2010 Yakima Valley Memorial Hospital Psych Skills Fair

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Yakima Valley Memorial Hospital 2010 Psychiatry Skills Fair

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Table of Contents Don’t forget the RED RULES! Whenever you are giving a patient any medications, you must verify with TWO patient identifiers. Double check all chemo, insulin, designated bolus anticoagulants, and blood product infusions. 1 North ’10 Skills Fair Yakima Valley Memorial Hospital

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3 Indications for Restraints Remember, there are only 3 legal reasons that we may place a patient into restraints or seclusion; the patient is a danger to self, a danger to others or maintenance of therapy. Least restrictive alternatives must be attempted prior to any type of restraint being applied. All least restrictive alternatives attempted must be documented. It is 1 North’s policy as well as the hospital’s policy that all patients be taken out of restraints/seclusion as soon as possible. The only risk free restraint is the one that is avoided!!! -Address underlying source of distress -Provide diversion -Reorient often; take time to explain procedures to the patient -Allow patient’s family to be involved in the care of the patient -Take time to listen to the patient’s concerns -Answer call lights promptly -Sitter -Move closer for observation -Utilize sensory room Least Restrictive Alternative Examples

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To Restrain or Not to restrain? Physician Order: Obtain an order immediately upon initiating seclusion. This task may be delegated to another staff member. If restraints continue to be used, a new order is required every 4 hours. Criteria for Behavioral Restraints: Patient is at risk for harm to self or others due to agression or violence directed at self or others. NOTE: Non-compliance with directives or agitation are NOT sufficient criterion for restraints or seclusion. Initiate Restraints: Only a RN can initiate any type of restraints. Notify physician immediately Consider and document alternative to restraints/seclusion Significant change in condition requiring restraints? Patient at immediate risk of harm to self or others? OR Alternatives ineffective? Continue to monitor Monitor and Document -At initiation 1 hour face to face, patient self-management/risk factors; least restrictive alternatives -Every 15 minute visual check (audio/visual monitoring) -Every 2 hours Vital signs, including Sa02 Nutritional and hydration needs CMS/ROM/positioning Hygiene and elimination Physical and psychological status and comfort; signs of distress or pain Readiness to be released. NOTE trial releases are NOT allowed. Patient maybe temporarily released for toileting, ROM, positioning, assisted ambulation and other nursing care. Patient education Response to interventions -Every shift Update plan of care to include restraints Restraint education -At discontinuation of restraints Debriefing

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Vital Signs: Materials and Equipment Don’t Forget The Pain Assessment… Part of YVMH’s vital sign’s are asking the patient what their current pain level is. This is a subjective level given by the patient. It is important to note where the patient is having pain and where they would rate that pain on a 0-10 scale. Knowing what is normal is important! In general, a healthy adults vital signs should be with in the following ranges: Blood Pressure: 130/85 (high side or normal) to110/75 (low side of normal) mm/Hg Respirations: 12-18 respirations per minute Pulse: 60-80 beats per minute at rest Temperature: 97.8-99.1 degrees Fahrenheit Oxygen Saturation: 95-100% Vital signs change with age, sex, weight, exercise tolerance and condition (i.e. anxiety, alcohol/drug withdrawl, etc). Times to Assess Vital Sigsn On admission to obtain baseline data. When the patient has a change in status. Before and after a procedure (i.e. ECT). Before and after a medication that could affect respirations or cardiac status.

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Proper Placement of Equipment Measuring Blood Pressure The cuff should be placed on the upper two-thirds of the limb. Locate the brachial artery and place the arrow on the cuff over this site. The cuff should be approximately 1 inch above the antecubital space of the patients arm. The diaphragm of the stethoscope should be placed on the brachial artery. Measuring Temperature The temporal thermometer should be placed flat against the patients forehead. Depress the button on the thermometer and run laterally across the patients forehead and tap it behind the patients ear. Release the button once the thermometer has been placed behind the patients ear. Measuring Oxygen Saturation Depress and release the blue button on the oximeter. Have the patient lie their hand on a flat surface and place the oximeter face up on the patients finger. Allow a few seconds to obtain an accurate reading.

