A2 Cardiothoracic Unit Orientation Competency Checklist Critical Care Addendum

Transcription

1 A2 Cardiothoracic Unit Orientation Competency Checklist Critical Care Addendum Orientee: Orientation Dates: to Employee #: Preceptor(s): Signature/Initials: Printed Name: Signature/Initials: Printed Name: Signature/Initials: Printed Name: Signature/Initials: Printed Name: Resource Clinician: Printed Name: Please refer to A2 Cardiothoracic Unit Orientation Competency Checklist Intermediate Care for comprehensive competency items Critical Care Competency 1: Open Heart Room Set Up Review document: Landing A Heart Critical Care Obtains assignment from Charge Nurse/Coordinator Plans care in order to make time for room set-up Gathers the following equipment: Open Heart Tote (Clean Supply) Med Box specific to patient (Med Room) IV Pole with pump and correct cables (Clean Supply) Bair Hugger O2 tank Ensures that the bed is assembled properly o Clean bed with single flat sheet o Bed zeroed with pillow, pillow case, sheet and

2 patient gown o O2 Tank on foot of bed o Pts Ambu bag hooked onto O2 tank o Cables and clamps to go to OR Ensures that all NA tasks are completed properly Two wall suctions set up and working Telemetry patches in place on leads Bair Hugger plugged in Supplies ready for Epicardial wire care Sets up IV pole D5.45 NS on left side of pole with Buretrol and filter Nipride gtt on right side of pole with tubing and filter 500cc D5W connected to Cardiac Output syringe All tubing primed, labeled IV Pumps on and programmed Sets up cables Ensures that cardiac monitoring cable is set up and turned on Plugs in arterial line cable Plugs in CVP cable Plugs in PAP cable Plugs in CO cable to the monitor and the syringe Organizes cables for quick identification and access Sets up monitor and PowerChart Ensures that monitor is NOT paired to a telemetry box Enters patient demographic data correctly Enters most recent height and weight Ensures all alarms are set appropriately Associates patient to monitor via INet/PowerChart Sets up vent side of bed Gravity blood tubing primed 5% Albumin primed Tubing connected with T-port stopcock Nurse B items ready

3 Critical Care Competency 2: Landing a Heart Reviews document: Early Complications Discusses assignment with Charge Nurse/Coordinator Receives and interprets Warming and Closing calls Solicits Nurse B assistance Reviews patient s history and recent labs Reviews that procedure that the patient is having Prepares room Functions as Nurse A during admission: Receives the patient into the room Connects SpO2 cable to determine pulse Connects hemodynamic cables and zeroes immediately Assesses hemodynamics and intervenes appropriately Connects Cardiac Output syringe to CVP port and Cardiac Output temperature probe to white port of Swan-Ganz catheter Measures cardiac output and assesses value Assesses chest tube output and intervenes as necessary Directs personnel in room according to patient condition Receives report from anesthesia Asks pertinent questions Obtains information regarding blood product administration and medication administration intraoperatively Ensures that the post-operative labs have been drawn and sent Ensures that the post-operative chest x-ray has been ordered Assists with post-operative chest x-ray

4 Performs initial head-to-toe assessment Remains in control of hemodynamics Initiates IV drips as needed or ordered Orders blood products as needed Interprets post-operative labs and intervenes as necessary Communicates with family Allows family to see patient if appropriate Passes on pertinent information to family Exchanges contact information with family Provides family with Privacy Code Provides competent support to family Critical Care Competency 3: Care of the Patient Immediately Post-Op Reviews document Early Complications Responds to all alarms and sets alarm parameters appropriately Continuously evaluates hemodynamic status Continuously evaluates bleeding from mediastinal chest tubes Continuously evaluates pts level of consciousness and response to stimuli Continuously evaluates pts safety and need for restraint application Evaluates pts core temperature and removes Bair Hugger warmer as appropriate Obtains appropriate labs at proper intervals Interprets lab values correctly Intervenes as necessary for the following abnormal labs: Abnormal ABGs Electrolyte disturbances Coagulopathies CBC disturbances Performs comprehensive head-to-toe assessment of

