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Published by darlene.mention, 2017-07-28 15:18:41

2017 Annual Education Book

2017 Annual Education Book


Annual Mandatory Education

Florida Hospital Tampa


This CBL is required for all Clinical employees hired before July 2017.
Approximate time to complete module is 90 minutes.
At the completion of this module, you will be required to take a test. You must receive an 80%
to pass.


At the end of this module, the learner will be able to:
o Recognize their role in keeping patients and their families safe.
o State the clinical practice protocols for clinical documentation.
o Incorporate best practices to reduce the spread of infection.
o Demonstrate how to safely administer medication.
o State how to safely dispose of biohazard wastes.
o Assess, intervene and evaluate pain.
o Safely complete point of care testing.
o Provide care to a culturally and developmentally diverse patient population.

Clinical Annual Education- August 2017


Child Abuse and Neglect

 There are many types of child maltreatment or abuse. These include Physical Abuse, Sexual Abuse,
Emotional Abuse, and Neglect.

 Physical abuse is the most visible form. In these cases the parent or caregiver is often the abuser and is
purposeful in their behavior towards the child

 Many cases are underreported due to
the victim being fearful of speaking up.
They oftentimes feel is their fault that
they are being abused


Child neglect occurs when a caretaker does not

meet a child's basic physical, developmental, or psychological needs. These needs include:

 Food  Safety  Love and nurturing

 Education  Shelter  Medical and dental care
 Clothing  Emotional support

Physical signs of neglect can include:

 Poor  Developmental delays  Frequent Accidents (lack of
Tooth decay supervision)
nutrition 
 Untreated medical
 Poor hygiene conditions (needs glasses,
hearing aids, etc)

Clinical Annual Education- August 2017

Physical Abuse

Physical signs of abuse range from mild to severe and may look like common childhood injuries such as:

 Bruises and  Cuts and scrapes  Abdominal injuries

welts  Fractures  Brain injuries

 Burns

The following lists of injuries are more indicative of possible physical abuse:
 Injuries on both sides of the body (bilateral)
 Injuries on many areas of the body at one time
 Injuries in various stages of healing
 Injuries that do not match the parent’s explanation
 Frequent, unexplained injuries
 Injuries in late stage of healing on arrival for

Sexual Abuse

Sexual abuse occurs when a caretaker involves a child in any
sexual activity such as:
 Fondling a child’s genitalia

 Exposing genitalia in front of a child
 Oral, anal, or vaginal sex with a child
 Child prostitution

 Child pornography
 Forcing or persuading a child to perform sex acts
with other children

Emotional Abuse

Many abused children are emotionally abused. This type of abuse happens when a caretaker treats a child in
any of the following ways on a regular basis:

Clinical Annual Education- August 2017

 Rejecting  Bullying or  Isolating
Threatening  Corrupting
 Degrading Ignoring

Reporting of Abuse

 All states have laws that require healthcare providers to
report suspected child abuse or suspected neglect.
Confidential information will need to be shared to the
reporting agencies, but this is not considered a violation
of HIPPA, the patient-provider privilege.
 Failure to report in most states is a criminal

misdemeanor. This may place you at risk for a civil liability
from the patient or the patient’s family.
 The number to call to report suspected abuse is 1-800-
96ABUSE (1-800-962-2873)

Elder Abuse and Neglect

 There are many types of elder maltreatment. These include
neglect (including self-neglect), physical abuse, sexual
Abuse, psychological abuse, and financial abuse

 Elders are more likely to be victims if they are already ill,
mentally impaired, over the age of 80, disabled, or

 Many cases are underreported due to the victim being
ashamed, afraid, or unable to speak up due cognitive
impairments of some kind.

Elder Neglect

Elder neglect occurs when a caretaker, spouse, or the actual person

(self-neglect) does not meet their basic physical, developmental, or psychological needs. These needs include:

 Food  Help with personal

 Education hygiene

 Clothing  Help with activities of

 Safety daily living

 Medications

Elder Physical Abuse

The following lists of injuries are more indicative of possible physical abuse:
 Injuries on both sides of the body
 Injuries in different stages of healing

Clinical Annual Education- August 2017

 Unexplained injuries
 Injuries with unlikely explanations
 Injuries when the patient and the caregiver do not give matching explanations
 Injuries when the patient makes light of the injury

Elder Sexual Abuse

Sexual abuse of an elder includes any sexual activity the elder does not agree to such as:
 Unwanted sexual exhibition
 Unwanted sexual touching
 Photographing an elder in sexual poses without permission
 Forcing an older person to watch pornography
 Forcing sexual contact with a third party
 Forced nudity
 Rape
 Sodomy

Elder Financial Abuse

Financial abuse happens when there is misuse of an elder's money. Funds are misused to benefit a family
member, caretaker, or other person. This can include:

 Tricking an elder into giving away money
 Stealing money or items from an older person
 Financial fraud, such as forging an elder's signature on

 Using an elder's money without the elder's permission
 Denying an older person access to his or her own

home or money
 Forcing an older person to sign contracts or other legal

 Abusing legal access to an elder's money

Clinical Annual Education- August 2017

Documenting & Collecting

 When assessing suspected victims of elder abuse and
neglect, careful documentation is critical.
 Documentation can provide evidence for legal action to
protect the elder and prosecute the abuser
 In some cases, the medical record provides the only
concrete evidence of abuse.

Reporting of Elder

 Reporting requirements can present an ethical conflict for healthcare providers
especially when dealing with patient confidentiality.
 The patient may not want the provider to make a report. The patient may expect
the provider to protect his or her confidentiality. The provider, on the other hand,
must report.
 In this cases explain that the law requires you to report. Work to keep a positive
relationship with the patient. Keep in mind that the goal is to improve the patient's
situation, not to punish the patient or his or her family.


What is it?

 Reducing sense of urgency (persistent coughing triggers
high pressure/increasing pressure alarm to avoid
alarm/responding when no real problem)

 Oversaturation of alarm noise/doesn’t just affect

 23% determined effective while over 40% ignored in
MICU environment1

 350 alarms per patient per day

How to Combat It?

