cctc ai record updated for november 26, 2015 revisions · cctc ai record updated for november 26,...

CCTC AI Record

Updated for November 26, 2015

Revisions

CCTC Nursing Documentation Information

Brenda Morgan, CNS, CCTC

A Few Points

• Use tick boxes to identify protocols that are in

effect (e.g., VAP prophylaxis, electrolyte

protocol); you don’t need to write this

narratively

• Describe abnormal findings and patient

specific details in the narrative space

A Few Points

• It is assumed that monitoring will be

according to CCTC standards (be sure you

know what they are by reviewing website)

• You don’t need to describe routine care in the

narrative note

• The “test” of whether monitoring is performed

as per standard is the actual documented

assessments

Reminders

• means that everything is the same as per

the last entry before arrowing began

• If you chart that something is abnormal or

outside of defined/normal limits, remember to

document the return to normal before arrowing

• If the last entry is an abnormal finding,

arrowing over means the abnormal state is

continuing

• Document a * to indicate that a descriptive entry had been made to

the Data-Assessment-Response (DAR) section of the AI record

Reminders

• Document the Plan of Care at the start of the

shift (days and nights)

• At end of shift, summarize the response to

the plan or any plan modifications

• Communicate the plan/modifications to

oncoming shift to ensure that the “loop is

closed” and issues do not get dropped

Reminders

• Narrative charting should focus on significant

findings, interventions and patient response

• Routine care per standard does not require

narrative entries unless response is not within

normal of defined parameter; record in

graphic record

• REMEMBER to document patient response to

interventions

Physician Notification

• When you page/speak with a physician about a

problem, include the name of the physician in

the documentation

• When you document that a physician is

notified, outline briefly the specific information

communicated (don’t just state “MD updated”

E.g., Dr. X notified of low BP, oliguria and

tachycardia.

Complete new assessment

at the start of each shift.

Enter the date, admission day

AND time when assessment

performed.

Document the details for findings

that are not Within Defined Limits

(WDL). If there is insufficient room

in the initial shift assessment, use

Panel 2 and 4.

Panel 1: Neuro Section

To reduce the chance of missing an important

neurological change, always perform a neurological

assessment together with the outgoing shift to confirm

findings/descriptions of findings.

Neuro/Comfort Section

• WDL applies only to very rare

ICU patients who are

completely awake, oriented

X3, communicating normally

and have normal motor

strength

• All patients should have a

neurological assessment

performed and documented

at the start of each shift and

PRN


• Assess motor strength to assess

for focal findings and to identify

generalized weakness of critical

illness

• Refer Bedside Assessment tools

for assessment tools/tips

• Make note if patient’s

neurological findings may be

influenced by sedatives or other

agents


• Describe deficits clearly; add DAR note if more space is

needed.

• Describe patient response in detail using straight forward

language

• Clearly identify the type of stimulus used and the patient

response (e.g., eyes open to voice, abnormal extension to

trapezius squeeze)

• Complete neuro section of 24 Hour Flowsheet


Gag is normal if stimulation of BOTH sides of the oral

pharynx elicits response


Normal cough should be able to bring secretions

forward.


Trauma is responsible for clearance and must enter an

order to confirm that precautions are cleared.


There must be documentation in the AI record of consent. Consent can

wait till morning on the night of application, but there must be a DAR

note to explain your decision and selection of LEAST restraint.

Consent is required by Ontario law. Continued use without consent is a

violation of the least restraint act.


Document ICP, CPP and leveling in the 24 Hour

Flowsheet

Record reference code for zeroing Codman Express™


• The order of assessment should be Pain, Agitation

(MAAS score) and Delirium (PAD).

• Pain and Agitation should be assessed at the start of

each shift, with each PRN medication and Q4H PRN for

all patients in CCTC.

• Delirium is screened once during the second half of the

shift.


SWAP tool is available on all nursing desk tops and can be

obtained by clicking on the icon from the critical care

analgesic or sedation care set.


