Description
To ensure appropriate use of Neutral Spine Precautions for patient mobility.
Behavioral Criteria
It is expected that all staff will gather all necessary equipment, perform effective hand hygiene, don appropriate personal protective equipment, identify patients using two appropriate patient identifiers, and explain procedures to patients and family members, as appropriate, before beginning any skill or procedure.
Nurse has reviewed appropriate reference procedure/protocol for this skill/equipment and verbalizes understanding.
Identifies components of Neutral Spine Principles (NSP); including keeping shoulders, hips and knees in line during all activities and positioning
No bending over/stooping, no bending sideways or backwards
No reaching arms behind / across body;
No arching or bridging back
No twisting / turning shoulders to reach or look behind body
No raising knees higher than hips when sitting / standing
Keep legs in symmetrical position when resting or still.
Limit sitting time to no more than 30 minutes or per provider order
No lifting anything heavier than your walker or approximately 3 pounds, or per provider order
No walking without your walker until cleared by provider
Ensure patient demonstrates adherence to Neutral Spine Principles in all daily activities.
Notifies RN of any abnormalities
Documents Patient's tolerance and distance ambulated in the electronic health record.
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
White, C. C. IV, et al. (2014). EMS spinal precautions and the use of the long backboard: Resource document to the position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. Prehospital Emergency Care, 18, 306–314. Accessed April 2020 via the Web at https://tandfonline.com/doi/pdf/10.3109/10903127.2014.884197?needAccess=true (Level VII)
The Royal Melbourne Hospital. (2015). “TRM08.04 management of the patient with spinal precautions” [Online]. Accessed April 2020 via the Web at https://www.thermh.org.au/sites/default/files/media/documents/clinical/TRM0804_0.pdf (Level VII)
Monday, July 10, 2023
To ensure appropriate use of Neutral Spine Precautions for patient mobility.
CNA Care of the patient undergoing Bariatric Surgery
CNA Care of the patient undergoing Bariatric Surgery
Additional Ratings
Description
Assists the professional nursing staff in caring for patient undergoing bariatric surgery
Behavioral Criteria
Recognizes the increased potential for postoperative complications in bariatric surgery patients
Monitors food and fluid intake
Ensures compliance with small feedings
Encourages modification in eating habits
Reports noncompliance in food and fluid intake
Provides routine post-op care and reports any abnormal finding to the nursing staff
Attends sensitivity training in order to empathize with the patient
Provides emotional support patient and family
Anticipates patient's special need related to inability to move independently
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Musculoskeletal Injury Prevention Plan and Policy (MIPP)
Care and Management of the Bariatric Patient
Thiele, T., & Osterreicher, A. (2011). Caring for your bariatric patient: A resource guide to the literature on care of the morbidly obese. Bariatric Nursing & Surgical Patient Care, 6(1), 43-48
Grindel, M., & Grindel, C. (2006). Nursing care of the person having bariatric surgery. MEDSURG Nursing, 15(3), 129-146
Muir, M., Heese, G., McLean, D., Bodnar, S., & Rock, B. (2007). Handling of the bariatric patient in critical care: A case study of lessons learned. Critical Care Nursing Clinics Of North America, 19(2), 223-240
CNA Cardiac (Monitoring)
CNA Cardiac (Monitoring)
Additional Ratings
Description
Cares for patient with continuous cardiac monitoring
Behavioral Criteria
Placing Electrodes on Patient:
Prep skin: select a flat, non-muscular area, Clean skin , Remove hair using clippers ( do not use a razor)
Apply electrodes- 5 lead
White "Right" (Directly below the clavicle and near the Right shoulder)
Black- "Smoke over fire" (Directly below the clavicle and near the Left shoulder) )
Red- "Fire under Smoke" (Left Lower abdomen)
Green- (Right Lower abdomen)
Brown- ( On the 4th intercostal space at the right sternal border)
Changes electrodes daily or more often, if needed to prevent irritation
Assist in changing batteries when directed by nurse
Report abnormal findings or alarms to nurse
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Cardiac Telemetry Monitoring
Toolbox: How to Guides to Technology Systems & Devices
Critical Care Nursing Clinics of North America. (2006). Practice Standards for ECG Monitoring in Hospital Settings: Executive summary and Guide for Implementation
Heart Lung. (1991). Electrode Site Preparation Techniques: A Follow Up Study.