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SBAR “allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.” -Insitute for Healthcare Improvement Situation-Data based on current situation of patient including but not limited to: name, diagnosis and secondary diagnosis, covering physician, vital signs, code status, diagnosis, IV fluids, significant lab values. Background-Patient focus problems, to include mental status, skin integrity, fall assessment, use of oxygen, mobility status, tolerance to activity, psychosocial issues/concerns, etc. Physician and ancillary staff consults, previous tests, allergies, and current code status. Assessment-Head to toe physical assessment, vital signs, IV’s, drip line assessment, oxygen, vent settings, current lung status, diagnosis specific assessment (i.e. bowel tones present for s/p abdominal surgery), wound status if present, MI, etc. pain assessment, drains, tubes, wound assessment and care, ADL's diet, activity, restrictions, isolation, fall, bleeding precautions, fluids etc, lab, diagnostics, responses to treatment, care partner, family updates. Recommendation-Follow up with physician, any communication needs with health care team or family, potential lab work, PT/OT, special programs, plan of care, needs to be addressed, orders pending completion, treatments, tests, discharge planning, Issues and barriers. Communication Handoff-SBAR Tool When Should SBAR Be Used? At shift change-staff to staff handoff. Anytime you contact a physician. When using the chain of command.

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Here is an example of a call to a physician using SBAR: Introduction Dr. Jones, this is Deb McDonald RN, I am calling from ABC Hospital about your patient Jane Smith. Situation Here's the situation: Mrs. Smith is having increasing dyspnea and is complaining of chest pain. Background The supporting background information is that she had a total knee replacement two days ago. About two hours ago she began complaining of chest pain. Her pulse is 120 and her blood pressure is 128/54. She is restless and short of breath. Assessment My assessment of the situation is that she may be having a cardiac event or a pulmonary embolism. Recommendation I recommend that you see her immediately and that we start her on 02 stat. Do you agree?

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Here’s another example of how SBAR might look when calling a physician: Introduction Dr. Love, this is Bob Call, RN, I am calling from Memorial Hospital about your patient Joe Smith. Situation Here's the situation: Mr. Smith is having increasing agitation, is slamming his hand in the door and yelling. Background The supporting background information is that he arrived on the unit this afternoon and received some news that he no longer hand housing. About an hour ago he received a phone call, but the caller and content of the discussion are unknown. Fifteen minutes after he got off the phone he began pacing the hallway. He has been pacing for a half hour now and 5 minutes ago began slamming his hand in the door and yelling. Assessment My assessment of the situation is that this patient is increasingly aggitated and appears to be harming himself. Recommendation It is my recommendation that he be placed into seclusion to prevent further self harm. What are your thoughts on this situation?

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Response Evasion Control yourself Keep talking Be patient Stay out of the way Get out of the way Pay attention Make a plan Track the attack, move in an arc, close the attack MINIMIZE, RELEASE, EVADE Call for help Crisis Communication: General Principles Self-control enables critical thinking. Assessment comes before action. Communication keeps the door open. Patience pays. Expect the unexpected. De-escalation Stress Model of Assault This is where staff should intervene. Most dangerous time for re-escalation Patients at highest risk to hurt self during this phase. Don’t leave the patient alone. The de-escalation techniques we use on 1 North are based on Pro-ACT principals. They emphasize self-control, assessment skills and verbal crisis intervention. The higher the distress the lower the ability to reason cognitively.

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Documentation Documentation should accurately reflect the incident. Who, what, where, how and why (if we know it). What interventions were used and were they sucessful or unsuccessful. If it’s not in writing, it didn’t happen. If it is in writing it happened exactly the way it’s written. Debriefing Discuss the event; what initiated the escalation and crisis, what about the crisis was handled well, what about the crisis might have been handled better. Support your co-workers, given them kudos for what went well and constructive criticism for what might be worked on for next time.

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Sensory Room…… A Little Refresher Potential Sensory Interventions Weighted blanket Listening to music Hot pack Deep breathing Coloring Progressive relaxation CD Cool eye mask Chew gum Stretching Utilizing the Sensory Room Ask the patient to identify their emotion and rate their level of discomfort before entering the room. This information should be recorded on the clipboard that resides in the sensory room. Allow the patient to find a comfortable place to sit as well as pick an item out of the sensory bin if they so desire. Determine if the patient is safe to be left alone in the sensory room or if a staff members presence is need ed. It is up to the patient on how long they stay in the sensory room. When the patient leaves, ask them to rate their discomfort again, recording this information on the same clipboard as earlier. How do you determine if a patient would benefit from use of a sensory item or the sensory room itself: Ask the patient on admission what they use to calm themselves in crisis. Ask our occupational therapist to assess the patient. Ask for a sensory diet evaluation. Sensory Room Safety Reminders Use the cavi-wipes on any item the patient handles while in the sensory room. The bean bag and weighted blanket/animals have to be gutted and washed after each patient use. Once the item is clean it should be placed in a clear plastic garbage bag and document on the outside of the bag date that it was clearned.

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