5 the post-op patient and documents appropriately Performs Q1hr neuro checks until the patient has responded Keeps stimuli to a minimum throughout the post-op recovery period Turns patient Q 2 hrs Provides pt with complete bed bath and linen change post-op and evaluates pts skin Infuses ATS per orders Provides family with support and guidance throughout recovery Maintains hemodynamic stability: Infuses fluid when appropriate Titrates iv medications as appropriate Evaluates CO/CI and perfusion Evaluates post-op blood glucose Manages elevated blood glucose levels with appropriate insulin coverage Initiates the A2 High Intensity Insulin Drip orders when blood glucose is > 150 Titrates insulin drip per orders Assists the patient in coping with intubation Communicates appropriately with intubated pt Communicates appropriately with family Assesses for spontaneous respirations on MMV mode of vent Evaluates ABG results as they relate to readiness to extubate Continuously evaluates pt for readiness to extubate and attempts to extubate within goal of < 6hrs post-op Works with RT to care for patient and adjust mechanical ventilation as appropriate Assists with extubation of post-op patient: Readies equipment required for extubation Communicates with pt and family regarding readiness for extubation Puts OGT to continuous suction

6 Assists RT with extubation Ensures airway patency Applies supplemental oxygen as needed Evaluates pts ability to speak post-extubation Assesses pts pain post-extubation Critical Care Competency 4: Hemodynamics and PA Catheter ECCO Skills Lab Hemodynamics A2 Education Cabinet HealthStream option courses Associated Lippincott Nursing Procedures and Skills: Pulmonary artery catheter and pulmonary artery wedge pressure monitoring and maintenance Pulmonary artery catheter, blood sampling Pulmonary artery catheter, removal Mixed venous oxygen saturation monitoring Cardiac output measurement, room temperature injectate Continuously evaluates hemodynamic status Verbalizes significance and definition of the following: PAP CVP/RAP PAOP CO/CI SVR SV Discusses interventions to manipulate hemodynamics including: Pressors Inotropes Fluid Afterload reducers IABP

7 Identifies accurate waveforms for the following: PAP CVP ABP Verbalizes normal values of the following: PAP CVP CO/CI Verbalizes how to trouble shoot: Overdampened waveforms Underdampened waveforms Demonstrates: Square wave test Properly performs cardiac output: Primes syringe with 10cc Ensures that the proper calculation constant is entered Prepares monitor for CO monitoring/measurement Turns stopcock off to the system Injects CO fluid with steady, swift motion Returns stopcock to neutral position Evaluates CO waveform Repeats measurement for a total of 3 waves Evaluates CO/CI value Performs a Hemo Calculation and prints Verbalized understanding of SvO2 measurement (physiology, meaning, importance) Continuously monitors SvO2 Correlates changes in SvO2 with hemodynamic status Demonstrates proper SvO2 recalibration: Prepares equipment/supplies Prepares monitor for In Vivo recalibration Turns stopcock off to system Draws waste

8 Draws sample Flushes port Returns stopcock to neutral position Ensures that waveform returns and is accurate Properly labels and send specimen Evaluates specimen value and recalibrates monitor Identifies and demonstrates understanding of the following on the PA Catheter: Cather station PA (distal) port Infusion (medial) port CVP ( proximal) port Temp sensor SvO2 sensor Balloon Sheath Identifies and demonstrates understanding of the following on the triple transducer set-up: PA line CVP line ABP line Flush bag Pressure bag Transducers Pigtails Stopcocks Demonstrates proper set-up of the triple transducer set Verbalizes when the pressure lines should be changed Verbalizes understanding of criteria for removal of PA catheter Demonstrates proper removal of PA catheter: Gathers equipment/supplies Verifies position of PA catheter on most recent CXR Disconnects applicable infusions/lines Readies the patient with mask

9 Dons a mask and begins procedure using sterile technique Removes dressing Cleanses site with CHG swab Unlocks sheath and exposes PA catheter Pulls PA catheter with swift motion Observes monitor for signs of unresolved ectopy Caps Cordis introducer Redresses site using full sterile technique and BioPatch States potential complications Critical Care Competency 5: Managing Post-Op Complications Associated Lippincott Nursing Procedures and Skills: Opening the Chest at the Bedside Cares for the patient with post-op bleeding: Continuously assesses bleeding via mediastinal chest tube Continuously monitors amount of blood loss Assesses lab values related to bleeding (CBC, plts, HgB, PT/INR, PTT) Remains in communication with provider regarding pts bleeding Verbalizes understanding of effect of bleeding on hemodynamic status Maintains patency of mediastinal chest tubes Manages infusion of multiple blood products Verbalizes understanding of following in relation to the bleeding patient: PRBC FFP Plts Cryoprecipitate