CNA Baseline Urinary Elimination
CNA Baseline Urinary Elimination
Additional Ratings
Description
Assists professional nursing staff in caring for patients with urinary elimination needs
Behavioral Criteria
Observes urinary elimination including frequency, odor, volume, amount and color
Obtains urine specimens as directed (non sterile)
Measures continuous bladder irrigation output as delegated by nurse
Secures urinary catheter and maintains closed urinary drainage systems
Maintains drainage bag below bladder, not touch floor, ensure tubing free of kinks.
Apply initial Purewick to famales as delegated by nurse, then change Purewick as needed or once a shift. Keep suction between 40-60 mmHg degrees.
Apply initial Condom catheter as delegated by nurse, then change as needed
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Care of the Patient with an indwelling cahteter
Craven, H. (2009). Core curriculum for medical-surgical nursing . (4ed.). New Jersey: Academy Of Medical Surgical Nursing
DiGiulio, M., Jackson, D., & Keogh, J. (2007). Medical-surgical Nursing Demystified. McGraw-Hill Professional
Cayir, G., Beji, N., & Yalcin, O. (2007). Effectiveness of nursing care after surgery for stress urinary incontinence. Urologic Nursing, 27(1), 25-33
CNA Baseline Tubes & Drains
CNA Baseline Tubes & Drains
Additional Ratings
Description
Assists the professional nursing staff in caring for patient with tubes, drains, and pouches
Behavioral Criteria
- Empties Jackson Pratt (JP) and Hemovac drains
- Measures and Documents in Electronic Health Record (EHR)
- output from JP,
- Hemovac,
- nasal gastric (NG),
- colostomy, ileostomy, and/or
- urinary drainage bags,
Reports abnormal finding to nursing staff
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Patient safety Attendants (PSA)
Carter,P. (2007). Lippincott's essentials for nursing assistants: a humanistic approach to caregiving. Philadephia: Lippincott Williams & Wilkins
Hegner, B., Acello, B., Caldwell, E. (2008). Nursing assistant: a nursing process approach. Clifton Park, NY: Thomson Delmar Learning
Frazer, C. (2012). Managing chest tubes. Med-Surg Matters, 21(1), 1
Doenges, M. E., Moorhouse, M., & Geissler-Murr, A. (2008). Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care. F.A. Davis Company
CNA Baseline Tubes & Drains
CNA Baseline Tubes & Drains
Additional Ratings
Description
Assists the professional nursing staff in caring for patient with tubes, drains, and pouches
Behavioral Criteria
Empties Jackson Pratt (JP) and Hemovac drains
Measures and Documents in Electronic Health Record (EHR) output from JP, Hemovac, nasal gastric (NG), colostomy, ileostomy, and/or urinary drainage bags,
Reports abnormal finding to nursing staff
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Patient safety Attendants (PSA)
Carter,P. (2007). Lippincott's essentials for nursing assistants: a humanistic approach to caregiving. Philadephia: Lippincott Williams & Wilkins
Hegner, B., Acello, B., Caldwell, E. (2008). Nursing assistant: a nursing process approach. Clifton Park, NY: Thomson Delmar Learning
Frazer, C. (2012). Managing chest tubes. Med-Surg Matters, 21(1), 1
Doenges, M. E., Moorhouse, M., & Geissler-Murr, A. (2008). Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care. F.A. Davis Company
CNA Baseline Postoperative/Post Procedure Care
CNA Baseline Postoperative/Post Procedure Care
Additional Ratings
Description
Assists the professional nursing staff in caring for the post-op patient
Behavioral Criteria
Assist the patient out of bed to chair
Encourages coughing and deep breathing exercises
Encourages use of incentive spirometer
Assists patient to ambulate
Reports complaints of pain to nursing staff
Reports patient's tolerance for increase in activity to nursing staff
Reports significant decrease in urine output to nursing staff
Applies sequential compression stocking as ordered
Takes vital signs and documents in Electronic Health Record
Reports changes in condition to nursing staff
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Prevention of Respiratory Complications with ICOUGH
Carter,P. (2007). Lippincott's essentials for nursing assistants: a humanistic approach to caregiving. Philadephia: Lippincott Williams & Wilkins
Hegner, B., Acello, B., Caldwell, E. (2008). Nursing assistant: a nursing process approach. Clifton Park, NY: Thomson Delmar Learning
