylenveeel.ds. nattessdischarge planning efforts. During the transitional phasethe • Identifyfollow-upproviderswhocanmeetuniquepatientneeds. nneeeedd ffoorr aaccuuttee ccaarree iiss ssttiillll pprreesseenntt;; bbuutt iittss uurrggeennccyy ddeecclliinneess,, aanndd patientts begin to address and plan for their future health care • Createalistoffollow-upprovidersthatofferservicesand needs. In the continuing-care phase patients are abletoparticipate accommodationsthatmeetpatient'scommunication,cultural, in ppllaanning and implementing continuing-care activities needed religious,mobility,andotherneeds. after discharge.In  hospitals  these  phases  can occur veryy quickly,  eeven within hours. • Referpatientstoappropriatecareprovider(e.g.,community clinic). TThe greatest challenge in effective discharge planning is com­- munication.Patientsandfamilies should be full partners in the ModiffiiedfromTheJointCommission(TJC):AAddvvaanncciinnggeeffffeeccttiivvee ccoommmmuunniiccaattiioonn,, discharge pplanning process and thus should be engaged in discuss­- cultural competence,, and patient- and family-centered care: a roadmap for ing what will be needed to make the transition in care safe and hospitals,,OakbrookTerrace,IL,2011,TheJointCommission.

SSKKIILLLL 22..33 DISCHARGINGPATIENTS 25 implications of health problems often causes a patient to develop ••  Gatherandsecurepersonalitemsandanyssuupppliesthattpatient complications. Poordischargeplanning ignores a patient’'s needs will take home or to new setting. within the home and increases the chance of the patient needing to reenter the health care system prematurely. •• Transportthepatienttothedischargetransportvehicllee.. Delegation and Collaboration Equipment The skills of assessment, care planning, and instruction included •• Wheelchairorstretcher in discharging patients cannot be delegated to nursing assistive ••  Dischargedocumentationforms((seeagenccyypolicy) personnel(NAP).ThenursedirectstheNAPto: •• Patientinstructionsheets •• Plasticbagforpersonalbelongings SSTTEEPP/ RRAATTIIOONNAALLEE AASSSSEESSSSMMEENNTT Ensurescorrectpatient.ComplieswithTheeJointCommission standardsandimprovespatientsafety((TTJC,22016a).. 11. Identifypatientusingatleasttwoidentiffiiers(e.g.,,nameand bbiirrthday or name and medical record number)accordingto Planningfordischargebeginsatadmissionnandcontinues agency poolliiccyy. throughout patient’'s stay in an agency to helpp patient achieve maximum functioning. The discharge planning assessment 2. Fromtimeofadmission,,assesspatient'’sdischargeneedsusing determines patient’'s continuing care neeeeddss after he or she nursing hhiistory data,, including assessments of patient'’s physical leaves the acute care hospital/post–-acute care aaggency sseetting hhealth,, functional status,, psychosocial support system,, fiinnaancial (USSDHHS,2014). resources, hheealth values,, cultural and ethnic background, level of education,, and barriers to care that are needed. Also review Allowsyoutobetterprioritizecareinterventionsthatmanage oonnggooiinnggaasssseessssmmeennttddaattaadduurriinnggyyoouurrsshhiiffttooffccaarree(ee..gg..,,pphhyyssiiccaall theseriskfactorsduringpatientstayinhospitaall..Conditions eexxaaminations and discussions with