10 Protamine DDAVP Amicar Cares for the patient returning to the OR: Maintains contact and communication with provider Efficiently packs patient up for trip to OR Obtains portable monitor Obtains Ambu bag and O2 task for transport Maintains monitoring and interventions throughout Maintains communication to family regarding pts condition Ensures that pt is as comfortable as possible throughout care Reports to anesthesiologists and OR staff Cares for the patient with tamponade: Verbalizes definition of cardiac tamponade Verbalizes risk factors associated with cardiac tamponade Able to verbalize and recognize clinical signs of cardiac tamponade: o Decreased urine output o Sudden decreased chest tube output o Decreased blood pressure o Rising PA and CV pressures o Equalization of heart pressures o Decreased CO/CI o Decreased SvO2 Intervenes as necessary when tamponade is suspected Verbalizes potential diagnostics o CXR o CT Scan o Echocardiogram o Return to OR (mediastinal exploration) Cares for the patient with hypotension: Continuously monitors ABP Ensures that ABP is accurate

11 Evaluates perfusion o Urine output o Capillary refill o LOC Troubleshoots possible causes of hypotension Intervenes as appropriate: o Fluid o Blood Products o Levophed o Dopamine Cares for the patent with decreased cardiac output: Monitors CO/CI at regular intervals Correlates CO/CI with other hemodynamic values Correlates CO/CI with signs of decreased perfusion Verbalizes why CO/CI may be decreased Maintains communication with physician Describes possible interventions for decreased CO/CI: o Inotropic agents o Fluid o HR o IABP placement o Afterload reduction Cares for the patient with neuro status changes: Evaluates pts neuro status Assesses pt for signs of stroke Cares for the patient with rhythm issues: Correctly interprets patient s heart rhythm Correlates HR and rhythm with perfusion and CO/CI Intervenes as necessary in the following situations: o Bradycardia - pacing o Ventricular ectopy electrolytes, antiarrhythmic o Tachycardia medications and cardioversion Cares for the patient with cardiac arrest: Observes a code situation in a post-operative patient Verbalizes things unique to coding a post-operative

12 patient Verbalizes how to communicate with the cardiothoracic service in the event of a code Open Chest at the Bedside: Locates equipment used in the emergent open chest at the bedside Verbalizes role of the critical care nurse in the open chest at the bedside situation Critical Care Competency 6: Mechanical Ventilation Works for 4 hours with RT contact Kara or Ernie Mendenhall, RRT to schedule Various videos available in A2 Education Cabinet Cares for the patient on the ventilator: Recognizes ETT placement and safe securement Measures and documents ETT station Recognizes possible need to reposition or re-secure ETT Performs thorough oral care at least q4hrs Determines presence or absence of cuff leak States definitions of vent settings: o MMV o IMV o CMV o PEEP o PS Defines low stretch ventilation States trouble shooting interventions for alarms Checks ventilator against current order q shift Assesses skin/oral mucosa during ETT and oral care Assure daily CXR is complete Performs ETT and tracheal tube suctioning Hyperoxygenates prior to suctioning Assures proper equipment is at bedside: Yankauer,

13 Ambu Bag Assists with weaning the patient from the ventilator Cares for the patient requiring CPAP or BiPAP: Assesses need for CPAP/BiPAP Applies BiPAP and CPAP devices Remove and replace the mask for drinking, oral care, etc. Assesses skin on nose and applies appropriate interventions Works with RT in determining CPAP/BiPAP settings Describes ventilator bundle orders and VAP prevention: HOB > 30 degrees PUD prophylaxis DVT prophylaxis Sedation Awakening Trial Weaning Oral Care Glycemic control SPAD Protocol Critical Care Competency 7: Respiratory Insufficiency/Reintubation Can relate abnormal assessment findings to specific diseases/condition: ARF ARDS COPD Pulmonary Emboli Pneumonia Cares for the patient with acute respiratory insufficiency: Opens airway Insert sand removes oral/nasal airway Correctly uses Ambu bag/bvm

14 Correctly performs suctioning: o Nasotracheal o ETT o Oral o Tracheal Applies appropriate supplemental oxygen Assists with reintubation: Locates A2 Intubation Box Reviews contents of A2 Intubation Box Works with RT to coordinate intubation Notifies CTS and anesthesia to coordinate intubation Provides appropriate sedation to patient for comfort Gathers additional medications (paralytics, etc) as needed Assists physician with intubation Communicates with family and patient Ensures all appropriate orders are entered postintubation: o VAP prevention measures o Sedation if needed o Ventilator orders o Pressure ulcer prevention interventions Critical Care Competency 8: Management of the Critical Care Patient Systems Review Cardiac Performs thorough cardiac assessment of the critical care patient Promptly attends to cardiac issues Continuously evaluates overall cardiac status Pulmonary Performs thorough pulmonary assessment Works with RT to provide the best care to the patient Promptly attends to pulmonary issues