DiGiulio, M., Jackson, D., & Keogh, J. (2007). Medical-surgical Nursing Demystified. McGraw-Hill Professional
CNA Baseline Patient Hygiene
CNA Baseline Patient Hygiene
Additional Ratings
Description
Provides Bathing/shower, oral hygiene , perineal and catheter care and linen change
Behavioral Criteria
Assists with bed bath or assisted bath
Assists patients with Medicated baths who have Central lines (includes PICC, Dialysis catheters and Mediports)
Daily bed linen change (Top sheet, bottom/draw sheet, Pillow cases)
Assist patient with medicated bath who is scheduled for surgery
Assists patient with ADL, as permitted with focus on improved self care
At a minimum, peri care/Foley Catheter care to be completed twice daily
Cleans incontinent patients
Changes wet or soiled linens
Assists patient to brush teeth and/or clean dentures after each meal and bedtime
Document care or refusal in the EHR
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Management of Patient Hygiene
Nose to Toes Pre-Operative Decolonization Procedure
Campbell, L., Gilbert, M. A., & Laustsen, G. R. (2010). Clinical Coach for Nursing Excellence. F. A. Davis Co
King, P., & Crawford, D. (2009). Healthcare assistants in the children's intensive care unit. Pediatric Nursing, 21(1), 48-51
BUTLER-WILLIAMS, C., JAMES, J., COX, H., & HUNT, J. (2010). The hidden contribution of the health care assistant: A survey-based exploration of support to their role in caring for the acutely ill patient in the general ward setting. Journal Of Nursing Management, 18(7), 789-795
Conway, J., & Kearin, M. (2007). The contribution of the Patient Support Assistant to direct patient care: An exploration of nursing and PSA role perceptions. Contemporary Nurse: A Journal For The Australian Nursing Profession, 24(2), 175-188
CNA Baseline Patient Hygiene
CNA Baseline Patient Hygiene
Additional Ratings
Description
Provides Bathing/shower, oral hygiene , perineal and catheter care and linen change
Behavioral Criteria
Assists with bed bath or assisted bath
Assists patients with Medicated baths who have Central lines (includes PICC, Dialysis catheters and Mediports)
Daily bed linen change (Top sheet, bottom/draw sheet, Pillow cases)
Assist patient with medicated bath who is scheduled for surgery
Assists patient with ADL, as permitted with focus on improved self care
At a minimum, peri care/Foley Catheter care to be completed twice daily
Cleans incontinent patients
Changes wet or soiled linens
Assists patient to brush teeth and/or clean dentures after each meal and bedtime
Document care or refusal in the EHR
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Management of Patient Hygiene
Nose to Toes Pre-Operative Decolonization Procedure
Campbell, L., Gilbert, M. A., & Laustsen, G. R. (2010). Clinical Coach for Nursing Excellence. F. A. Davis Co
King, P., & Crawford, D. (2009). Healthcare assistants in the children's intensive care unit. Pediatric Nursing, 21(1), 48-51
BUTLER-WILLIAMS, C., JAMES, J., COX, H., & HUNT, J. (2010). The hidden contribution of the health care assistant: A survey-based exploration of support to their role in caring for the acutely ill patient in the general ward setting. Journal Of Nursing Management, 18(7), 789-795
Conway, J., & Kearin, M. (2007). The contribution of the Patient Support Assistant to direct patient care: An exploration of nursing and PSA role perceptions. Contemporary Nurse: A Journal For The Australian Nursing Profession, 24(2), 175-188
CNA Baseline Patient Experience, including age related/cultural/religious considerations
CNA Baseline Patient Experience, including age related/cultural/religious considerations
Additional Ratings
Description
Builds patient trust and confidence through effective communication and visible demonstration of staff teamwork Interacts with patient in a manner that is appropriate for developmental or chronological age to provide safe and effective care and communication Identifies cultural and religious needs of patient for individualized care
Behavioral Criteria
General Considerations for Patient Centered Care:
Receives report from off-going staff; ensures all members of patient team have received report, using ISBAR and bedside handoff
Reviews and updates goals with patient using communication board in room.