Screen all patients who are receiving continuous infusions

of narcotics or sedatives with the SWAP tool every shift, to

assess readiness for sedation reduction.

Attempt weaning automatically if

SWAP is passed (weaning protocol

can as per routine orders).

Weaning protocols are available

from the Protocols Page of the

CCTC website under “Analgesic

orders” and “Sedation orders”.


http://www.lhsc.on.ca/Health_Professionals/CCTC/protocols/index.htm

If SWAP assessment is failed, review

sedation plans during rounds.

*Even when deep sedation remains the

target, slow and cautious reduction can be

attempted to see if targets can still be

achieved with less medication (except when

neuromuscular blockade is in use).



• Describe the plan for sedation. Wean means to reduce sedating

drugs as tolerated as per routine orders. Maintain means to

continue the current sedation targets. Describe plan if > 1 agent to

be weaned or not as per analgesia orders.

• *Even when deep sedation remains the target, slow and cautious

reduction can be attempted to see if targets can still be achieved

with less medication (except when neuromuscular blockade is in

use).


• Identify whether patient is receiving any antipsychotics (including

PRN only)

• Examples of antipsychotic medications: haldol, lamotrigine,

loxapine, olanzapine, methotrimeprazine, quetiapine, risperidone


• If antipsychotics are in use, assess for signs of EPSE/NMS (see

Delirium Protocol)

• If positive, * and DAR

• Remember to assess QT interval if patient receiving antipsychotics


• Screen ALL patients > 24 post admission for delirium

during the second half of EVERY shift.

• Screen patients even if they are not ventilated

• Screening is used to help identify potential delirium and to

monitor delirium progress following initiation of treatment


• Document the time when the screen was completed.

• Screen during second half of shift to ensure sufficient time to

assess for symptom fluctuation

• Report screen results as “screen positive” (if ICDSC is > 4) or

“screen negative” (if < 4 ) during rounds and communicate during

shift-to-shift handover.


• Record the time that the screen was completed

• Screen for pain, VAMAAS and delirium at same

assessment point

0430


• If patient able to self-report, circle NRS and enter

pain score as 0-10/10

0430 3/10


• If patient is unable to self-report, circle CPOT and

enter pain score as 0-8/8

0430 4/8


• Assess for agitation using MAAS score

• Enter the MAAS or score (unventilated patient) or

VAMAAS (ventilated patient)

0430 4/8

4


• Circle all of the ICDSC (Intensive Care Delirium

Screening Checklist) criteria that apply

• Give one point for each item circled and enter the

score out of 8 for the ICDSC

0430 4/8

4

5


• If any criteria from 1-7 change between between day

and night shift or throughout your shift, assign a point

for #8 symptom fluctuation.


• If MAAS < 2 (and sometime if it is 2), patient’s level

of consciousness is too low to screen for delirium.

0430 4/8

1A


• If MAAS is too low, complete the Pain and MAAS

score and record the Delirium Score (ICDSC) as

“U/A”

• This section must be completed for ALL patients

even if sedation is too deep for screening

0430 1/8

1A

U/A

Respiratory Section

Respiratory Section

• Identify and oxygen or ventilation support that is in use

Respiratory Section

• Describe the oxygen and ventilator settings as well as

the type of airway in use

Respiratory Section

• Use the codes to illustrate on the diagram the type of

breath sounds heard.