 Eliminating redundancy
 Setting parameters appropriately
 Avoid complacency

Clinical Annual Education- August 2017

Strategies for Successful Alarm

 Establish multidisciplinary team
 Generate policies standardizing throughout facility
 Practice evidence based strategies
 Incorporate alarm strategies in training; make it a core
 Share successes and shortfalls
 Improve practitioner discipline (mandate confirmation during
 Research areas of alarm concerns
 Generate systems using clinician feedback/human factors


Bloodborne Pathogens

A pathogen is an organism that causes disease. Bloodborne
pathogens are pathogens carried in a person's bloodstream.
They also may be present in other body fluids.

Pathogens include:

 Bacteria
 Viruses
 Fungi
 Parasites

Three important bloodborne pathogens are:

 Hepatitis B virus (HBV)
 Hepatitis C virus (HCV)
 Human immunodeficiency virus (HIV)

Exposure & Transmission: Modes

Bloodborne diseases can be spread in several ways.
The three most important ways are:

 Sexual contact

Clinical Annual Education- August 2017

 Sharing drug needles
 Mother-to-baby exchange of bodily fluids

High-Risk Activities for contracting a Bloodborne Disease:
 Unprotected sex
 Using dirty needles for injection drugs

Exposure & Transmission:
Healthcare Workers

 In the healthcare setting, workers can
be exposed to bloodborne pathogens in additional ways.

 Workers are at highest risk of Hepatitis B, Hepatitis C, or HIV infection from needle stick or other
sharps injury.

 Healthcare workers can also be exposed to bloodborne pathogens if they have:
o Mucous membrane (eye, nose, mouth) contact with infectious materials
o Non-intact skin contact with infectious materials

 Healthy, intact skin is the best natural defense against bloodborne pathogens. Even a simple hangnail
or a rash can be an entry point for pathogens.

Standard Precautions

 Standard precautions address the risk from body fluids,
secretions, and excretions in the transmission of hospital-
acquired infections.

 Standard precautions are used with all individuals
regardless of diagnosis or possible infection status.
Standard precautions apply to blood and body fluids,
including non-intact skin and mucus membranes.

When to Use:

 Standard Precautions are used whenever a healthcare
worker may have contact with:
o All body fluids
o All secretions
o All excretions

Clinical Annual Education- August 2017

o Patient blood

Personal Protective Equipment

Personal protective equipment (PPE) is special clothing or equipment worn to protect against a hazard. Using
proper PPE around blood and OPIM is another important part of Standard Precautions. Ensure the disinfectant
is maintained for the proper contact time; “purple top” wipe contact time is 2 minutes and “orange top” wipe
is 4 minutes.

 Examples of PPE include:
o Gloves
o Masks
o Eye protection
o Face shields
o Shoe covers
o Lab coats

The one exception is sweat. Standard Precautions do not apply to sweat. In other words,
Standard Precautions are used with all patients.

 Certain other body fluids and materials also carry bloodborne pathogens
 Use Standard Precautions to help protect against exposure to bloodborne diseases. (OPIM – other

potentially infectious materials)


Vaginal fluids

Fluids from around an unborn baby

Fluid from any human body cavity

Unfixed tissue or organ
Human cell, tissue, or organ culture

Saliva from a dental procedure

Any other body fluid contaminated with visible

Anybody fluid when it is impossible to tell which
body fluid is which

Types of PPE Used in Healthcare Settings

 Gloves – protect hands
 Gowns/aprons – protect skin and/or clothing
 Masks and respirators– protect mouth/nose
 Respirators – protect respiratory tract from airborne infectious agents
 Goggles – protect eyes
 Face shields – protect face, mouth, nose, and eyes

Clinical Annual Education- August 2017

Key Points About PPE

Keep in mind, the combination of PPE used, and therefore the sequence for donning, will be
determined by the precautions that need to be taken.

How to Safely Use PPE

 Keep gloved hands away from face
 Avoid touching or adjusting other PPE
 Remove gloves if they become torn; perform hand hygiene before donning new gloves
 Limit surfaces and items touched

Clinical Annual Education- August 2017

Clinical Annual Education- August 2017

CDC Recommendations for PPE

Component/Personal Protective Recommendations
Equipment (PPE)
Hand hygiene After touching blood, body fluids, secretions, excretions, contaminated
Gloves items; immediately after removing gloves; between patient contacts.
Gown For touching blood, body fluids, secretions, excretions, contaminated
items; for touching mucous membranes and nonintact skin
Mask, eye protection (goggles), During procedures and patient-care activities when contact of
face shield clothing/exposed skin with blood/body fluids, secretions, and excretions
is anticipated.
Soiled patient-care equipment During procedures and patient-care activities likely to generate splashes
or sprays of blood, body fluids, secretions, especially suctioning,
endotracheal intubation. During aerosol-generating procedures on
patients with suspected or proven infections transmitted by respiratory
aerosols wear a fit-tested N95 or higher respirator in addition to gloves,
gown and face/eye protection.
Handle in a manner that prevents transfer of microorganisms to others
and to the environment; wear gloves if visibly contaminated; perform
hand hygiene.

Clinical Annual Education- August 2017

Environmental control Develop procedures for routine care, cleaning, and disinfection of
Textiles and laundry environmental surfaces, especially frequently touched surfaces in
Needles and other sharps patient-care areas.
Handle in a manner that prevents transfer of microorganisms to others
Patient resuscitation and to the environment
Patient placement Do not recap, bend, break, or hand-manipulate used needles; if
recapping is required, use a one-handed scoop technique only; use safety
features when available; place used sharps in puncture-resistant
Use mouthpiece, resuscitation bag, other ventilation devices to prevent
contact with mouth and oral secretions
Prioritize for single-patient room if patient is at increased risk of
transmission, is likely to contaminate the environment, does not
maintain appropriate hygiene, or is at increased risk of acquiring
infection or developing adverse outcome following infection.

Work Practice Controls: Hand Hygiene

Hand hygiene is a critical work practice control, and a critical part of Standard Precautions. It is also the most
effective method to prevent transmission of infection.
Other work practice controls to prevent bloodborne pathogen exposure are:

 Dispose of sharps in proper containers.
 Do not recap or bend needles.

Work Practice Controls: Personal

Additional examples of work practice controls are:
 Do not eat or drink in contaminated areas.
 Do not apply makeup in areas where exposure could
 Do not handle contact lenses in areas where exposure
could occur.
 Do not store food in refrigerators with contaminated

Contaminated linen needs to be placed in a blue plastic bag. Utilize the approved “goose neck” enclosing
technique versus the “dog ear” tie. Biohazardous trash is placed in a red bag and closed via the “goose neck”
enclosing technique.