patient and health care affect either patient’'s ability to become physically or provider). Be sure that the dischargeplan isculturally psychologically ready for discharge or aabbiility and readiness oof aapppprroopprriiaattee((ee..gg..,,lleeaarrnntthheeppaattiieenntt'’sspprreeffeerreenncceessaannddvvaalluueess a caregiver to assume patient’'s care inn the home. aabboouuttccoonnttiinnuuiinngghheeaalltthhccaarreeaafftteerrddiisscchhaarrggee)).. IImmpprroovveessuunnddeerrssttaannddiinnggooffhheeaalltthhccaarreenneeeeddssaannddaabbiilliittyyttoo 3. Identifyriskfactorsthatmayincreasethechanceofpatient achieveself-careathome.IInclusionoffamilycaregiverin bbeeiinnggrreeaaddmmiitttteeddaafftteerrddiisscchhaarrggee((TTJJCC,,22001133))::DDiiaaggnnoosseess teaching sessions provides patient with available rreessoource. aassssoocciiaatteeddwwiitthhhhiigghhrreeaaddmmiissssiioonnss(ee..gg..,,hheeaarrttffaaiilluurree,,cchhrroonniicc EEnnggaaggiinnggppaattiieennttaannddffaammiillyyiinntthheeaasssseessssmmeennttssuuppppoorrttss lluunnggddiisseeaassee));;ccoo--mmoorrbbiiddiittiieess;;tthheenneeeeddffoorrnnuummeerroouuss ppaattiieenntt--aannddffammiillyy--cceenntteerreeddnnuurrssiinngg((TTJJCC,,22001155)).. medications;; a hhiistory of readmissions,, psychosocial and eemmotional factors such as issues relating to mental health, DDeetteerrmmiinneessttiimmiinnggaannddaapppprrooaacchhttooiinnssttrruuccttiioonn..DDiiffffeerreennttttyyppeess iinntterpersonal relationships,, or family matters;; the lack of a of educational materials are effective with different individual family caregiver who could provide support or help with care; lleeaarrnniinnggssttyylleess..IIffpprriinntteeddmmaatteerriiaalliissttoobbeeuusseedd,,bbeessuurreetthhaatt oollddeerraaggee;;ffiinnaanncciiaallddiissttrreessss,,ddeeffiicciieennttlliivviinnggeennvviirroonnmmeenntt((ee..gg..,, material is written at proper reading level. wwaatteerrssuuppppllyy,,hheeaattiinngg)) EEnnvviirroonnmmeennttaallffaaccttoorrsswwiitthhiinnppaattiieenntt’'sshhoommeeppoosseessaaffeettyyrriisskkssoorr 44.. IIffppaattiieenntt'’ssddeessttiinnaattiioonnaattddiisscchhaarrggeewwiillllbbeetthheehhoommee,,aasssseessss pprroobblleemmssffoorrsseellff--ccaarree((sseeeeCChhaapptteerr4433))..EEaarrllyyiiddeennttiiffiiccaattiioonnooff patient'’s and family caregiver'’s learning needs as soon as these ffaactors allows you to arrange for home health rreeffeerrrral. ppoossssiibbllee((ee..gg..,,ppssyycchhoommoottoorrsskkiillllss,,mmeeddiiccaattiioonnmmaannaaggeemmeenntt,, ssyymmppttoommrreeccooggnniittiioonn))..EEnnggaaggeeppaattiieennttaannddffaammiillyyaassppaarrttnneerrss TThheesseeccoonnddiittiioonnssaarreenneeeeddeeddffoorrMMeeddiiccaarreerreeiimmbbuurrsseemmeennttooff in tthe discharge teaching plan by having them identify their hhoommeehheeaalltthhsseerrvviicceess..PPaattiieennttmmuusstthhaavveeaa“\"sskkiilllleeddnneeeedd”\"tthhaatt concerns about discharge. rreeqquuiirreesstthheesskkiillllssooffaalliicceennsseeddnnuurrssee,,ssppeeeecchhtthheerraappiisstt,,oorr physical therapist to perform. A health care provider’'ss order iis 55.. AAsssseessssffoorrccuurrrreennttbbaarrrriieerrssttoolleeaarrnniinngg((ee..gg..,,aaggee,,ffaattiigguuee,,ppaaiinn,, also needed. llaacckkooffmmoottiivvaattiioonn))..AAsssseessssppaattiieenntt'’sshheeaalltthhlliitteerraaccyy((sseeeeSSkkiillll 22..11,,AAsssseessssmmeenntt,,SStteepp66)).. 