• REMEMBER: edema, secretions and atelectasis is

most prevalent in the lower lobes (or bases); you need

to listen to the back of the patient to hear the bases

Respiratory Section

• List any thoracic tubes here and describe chest

drainage tube assessments

Respiratory Section

• Select VAP Prophylaxis to indicate that VAP Prevention

strategies are in place (e.g., HOB elevation, oral rinse

with CHG, teeth brushing, subglottic drainage tube,

enteral feeding or TPN within 48 hours of admission

and sedation reduction/minimization

Respiratory Section

• Identify oxygen/ventilator targets/orders

• Add other therapies (e.g. prone until 0300 hrs, PCO2

orders for patient with Traumatic Brain Injury)

Respiratory Section

• Identify orders are plans for ventilator change

• E.g. “ARDNet protocol” or “start TM trials up to 1 hr

TID as tolerated”

• Be sure to identify if patient is to be rested overnight

Respiratory Section

• Remember to “re-FRI” for patients in CCTC with new

symptoms or coming from ward (it isn’t just ED)

Respiratory Section

• Use this to elaborate upon abnormal findings or patient

specific plans

Cardiovascular Section


• Identify monitoring lead at the start of each shift and

confirm that all leads are in the correct chest position

• POST A COPY of the rhythm strip at the start of each

shift and document analysis on the strip

• Record your analysis here

• *One full page strip can be posted to display ECG

rhythm and all required waveforms


Document pulse assessment


Document the time in seconds to capillary refill; > 2

seconds is prolonged (cold ambient room temperature can

prolong refill)

Assess for symmetry (e.g., delay on one side suggests a

local flow obstruction versus generalized shock)

Upper and lower can be assessed; delayed refill in great

toes is suggestive of shock or peripheral vascular disease


Document skin temperature, colour and any

abnormality of the skin texture

Charted detailed skin assessment in Integumentary

diagram


Identify how BP measured

Describe quality of arterial line waveform and identify

if positional


If a patient has a pacemaker, assessment should include:

Site: insertion site (e.g. Left SC) for a temporary or permanent

transvenous pacemaker or the status of transvenous

pacemaker pads (e.g., pads intact, change at 1200 hrs)


• Identify where pads are placed (e.g., anterior and

posterior or anterior only)

• Change transcutaneous pads every 2 hours if in

continuous use, every 6 hours if intermittently used

and every 12 hours if pads in place but no pacing.

• Inspect for skin burns.


Pacemaker TYPE:

Permanent, temporary transvenous or trancutaneous AND the 3

(temporary) or 5 (permanent) letter pacemaker code

Patients with permanent pacemakers should carry a wallet card

that identifies the pacemaker code and setting; if unavailable,

information may be may be available in Power Chart or by

calling pacemaker clinic

Example

VVI: This code is frequently used in temporary (transvenous or

transcutaneous) pacing. It would indicate that the pacemaker only has

the ability to pace or sense the ventricle and the response to a sensed

event would be to inhibit. This is what we frequently call a “demand

ventricular pacemaker”.

What do the Code Letters Mean?

Example

DDDMD: Five letter codes are used to describe permanent pacemakers that

have programmable features (can speed up when the patient exercises). In

this example, there would be both an atrial and a ventricular wire in place so

that both the atria and ventricle can be sensed and/or paced as needed. The

M indicates that the device has been programmed for more than one function

and D means it can have both programming or rate changes AND shock

capability.

What do the Code Letters Mean?


• The pacemaker Rate is the Set Rate (HR should not fall below this

rate)

• The MA is also called the output. This is the amount of current that

will be delivered to the heart with each paced beat (measured in

milliamps or MA).

• The pacemaker should be assessed each shift to ensure that it

captures when the rate is increased above that of the patient and

identify whether it can sense the patient’s own beats.


• The Sens. Is the sensitivity setting. Record the sensitivity in mVolts.

This reflects the size that a native beat has to reach in order for the

pacemaker to recognize or sense it

• Turning the sensitivity “down” or to the “left” will make the mVolts

number higher. These would mean that the patient’s own QRS would

need to be taller or stronger in order to be detected (less sensitive)

• Turning the sensitivity “up” or to the “right” makes the mVolt numbers

lower. This identifies that the QRS only needs to reach this height in

order to be detected which makes the pacemaker more sensitive.


• If a pulmonary artery catheter (Swan Ganz™) is in place, identify the

catheter position as close to the insertion site into the introducer (AKA

Cordis)

• Remember: A pulmonary artery catheter can still migrate into a

spontaneous wedge position or recoil with the tip in the right ventricle

without any change in the insertion point.