If you are exposed to blood or OPIM: WIN
This stands for:
 Wash the exposed area immediately with soap and water.

Identify the source of the exposure.
Notify your supervisor immediately.

Clinical Annual Education- August 2017

Post Exposure Follow-Up

If you are exposed, please let your immediate supervisor know and contact Employee Health.


Patients that come to the hospital with an infection are known as community-onset infections (CO).
An infection that develops in the hospital or after treatment is a healthcare-associated infection (HAI).

Infectious Agent

Bacteria and viruses are the most common cause of Healthcare-Associated Infection. Fungi also can cause
healthcare-associated infections. However, this is less common.

Examples of bacteria that can cause infection are:

 Staphylococcus aureus
 E. coli
 C. difficile
 Tuberculosis

Examples of viruses that can cause infection are:

 Influenza, Hepatitis B, Varicella zoster (chickenpox and
shingles virus)

Method of Transmission

The method of transmission is how a
pathogen travels.
From person to person, a pathogen
can travel by:

 Contact. This can direct skin-to-skin contact. It also can be indirect contact. Indirect contact happens
when an infected person touches a surface. Later, the susceptible host touches the same surface and
picks up the pathogen. Another method of indirect transmission is a healthcare worker touches a
contaminated surface, does not sanitize their hands and then cares for another patient.

 Droplet. Respiratory droplets come from coughs, sneezes, or talking. They travel from 3-6 feet in the

 Airborne. Small, aerosolized particles that can travel a long way through the air from the reservoir to
the susceptible host.

 Bodily fluids. Blood and other bodily fluids can transmit disease if they contact a susceptible host's
broken skin or mucous membranes.

Clinical Annual Education- August 2017

Airborne Threats

Three important pathogens are known to be spread by the airborne route. These are:
 Varicella-zoster virus (VZV), the cause of chickenpox and shingles
 Measles virus
 Mycobacterium tuberculosis, (cause of TB)
All three pathogens also can cause severe disease. This is particularly true in certain hospitalized patients.
These patients include:
o Patients with weakened immune systems
o Patients with chronic illnesses

Respiratory Protection

 Healthcare staff must wear certified respiratory protection when working
with patients on Airborne Precautions.

 N95 respirators are required to care for patients in Airborne isolation.
 A surgical mask:

o Is NOT a certified respiratory
o Will not protect against airborne transmission
 Healthcare staff that wear N95 respirators need to be fit tested through
Employee Health. N95 respirators need to be checked each time the
respirator is worn to ensure a tight seal is obtained.
 Patient Transport
o Patients on Airborne Precautions should not be transported unless

o During necessary transport, the patient should wear a surgical mask, if possible.

Clinical Annual Education- August 2017



What is a consent?

Merriam-Webster (2016) defines consent as to “agree to do or allow something: to
give permission for something to happen or be done”.

What is the difference between a consent and informed consent?

FHT Consent Policy: 100.04

 Informed Consent is a mechanism that ensures respect for persons through the provision of informed

 It is every patient's right to receive information regarding their hospital care and to provide consent to
care and treatment.

 The presumption is that a patient has the right to self-determination
 Purpose is to voluntarily consent to a surgical procedure, invasive treatment or other treatments

FHT Consent Policy

What is the most important aspect for the nurse when obtaining the patient’s signature for an informed

FHT Consent Policy: 100.04
 Based upon the information provided by the healthcare provider, the patient has a general
understanding of the procedure, the medically acceptable alternatives and the substantial risks of the
proposed treatment.

Purpose of Consents

 TO ENSURE that each patient or that patient’s legally authorized representative (LAR) when applicable
is able……

 TO EXERCISE the patient’s right to make informed decisions regarding:
o Hospital care
o Surgeries
o Invasive procedures
o Treatments

 TO DOCUMENT evidence that informed consent was provided.

What is the physician’s responsibility?

 The physician obtains the patient or his or her LAR’s(legally authorized representative) informed
consent for any surgical or invasive procedure or treatment

 Delineates the wording (describe or portray precisely) the procedure on the consent form.

Clinical Annual Education- August 2017

 The physician may also document the patient’s informed consent in the progress notes; however, such
documentation in the progress notes cannot serve a substitute to the requirements of this policy.

What is the nurse’s responsibility?

The Nurse can witness a patient's signature on the consent form, after the physician has signed the informed
consent form or documented the conversation in the EHR to include date and time (this should be prior to the

patient’s/LAR’s signature.


 Did the doctor speak to you about your
 Do you understand the procedure the
doctor discussed with you? (* The patient must
be 18 years old & of sound mind).
 Can you describe what the doctor will be
 What did the doctor say about potential
risks, benefits, alternatives, & outcomes with &
without the surgery?
 How long did the doctor say the procedure
take? And Recovery time?
 What are the major areas on the consent
that must be completed within the preoperative

Clinical Annual Education- August 2017

Is it a “Booking” or an “Order”?


 THIS IS the Department Scheduled BOOKING

The booking and the order are
similar; but the order is what

counts on the CONSENT

Physician’s Order

(Must Say Obtain Consent)

Actual Order

The wording on the consent should

MATCH the actual order to obtain
patient signature for…..This is the ONLY

area where you may transcribe
procedure information onto the consent

What are the major areas on the consent that must be completed
within the preoperative process?

Clinical Annual Education- August 2017





Is it clear?
Is it spelled correctly?
Is it the ordered procedure?
Does it match the: surgical schedule;
H&P/Progress/Consult Note?
Does the patient/family agree with what is
on the consent?

NOTE: The order states to obtain patient
signature on consent………. this is the ONLY area that you may transcribe procedure information onto the


Clinical Annual Education- August 2017

C - What’s the Doctor’s Name?

 It is important to check that the correct doctor’s FIRST & LAST NAME is EXACT on the
consent who will be doing the procedure

Dr. U R Doingsurgery

D - Witness

Where is the witness?
 The Nurse is responsible for obtaining & witnessing a patient’s signature on a consent

E - Date and Time

What Day? What month? What time is it?
 It is necessary for the Date and Time to be on every area that is indicated.