Maximizes perception of time spent with patients by speaking slowly with courtesy and respect, using eye contact, and giving patients time to ask questions or voice concerns
Uses plain language; presents information in an appropriate and clear manner with an understanding of age-specific guidelines, cultural considerations, and culturally appropriate language; asks specifically about preferences and needs
Displays respect and understanding for patient’s values and practices; makes effort to learn about patient needs and preferences, especially concerning healthcare treatment and ways of communicating/interacting
Listens attentively; responds appropriately to patient/family requests, questions, and concerns; shows compassion and empathy
Explains all tasks to be performed with/on patient so that patient understands what is happening and why and what is expected of him/her.
Asks patient to describe using own words what has been taught about his/her health and care, i.e. activities, diet, medication and side effects, restrictions, etc.
Engages and includes family members; recognizes their importance in patient’s care
Stop to check on patient and respond to requests when a call bell is lit; participates in Purposeful Rounding schedule with healthcare team to anticipate patient needs.
General Considerations for Age-Specific Care:
Note: Chronological age may not reflect developmental age, especially in special needs patient population. Plan of care should be tailored to reflect specific needs of each patient.
Recognizes vital signs, labs that are out of normal range for age of the patient. Responds as required
Chooses equipment and supplies appropriate to patient’s age/size.
General Considerations for Cultural and Religious Practices:
Asks patient about any cultural or religious beliefs or practices that will affect the patient’s hospital stay, including practices the patient would like to continue, and communicates information to healthcare team
Contacts spiritual advisors, as indicated by patient
Asks patient about food preferences
Asks patient about preferred language, whom to include in conversations and teaching and communication practices that should be avoided (eye contact, touching)
Utilizes hospital's interpreting services whenever needed
Asks open ended-questions, allowing ample time to answer
Assures patient of healthcare team’s desire to understand patient’s needs and concerns
Identifies resources to seek information about patient behavior related to their culture or religion
Documentation reflects considerations and individualized interventions.
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
References:
Borenstein, K. MSN, RN, CCRN (Oct 2011). Bedside Report: A change project could result in improved patient and nurse satisfaction.” Advance for Nurses, Vol. 8, Issue 9, 24.
Copeland, L., Desmond, J. (2000). Communicating with Today’s Patient: Essentials to Save Time, Decrease Risk, and Increase Patient Compliance. New Jersey: Jossey-Bass
Shelton, Patrick J. (2000). Measuring and Improving Patient Satisfaction. New York: Aspen Publishing
N.A. (2005). Improving Patient Safety through Informed Consent for Patients with Limited Health Literacy. National Quality Forum. Retrieved from: http://www.ethics.va.gov/ETHICS/docs/infocus/InFocus_20060401_Teach_Back.pdf
N.A. (Nov/Dec 2005). Case Study: Improving Medication Compliance – One hospital targets patient education, medication compliance, and medication reconciliation. The Joint Commission Benchmark, Vol. 7, No. 6, 4-10.
CNA Baseline Oxygen Therapy
CNA Baseline Oxygen Therapy
Additional Ratings
Description
Assists the professional nursing staff in the caring for patient with oxygen therapy
Behavioral Criteria
Recognizes abnormal respiratory patterns and reports to the nursing staff
Encourages the patient to cough and breathe deeply
Maintains nasal cannula and simple face mask
Obtains and reports pulse ox
Recognizes hypoxia and abnormal respirations
Assists patients with oxygen therapy safely for turning and moving
Safe transport of patient- ensures portable oxygen tank is full (greater than or equal to 1500 PSI) switches wall oxygen to portable tank at arrival of transporter
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Patient Care- Oxygen Administration in the Adult Patient
Hegner, B., Acello, B., Caldwell, E. (2008). Nursing assistant: a nursing process approach. Clifton Park, NY: Thomson Delmar Learning
Craven, H. (2009). Core curriculum for medical-surgical nursing . (4ed.). New Jersey: Academy Of Medical Surgical Nursing
Woodrow, P. (2007). Caring for patients receiving oxygen therapy. Nursing Older People, 19(1), 31-36
McGloin, S. (2008). Administration of oxygen therapy. Nursing Standard, 22(21), 46-48
CNA Baseline Nutrition Feeding
CNA Baseline Nutrition Feeding
Additional Ratings
Description
Participates in meeting the nutritional needs of patients with feeding difficulty
Behavioral Criteria
Assists or feeds patient who is unable to feed self
Observes for coughing, choking and reports observations to nurse
Arranges food in relation to numbers on a clock if patient is visually impaired
Records calorie count
Reinforces swallowing precautions
Documents Percent taken of meals in Electronic Health Record.