• Use the Pulmonary Artery and Flotrac Checklists to ensure all

appropriate monitoring is performed

• A daily Chest Xray is required to rule out distal placement of the tip

(which increases the risk for both pulmonary infarction and

hemorrhage)


• IPC is intermittent pneumatic compression device (AKA

SCD)

• A waveform must be posted to the chart upon admission,

insertion and Q shift if the patient has a femoral, IJ or SC

central venous line to reconfirm tip location/rule out

arterial or interstitial locations (excludes PICC/HD lines).

• If a patient has both a femoral and IJ/SC central venous

line, BOTH require waveform assessment

• If an arterial line is in place, post a waveform to the chart

to confirm adequacy of waveform.

• One full page waveform can be printed to confirm ECG,

arterial, central venous waveforms and ICP.

Reminder: Required Waveform

• Tick to indicate that waveform is posted and analysis

included on printout.

• ICP can be printed simultaneously on the single

printout (which is why it was included under CV

section).

Reminder: Required Waveform

• When you print a full page of waveforms or review a

screen shot, the order that the waves appear is defined

by the Monitor MODE; you cannot change the order of

either the printed or displayed waveforms unless you

change the MODE.

• The MODE is displayed in the top right hand corner of

the monitor

• “CCTC Gen.” shown

here is the default

Understanding Full Page Printing

When the mode is CCTC Gen. the waveforms that can be

printed are as follows (printed in this order):

Wave 1: ECG 1

Wave 2: P2 (regardless of the pressure being measured on P2)

Wave 3 P1 (regardless of the pressure being measured on P1)

Wave 4 ECG 2



Normally, we use P2 for CVP, P1 for arterial line and P4 (is

unused). Thus, a typical printout in CCTC Gen. is: ECG wave

CVP wave (P2 content)

Arterial wave (P1 content)

ECG 2

Blank (P4 content)

The order of printing is by pressure module, not wave. If P1

is used for CVP and P2 is used for the arterial line, the

printout from CCTC Gen. mode will be: ECG wave

Arterial wave (P2 content)

CVP wave (P1 content)

ECG 2

Blank (P4 content)


Swan Ganz mode will display and print waves from P1, P2

and P4, but the printout order is changed to:

Wave 1: ECG 1

Wave 2: P4 (regardless of the pressure being measured on P2)


Wave 4 ECG 2


In the snapshot display, the 2nd

ECG position is moved to the

bottom (display sequence is

slightly different than printout)


The Swan Ganz MODE should be used if you are putting in a

Pulmonary Artery Catheter. By using this mode, other default settings

are initiated to streamline insertion and monitoring.

For example, use of the Swan Ganz MODE will also turn on the correct

temperature modules for measuring both blood temperature from the

pulmonary artery and the injectate temperature during cardiac ouptut

measurement.


Appears as soon as pressure

is connected to P4.

Temperature e digit fields are default settings in the

Swan Ganz Mode

• If you need > 2 pressure waveforms (e.g, a second

central line or an ICP waveform) you need to obtain a

P3 or P4 module

• If a P4 module is used P1, P2 and P4 will print in either

CCTC Gen. or Swan Ganz Mode

• Waveforms measured using a P3 module will NOTE be

displayed unless you change to CCTC Neuro Mode.

• Use the CCTC Neuro Mode will display and print ALL

pressure modules (P1, P2, P3 and P4). Use this mode

if you are using both a P3 and P4 module.


How to Change Modes: Go to “Admit/Discharge” from the navigation bar.

Choose “Select Mode”

Choose the desired mode

When you change modes, alarms settings will return to the

defaults. All patient data is saved and can be retrieved in the new

mode setting.


ECG and all waveforms (including ICP) can be printed

on a single page.

Use CCTC NEURO MODE if you use a P3 module (both

P3 and P4 will print in this mode). P3 waves will NOT

print in the CCTC Gen. or the Swan Ganz modes.