Clinical Annual Education- August 2017

F – Patient/Legally Authorized Representative

Who signs this document?
 Only the patient or a LAR can sign the consent.

G - Patient Labels

Where is the label?
 The consent must have the patient's label and match EXACTLY to the patient’s name
written on the consent
NOTE: This is a second safety check to ensure that the patient’s name is exactly the same

What do you do if…….? Contact the

What is the Pre-Procedure Review?

Cerner Pre-Procedure Review Check List
The Next Step in The Preoperative Process

Clinical Annual Education- August 2017


Anesthesia Awareness Definition

 Anesthesia Awareness is also known as unintended intraoperative awareness.
 A patient experiencing anesthesia awareness may be aware of some or all events that occur during

 These patients have described auditory awareness, sensations of not being able to breathe, and pain.

Reducing the Risks

 All members of the healthcare team must be aware of the potential for any patient undergoing general
anesthesia to experience awareness

 Listen carefully to patients for cues about previous negative experiences with anesthesia
 Proper preventative maintenance and cleaning of Anesthesia machines

Reviewing the patient chart for risk factors

 Substance use or abuse
 Previous episode of awareness
 History of difficult intubation
 Chronic pain patient on high doses of opiods
 ASA status of 4-5
 Limited hemodynamic reserve

Other risk factors

 Cardiac, trauma, emergency surgery or Cesarean section patients undergoing general anesthesia
 Impaired cardiovascular status
 History of heavy alcohol intake
 Patients considered to be at increased risk should be informed of the potential for awareness by the


Responding to Incidents

 Early recognition of anesthesia awareness is crucial to acknowledging the patient’s experience,
understanding his or her distress, sympathizing with him or her, and initiating appropriate

Clinical Annual Education- August 2017

 Healthcare team members should acknowledge the occurrence and approach the patient with
concern, compassion, and understanding.

 Do not dispute or trivialize their experience.

Reporting the Incident

 Immediately notify:
o The anesthesiologist
o The procedure physician
o The admitting physician, if different from the procedure physician
o Nurse Leader or Supervisor
o Document the episode and your response in the EMR
o Complete a Riskmaster Incident Report for quality management purposes


National Patient Safety Goal 03.05.01 is focused on reducing the likelihood of
patient harm associated with the use of anticoagulant therapy.

Anticoagulation medications are high-risk drugs with narrow windows for
therapeutic dosing: too much of a drug can cause bleeding, and too little may

lead to clotting

Multi-disciplinary Approach to Improved Anticoagulation Therapy
and Safety

 Physicians
o Decision of anticoagulation therapy remains with the treating physician and overall
management of patient. Uses approved protocols for the initiation and maintenance of therapy
anticoagulation therapy.

 Pharmacist:
o Drug interaction monitoring/Renal dosing
o Drug information resource

 Lab
o Timely reporting of lab values
o Assists in trending lab values

Clinical Annual Education- August 2017

 Medical Nutrition Therapist (MNT)
o Nutrition Care Manual (on ARC)
o Provides consistent diet
o MNT as resource

 Nursing
o Ensures necessary labs are obtained
o Notifies physicians of critical labs (e.g. INR, aPTT) and platelet drops
o Monitors for signs and symptoms of bleeding notifying physician of unusual bleeding

NPSG requirement: Lab Monitoring

 Assess patient’s baseline coagulation status if not done in the previous 12 hours when therapeutic

anticoagulation ordered. Mandatory laboratory tests to be ordered (PCS 6-032 Anticoagulation

 Mandatory baseline INR before pharmacist verifies warfarin. INR may be ordered if not available or
ordered by prescriber prior to initiation of any warfarin.

Drug Hgb, Hct, platelets PT/ INR aPTT SCr


Warfarin x xx

Heparin x xx

LMWH -enoxaparin (Lovenox) x x

Factor Xa inhibitor- fondaparinux x x


Administration & Monitoring

 Review lab values before administration of dose.
 Notify physician if hemoglobin is 2 gm/dL lower than baseline
 Notify physician if unusual bleeding occurs
 Notify physician of neurological changes, platelet counts less than 100,000 or decrease to less than

50% of baseline (heparin)
 Be aware of last dose administered when transitioning from one parenteral anticoagulant to another---

may need to delay the start of one product.

Clinical Annual Education- August 2017

o Converting from LMWH ( enoxaparin , Lovenox; /Factor Xa inhibitors ( fondaparinux (Arixtra)
Rivaroxaban (Xarelto), Apixaban (Eliquis); direct thrombin inhibitor Dabigatran (Pradaxa)
to heparin: initiate heparin no sooner than 1-2 hrs before the next dose was due of the
previous anticoagulant
 Example: A patient in the ED received enoxaparin 100mg (1mg/kg) at 0600. The
admitting physician changes the anticoagulant therapy to a heparin drip. Heparin drip
can be started after 1600
 IM Injections should be avoided in patients on anticoagulation therapy
o Contact physician for change in administration route
o Small bore needles for vaccination may be used with caution
 Epidural and Spinal Anesthesia or Spinal Puncture, IM Injections and Anticoagulation

o [U.S. Boxed Warning]: Spinal or epidural hematomas, including subsequent long-term or
permanent paralysis, may occur with recent or anticipated neuraxial anesthesia (epidural or
spinal anesthesia) or spinal puncture in patients anticoagulated with LMWH or heparinoids

o Notify the physician if the patient is taking any anticoagulants

Adverse Effects:

 Bleeding is the most common side effect, and may present in a variety of ways: epistaxis, gum
bleeding, hemoptysis, hematuria, melena or hemorrhage. Undiagnosed and uncontrolled bleeding may
lead to cardiovascular collapse or cardiac tamponade.

 Heparin and aPTT
o Repeat STAT PTT every 2 hours using peripheral blood draw until aPTT < 100.
o Then, resume infusion at DECREASED dose from previous dose and repeat aPTT in 6 hours.
o If unable to get PTT, ask for assistance. Lack of monitoring heparin closely increases the risk of
patient having a severe bleed.