6. Ask patient and/or family caregiver to describe the home eenvironment and assess ffor eennvironmental factors that may iinntteerrffeerreewwiitthhsseellff--ccaarree((ee..gg..,,ssiizzeeooffrroooommss,,ddoooorrwwaayycclleeaarraanncceess ffoorrwwhheeeellcchhaaiirr,,sstteeppss,,lliigghhttiinngg,,bbaatthhrroooommffaacciilliittiieess))..((AAhhoommee care nurse is usually available on referral to help with 77.. CaCacssaoossreellellssaassnbmbmuooeerrrsnnaaetttte.e.i))swwuiisttuhhalttlhhyeeaiivnnattieelarrppbrrloeoffoeessnssiirooennfeaarllrttaeelaatmmo httooelaapssssweeisstsshppaattiieenntt'’ss anticipated needs after discharge and his or her eligibility for hhoommeeccaarreerreeiimmbbuurrsseemmeenntt..AAsskktthheesseeqquueessttiioonnss::\"“DDooeessppaattiieenntt hhaave an injury or illness that makes it diffiiccuulltt too lleeave hoommee ((ee..gg..,,rreeqquuiirreesstthheeaaiiddooffssuuppppoorrttiivveeddeevviicceessssuucchhaassaa wwhheeeellcchhaaiirroorrwwaallkkeerr;;rreeqquuiirreetthheeuusseeooffssppeecciiaallttrraannssppoorrttaattiioonn;; nneeeeddtthheeaassssiissttaanncceeooffaaffaammiillyyccaarreeggiivveerr))??\"”DDooeesstthheeppaattiieenntt hhaavveeaa\"“sskkiilllleeddnneeeedd\"”tthhaattrreeqquuiirreesssskkiillllssffrroommaassppeecciiffiicchheeaalltthh ccaarree pprroovviiddeerr??\"”

26 CCHHAAPPTTEERR 22 ADMITTING,TRANSFER,ANDDISCHARGE SSTTEEPP/ RRAATTIIOONNAALLEE 88.. AAsssseessss ppaattiieenntt'’ss aanndd ffaammiillyy'’ss ppeerrcceeppttiioonnss ooff ccoonnttiinnuueedd hheeaalltthh Familycaregivingisahighlystressfulexperience.Family ccaarree nneeeeddss oouuttssiiddee tthhee hhoossppiittaall.. AAsssseessss ffaammiillyy ccaarreeggiivveerrss'’ mmeemmbbeerrss wwhhoo aarree nnoott pprrooppeerrllyy pprreeppaarreedd ffoorr ccaarreeggiivviinngg aarree ppeerrcceeiivveedd aabbiilliittyy ttoo pprroovviiddee ccaarree ttoo ppaattiieenntt,, iinncclluuddiinngg tthheeiirr frequentlyoverwhelmedbypatient’'sneeds,whichcan lleevveell ooff ssoocciiaall aanndd ccoommmmuunniittyy ssuuppppoorrtt aanndd tthheeiirr aabbiilliittyy ttoo lleeaadd ttoo uunnnneecceessssaarryy hhoossppiittaall rreeaaddmmiissssiioonnss.. mmaannaaggee mmuullttiippllee mmeeddiiccaattiioonnss wwiitthh wwhhiicchh tthhee ppaattiieennt iiss ddiisscchhaarrggeedd.. Clliinniiccaall DDeecciissiioonn PPooiinntt IItt iiss oofftteenn nneecceessssaarryy ttoo ttaallkk wwiitthh ppaattiieenntt aanndd ffaammiillyy sseeppaarraatteellyy ttoo lleeaarrnn aabboouutt ttrruuee ccoonncceerrnnss oorr ddoouubbttss.. 99.. AAsssseesss ppaatient'’s acceptance of hheealth problems and related Affects willingness to follow therapies and restrictions. rreestrictions. NNUURRSSIINNGG DDIIAAGGNNOOSSEESS •• AAnnxxiieettyy ••  Ineffectivehealthmanagement ••  Relocationstresssyndrome •• CCaarreeggiivveerrrroolleessttrraaiinn ••  Interruptedfamilyprocesses ••  Self-caredeffiicit:feeding,toileting, •• DDeeffiicciieennttkknnoowwlleeddggeerreeggaarrddiinngghhoommee ••  Readinessforenhancedhealth dressing/grooming, bathing/hygiene ccaarree rreessttrriiccttiioonnss mmaannaaggeemmeenntt RReellaatteedd ffaaccttoorrss aarree iinnddiivviidduuaalliizzeedd oonn tthhee