Instruction on the use of Modes/Printing can be found

from the CCTC Procedures menu under “Monitor

Modes”

What Does a Normal ICP Waveform Look Like?

Looks like an arterial waveform with an extra bump in

between the peak and dicrotic notch.

Three bumps labeled P1, P2 and P3. P2 and P3 are

normally lower than the P1 pressure.

Normal ICP:

Note that P2 or P3 have become equal to or higher than P1. The

entire waveform may “merge together” into one full figured bump.

These subtle changes may demonstrate that brain is “tight” before the

pressure rises significantly and offers an earlier warning.

Decreased

Brain

Compliance


• Describe any additional abnormal findings or patient

specific plans/actions.


• Remember to initial page.

IV Solutions Section

On left column, list all

central and peripheral

venous lines and lumens

and include:

1.Side of body (L/R)

2. Insertion site

3.Type of catheter

R IJ Introducer

R IJ Double lumen

Brown

White

Blue

L forehand #18 peripheral

IV Assessment Section

Documentation Standards for IV

Solutions

R IJ Introducer

R IJ Triple lumen:

Brown

White

Blue


0.9% Normal Saline

CVP/0.9% normal saline

Levophed

TPN

Saline Lock

• On right column, record ONLY the SOLUTION and

MEDICATION ADDED.

• This documentation identifies where solutions are running.

• If you change either the site, solution or medication, you

must make a DAR entry to indicate the change.


• Include all central and peripheral access (including locked

catheters)

• ONLY chart infusion solution and name of medication

added

• Do not chart rate or concentration

R IJ Introducer

R IJ Triple lumen:

Brown

White

Blue


0.9% Normal Saline

CVP/0.9 % normal saline

Levophed

TPN

Saline Lock


*Remember this should be also updated on the kardex

If you change sites for any medication, * and DAR (e.g., the

norepinephrine is in the introducer at the start of the shift

and you switch it to the white port at 1400 hrs)

R IJ Introducer

R IJ Triple lumen:

Brown

White

Blue


0.9% Normal Saline

CVP / 0.9% normal saline

Levophed

TPN

Saline Lock

Gastrointestinal Section

Document abdominal assessment here.


Document bowel sounds. If bowel sounds are not heard,

document “not heard” as this does not mean they are not

present and is not alone a contraindication to feeding.


Remember to document bowel function. Unless

contraindicated, check for impaction Q 3 Days and ensure

bowel routine is initiated.

NOTE: Bowel Routine is NOT PRN for patients with spinal

cord injury. Patents must have bowel movement at least Q2

Days.


Document use of fecal management system.


Tick if bladder pressure is being monitored


Record diet.


Document feeding tube and identify location of feeding

tube tip


Confirm if GI prophylaxis and prokinetic in use


Tick if care sets have been initiated for:

• Bowel Routine

• Insulin Protocol

• DKA Protocol


Document identification and assessment of GI ostomies.


All other GI tubes are documented here.


Use lines for abnormal findings or patient specific plans.

Protocols and routine care standards do not need to be

describe unless changes have been made.

Genitourinary Section


Document urinary drainage tubes, stents and/or ileal

conduit (urinary diversion systems) here.


Document here if patient is voiding without the use of a

tube.


Document urine volume. Blank line is to describe

volume that is not WDL (e.g., < 0.5 ml/kg or high volume

output)


Describe urine appearance here.


Document dialysis, dialysis type and catheter.


Document perineum assessment.


Tick if electrolyte protocol is in use. You do not need to

narratively describe the orders or expected monitoring

for this or other care sets once you identify they are in

use.


Use blank spacing to describe abnormal findings or

actions that are unique to this patient’s care or response.

Obstetrical/Gynecological

Pregnant Patients:

• Download Admission Guidelines and Checklist for Care of

Pregnant Patient in CCTC

Post Partum Patients:

• Download Checklist and Guidelines for Care of Post Partum

Patients

Educational reminders/instructions on how to perform post partum

assessment are provided on website.