 Undercoagulation- increase risk of clotting: If aPTT < 52 secs after 2 consecutive aPTT notify physician.
 Warfarin and Excessive INR (Note:Vitamin K is often NOT indicated for elevated INR)

o Inappropriate use of Vitamin K can overcorrect the INR and lead to warfarin resistance for up to
one week

o Oral Vitamin K is preferred - predictable, quicker onset than SC, convenient, safe. IM route
should be avoided due to the risk of hematoma formation

o IV administration should be limited to severe bleeding situations. If IV, further dilute and
administer slowly over 30 minutes.


 Provide education regarding anticoagulation therapy to staff, patients and families. Review the patient
education monograph and document the following:

 Education must include the following:
o Importance of follow-up monitoring
o Compliance
o Drug food interactions
o The potential for adverse reactions and interactions

Clinical Annual Education- August 2017


World Health Organization Statistics

 Worldwide obesity has more than doubled since 1980.
 In 2014, more than 1.9 billion adults, 18 years and older, were overweight. Of these over 600 million

were obese.
 39% of adults aged 18 years and over were overweight in 2014, and 13% were obese.
 Most of the world's population live in countries where overweight and obesity kills more people than

 42 million children under the age of 5 were overweight or obese in 2013.
 Obesity is preventable.

What Does the Evidence Show Regarding Obesity Factors?

 Biological
 Genetic
 Environmental factors

United States Statistics

 Personal Lifestyle Behaviors Reflect Only One Contributing Factor Among the Complex causes of

 More than one-third (34.9% or 78.6 million) of U.S. adults are obese.
 Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer,

some of the leading causes of preventable death.
 The estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars; the

medical costs for people who are obese were $1,429 higher than those of normal weight

Clinical Annual Education- August 2017

Obesity Trends

Prevalence of Self-Reported Obesity Among U.S. Adults by State
and Territory, BRFSS, 2015

Clinical Annual Education- August 2017

Healthcare Providers

 Assume obesity can be prevented
 May feel patient’s lack self-control
 May feel patients are non-compliant
 May feel obesity is caused by emotional problems

2012 Study Healthcare Providers

 Have similar levels of bias against people who are
overweight as the general public

 Physicians are likely not aware of their own biases
 Results showed that female doctors were less biased

against obese people than male doctors
 Obese doctors were generally more sympathetic to overweight


Psychological Impact of Weight Bias

Negative Psychological Consequences

 Increased risk for depression
 Low self-esteem
 Body image disturbance
 Suicidal thoughts and behaviors
 Take a toll on patients’ emotional well-being is significant

Improving Health Care Delivery Weight Bias

Health Care Providers Can:

 Make important changes in their practice to increase sensitivity in health care delivery
 Promote positive health care experiences for obese patients
 Reduce negative attitudes that fuel weight bias

Sensitive Communication

Communicate Empathy for Patients Who Have Experienced Weight Stigma

 Helps build support and improve patient-provider interactions

Clinical Annual Education- August 2017

Be Mindful of Language You Use About Weight

 Certain words or comments that describe weight may be offensive to patients

Behavioral Changes

 Emphasize the Importance of Behavioral Changes Rather Than Focusing on Weight Loss
 Help Set Realistic Behavioral Goals
 Facilitate Lasting Lifestyle Improvements
 Acknowledge the Difficulty of Making Lifestyle Changes
 Recognize Small Successes in Behavior Changes
 Help Patients Recognize that Small Weight Losses Can Have Important Health Gains

Sensitive Weighing Procedures

 Ask patients for permission to be weighed
 Use empathetic, sensitive communication
 Ensure privacy when weighing
 Record weight without comments
 Offer patients the choice of not seeing their weight
 Ask patients if they wish to discuss their weight or health
 Avoid using the term obesity

Weight-Friendly Environment

 Provide gowns that are sized to accommodate obese patients
 Easy access to x-large blood pressure cuffs
 Provide a scale that weighs over 350 pounds and ensure it is located in a private area
 Provide armless chairs in patient room/waiting rooms
 Floor mounted or floor supported toilets for patients over 350 pounds.

Plan Ahead

 Obtain necessary equipment for obese patients in advance

Promote Sensitivity

 Encourage all staff to be sensitive to the needs of obese patients.
 Provide sensitivity training when needed

Obtain Feedback from Patients

 Obtain assistance from a patient advocate or from a patient advocacy organization if necessary.
 When performing patient satisfaction surveys, ask about comfort of the environment.

Increase Self-Awareness

 Challenge Your Personal Attitudes and Assumptions About Weight
o What assumptions do I make based only on weight regarding a person’s character, intelligence,
professional success, health status, or lifestyle behaviors?

Clinical Annual Education- August 2017

o Could my assumptions be impacting my ability to help my patients?

Increase Self-Awareness

 Do I consider all of a patient’s presenting problems, in addition to weight?
 What Kind of Feedback Do I Give to Obese Patients?
 Do I encourage healthful behavior change?
 Am I sensitive to the needs and concerns of obese individuals? Encourage all staff to be sensitive to

the needs of obese patients. Provide sensitivity training where needed.



 Identify order placed in Computerized Physician Order Entry (CPOE) for blood product.
 Consent was completed by physician and witnessed by the nurse.

o Only 1 consent needed per visit as long as consent decision has not changed.
o The patient should sign the refusal of blood form if they refuse blood products.
 Collect Type/Screen & send to Blood Bank.


 Safety begins with proper identification of the patient and collection of the specimen.
 Blood samples MUST be done at the bedside by 2 licensed people
 Verification must include: Full first and last name, DOB, FIN#.
BEWARE: Labels not checked at the bedside or not applied at the bedside are the first opportunity for a

clinical error.

Clinical Annual Education- August 2017

TYPENEX Blood Band

Clinical Focus: Eliminating worry and focus more minimizing
error and maximizing efficiencies; designed to help reduce
blood transfusion errors associated with patient


Assess what?

 Vital signs per institution protocol #7-007
o Assessed prior to initiating the transfusion for a baseline, 15 minutes after the transfusion is
started, PRN and when the transfusion is completed.
o Temperature/Heart rate/baseline pulse oximetry/lung sounds.
o CHART in the EMR each time – follow up even when delegated to the Nurse Technician.

SIGNS/SYMPTOMS OF A REACTION  Fall in blood pressure
 Blood in the urine
 Fever  Bleeding or bleeding at the infusion site
 Chills  Urticaria, erythema, hives, and itching
 Chest pain
 Sharp pain in the lumbar area (allergic reaction)
 Tachycardia
 Dyspnea or tachypnea


 STOP the transfusion immediately…using the clamp closest to the patient.
 Infuse Normal Saline using new IV tubing.
 Monitor vital signs and notify MD at once.

o Fill out the blood transfusion reporting form.

