Director of Nursing Training Manual

Transcription

1 U UNIFORM/DRESS CODE... 1 GENERAL INFORMATION... 1 UNACCEPTABLE DRESS OR APPEARANCE... 1 URINARY INCONTINENCE... 2 GUIDANCE TO DECREASE THE INCIDENCE OF URINARY TRACT INFECTIONS... 3 PURPOSE... 3 IDENTIFICATION... 3 TREATMENT... 4 JUSTIFICATION FOR INDWELLING URINARY CATHETER... 4 Physician order for catheter... 5 URINARY TRACT INFECTIONS IN THE ABSENCE OF A CATHETER... 6 CRITERIA FOR URINARY TRACT INFECTION IN THE ELDERLY... 6 April 2014

2 Uniform/Dress Code GENERAL INFORMATION In an effort to present a professional image and assist patients and family in identifying facility personnel, uniforms are required for the majority of personnel who provide care and perform specific responsibilities, particularly nursing, dietary, housekeeping, and laundry. Proper anti-skid shoes (predominantly white in color) and facility issued identification badge must be worn at all times. Crocs are prohibited due to the safety hazards they pose. Employees are expected to present themselves for work in clean, neat and wrinkle free uniforms. Registered and licensed nurses, MDS coordinators, staffing coordinators, medical records personnel, PPS nurses and risk management nurses are to wear any type and color of scrub/uniform top with coordinating solid colored scrub/uniform pants. CNAs may also wear scrubs/uniforms as outlined above with the exception of white as it is reserved for licensed nurses in keeping with the medical dress code protocol. The Director of Nursing and Assistant Director of Nursing have the option to wear either business attire, with a white lab coat or vest or the above described scrub/uniform or the traditional white nurse uniform. UNACCEPTABLE DRESS OR APPEARANCE Jewelry and/or long nails (natural or artificial) which could cause harm to self or patients cannot be worn. An inappropriately dressed employee will be instructed to clock out and return to duty only after he or she complies with the facility dress code. The Administrator or DON will determine the appropriateness of the employee's appearance. Unacceptable appearance examples include but are not limited to eyebrow, nose, tongue, or other offensive facial piercing; offensive tattoos; inappropriate undergarments which can be seen through a uniform, body odor; soiled or stained uniforms, etc. April 2014 Page 1

3 Urinary Incontinence See Bowel and Bladder Program in Section B of this Manual. January 2014 Page 2

4 Guidance to Decrease the incidence of Urinary Tract Infections PURPOSE Urinary Tract Infections (UTIs) are the most common bacterial infections encountered in nursing home patients. The aim of this guidance is to provide standardized evidence-based best practices to decrease the incidence of Urinary Tract Infections in our facility. Adherence to guideline recommendations will not ensure a successful outcome in every case; therefore, the ultimate judgment regarding a particular treatment plan must be made by the clinician in light of the clinical data presented by the patient. IDENTIFICATION Urinary Tract Infections are more common in women. Post-stroke victims, patients with restricted mobility, diabetes, or patients with a history of previous UTIs are at high-risk. These high risk groups should be routinely monitored for changes that are indicative of a possible UTI. Elderly patients with a UTI are often misdiagnosed with dementia or Alzheimer s disease, because a UTI can mimic symptoms of such conditions. An elderly person who is experiencing sudden onset of mental difficulties should lead one to investigate possible UTI. They should be closely monitored for other signs of a UTI such as: Urine that appears cloudy Hematuria Strong or foul-smelling urine Frequency or urgency Pain or burning with urination Elderly patients are challenging as they present often with atypical signs (e.g., behavioral changes, incontinent episode, or apathy). They also have a muted sense of thirst and possibly refusal of fluids. The facility infection preventionist / nurse should routinely monitor for signs and symptoms of a possible undiagnosed UTI. January 2014 Page 3

5 TREATMENT Treatment of symptomatic UTI should not be delayed while waiting for culture and sensitivity results. It may be helpful to start empiric treatment, taking into account previous urine cultures and sensitivity reports, results, and the ATB sensitivity pattern in the facility. Generally speaking elderly women with uncomplicated UTI may be treated with a 10 day course of ATB therapy. Elderly men may need to receive a 14 day course of ATB therapy. Abbreviated courses of therapy (<7 days) to a UTI in the elderly are generally not recommended because of relative rates of treatment failure and infection relapse. With pyelonephritis or urosepsis is generally treatment for a minimum of 14 days. If left untreated, UTIs can lead to severe illness such as pyelonephritis and sepsis. Continued bacteriuria without residual symptoms does not warrant repeat or continued ATB therapy. The goal of treating a UTI is to alleviate systemic or local symptoms, not to eradicate all bacteria. Therefore, a post-treatment urine culture is not routinely necessary. JUSTIFICATION FOR INDWELLING URINARY CATHETER In addition to removing catheters as soon as possible, we should also restrict their usage to the patients that really need them. Facility Directors of Nursing should make attempts to discontinue catheters. A daily review of catheter necessity during medical, nursing, or multidisciplinary rounds will keep a focus on catheter usage. Privacy bags should be utilized for these patients. Reasons that would necessitate an indwelling catheter are: 1. Urinary retention (which cannot be treated medically or surgically) caused by a disease such as multiple sclerosis, prostatic enlargement, cerebrovacular accident, or spinal cord injury. These must have supporting documentation and conditions: Documentation in the medical record of post void residual (PVR) volumes in a range over 200 milliliters (ml) (documented attempts to discontinue should be written in the record) Inability to manage the retention with intermittent catheterization Symptomatic infections or a condition that would require aggressive urinary output measurement. 2. Possible Contamination of stage lll or IV pressure ulcer: Should be for a short period of time and good communication to discontinue when the stage is no longer appropriate for a catheter January 2014 Page 4