Rule out Pregnancy:

• All patient < 50 should have pregnancy rule out by pregnancy

test (this is usually done in ED; should be sent in CCTC if it has

not been obtained)

• If patient has had a hysterectomy or is immediately postpartum,

the appropriate box to identify why pregnancy test is not

required.

*Spelling error “post partem” X2 will be corrected to post partum

with next printing”


• If pregnant, document number of weeks and days

• This is described as 26 and 1 for 26 weeks and one day


Pregnant Patients:

• Confirm that admission/Q shift checklist for a pregnant patient

has been activated.


• Describe fetal monitoring plan


• For postpartum patients, identify date of birth and neonates

information

• “Status” can be used to identify stillbirth, NICU, at home with

maternal grandmother etc.


• Tick to confirm activation of PostPartum Admission/Q Shift

Checklists

• Instructions/educational reminders are included in these

documents


• Document feeding plan/mother’s wishes regarding lactation and

breast/nipple assessment


• Document fundal height and tone


• Use this code to record pad saturation

• * and DAR if more space is required and document in the AI

nurses notes section

Integumentary Section

• Complete the Braden score each shift

• Circle the appropriate score for each of the 6 criteria to show

calculation

• Record the final score out of 23


• Document the bed surface


• Describe wound care/skin care plan

• Use AI nurses notes if more room is required


• Use this area to show lines, tubes and wound locations


• Describe mobility plan

• Specifically identify goals (not just “AAT”)

• For example, “attempt weight bearing at bedside” or up in chair

with lift

Other Section

• Document resuscitation code

Other Section

• Identify precautions

• “Negative Pressure” has been added as an option

• If patient refuses consent, a blood transfusion refusal

form must be completed and ALL options refused or

accepted

• Ensure that Blood Transfusion Lab is notified and form

is faxed

Other Section

• Verify correct armband

• Tick yes if on patient

• If unable to place on patient, explain why and identify

where the armband is located

Other Section

• This section MUST be ticked if emotional support or

assistance with ADLs is selected

AI-DAR Section

Reassessment and narrative nurses

notes section.

D: data

A: action

R: response

Remember the “R”!

AI-DAR Section

Highlight in point form the plan of

care following morning AND

afternoon rounds.

Review plan from previous shift

before rounds to ensure intended

actions have not been missed.

If plan changes, document

modifications.

Be sure that documentation shows

“closure of the loop” by summarizing

plan outcome at the end of your

shift.

AI-DAR Section

NEW

AI-DAR Section

Reminder to provide

summary charting at least

once per shift on use around

comfort, delirium screening

and wound care.

AI-DAR Section

Reminder to provide summary charting

at least once per shift on “Patient

Comfort”.

This should include weaning actions and

response to weaning of medications.

Plan for sedation is outlined in initial

assessment.

Minimum charting is an end of shift

summary to describe patient comfort and

response to treatment or weaning.

AI-DAR Section

Reminder to provide summary charting

at least once per shift on “Delirium”.

This should include screening results,

assessment for causes of delirium if

present, treatment and response to

treatment/weaning of medications.

Include non-pharmacological actions.

Assess QTc and EPS/NMS with initial

assessment and PRN. Document

abnormal findings here if present.

AI-DAR Section

Document if risks change from initial

assessment, bed changes, wound

descriptions and any interventions to

address/prevent skin issues.

If no change from initial assessment and

no wound care interventions, arrow over.

AI-DAR Section

Reassess and add updated DAR or

arrow over if unchanged from initial

assessment Q 4 H and PRN for the

following:

1. Neurological assessment

2. Respiratory Assessment

3. Cardiovascular assessment

4. GI assessment

5. GU assessment

AI-DAR Section

DAR PRN when indication exists.

cctc ai record updated for november 26, 2015 revisions · cctc ai record updated for november 26,...

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