bbaassiiss off ppaattiieenntt'’ss ccondition or needs.. PPLLAANNNNIINNGG Increaseslikelihoodofcarenotbeinginterruptedinhome(or otheragency)andreduceschancesofunplannedreadmission 11.. EExxppeecctteeddoutcomesffollowingcompletionofprocedure:: to the hospital. ••  Patientoorfamilycaregiverexplainshowhealthcareisto ccoonnttiinnuueeiin hhoommee((oorrotheerraaggeenncy),,ffoorrwhich problems  Feedbackensureslearning. ttoo oobbsseerrvvee aanndd wwhhaatt to do,, wwhhiicchh treatments or mmeeddiiccaattions ppaattiient nneeds,, aand when too go to next Patientisoftenphysicallyweakenedorhasphysicalchanges mmeeddiiccaall aappppooiinnttmmeenntt. resulting from illness that predispose to injury. ••  Patientisabletodemonstrateself-careactivities(orfamily ccaarreeggiivveerriissaabblleetto aaddmmiinnister care measures). ••  OObstaclestopatient'’smobilityandhazardstoambulation iinn hhoommee sseettttiinngg aarree removed. IIMMPPLLEEMMEENNTTAATTIIOONN Maintainspatient'’slevelofindependenceandabilitytoretain function within safe environment. 11.. PPrreeppaarraattionbbeeffooreddaayyofddiissccharge:: aa.. PPaarrttnnerwwithpatientandffamilyinidentifyingwaysto Communityresourcesofferservicesthatpatientorffaamily cchhaannggee pphhyyssiiccaall aarrrraannggeemmeenntt ooff hhoommee tthhat will be cannot provide. rreeqquuiirreeddttoommeeeettppaattiieennt'’s nneeeds ((see CChapter 4433). bb.. PPrroovviiddepatientandffamilywithinformationabout Gives patient opportunities to practice new skills, ask ccoommmmuunniittyyhheeaalltthhccaarreeresourcceess(e.g.,,medicaall questions,andobtainnecessaryfeedbacktoensurelearning. eeqquuiippmmeennttccoommppaanniieess,,MMeeaalls oonnWWheelss,,adult day care).  RReeffeerrrraallssaarreeuussuuaallllyymmaaddeewhile ppaatient is in hospitaall.. A combination of written and verbal inffoormation is effective in cc.. CCoonndduucctttteeaachingsseessionswithpatientandfamilyas improvingpatientsatisfactionandknowledge(TJC,2015). ssoooonnaassppoossssiibblleedduurriinngghhoossppiittaalliizzaattiioonn..CCoveerrthese  Insomesettingselectronicprogramsareavailablethatallow ttooppiiccss::DDeessccrriippttiioonnooffwwhhaattlliife atthhome will be like;; you to tailor patient-specific media instructions. rreevviieeww ooff mmeeddiiccaattiioonnss andd ddoossiinngg sscchheedules;; warning you to tailor patient-specific media instructions. ssiiggnnss ooff ppoossssiibbllee hheeaalltthh pprroobblleemmss;; eexxppllaanation of test results; explanation of how to provide therapies or use Facilitatescontinuityandachievementofanindividualized fhrfhrreoooosmmmumleethhsm;meeaeaeelxlddttphihiclcaaaaanllllttaeeeetqqrriaouauttniiipipoomomnnfesse;hn;naotat;nnw;drrdeetvwoviihepewewronvootfifodrreemessttathrrkieicecrttaififpooooinlnelsosswrroee-rssuuuupllstteiinngg discharge plan. aappppooiinnttmmeenntt((AHHRQQ,,22001133)). UUsse appropriate materials  ssuucchh aas ppaammpphhlleettss,, bbooookkss,, oorr mmuullttiimmeedia rreessoources. RReeffeerrppaattiieennttttoorreelliiaabblleeaannddcurrrreennttrreesources on the  IInntteerrnneett.. dd.. CCoommmmuunniiccaatteeppaattiieent'’sandfamilycaregiver'’sresponseto tteeaacchhiinngg aanndd pprrooppoosseedd ddiisscchhaarrggee plaann to othheerr health ccaarree tteeaamm mmeemmbbeerrss..