6 3. Terminal illness or severe impairment which makes positioning or clothing changes uncomfortable, or associated with intractable pain. 4. Urinary obstruction could also be a reason for a long-term catheter. Catheters should be discontinued as soon as possible to prevent catheter-associated urinary tract infections and to reduce patient discomfort, activity restrictions and to eliminate restraining the patient that in turn could promote venous thromboembolism. Nurses should notify physicians of catheter presence on any patient. If no justification, these should be discontinued immediately. Upon admission if a patient has recently had a Foley catheter discontinued it would be prudent, if medically possibly, to apply a positive nursing intervention such as increase the water intake on the MAR. Some patients do need to use an indwelling urinary catheter on a long-term basis, perhaps for the rest of their lives. Some steps can be taken to decrease the incidence of acquiring a UTI. 1. Ensure education and proper hand hygiene practices for those who insert catheters and manipulate urinary catheters and drainage bags in daily patient care. 2. Keep the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging of the catheters or cause an UTI due to the injury. Catheters should be anchored at all times. Nurses should educate the patients and other nurses what to do to get the urine flowing, such as, increasing fluid intake or check for proper placement. Fewer incidences of UTIs occur when patients with catheters have no blockage. 3. Keep the urine flowing. Reflux can in turn cause kidney infections. Position catheters below the bladder at all times. It may be appropriate to increase the fluid intake on anyone with a sluggish (less than 1200 ml.) output. Patients with catheters should be encouraged to increase fluid input if not contraindicated. Physician order for catheter The physician orders for a catheter must include: 1. Foley Catheter (size) for (appropriate dx) 2. Change Foley catheter with insertion tray every month and PRN 3. Empty drainage Bag qs and PRN 4. Change drainage bag 2x month and PRN 5. Change leg strap every month and PRN 6. Catheter care every day and PRN with soap and water January 2014 Page 5

7 URINARY TRACT INFECTIONS IN THE ABSENCE OF A CATHETER Recurrent UTIs (2 or more in 6 months) in a noncatheterized patient may warrant additional evaluation (abnormal post void residual (PVR) or a referral to an urologist to rule out structural abnormalities (enlarged prostate, prolapsed bladder, periurethral abscess, strictures, calculi, polyps and tumors). Here are a few suggestions to increase fluid intake. Patients that have recurrent UTIs may benefit from cranberry juice daily and yogurt sent as their bedtime snack. Since all patients must receive a bedtime snack this serves as an opportunity to decrease their chances of reoccurrence. It may also be appropriate to increase fluid intake on the MAR of that patient (does not require a physician order). Amounts could be designated in order to reach the goal. This step could be in addition to the hydration program. This is a nursing judgment that may help in your efforts to decrease UTIs. Long term ATB usage should not be encouraged before a clear cause is discovered for this patient and documented. The hydration program can assist with decreasing the incidence of UTIs in the facilities. This program should be functional and should supply fluids twice daily. Hydrating patients decreases the incidence of falls, behaviors, pressure areas, infections, and many more. Administrators and directors should insure this program is administered daily with consistent staff. Nurses should take the opportunity to give full glasses of water with each med pass when possible. This will increase efforts to keep patients hydrated. The elderly population has a diminished sense of thirst and so efforts should be on the health care worker to educate and hydrate patients these patients will often refuse fluids because they fear they will have to urinate more frequently. This is a good thing. Patients will have an increase in their mobility which is good for the caregiver and the patient. This increase in urination will keep down the incidence of infection and provide strengthening rehab for the patient at the same time. Incontinence is not only a symptom but a risk factor for UTIs in the elderly. In the case of the long term care patient it may be more beneficial to manage the incontinence to control the bacteriuria instead of treating the bacteriuria with antibiotics. Incontinent patients should be identified and treated appropriately. CRITERIA FOR URINARY TRACT INFECTION IN THE ELDERLY The literature recommends removing the current catheter and inserting a new one and obtaining a urine sample via the newly inserted catheter. Symptomatic UTIs are based on the following criteria: January 2014 Page 6

8 Patients without a catheter should have at least three of the following signs and symptoms: 1. Fever (increase in temperature of >2 degrees or rectal temp >99.5 degrees F or single temperature >100 degrees F (rule out other possible causes for the fever) Baselines should be on charts. 2. New or increased burning on urination, frequency, or urgency: 3. New flank or suprapubic pain or tenderness; 4. Change in character of urine (e.g. new bloody urine, foul smell, or amount of sediment or as reported by the laboratory (new pyuria or microscopic hematuria) and/or 5. Worsening of mental or functional status (e.g., lethargy, confusion, decreased appetite, unexplained falls, incontinence of recent onset, lethargy, decreased activity) Patients with a catheter should have at least two (2) of the following signs and symptoms: 1. Fever and chills (need a clear indication of the origin of the fever) 2. New flank pain or suprapubic pain or tenderness; 3. Change in character of urine (e.g., new bloody urine, foul smell, or amount of sediment) or as reported by the lab (new pyuria or microscopic hematuria) and or; 4. Worsening of mental or functional status. Local findings such as obstruction, leakage or mucosal trauma (hematuria) may also be present. January 2014 Page 7