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Plan for Provision of Nursing Care
Carter,P. (2007). Lippincott's essentials for nursing assistants: a humanistic approach to caregiving. Philadephia: Lippincott Williams & Wilkins
Hegner, B., Acello, B., Caldwell, E. (2008). Nursing assistant: a nursing process approach. Clifton Park, NY: Thomson Delmar Learning
Simmons, S. (2007). Quality improvement for feeding assistance care in nursing homes. Journal Of The American Medical Directors Association, 8(3), S12-7
CNA Baseline Lab Specimen Collection and Labeling
CNA Baseline Lab Specimen Collection and Labeling
Additional Ratings
Description
Demonstrates appropriate technique when acquiring lab specimens
Behavioral Criteria
Identifies patient using two patient identifiers and verifies orders for sample
Utilizes computerized barcode labeling system to collect & label specimens at bedside
Uses appropriate specimen collection receptacle
During down times, labels specimen at the bedside, in the presence of the patient, including time and date of collection, own initials, and source of specimen, if non-blood
Prepares/transports specimen to appropriate place, ensuring specimen is in labeled, sealed biohazard container/bag with appropriate paperwork
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure) Speciment Collection utilizing Soft ID
Toolbox: How to Guides to Technology Systems & Devices
Becton, Dickinson and Company. (2004). "Midstream clean catch urine procedure" [Online]. Accessed April 2020 via the Web at http://legacy.bd.com/resource.aspx?IDX=11181
Craven, R. F., et al. (2017). Fundamentals of nursing: Human health and function (8th ed.). Philadelphia, PA:Wolters Kluwer
MedlinePlus. (2017). "Clean catch urine sample" [Online]. Accessed April 2020 via the Web at http://www.nlm.nih.gov/medlineplus/ency/article/007487.htm
Sharma, L. (2018). Evidence summary. Fecal specimen: Collection and assessment. The JBI EBP Database. AN: JBI211
CNA Baseline Infection Control
CNA Baseline Infection Control
Additional Ratings
Rater
Huang, Judy C
Not Yet Rated
Peer
Nurse, Nurse
Not Yet Rated
Description
Adheres to infection control practices
Behavioral Criteria
Demonstrates knowledge of medical asepsis and contamination
Demonstrates appropriate hand washing
Implements Standard Precautions to reduce the risk of pathogens
Utilizes personal protective equipment
Wears gloves when touching blood, body fluids, secretions, excretions and contaminated items
Changes gloves between tasks and procedures
Handles used equipment per organization policy
Transports and handles linen that is soiled as per organization policy
Prevents injuries when handling and cleaning sharp instruments after procedures
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Infection MRSA, C-Diff
Infection Control Flip Guide
Rowley, S., Clare, S., Ruffell, A., & Beer, J. (2010). High impact actions: fighting infection. Nursing Management - UK, 17(6), 14-19
Lewis, K., & Thompson, J. (2009). Health care professionals' perceptions and knowledge of infection control practices in a community hospital. Health Care Manager, 28(3), 230-239
Hegner, B., Acello, B., Caldwell, E. (2008). Nursing assistant : a nursing process approach. Clifton Park
If certain equipment is NOT used in practice area, please indicate this exception(s) in Comment section.
CNA Baseline Equipment General Use
Additional Ratings
Description
Safely and appropriately demonstrates use of all features listed for each piece of equipment (see Resources).