SKILL 2.3 DISCHARGINGPATIENTS 27 SSTTEEPP/ RRAATTIIOONNAALLEE 22.. Procedureondayofdischarge:: Allows for ffiinal clarification of information previously a. Encouragepatientandfamilycaregivertoaskquestions discussed.Helpsrelieveanxiety. oorr ddiissccuussss iissues related to home care. A finnal Onlyahealthcareproviderisabletoauthorizeadischarge. Earlycheckoforderspermitsyoutoattendtoanylast-­ ooppppoorrttuunniittyy to demonstrate learned skills is helpful. minute treatments or procedures well before discharge. b.. CCheckhealthcareprovider'’sdischargeordersfor Patient’'sconditionatdischargedeterminesmethodof pprreessccrriipttiions,, cchange in treatments,, or need for special transport. mmedical equipment. (Make sure that orders arewrittenas earlyyasspossible.) Arrange for delivery andsetupof Preventslossofpersonalitems.Patient’'ssignatureveriffiies equipment ((ee..g.,,hospital bed,,ooxxygen)beforepatient receipt of items and relieves nursing department of liability for losses. aarrrriivveess hhoommee. c. DDeetterminewhetherpatientorfamilyhasarrangedfor Decreasesriskofmedicationerrorsandensuresthatpatientis receivingcorreccttmedicationnathome((TJC,,22016a).The trraansporttaattiioonn.. new medication regimen prescribed at the time of discharrgge d.. Provideprivacyandassistanceaspatientdressesand may inadvertently omit needed medications, unnecessarily duplicate existing therapies, or contain incorrecctt dosages ppaackkssall personaallbbeelongings. CCheck closets and drawers  (AHRQ,2015b6).Reviewprovidesfeedbacktodetermine ffoorrbbeelloonggiings. Obtaaiinncopy of list of valuables signedby patient’'s success in learning about medications ppaattiieentt aand have security or appropriate administrator Providespatientwithcontactforquestionsthatariseafterdischargee.. Ensurescontinuityofcaretopreventrehospitalization. ddeelliivveerr vvaalluuaabbllees tto patient. e. CCompletemedicationreconciliationperagencypolicy. Sourceofconcernformanypatientsiswhetheragencyhas accepted insurance or other payment forms. CChheecckkddiisscharge mmeedication orders  against the Providesfoorsafetransport. mmeedication administration recordd and home medication lliisstt..Provide patient with prescriptions orpharmacy­- PPrreevveennttssiinnjjuurryyttoonnuurrsseeaannddppaattiieenntt..AAggeennccyyppoolliiccyyrreeqquuiirreess escort to ensure patient’'s safe exit. Agency’'s liability ends ddiissppeennsseedd medications ordered by health care provider. once patient is safely in vehicle. OOffffeerra fiinnaallrreevviieewwooffiinnffoorrmmaattiioonnnneeeeddeed tto ffaacilitate  Allows agency to prepare for admission of next patient. ssaaffe mmedication self-administration. ff.. Provideinformationonfollow-upappointmentsto hheeaallth carree provider'’s offiiccee.. g.. CContactagencybusinessoffiicceettoddeterminewhether ppaattiieent needdssto fiinnaalliizzeeaarrrraannggeemmeennttssffoor ppaayyment of  bbiillll.. Arrange ffoor patienntt or ffaamily to visit business offfiice. hh.. AAccqquuiirreeuuttiilliittyyccaarrttttoommoovveeppaattiieenntt'’ssbbeelloonnggiinnggss..OObtain wheelchair ffoor patient.. TTransport patients leaving by aambulaancee on ambulance stretchers. i.. HHeellppppaattiieennttttoowwhheeeellcchhaaiirroorrssttrreettcchheerruussiinnggssaaffeeppaattiieenntt hhaannddlliinnggaannddttrraannssffeerrtteecchhnniiqquueess((sseeeeCChhaapptteerr1111)).. EEssccoorrttppaattiieennttttooeennttrraanncceeooffaaggeennccyywwhheerreessoouurrcceeooff ttrraannssppoorrttaattiioonniisswwaaiittiinngg((sseeeeaaggeennccyyppoolliiccyy))((sseeee iilllluussttrraattiioonnss))..LLoocckkwwhheeeellcchhaaiirrwwhheeeellss..HHeellppppaattiieenntt ttrraannssffeerriinnttoottrraannssppoorrttvveehhiiccllee..HHeellppppllaacceeppeerrssoonnaall bbeelloonnggiinnggss iin vveehicle. jj. RReettuurrnnttooddiivviissiioonn..NNoottiiffyyaaddmmiittttiinnggoorraapppprroopprriiaattee ddeeppaarrttmmeenntt off time of discharge. NNotify housekeeping of nneeeedd to cclleean patieenntt'’ss room. AB SSTTEEPP 22ii AA,, NNuurrssee eessccoorrttss ppaattiieenntt ttoo ttrraannssppoorrtt vveehhiiccllee aatt ttiimmee ooff ddiisscchhaarrggee vviiaa aa wwhheeeellcchhaaiirr.. BB,,MMaannyyppaattiieennttssaarreeddiisscchhaarrggeeddvviiaassttrreettcchheerr..