Clinical Annual Education- August 2017

o Draw lab work and administer medications per FHT policy 7-007 – transfusion reaction

o Closely monitor patient and chart the incident.
Special Note: Obtain orders to implement the “Investigation of Suspected Transfusion Reaction” PowerOrder
and “Transfusion Reaction Workup” PowerOrders.

 Transfusion may be restarted if directed by physician.


 Clots, discoloration, or a difference in color between the contents of the bag
o (Hemolyzed by contaminating bacteria) and the contents of the segmented tubing attached to
the bag (not hemolyzed, no bacteria).

 Notify blood bank immediately if reaction occurs - # 55214.
 Send bag of blood products w/tubing, requisition w/type of reaction and chart you did this in the EMR.


 The immune system can react to anything in the donor blood.
 One of the most serious reactions is called ABO incompatibility.

Clinical Annual Education- August 2017

o The 4 main blood types are A, B, O, and AB.
o The immune system will try to destroy donor cells that are the wrong type for the person.
o Another reaction happens when a person is allergic to something in the donor blood.

 Allergic reactions are usually mild but can become a life-threatening reaction called
what? anaphylaxis


 Fever
 Hypotension
 Flushing
 Wheezing
 Anxiety
 And/or red-colored urine


 Typically, only fever is present
o However, some recipients experience severe rigors, shaking, chills, hypotension, and vomiting.

 Allergic Reaction
o Maculopapular rash and/or urticaria without fever or hypotension

 Anaphylactic reactions Dyspnea.
 Wheezing.
 Hypotension without fever.
 Bronchospasm in severe cases.
 Anxiety.


 SOB.
 Hypoxemia.
 Rales, with orthopnea.
 Tachycardia.
 Distended jugular veins.
 And/or other evidence of cardiac decompensation.
 Bacterial contamination.

o High fever, shock, tachycardia, and weak pulse, without a clear focus of infection.

Clinical Annual Education- August 2017


What is Bedside Shift Report?

 A safe and effective handover from one nurse to another that includes
the patient
 Taking shift report to the bedside…where the patient is
 An exchange of real-time information
 An opportunity to ensure that the patient will continue to receive safe
and competent care
 A key to Patient and Family Centered Care

Benefits For the Nurse

For the Patient  Improves the nurse/patient relationship
 Shared accountability by both shifts
 Decreases potential for errors and  Decreased call light usage
omissions  Saves time for on-going and off-going nurses
 Fosters teamwork and improves nurse-to-
 Involves patients and families in their
care nurse communication

 Decreases feelings of patient

 Reduces frequency of patient falls
 Decreases patient anxiety and stress

 Increases likelihood of compliance with

treatment plan
 Allows patients to ask questions and add



 S= situation
 B= background
 A= assessment
 R= recommendation
 T= thank you
 s = sensitive information

80/20 Rule = 80% at the bedside

Clinical Annual Education- August 2017

20% in the hallway-sensitive information, labs, vitals, progress notes

Impact on Patient Experience

 Implementing BSR successfully can positively impact:
o Nurses treat you with courtesy and respect
o Nurses listen carefully to you
o Nurses explain things in a way you can understand
o Overall Hospital Rating
o Willingness to Recommend

Prep Work for BSR

 Preparing the Patient and/or Family
o Educate the patient upon admission and at the top of each shift on the purpose of BSR (night
shift should set up the night for the patient and gain their permission at that time for BSR and
ask them how they want to be woken up)
o Advise patient 30-60 minutes prior to shift change
o Allow patient opportunity for choice in whether they participate in BSR, and if family members
may be present

The Process of BSR

 Form a triangle that includes the patient
 Make introductions and manage up
 Update communication board

o name, date, pain assessment
 Encourage patient involvement
 Relay clinical information

o Conduct a verbal SBAR(Ts) report
 Allow for questions


 HIPAA – Semi private rooms
o Acknowledges incidental disclosure may occur
o Asks permission to perform BSR for their safety
o Take reasonable safeguards to protect privacy
o Disclose only or use the minimum necessary information

 Waking up the patient
o Process discussed with patients upon admission (night-shift should set up the patient’s night
and asks whether the patient wants to be involved (it is for their safety) and patient preference
for how they want to be woken up)

Clinical Annual Education- August 2017

 Isolation patients
o Must go in the room anyway to do assessment. These patients are “isolated” and all the more
reason to get them involved.


Requirements for Hospitals

 Provide a medical screening examination (MSE) to all patients that
present upon our premises, regardless of ability to pay.
 Provide stabilizing care within the facility’s capability and
treatment to any patient who seeks care or the institution
must transfer the patient to another facility where that care
can be obtained.

Emergency Medical Condition

 A medical condition manifesting itself by acute symptoms
of sufficient severity (including severe pain, psychiatric disturbances, and/or
symptoms of substance abuse) such that the absence of immediate medical attention could reasonably
be expected to result in any of the following:
o Placing the health of the individual (or, in the case of a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy.
o Serious impairment to the patient’s bodily functions
o Serious dysfunction of any bodily organ or body part.
 In the case of a pregnant woman:
o There is inadequate time to effect a safe transfer to another hospital before delivery
o The transfer may pose a threat to the health or safety of the woman or the unborn child
o There is evidence of the onset and persistence of uterine contractions or rupture of the
membranes. Fla. Stat 395.002(8)

Who Does the MSE?

 A medical screening exam is performed by a physician or mid-level provider only.
 An ED RN or PCT cannot perform a MSE.
 The hospital cannot refuse to provide the MSE for any reason.
 Cannot delay MSE asking for financial information. (Registration should not request any financial

information from the patient before the triage or primary nurse assesses the patient).
 Psychiatric patients fall under EMTALA.
 Pediatric patients must have a MSE without delay while waiting for parental/guardian consent.

Clinical Annual Education- August 2017

OB Patients

 If less than 20 weeks, ED sees the patient and calls OB if necessary.
 If patient over 20 weeks and has any c/o relating to the pregnancy, call OB and transport the patient to

Women’s Pavilion.
 If the c/o is not related to the pregnancy (ex. laceration to finger), ED sees the patient and calls OB to

come assess the patient (Fetal Heart tones should be documented on all pregnant patients, whatever
the presenting c/o).