Behavioral Criteria
If certain equipment is NOT used in practice area, please indicate this exception(s) in Comment section.
Vital sign Machine
AED/Defibrillator
Ambu bag
Bladder scanner
Low Air Loss Pump for Patient bed
Vertical and horizontal patient transfer devices (hovermat, z-slider)
Powered Air Purifier Respirator (PAPR)
Safe Patient Handling Equipment- (Sara Steady, Sara Plus, Sky lift, etc.)
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
Resources
Link to clinical lift and transfer devices
References
Toolbox (Policy/Procedure)
Fall Prevention
Musculoskeletal Injury Prevention Plan and Policy (MIPP)
Safe Patient Handling
Toolbox: How to Guides to Technology Systems & Devices
CNA Baseline Duties as a Patient Safety Attendant (PSA)
CNA Baseline Duties as a Patient Safety Attendant (PSA)
Additional Ratings
Description
Standard Duties of Patient Safety Attendant (PSA)
Behavioral Criteria
Get report from off-going PSA and nurse
Complete documentation for safety observations (activity, behaviors, interventions)
Try to keep patient on normal sleep/wake cycle
Wake patients, assist with toileting/diaper changes, oral care (open window blinds)
Have patient out of bed and performing activities as much as possible during daytime hours
Provide bedtime care (offer lavender lotion/oil, give sleep hygiene)
Collect vital signs at ordered times, report data to Nurse as soon as completed
Bathe patients
Prepare patient for meals including hand washing and sitting them up in the chair if appropriate
Ensure assistive devices in place (dentures, glasses, etc.)
Help patients who can’t feed themselves
Ambulate patients or turn patients
Provide toileting regularly, do not leave patient unattended in bathroom
Provide activity for confused patients (i.e. wheeling around the unit, using items from the GREAT kit)
Prepare and accompany patient for off unit procedures
Report any changes in baseline to the nurse
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Duties as a Patient Safety Attendant
Handoff Communication
Mezey, M. (2016). Decision-making and dementia. Try this: Best practices in nursing care to older adults with dementia, D9. Accessed April 2020 via the Web at https://consultgeri.org/try-this/dementia/d9decision2016r3.pdf
The Joint Commission. (2020). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
World Health Organization. (2009). "WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean care is safer care" [Online]. Accessed April 2020 via the Web at https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1 (Level IV)
National Institute on Aging, National Institutes of Health. (2017). "Talking with your older patient: Communicating with a confused patient [Online]. Accessed April 2020 via the Web at https://www.nia.nih.gov/health/communicating-confused-patient
CNA Baseline Collecting and documenting vital signs and measuring weight
CNA Baseline Collecting and documenting vital signs and measuring weight
Additional Ratings
Description
Monitoring/Documenting Vital signs, pain level and patient measurements (weight, height, neck circumference)
Behavioral Criteria
Verify the identity of your patient, and explain that you are going to take their Vital Signs (Blood Pressure, pulse, temperature, oxygen saturation):
Blood Pressure:
Position of patient -sitting or lying down, Legs kept uncrossed and remain quiet (no talking)
Select the appropriate size cuff and apply it directly over the skin, above the elbow.
Does not take blood pressure on Restricted Extremity, over an intravenous line (IV), injured or painful extremity.
Obtain reading from display and document Systolic, Diastolic and Mean Arterial Pressure (MAP) in Electronic Health Record (EHR)
Notify nurse of abnormal reading
Pulse Oximetry:
Ensure patient hand is clean (no nail polish or false nails)
Place oximetry probe onto one of the patient's fingers
Obtain reading from display and document in EHR
Notify nurse of abnormal reading
Respiratory Rate:
Observe the patient as they breathe, and count each rise and fall of the chest as one respiration. Count the breaths for one minute.
Record the respiration rate in the EHR.
Notify the nurseif patient is having any difficulty with achieving regular deep breaths
Pulse:
Obtain reading from display and document in EHR
Notify nurse of abnormal reading
Temperature:
Select appropriate placement for oral, axillary, or temporal to obtain temperature
Obtain reading from display and document in EHR
Notify nurse of abnormal reading
Pain Level:
Obtain/document stated pain level from patient
Notify nurse of pain level
Weighing Patient:
Standing scale
Check that scale reads zero to ensure accurate measurement.
