the process of evaluating findings through the use of observation, palpation, percussion, and auscultation

1. Recognizes normal and abnormal findings for the following organ systems: • Cardiovascular • Digestive • Integumentary • Musculoskeletal • Neurological • Respiratory • Urological • Other:

the process of evaluating a person's mental health and social status

1. Includes the following in the psychosocial assessment: • Advanced Directives o Location in EMR (EPIC Media Tab) o Apply purple band once order is obtained and signed by MD • Abuse/Neglect • Cultural/Religious Needs • Family Support • Homicide/Suicide Risk • Mental Health • Socioeconomic Status • Substance Use/Abuse—consider the need for: o Guideline for Medication Management of Opioid Withdrawal o Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar)

the process of determining a person’s ability to perform in a desired/designated manner

1. Includes the following in the functional assessment: • Adaptive Equipment • ADLs • Hearing/Language • Learning Readiness • Mobility • Lift equipment/devices • Vision

1. Includes the following: • Assessment (initial and ongoing) • Plan • Intervention • Non-Pharmacological § Heat (obtain MD/LIP order) versus cold Skin assessment before/after treatment § Alternative therapies (i.e. Reiki, etc.) • Pharmacological • Pain Pump (PCA/Epidural/PNB) • Consultation • Documentation: Evaluation and Reassessment • AIR Cycle • Sedation Scales • Patient/Family Teaching

1. Direct observation by preceptor: • Completes fall risk assessment tool appropriately • Implements fall prevention interventions based on low, moderate, high risk for fall • High fall risk –need to implement all fall precaution interventions • Review Post-Fall: post fall process algorithm including appropriate documentation & debriefing • Patient/family teaching for fall risk patients

1. • Nursing Care Plan o Problem list- CPG § Individuality/Mutuality § Problem Resolution o Interventions o Measurable Goals with achievable dates o Evaluation/ Measurable Outcomes • Admission/Transfer/Discharge o Navigators/Flowsheets o Med Reconciliation o Patient/Family Education o W-10 o AVS/Educational Handouts o Referrals/Consults • Review downtime documentation/forms

1. • Identify risk factors (Braden Scale) • Prevention strategies • Identify abnormal findings • Pressure injury staging and measurements • Wound care nurse consultation as indicated • Treatment modalities o Pharmacological o Non-pharmacological § Dressings § Wound vacs § Specialty beds § Pressure relieving devices • Document appropriate assessment and ongoing management

1. Reviews the following processes per policy including but not limited to: • Pre-transfusion o Patient assessment o Patient consent o Type and screen o Viable vascular access o Blood product request • Administration of blood products o Dual sign off o Patient assessment- Monitoring/vital signs • Post transfusion • Transfusion reaction o Recognizes signs/symptoms o Assessment and Management

1. Reviews the following processes per policy including but not • Monitor Set up and maintenance- individualized alarm limits • Patient preparation-skin, leads • ECG rhythm interpretation • Recognition of baseline/normal rhythm strips • Recognition of life-threatening/abnormal rhythm strips

1. • Verifies order • Performs proper skin preparation • Performs proper lead placement • Performs 12 lead ECG • Troubleshooting/eliminate artifact as needed • Changes lead paper • Provider notification as appropriate

1. • Verifies order • Insertion per unit standard • Maintenance o Assessment of site o Recognition of and interventions for infiltration/extravasation/phlebitis • Removal

1. Reviews the following processes per policy including but not limited to: • Discusses different types of CVADs o Verifies patient specific type and location o Verifies correct order set • Maintenance o Assessment of site o Dressing change o Verifies placement and patency prior to use o Verifies maintenance order present o Adheres to CLABSI Prevention Bundle o Demonstrates proper technique for blood draw, flushing and medication administration o Proper cap and line changes • Documentation o Daily documentation o Discharge/transfer-including line verification report/ W10 • Troubleshooting problems associated with CVADs o Identifies complications o Reports concerns to LIP/MD • Patient/Family education as appropriate • Discontinuation of therapy o Daily review of necessity and prompt removal of unnecessary lines o De-access/flushing implanted ports

1. • Performs line reconciliation at every hand off • Identifies and assemble appropriate tubing with proper labeling • Smart Pump set-up o Selects appropriate care area o Programs pump correctly o Troubleshooting/clinical advisories

NOTE: If performing a blood culture from a CVAD, ensure patient meets appropriate algorithm criteria. Use central venous blood culture kit, central venous blood collection checklist and a two-person process.