Patient’s Refusal to Sign

 If a patient or caregiver refuses an MSE, complete AMA form and try to obtain a signature after
explaining the risks and benefits (up to and including death). This must be documented in the patient’s
record as well as the AMA form.

 If patient/caregiver refuses to sign the AMA, document this in the patient’s EMR.
 Remember to put a patient label on the AMA form.


 If FHT does not comply with EMTALA regulations, the fine can be up to $50,000 per incident including
the loss of Medicare.


 Medically Necessary Transfer – occurs when a patient is in immediate need of treatment for an
emergency medical condition and the transferring facility lacks service capability or service capacity.

 For FHT, Examples of this would be patient w/ extensive burns, major trauma patients, pediatrics
requiring surgery, or major medical care.

 The transferring hospital must:
o Seek out the closest capable facility
o Have an acceptance from the receiving hospital
o Provide all medical records to receiving hospital
o MD must complete certificate of transfer stating the risks and benefits
o Send any diagnostic studies needed to complete the MSE included in the transfer.

Accepting Hospital

 Must have the capability and the bed capacity to care for the patient.
 Communication must occur between:

Clinical Annual Education- August 2017

o Transferring physician and receiving physician
o Primary nurse to receiving nurse
o Primary nurse to transport personnel


Comfort Care

 Controlling pain and other distressing symptoms which may indicate physical, emotional or spiritual

 Treating the dying patient with dignity
 Respecting the dying patient's cultural beliefs around death and dying
 Respecting the dying patient's wishes not to receive life-sustaining treatments that do not improve the

quality of life
 Meeting the dying patient's psychological and

spiritual needs
 Meeting the dying patient's social and

interpersonal needs

Goal is to give the patient the highest possible quality of
life during his or her final days, weeks, or months.

End of Life: Physical Symptoms.

 Managing pain and other physical symptoms is
often an end-of-life care goal. End-of-life symptom will be assessed and addressed during the
admission assessment and during continued care.

Ask about:

 Pain  Lack of appetite
 Dry mouth  Constipation
 Nausea  Shortness of breath
 Water retention and


A palliative care consultation maybe ordered by the physician to assist with care of patients exhibiting one or
more of these symptoms.

Clinical Annual Education- August 2017

Personal Goals for End of Life

 The patient knows his or her prognosis. The next step is for the patient to decide on personal end-of-
life care goals.

 This often requires input or help from clinicians and family members.
 It may be helpful for a Palliative Care Practitioner to help the patient explore their goals for End of Life

Care (RN must obtain physician order for palliative care consult).
 The patient may consider goals such as:

o Managing pain and other physical symptoms
o Taking care of psychological, spiritual, or social issues and concerns
o Avoiding unwanted postponement of dying
o Maintaining control over the course of care by completing an advance directive
o Creating a comfortable inpatient environment
o Returning home
o Avoiding future hospitalization

Support Systems: Fear of Being a Burden

 Common psychosocial and spiritual issues near the end of life are:
o Fear or denial of death
o Concerns about finances, especially the financial stability of the patient's family after his or her
o Wanting to find closure or meaning
o Wanting to strengthen relationships with loved ones

 Patients near the end of life do not wish to die alone. At the same time, they may fear burdening their
loved ones.

 The palliative care consultation should address this fear. It is best to do so with the patient's loved ones

 The goal should be to:
o Reassure the patient that his or her care can be arranged in a way that does not create too
much of a burden on loved ones.
o Identify resources for family members, for support if and when they feel overwhelmed.

Needs of the

End of Life Care must
consider the needs of the family as well as the patient.

 When a person is dying, typical needs of the family include:
o To be with the person
o To be helpful to the person
o To be informed of the person's changing condition
o To understand what is being done to the patient, and why

Clinical Annual Education- August 2017

o To know the patient is comfortable
o To express their emotions and be comforted
o To be reassured that they have made the right decision (when family members make decisions

to withhold or withdraw life support)
o To find meaning in the death of the person

Needs of the Patient

 Encourage and support the presence of family members.
o Place in a private room to allow the patient to have physical and emotional intimacy with family
o Relax visiting hours.
o Prepared for large groups at the bedside.
o If the death involves withdrawal of life support, the withdrawal should be planned so that
distant family members have enough time to arrive.
o During withdrawal of life support, distractions and barriers should be removed.

 Unless it is against organizational policy or patient/family preference’s:
o Monitors should be turned off.
o Leads, cables, and catheters should be removed.
o Bedrails should be lowered.

Family/Visitor Comfort

 Obtaining a pager or cell phone number can allow family members to leave the bedside briefly,

without fear of missing the patient's last moments.

 Consider providing simple amenities. This can help make the family's stay more comfortable.

 Simple amenities include:

 Tissues  Blankets/pillows  Water

 Chairs  Coffee  Telephone

 Other amenities include:
o Allow soft music to be played\
o Allow for pictures of loved ones to be displayed
o Allow for Aromatherapy

Family Support

Family members often have a strong desire to be helpful to the dying person. This is
especially true of parents of a dying child.

 Allow family members to be helpful by teaching them how to perform:
o Mouth care
o Bathing
o Repositioning

Clinical Annual Education- August 2017

o Assessing pain

Also, encourage family members to bring meaningful personal articles that might comfort the patient

To Be Informed of the Person's Changing Condition

 Clinicians should take the time to explain the process of dying to family members. This should include a

clear description of:
o How the patient will die

o What the process of dying will look like

 Clinicians often need to anticipate and answer questions that family members are unable to put into

words. It is especially important to describe the signs and symptoms of imminent death. These include:

o Decrease in consciousness o Changes in breathing sounds or

o Visions patterns

o Increase in confusion or restlessness o Decreased appetite
o Cool or bluish arms or legs o Inability to respond to touch or


 Family members often wish to be present in the final moments of the patient's life. Describe the above

signs and symptoms to these family members both:

o Before the signs develop
o As the signs develop

 This ensures that family members will not leave the bedside at a critical moment.