Assist patient onto the scale and remain close to the patient to prevent falls
Have the patient stand as still as possible for accuracy
Obtain reading from display and document in the EHR
Notify nurse if abnormal reading
Bed Scale
Zero bed prior to weighing patient
Weigh patient
Obtain reading and document in the EHR
Measuring Neck Circumference
Use paper measuring tape- place around patient's neck.
Record measurement in cm in EHR.
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in EHR accurate and complete
References
Toolbox (Policy/Procedure)
Specimen Collection Utilizing Soft Id System
Mohammad, Y., et al. (2010). "Clinical use of pulse oximetry: Pocket reference 2010" [Online]. Accessed January 2021 via the Web at https://www.networks.nhs.uk/nhs-networks/south-east-coast-respiratory-programme/documents/OximetryPG.pdf
The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission
World Health Organization. (2011). "Pulse oximetry training manual" [Online]. Accessed January 2021 via the Web at https://www.who.int/patientsafety/safesurgery/pulse_oximetry/who_ps_pulse_oxymetry_training_
Hanlon, P. (2015). Patient monitoring: Oximetry enhances care. RT for Decision Makers in Respiratory Care, 28(2), 15–18.
American Association of Critical-Care Nurses. (2016). "AACN practice alert: Obtaining accurate noninvasive blood pressure measurements in adults" [Online]. Accessed April 2020 via the Web at https://www.aacn.org/clinical-resources/practice-alerts/obtaining-accurate-noninvasive blood-pressure--measurements-in-adults
Kallioinen, N., et al. (2017). Sources of inaccuracy in the measurement of adult patients’ resting blood pressure in clinical settings: A systematic review. Journal of Hypertension, 35, 421–441. [Online]. Accessed April 2020 via the Web at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5278896/
Davie, A., & Amoore, J. (2010). Best practice in the measurement of body temperature. Nursing Standard, 24(42), 42–49.
Geijer, H., et al. (2016). Temperature measurements with a temporal scanner: Systematic review and meta-analysis. BMJ Open, 6(3), e009509. Accessed April 2020 via the Web at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4823400/
Tipton, P. H., et al. (2012). Patient safety: Consider the accuracy of height and weight measurements. Nursing, 42(5), 50–52. Accessed April 2020 via the Web at https://journals.lww.com/nursing/Fulltext/2012/05000/Consider_the_accuracy_of_height and weight
CNA Baseline Bed and Chair Alarm Safety Features Copy
CNA Baseline Bed and Chair Alarm Safety Features Copy
Additional Ratings
Description
Demonstrates competency in use of safety features of bed and chair alarms
Behavioral Criteria
Bed features
- Connect bed to power source
- Operate bed functions including, brake, side rails, CPR function, height, and head/foot adjustments
- Zero bed and utilize bed scale
- Set bed alarm appropriate for level of activity of patient
- Utilize iAwareness, when available
Chair alarm features
Connect pad (single-patient use) to chair alarm
At Mountain View Campus, connect auxiliary cord to nurse call panel
Verbalizes that bed exit alarms and chair alarms will be utilized on all patients deemed to be High Fall Risk
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete
References
Toolbox (Policy/Procedure)
Patient Safety Visual Centralized Monitoring
Fall Prevention
Musculoskeletal Injury Prevention Plan and Policy (MIPP)
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CNA Baseline Application of Non-Violent Restraints
CNA Baseline Application of Non-Violent Restraints
Additional Ratings
Description
Assists professional nursing staff in caring for patients in restraints
Behavioral Criteria
Implements alternative to restraints as delegated by nurse
Applies soft restraints as directed by nurse
Demonstrates securing devices using a quick release
Observes for breathing, skin redness, color, temperature and reports observations to nurse
Performs patients needs for elimination, hydration and safety are addressed while restraints are in use
Demonstrates removal of restraint as directed by nurse
Verbalizes understanding that vest restraints are used only in CCU-MV
Evidence of Achievement
Direct observation of competency in all areas through patient care or simulation / case study; documentation in electronic health record accurate and complete