1. • Verifies order and rationale for lab test(s) • Prints labels and selects appropriate tubes • Verifies patient identification • Selects appropriate site • Gathers appropriate supplies specific to procedure (phlebotomy vs. blood cultures) • Performs venipuncture and follows correct procedure (phlebotomy vs. blood cultures) with correct order of draw • Correctly labels each specimen at bedside • Performs Final Check

1. • Verifies order • Correctly applies, administers and maintains patient specific oxygen delivery system o Portable o Wall • Documents oxygen therapy and patient response in EMR

1. • Gathers supplies • Performs post mortem care • Ensures post mortem checklist is complete • Completes post mortem electronic documentation • Notifies New England Organ Bank (NEOB) within 1 hour of patient death • Discusses resources to support family/friends

1. • Completes Universal Protocol Verification Form (as appropriate for procedures) • Determines which procedures require time-out verification • Accesses and completes pre-op/pre-procedure checklist • Incorporates and documents pre/post-operative and pre/post-procedure patient and family education • Discusses potential risk and complications related to specific procedures • Reconciles pre/post-operative/procedure orders o MAR Hold o Signed and Held orders o Medication Reconciliation

1. Reviews the following processes per policy including but not limited to: • Discusses different types of enteral tubes and feedings • Setup & Maintenance o Feed and flush or for decompression o Gastric Residual Volume Management § Via syringe § Via wall suction (intermittent vs. continuous) o Aspiration precautions o Verifies label(s) o Infection control o Medication administration • Troubleshooting • Patient/Family education • Discontinuation of therapy • Documents: o Type of tube, placement verification (initial and ongoing when accessing tube), type of tube feeding, formula, amount of feeding and residual o Patient tolerance o Skin integrity

1. • Adheres to CAUTI Prevention Bundle o Discusses CDC indication for indwelling catheter o Bladder scan prior to any urinary catheterization o Two-person insertion checklist o Nurse driven foley removal algorithm o Perineal care and catheter care • Discusses different types of catheters-including but not limited to condom, straight, indwelling, urostomy, suprapubic • Documentation • Troubleshooting • Patient/Family education • Discontinuation of therapy

1. • Collaborates with Respiratory Therapy as indicated • Suction equipment o Select appropriate suction equipment o Setup and demonstrate use of suction equipment • Patient/family education • Techniques (select and demonstrate appropriate method): o Clean o Sterile • Documents: o Frequency o Amount o Description o Patient tolerance

1. • Collaborates with Respiratory Therapy as indicated • Inflation/deflation status of balloon • Equipment o Identify types of tracheostomy tubes/equipment o Select appropriate tracheostomy supplies o Maintain at bedside: spare trach tube/obturator, manual resuscitator, and oxygen flow meter, yankauer/suction catheters, and suction equipment • Patient family education • Techniques o Tracheostomy care o Mouth care o Skin care under and around tracheostomy o Aspiration precautions o NPO status (as indicated) • Communication methods • Documents: o Skin integrity o Size o Need for supplemental oxygen o Respiratory therapy o Patient tolerance

1. • Indications for chest drainage • Types of chest drainage o Systems/products § Setup § Measurement § Change • Patient and family education • Maintenance/care o Orders (e.g. CXR, frequency of drainage for pleurx cath.) o Water seal o Dressing o Activity o Suction setting o Troubleshooting • Explains correct method for transporting patient with a chest tube • Documents: o Skin integrity o Size & location o Output (amount and color) o Pain management o Patient tolerance

1. • Collaborates with Respiratory Therapy • Indications for NIPPV, BIPAP, CPAP • Recognizes and responds to patient responses requiring medical intervention • Orders o Equipment from home (approved through engineering) o Settings o Frequency/duration § Scope of service/patient placement • Documents: o Skin integrity o Patient Tolerance • Provides patient and family education

1. • Implements hospital initiative early mobilization program • Collaborates with rehabilitation services/lift coordinator • Indications for lift equipment use o Patient types o Equipment types • Demonstrates proper use of unit-based safe-lifting devices • Patient and family education • Documents: o Patient specific activity level/frequency/distance o Type of lift device or assistive devices o Communication/handoff

1. • Identifies various ostomy appliances • Provides ostomy care o Assesses ostomy surrounding site and stoma o Assesses output characteristics o Changes appliance prn • Collaborates with wound/ostomy nurse • Identifies abnormal findings and/or complications and escalate concerns to MD/LIP • Provides patient/family education

1. Transfers: • Handoff report to receiving area • Ticket to Ride • Documentation • If transferring to an ICU setting, transfers patient on cardiac monitor with physician and/or RN • If transferring to a higher level of care, must give a verbal report Discharges: • Collaborates with care management for ongoing discharge needs • Completes W-10 as needed • Patient/family education • Provides After Visit Summary (AVS) • Discharge folders