28 CCHHAAPPTTEERR 22 ADMITTING,TRANSFER,ANDDISCHARGE SSTTEEPP/ RRAATTIIOONNAALLEE EEVVAALLUUAATTIIOONN Measurespatient’'sorfamilycaregiver’'slearning. 11.. AAsskk ppaattiieenntt oorr ffaamily caregiver to describe nature of illness,, Returndemonstrationsallowyoutoevaluateleveloflearning. treatmmeenntt and medication regimens,, and physical signs or Providescontinuityofcare. ssymptoms to be rreeported to a health care provider. Determinespatient’'sandfamilycaregiver’'slevelofunderstanding 22.. HHaavveeppaattiieennttorrffaammiillyycaregiverperformanytreatmentsthat of instructional topic. wwiillll continuee in the home. 33.. HHoommeeccaarreenurseinspectshhome,,identifiieessoobbssttaacclleesstthhaattpose risks for patient,, and recommends revisions. 44.. UUssee TTeeaacchh--BBaacckk::\"“IIwwaanntttobesureyouunderstandwhenyour followw--up appointmeennttis. Canyoutell mewhenyouare coming back to the clinic?\"”Revise yourinstruction nowor develloopp a plan for reviseedd patienntt or familyy caregiveerr teaching if patient or family caregiver is not able to teach back correctly. UUnneexxppeecctteedd Outtccoommeess Related Interventions 11.. PPaattiieennttoorrffaammiilyyccaarreeggiiver iissunabletoexplainordemonstrateself-care • Provideimmediateclarificationoradditionalinstruction. • Planadditionaltimetodemonstratetreatmentmeasures. measures.. • Askpatienttoexplainwhichaspectofprocedureisdifficulttoperform 22.. EEnnvviirroonnmmeennttaall rriisskkss aarree ssttiilll pprreessent in home. and why. • Ifpatientorfamilycaregivercontinuestobeunabletocorrectlydem- 33.. PPaattiieenntt oorr ffaammiillyy ccaarreeggiiver rreessiissttss ddiisscchhaarge plans and refuses assim­- iillaattiioonn ooff nneeww rrooles nneeddedd for home care.. onstrate treatment measures, request referral for home care services. • Reassessreasonforchangesnotbeingimplemented. RReeccordiinngg aand Reporting • Homecarenursewillproblemsolveandseekappropriatesolution. • Contact additional resources (e.g., social work, home care, pastoral •• CCoommpplleeteddooccuummeennttation of patient'’s discharge on discharge ssuummmmary ffoorm (Boxx2.6). Give patienta signed copy ofform. care). •• DDooccuummeenntt uunresolved pprrooblems and description of arrange­- Home Care mmeennttss made for resolution in nurses'’ notes in electronic health ••  Assess availability and skill of primary family caregiver (e.g., rreeccoorrdd((EEHHRR))oorrcchhaarrtt.. spouseorfriend):assesstimeavailability,abilityandwillingness •• DDooccuummeennttppaattiieenntt'’ssvviittaallssiiggnnssaannddssttaattuussooffhheeaalltthhpprroobblleemmssaatt to give care, emotional and physical stamina, knowledge of ttiimmeeooffddiisscchhaarrggeeiinnnnuurrsseess'’nnootteessiinnEEHHRRoorrcchhaarrtt.. ccaarreeggiivviinngg rreeqquuiirreemmeennttss,, aanndd ttyyppee ooff rreellaattiioonnsshhiipp hheelldd wwiitthh patient. Assess additional resources, including friends or neigh-­ •• DDooccuummeenntt yyoouurr eevvaalluuaattiioonn ooff ppaattiieenntt aanndd ffaammiillyy ccaarreeggiivveerr bors who are available to help. lleeaarrnningg.. ••  