Person’s Changing Condition

 Remember: Family members should be informed about the process of dying.

o However, avoid making firm predictions about a patient's exact clinical course.
o These predictions are:

 Difficult to make and often inaccurate
o When a loved one is dying, family members need to feel the utmost trust in the knowledge,

expertise, and competence of the care team. Inaccurate predictions about a patient's death can
cause family members to lose trust.
o Clinicians should be able to tell family members that the patient is comfortable. This message
should be honest and believable.
o This requires:

 Ongoing assessment and reassessment of the patient's physical pain and suffering
 Drugs and treatments for relieving pain, to be used as needed
 Very close to death, patients may moan or grunt as they breathe. Family members may

fear that the patient is in pain. Explain that these breathing patterns usually do not
have to do with pain. Provide this assurance even if family members do not ask.

Clinical Annual Education- August 2017


 Everyday in healthcare, professionals are tasked with making several decisions which effect the
outcomes of patients and their families.

 Using a code of ethics to guide our thinking ensures that we are always putting the safety and well-
being of the patient first.

 The code of ethics involves the use of autonomy, justice, non-maleficence, beneficence, & veracity

Ethics Committee

 The Ethics Committee has 3 functions:
o Review of Ethics Consultations
o Education of themselves and the institution
o Policy making

Clinical Annual Education- August 2017

 The Ethics Committee consists of nurses, physicians, clergy, pharmacists, dieticians, secretaries,
administrators, and students.

 Examples of the following are able to request an Ethics consult: physicians, nurses, techs,
administrators, patients, or families.


Who is “Everyone”?

 Any Employee Caring for Patients
o Clinical Staff – RN, Nurse Tech, CNA, PT, RT, Radiology Tech, etc.

 All Employees working around patients
o Engineering/Maintenance, Environmental Services, Food & Nutritional Services, Clerical, etc.

What is the MORSE Fall Scale?

The Morse Fall Scale (MFS) is a rapid and simple method of assessing a patient’s likelihood of falling. It consists
of six variables that are quick and easy to score, and it has been shown to have predictive validity for a fall. The
MFS is used widely in acute care settings, both in the hospital and long term care inpatient settings.

Fall Prevention

 Recognize the Risk for Your Patients When You:
o Conduct a Morse Assessment:
 Upon Admission
 Every 24 hours
 Post Fall/Post Procedure
 Upon Receiving of Patient from another Unit or surgery
 Upon Change of Condition – PRN
o Document Fall Interventions for the Patient
 In I-View charting every shift (I.e. updated MORSE scale PRN after initial assessment
upon admission, color of socks that correlate with fall scale number, assistive devices,
gait belt usage, yellow wrist band in place).

Clinical Annual Education- August 2017


 Educate the Staff, Patient and Family
o (I.e. every shift of potential hazards for a fall, using call bell for assistance in and out of bed,
chair, repositioning, etc.).

 Communicating with Caregivers and Ancillary Staff

Key Assessment Tools


Universal Fall Precautions

 Maintain room free of clutter and keep
pathways clear

 Administration of medication:
o Evaluate patients for any potential side
effects to medications
o Consider peak effect on level of
consciousness, gait and elimination
when planning patient’s care
o Pharmacist reviews medications and supplements upon request to evaluate and promote the
reduction of fall risk


Clinical Annual Education- August 2017

Heart Failure

A complex clinical syndrome that results from any change in the structure of
function of the heart that causes a pumping or filling impairment
Signs and Symptoms:

A.C.E. Heart Failure Each Time

Clinical Annual Education- August 2017


Are HIV & AIDS the Same Thing?

 HIV and AIDS are not the same.
 HIV is a virus that affects the human immune system.
 AIDS is the disease in which that impacts the body’s immunity, greatly lowering the resistance to

infection and malignancy.

HIV Contact & Transmission

 Transmission of HIV can occur when an infectious bodily fluid comes into contact with certain
vulnerable areas of an uninfected person's body such as non-intact skin, mucous membranes, and the

 Contact can happen as a result of:
o High-risk behaviors
o Mother-to-child exposure
o Occupational Exposure

Occupational Exposure

 Healthcare personnel are at risk for HIV infection from needlestick or other sharps injury, splashes,
sprays, or other sources bodily fluids to mucous membranes

 This is especially likely if the healthcare worker is not following Standard Precautions.


Definition of Hypoglycemia

 Blood glucose of < 70 mg/dl
 Severe hypoglycemia if < 50 mg/dl

Clinical Annual Education- August 2017

 Symptomatic or Asymptomatic
 May lead to additional complications: seizure, tachycardia, elevated blood pressure MI, angina, cardiac

arrhythmia, sudden death

Who is at risk for hypoglycemia?

 Any Insulin User (Type 1 high incidence)
 NPO order
 Poor Appetite (less than 2 carb serv consumed at meal)
 Gastroparesis
 Use of Sulfonylureas in the Older Adult (Glucotrol, Amaryl, Micronase)
 Post Dialysis
 Slow Eaters
 ETOH intake without food
 Patients with poor control (Hemoglobin A1c > 9%)

Signs & Symptoms

Clinical Annual Education- August 2017

 Observe patient for symptoms
 Include risk for hypoglycemia in report to Tech
 Monitor patients dietary intake
 Be mindful cognitively impaired/ nonverbal patients
 Instruct patients to report symptoms immediately


Treating Hypoglycemia

 Tech must report immediately any result of < 70 mg/dl.
 Only repeat fingerstick if suspicion of error
 Assess patient level of consciousness and follow algorithm (15/15 Rule)
 Retest and Retreat until glucose is 100 mg/dl
 Florida Hospital Tampa “Adult Hypoglycemia Protocol” is to be follow (located on ARC)

Clinical Annual Education- August 2017

Hypoglycemia Huddle

 Notify your Team Lead of event
 If severe hypoglycemia < 50 mg/dl or patient unalert, call Rapid Response
 Discuss event with team
 Notify Provider
 Complete Hypoglycemia Huddle Form
 If severe event, enter Risk Master


 Hypoglycemia Huddle Form must be faxed to Diabetes Department
 Document event in Special Charting including when patients refuse or if Provider opting to not follow

 When charting administration of D50, document in ML not grams (ex: 30 ml)

What can cause hypoglycemia?

 Change in insulin (increase in dose, addition of insulin, insulin naïve, transition from IV to SubQ

Clinical Annual Education- August 2017

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