1. • Confirms patient meets criteria for therapy • Obtains/verifies MD/LIP order • Identifies process for obtaining equipment • Maintenance/Documentation o Monitors VS as indicated o Assesses skin integrity o Identifies criteria for discontinuation

1. • Reviews and individualizes alarm settings upon application and as indicated • Disables alarms when no longer indicated • Responds to and resolves clinical alarms per priority level and response expectation o High: audible advisory alarms that require immediate attention o Medium: audible advisory alarms that require attention as quickly as possible, but are not considered an emergency o Low: audible advisory alarms that require reassessment of patient and/or equipment

1. • Observes and follows 5 Basic Rights for medication administration • Medication Reconciliation verifies upon admission, transfer/pre-post procedure and discharge • Verifies order o Appropriateness of medication o Consideration for dosing older adults/specific patient populations i.e. onc, renal, hepatic, etc. o self-administration of meds • Reviews drug use and potential side effects o Teach back method with patient • Monitors appropriate VS and lab orders as needed • Verifies/documents presence of allergies (allergy band present as applicable) • Collaborates with unit pharmacist • Utilizes pharmacy resources o Drug use guidelines o IV compatibility o Micromedex o Exit Care o Adult IV guidelines • Utilizes Pyxis med station o Ensures that medications not immediately administered and/or not in original packaging should be labeled appropriately including drug name, dose, concentration, expiration date and two patient identifiers o Ensures medications are properly secured o Proper narcotic waste with witness • Utilizes Narcotic Proof of Usage sheet as needed • Identifies High Risk Medications o Independent double-check/dual sign off o Tall man lettering o Look alike/sound alike drugs • Use of vaccines o Verify need for vaccination upon admission, transfer, prior to discharge o Provide vaccine Information Sheet (VIS) in EPIC • Documentation o Barcode Scanning –patient/medication o EMAR o Downtime procedures o Patient response o Refusal o Adverse reactions § Recognition § Escalate concerns to appropriate MD/LIP (Provider notification tab) § event reporting • Rescheduling/canceling meds • Demonstrates proper procedure using aseptic technique for adding medications to IV bags o Mini-bag plus diluent bag o Non mini-bag diluent bag

1. • Completes Abbreviated NIHSS Training per unit standard • Identifies risk factors • Assesses for signs and symptoms---FAST scale • Activates a Stroke Code and know responsibilities during the code • Anticipates diagnostic testing: CT/MRI/MRA/Echo/ Cardiac Ultrasound • Monitors the following: o BP o Glucose reading o Temperature o Telemetry o Seizure activity • Identifies patient’s stroke type • Patient may require transfer to neuroscience unit/ICU • Performs dysphagia screening • Appropriately consults with services for rehabilitation and stroke recovery care • Patient/family education: Take 5: Take 5 folder o Warnings Signs: sudden weakness/difficulty with speech/vision/headache/dizziness-loss of balance o Risk factors o Follow-up appointment o Medication review o Warning signs o Call 911

1. • Differentiates between bariatric and morbidly obsess based on BSI • Skin care • Medication management/dosing implications • Safety-Bariatric Bundle • Mobility • Psychiatric considerations/consult as appropriate • Patient/family education

1. • Differentiates between delirium and dementia • Assesses signs and symptoms: non ICU CAM tool • Treats the cause as ordered • Reviews medications and lab values with MD/LIP • Maintains a safe environment • Utilizes nonviolent non self-destructive restraints per order and indication • Applies reality reorientation as needed • Obtains appropriate consults • Assists with self-care deficits

1. • Recognizes signs of escalating behavior • Utilizes violent self-destructive restraints as ordered and indicated • Maintains safe environment • Utilizes the panic button as necessary • Contacts Protective Services for emergency intervention and support as needed

1. • Recognizes risk factors • Discusses precipitating factors • Describes key nursing assessments: o Lungs sounds o Edema o Daily weights o Urinary output • Assists patient with psychological needs • Identifies appropriate consults • Documents: o Signs and symptoms o Interventions o Complications • Patient and family education utilizing the Heart Failure Management Plan as indicated

1. • Identifies risk factors • Identifies symptoms including fluid overload • Monitors lab values • Monitors strict I and O • Discusses need for nutritional consult and/or renal diet • Discusses modes of dialysis-CAPD, cycler, hemodialysis • Discusses nursing implications re: med management