IInnffoorrmm ppaattiieenntt oorr ffaammiillyy ccaarreeggiivveerr aanndd ppaattiieenntt’'ss hheeaalltthh ccaarree provider about decision to accept or not accept patient for SSpecciiaall Considerations admission to home care agency. TTeeaacchhiinngg BOX 2.6 •• AAsssseessssppaattiieenntt'’ssffaattiigguueeaannddppaaiinnlleevveellssbbeeffoorreebbeeggiinnnniinnggaannyyiinn­- ssttrruuccttiioonn..KKeeeeppffooccuusseeddoonntthheeiimmppoorrttaanntttteeaacchhiinnggttooppiiccssttooccoovveerr.. Elements of a Written DDischarge Summary FForm Peeddiaatriicc • Modeofdischarge:Ambulatory,wheelchair,stretcher •• OOnncceeffaammiillyyccaarreeggiivveerrsshhaavveelleeaarrnneeddhhoowwttooppeerrffoorrmmaannyynneecceess­- • Instructionsforself-careactivities:Activity;diet;medications; ssaarryy caregiver skills,, have them assume care before child returns specialtreatmentssuchaswoundcare,self-catheterization, hhoommee..MMaannyyhhoossppiittaallssiinnccoorrppoorraatteeaattrriiaallppeerriiooddrreeqquuiirriinnggffaammiillyy tracheostomycare ttoommaannaaggeeccaarreebbeeffoorreecchhiilldd'’ssddiisscchhaarrggeehhoommee((HHoocckkeennbbeerrrryyaanndd • Reconciledlistofdischargemedicationswithdose,frequency, WWiillssoonn,,22001155)).. route,reasonsforchangeinmedicationorfornewlyprescribed •• CCoommpplleetteeddiisscchhaarrggeeppllaannnniinnggiinnppaarrttnneerrsshhiippwwiitthhcchhiillddrreennaanndd medications rprpeeaaqqrrueeuninirrtteess..ccOOoommvveepprrllee88xx00%%tteeaaooccffhhppiieennddggiiaaoottrrrriippcclladdaninissnncchihinnaaggrrgg((eeGGssiiaabbrrbebeeessnniimmss,,pp22lle00e11aa00nn))dd..ddoonnoott • Signsandsymptomsofcomplicationsordrugreactionsforwhich tobeobservant Geerroonnttoollogiiccal • Signsandsymptomsthatpatientshouldconsidernormal •• OOllddeerraadduullttssaarreeiinntteerreesstteeddiinnmmoorreeiinnffoorrmmaattiioonnaabboouuttccoommmmuu­- • Correctsettingsforanyequipmentrequired • Plannedfollow-upappointmentathealthcareprovider'sofffiice, nniittyyrreessoouurrcceessaannddssoocciiaallssuuppppoorrttssoonncceeddiisscchhaarrggeedd((PPrriiccee,,22001111)).. clinic •• OOllddeerraadduullttssaannddtthheeiirrffaammiilliieessoofftteennoovveerreessttiimmaatteetthheeiirraabbiilliittyy • Nameandcontactinformationofhealthcareproviderand/or nursingunit ttoo mmaannaaggee ccaarree aafftteerr ddiisscchhaarrggee.. TThheeyy aallssoo ddiissaaggrreeee aabboouutt wwhhaatt • Explanationofpertinentemergencyprocedures ppoossttddiisscchhaarrggee ccaarree iinncclluuddeess.. MMaakkee rreeffeerrrraallss ttoo hhoommee ccaarree ttoo • Patient'ssignature,showingunderstandingofinstructions aaddddrreessss nneeeeddss aassssoocciiaatteedd wwiitthh ffuunnccttiioonnaall ddeecclliinnee aanndd hheellpp pprreevveenntt rreeaaddmmiissssiioonn ttoo tthhee hhoossppiittaall.. ModiffiiedfromLoudenK:Creatingabetterdischargesummary,AACCPP HHoossppiittaalliisstt 3:1, 2009;NationalQualityForum(NQF):National voluntary consensus report, ssttaannddaarrddss ffoorr ppuubblliicc rreeppoorrttiinngg ooff ppaattiieenntt ssaaffeettyy iinnffoorrmmaattiioonn:: aa ccoonnsseennssuuss rreeppoorrtt,, Washington,  DC, 2010,  NOF.