15 Continuously evaluates overall pulmonary status GI/Nutrition Performs thorough GI assessment Assesses nutritional status and bowel function Promptly attends to GI issues Cares of the patient requiring tube feeding o Evaluates tube feeding tolerance o Evaluates pertinent lab data o Checks residuals and documents Cares for the patient with GI disturbances: o Ileus o Colostomy/Ileostomy o Liver failure/liver issues o Necrotic Bowel Cares for the patient requiring TNA: o Works with NST o Properly cares for infusion line o Evaluates labs as appropriate GU/Renal: Performs thorough GU/renal assessment Promptly attends to GU/renal issues Continuously evaluates overall renal/gu status Continuously evaluates urine output and documents Obtains daily weight Evaluates labs Cares for the patient requiring bedside hemodialysis: o Coordinates and communicates with the dialysis nurse o Monitors patient throughout therapy o Weighs patient post-dialysis o Assesses dialysis catheter if present Neuro Performs thorough neuro assessment and documents Reports any neuro status changes Promptly attends to neuro issues Cares for the patient post-stroke Skin

16 Performs thorough skin assessment Implements appropriate interventions to prevent pressures ulcer formation Promptly attends to skin issues Consults WOCN as needed Musculoskeletal/Activity Performs thorough assessment of patient s musculoskeletal and functional status Utilizes the principles of progressive mobility when caring for the critical care patient Performs ROM with patient Suggests PT consults as appropriate Works with PT to coordinate care Psychosocial Continuously assesses patient for psychological distress Promptly attends to psychological issues: o Ethical dilemmas o Depression o Family support o Anxiety Consults MSW as appropriate Consults Pt Liaison as appropriate Cares for the overdose/suicide pt o Use of safety companion o Use of restraints Critical Care Competency 9: Management of the Patient with Sepsis/Multi-organ Dysfunction Reviews diagnoses associated with multi-system organ dysfunction: Sepsis Septic Shock MODS

17 DIC Demonstrates competence in the management of the patient with sepsis and/or severe sepsis Recognizes the signs and symptoms of early multisystem organ dysfunction Screens patients for sepsis Identifies indicators requiring physician intervention Critical Care Competency 10: Intra Aortic Balloon Pump Counterpulsation - Intro Website Associated Lippincott Nursing Procedures and Skills: Intra Aortic Balloon Pump (MUNSON) Intra-aortic balloon pump management Discusses indications for IABP therapy Discusses IABP therapy goals: o Decrease workload of heart o Increase coronary artery perfusion o Decrease afterload Discusses situations in which the a patient would have IABP therapy on A2: o Severe pre-op MI o Intra-op assistance o Post-op insertion for support Discusses considerations in caring for the patient with IABP therapy: o Documentation requirements o Education requirements o Evaluation of need for restraint/sedation o Weaning therapy o Use of additional support Critical Care Competency 11: Continuous Renal Replacement Therapy (CRRT) - Intro

18 A2 Bedside Reference Manual Associated Lippincott Nursing Procedures and Skills Continuous Renal Replacement Therapy (MUNSON) Continuous renal replacement therapy Discusses indications for CRRT Discusses how CRRT may be implemented Discusses various modes of CRRT: o CVVH o SLED o SCUF o CVVHD Discusses goals of CRRT therapy: o HD in hemodynamically unstable pt o Fluid removal o Ultrafiltration o Renal assistance for acute kidney damage post-op Discusses considerations in caring for the patient with CRRT: o Documentation requirements o Education requirements o Coordination with HD department o Central access/iv site o Family support o Blood loss potential o Decreased core temp potential o Additional support management Critical Care Competency 12: Critical Care Equipment A2 Bedside Reference Manual A2 Education Cabinet

19 Demonstrates competent use of the following: Hot Line Blood/Fluid Warmer Mini-Med IV Pump Phillips Monitor and cables Bovee Defibrillator with Internal Paddles Wound VAC Transport Monitor Locates unit crash carts Locates unit Line carts and describes contents Locates unit intubation boxes and describes contents Locates unit cardioversion cart and describes contents Locates open chest supplies Plan for IABP Plan for CRRT