1. • Identifies risk factors • Identifies symptoms o Chest pain characteristics o Atypical symptoms (jaw, shoulder and back pain, GI symptoms) • Performs timely ECG o Recognize basic ECG changes o Notify physician in timely manner for interpretation o Differentiate between ischemia and infarction • Verbalizes understanding of cardiac markers • Verbalizes immediate interventions (MONA): o Morphine o Oxygen o Nitroglycerine o Aspirin • Discusses potential complications including but not limited to dysrhythmia, heart failure, pulmonary edema, pericarditis, cardiogenic shock, sudden death • Documents: o Signs and symptoms o Interventions o Complications o Patient and family education

1. • Identifies risk factors • Recognizes symptoms o Fever o Hemodynamic instability o Altered mental status o Decreased urine output • Discusses appropriate interventions (as ordered): o IV fluids o Obtain blood cultures o Administer antibiotics o Transfer to a higher level of care as needed • Documents: o Signs and symptoms o Interventions o Complications o Patient and family education

1. • Identifies risk factors • Discusses indications for the need for anticoagulation • Discusses anticoagulants and appropriate baseline and ongoing lab tests • Initiates heparin therapy or the Adult Heparin Infusion Protocol as ordered • Reports lab results outside of the prescribed parameters • Documents: o Signs and symptoms: warmth, swelling, possible pain o Interventions o Complications o Patient and family education

1. • Identifies risk factors • Recognizes symptoms • Discusses appropriate interventions (as ordered): o Fluids o Rest o Oxygen o Antibiotics as indicated o ABGs o CXR o Sputum culture • Documents: o Signs and symptoms o Interventions o Complications o Patient and family education

1. • Differentiates type 1 from type 2 diabetes • Identifies precipitating factors, signs, and symptoms of hypoglycemia and hyperglycemia • States critical high and low values of blood glucose • Demonstrates immediate interventions to take as related to hypoglycemia/hyperglycemia • Describes onset, peak, and duration of various types of insulin and oral hypoglycemic agents • Monitors bedside glucose as clinically indicated and as ordered • Discusses the importance of patient education as it relates to meal consumption and insulin administration • Coordinates insulin/hypoglycemic medication with patient meals • Identifies consults required to assist with patient management, education, and discharge needs • Newly diagnosed patients should have a consult placed with the diabetic CNS • Initiates Non-Critical Care Insulin Infusion Protocol per MD/LIP order

1. • Reviews patient’s advance directive • Obtains order for comfort care • Demonstrates interventions to ensure optimal symptom management related to but not limited to: o Secretions o Pain-comfort care opioid infusion as clinically indicated • Provides emotional support to patient/family • Offers Comfort Cart to family • Obtains appropriate consults, such as: o Chaplin o Virtual Hospice o Social Services

1. • Engages in early identification • Performs assessment of: o Understanding of the illness o Pain o Physical problems o Psychosocial problems § Coping skills § Family supports o Spiritual problems • Utilizes a multidisciplinary approach including the family • Advance directives

1. • Discusses role in emergency response for the unit • Reviews department specific fire response o Code red emergency number o PASS/RACE o Location of fire alarms • Reviews emergency exits • Reviews department specific emergency evacuation plan • Locates oxygen shut off valve o Can only be tuned off by a certified respiratory therapist • Locates gas shut off valve • Identifies clean/dirt equipment storage specific to area • Reviews hazardous waste disposal specific to area • Maintains proper egress o Keeps fire doors clear o Keeps fire extinguisher unobstructed o Keeps oxygen shut off valve and gas shut off valve unobstructed o Keeps stairwell clear

1. • Verifies sticker with appropriate maintenance review date (notify appropriate personnel if outdated) • Completes equipment repair form/ call for repair as required • Completes emergency equipment checklist daily or as delegated • Notifies engineering for any personal equipment from home

1. • Demonstrates ability to access: o Policies and procedures o Nursing website o Nursing resource Index o Mosby’s Skills o Micromedex o Pharmacy resource o LIP credentialing o Materials Safety Data Sheets (MSDS)

1. • Demonstrates proper hand hygiene • Utilizes standard precautions with all patients • Follows additional isolation precautions when indicated • Utilizes personal protective equipment (PPE) appropriately when indicated • Disinfects all medical equipment in contact with patients between patient use o Ensure proper wet time of disinfecting wipes o Ensure proper wet time of bleach wipes • Demonstrates proper sharps disposal • Notifies environmental associate to replace sharps disposal container when >3/4 full • Patient/family education o Hand hygiene o Isolation precautions in use o Use of PPE o Discontinues isolation precautions when appropriate

1. • Verifies patient identification using 2 accepted identifiers o Patient name o Date of birth • Engages patient in identification process • Verifies presence of identification band • Discusses process of rebanding • Reviews special alert bands/color bands • Performs bar code scanning for identification and safe practice (i.e. med admin, lab specimens) • Performs “Final Check” as applicable