CCHHAAPPTTEERR 22 ADMITTING,TRANSFER,ANDDISCHARGE 29 CLINICAL DEBRIEF Agency ffoor Healthcare Research andd Quality (AHRQ): Healthcare litterraacy measurementtools,Revised,20155aa,,http://www.aahrrqq..govv//pprroffeessssiioonnaals//qquuaalliittyy-­ A69-year-oldwidowwasadmittedtotheacutecareunitwithaleft-sided patient-safety/quality-resources/ttoools//litteracy/indexx..hhttmmll.. AAcccceesssseedd JJaannuuaarryy stroke.Thepatienthasahistoryofdiabetesmellitusandarthritis.Sheis 16,20166.. abletohelpwithmanycareactivitiesbutrequireshelpwitheating.She hasasisterwhowillbeherfamilycaregiver.Onadmission her assess­ Agency ffoor Healthcare Research and Quality (AHRQ): Patient ssaaffeettyy nneettwwoorrkk:: mentshowedanareaofskinbreakdownonherlefthip,assessedasa medication reconciliation, 2015b6, httppss:////ppsnneett..ahhrrqq..ggoovv//pprriimmeerrss//pprriimmeerr//11// stage1pressureinjury.Hermedicationsonadmissionweremetformin, medication-reconciliation..AAccccessedOctober266,,22001155.. lisinopril,andSt.John'sWort.After3 daysshewastransferredtothe rehabilitationunit.Hermedicationsontransferweremetformin,lisinopril, Blouin A: Improving hand-off communications: new solutions ffoorr nnuurrssee,, JJ NNuurrss andwarfarin.Shehasleft-sidedweaknessfromherstrokeandwilllikely CCaarree QQuuaal!26(2):97,2011. requireawalker. 11.. Duringthepatient'sadmissionassessment,whichphysical assess­ Centers ffoor Medicare and Medicaid Services (CMSS)):: Hosppiittaall--aaccqquuiirreedd conditions, 2008, https://www..ccmms.gov/Medicare/Medicare-FFeeee--ffoorr--SSeerrvviiccee-­ mentffiindingsareaprioritytodocumentandwhy? Payment/HospitalAcqCond/Hospital-AAcquuiirred_Conditiioons..hhttmmll.. AAcccceesssseedd 22.. Duringhertransfer,whichkeypieceofinformation,reffllectingapoten­ January10,2016. tialrisk,shouldbesharedduringthehand-offwiththe nurse on the Centers ffoor Medicare and Medicaid Services (CMS): Medicare anndd MMeeddiiccaaiidd rehabilitationunit? programs, hospital conditions of participation: patients’' rriigghhttss,, final rule, FFeedd 33.. Atthetimethepatientisadmittedtorehabilitation,thenurseconducts Reeggist71(236):71426,2009.. an assessment inan effort to plan for discharge in 2 weeks. The patientwillbegoinghomeandstayingwithhersisterfor at least a Centers ffoor Medicaree and Medicaiidd Servicess (CMS): Chapteerr IV: MMeeddiiccaarree aanndd month. During the assessment the nurse learns that the sister is MMeeddiiccaaiidd SSeerrvviicceess,, DDeeppaarrttmmeenntt ooff HHeeaalltthh aanndd HHuummaann SSeerrvviicceess Ceenntteerrss,, PPaarrtt concernedaboutbeingabletomanagethepatient.The sister has 482..43, connddiittiioonnooff ppaarrttiicciippaattiioonn,, ddiisscchhaarrggeeplaannnniinngg,2012a,https://www..gpo.gov/ heartfailureandlimitedexercise tolerance.Assessmentalso reveals thatherskinhasclearedoverthelefthip.Thepatientwillbetrained fdsys/pkg/CFR-2011l-titllee42-vol5//pdf//CCFFR--220011l--tiittllee4422--vvooll55--sseecc448822--4433..ppddff.. tousethewalkersafelyin rehabilitation.Write anSBAR to commu­ AccessedJanuary16,2016. nicatethissituation. Centers ffoor Medicare and Medicaid Services (CMS): Emergency MMeeddiiccaall TTrreeaatt-­ REVIEW QUESTIONS 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