1. • Confirms patient allergies in the medical record and/or with patient • Documents allergies in EMR • Verifies the presence of an allergy band • Consults dietician regarding food allergies

1. • Discusses the 5 P’s and why they are important-Potty, Pain, Positioning, Proximity, Preference • Demonstrates key behaviors • Utilizes white boards in patient rooms

1. • Discusses process for escalation of care • Discusses procedure on activating an emergency • Identifies criteria used to call RRT vs code • Identifies roles (see supervisor for assigned role) • Discusses appropriate hand off communication (SBAR) o RRT o Code Team o Receiving unit • Identifies emergency equipment/ discuss proper use of o Code cart o AED/defibrillator o EKG machine • Discusses family/significant other support resources • Documentation o RRT o Code o Code evaluation form o Transfer to a higher level of care • Verbalizes procedure for code cart replacement • Discusses family presence at bedside

1. • Discusses alternatives for restraint use • Identifies potential triggers that may lead to restraint use • Differentiates between the following restraint standards: o Violent/Self Destructive o Non-violent/Non-self-destructive • Discusses use of and care of custodial restraints • Discusses purpose/use of the restraint crisis bag • Identifies non-physical interventions (i.e. de-escalation, reducing stimulation, verbal redirection) • Obtains original order from LIP • Discusses order renewal process/frequency • Chooses least restrictive device for the situation • Demonstrates/discusses proper application (quick release) and removal • Discusses/identifies signs of physical/psychological distress due to restraint use • Identifies indications that restraints are no longer needed • Documents: o Restraint flow sheet ü Alternative interventions tried ü Clinical justification ü Restraint monitoring-visual checks, circulation, ROM, fluids, food, and elimination o Assessment of continued need o Patient/family education o Modify plan of care as needed o Use of restraint downtime forms

1. • Identifies language barrier needs • Identifies procedure for obtaining interpreter services • Requests interpreter services or equipment within 15 minutes of patient/family contact • Locates appropriate auxiliary aids such as telecommunication or personal listening device

1. • Reviews steps for on-line event reporting • Discusses unit chain of command for problem solving patient care issues • Discusses escalation of care issues • Adverse events: o Identify circumstances and/or events that require reporting • Medication variance o Notify the appropriate action(s) to take o Notify MD/LIP

1. • Discusses Shared Governance Structure and the role of the clinical nurse o Locate and review nursing website o Practice change requests o Practice change alerts o Open comments • Identifies unit representatives • Professional Practice Model (PPM) • Magnet designation: o Ethics resources o Evidenced Based Practice (EBP) resources o Peer Review o Nurse sensitive indicators

1. CHAMP Behaviors: • Communicates clearly and effectively o Reads back/read backs with clarifying questions o Phonetic and numeric clarifications o Discusses procedure for accepting verbal orders, critical lab results • Handoff effectively o SBAR o Reviews hand off tools and unit-specific tools • Attention to Detail o Self-check using Stop, Think, Act, Review (STAR) • Mentor each other-200% accountability o Cross checks and coaches teammates o Speaks up for safety • Practices and accepts a Questioning Attitude o Validates and verifies o Stops the Line o Seeks clarification when needed o Demonstrates effective problem-solving skills

1. • Identifies team members • Shows respect for team members • Differentiates roles and responsibilities of the interdisciplinary team o Nursing o Medicine/surgery o Ancillary services

1. • Demonstrates the ability to delegate appropriately to the following staff within their scope of practice: o RNs o LPNs o Unlicensed Assistive Personnel • Performs appropriate follow up with staff on assigned delegated activity • Evaluates outcome of delegated tasks

1. • Exercises courtesy and helpfulness towards all customers • Professional appearance/uniform • Displays ID badge • Accepts responsibility for own actions • Role models professional behavior • Respects cultural and personal differences • Manages change effectively

1. • Able to prioritize shift’s activities appropriately • Effective organizational skills • Asks for help when appropriate • Performs assignment responsibilities with appropriate timeliness

1. • Shows respect for patients and families • Demonstrates cultural & spiritual sensitivity • Applies principles of patient/family centered care • Establishes mutual goals with patient/family • Ensures privacy • Responds to patient/family concerns • Performs bedside report • Utilizes white boards • Performs service recovery when indicated • Identifies unit performance based on: o HCHAPS / Press Ganey

1. • Recognition Clinical Advancement Program (RCAP) • Committee involvement • Specialty certification • Educational advancement • Ongoing annual competencies o Regulatory o Unit based • Professional organizations