CCTC Graphic Record RevisionsIntroduce new graphic record

Provides more area for charting routine interventionsComplements the soon-to-be revised AI recordProvides the basis for EPR

Define documentation standardsDocumentation standards define the ruler used to measure practiceKnowledge of standards essentialStandards of Nursing Care can be found on CCTC website under “Standards”

CCTC Graphic RecordOn AI record, a “tick” means within normal limitArrow over if everything is the same as last chartingIf findings are outside normal limits, you must “Star” and “DAR” in the AI recordRemember to chart responses to interventionsREMEMBER TO INITIAL at the bottom of each column when data is entered

CCTC Graphic RecordIf you carry out an intervention by “prn” option (e.g., measure a blood gas), you are required to document the reason

Failure to document rationale is equal to carrying out a medical act without an order

If you chart that you will “Monitor electrolytes and treat per PPO” on the 0700 hrs Assessment Record, you don’t need to chart why you gave a potassium bolus and repeated the lytesIf you measured lytes due to an arrhythmia, this is outside the PPO and requires a reason documented

CCTC Graphic RecordRemember to document the response to an intervention

Failure to document response indicates pre-existing problem is still present (e.g., if charting indicates SpO2 has decreased and FiO2was increased, failure to chart the response indicates the patient still has a low SpO2)“Arrow over” means everything is the same as charted in the last notationDo not arrow over from a “Star” and DAR” for a one time event (e.g., family meeting, dressing change)

Neuro Page

• Chart all labs and diagnostic tests

• Chart transfers in and out

STANDARD:• Must document in AI record reason labs are

drawn if by “prn” protocol

• Labs not included in preprinted protocols require an order (e.g., cardiac enzymes, liver enzymes, cultures)

Neuro Page

• ICP, CPP, zero/level and SjO2 moved to neuro section

• Add Train of Four here is needed

STANDARD:• Chart hourly if ICP in place

• Calculate CPP

T.O.F. 2/4

Neuro Page

• Neuro definitions simplified

• Link scores to create graph

STANDARD:• Document q shift for all patients

• Document q 1 h for all acute neuro

• Document q 1-4 h for stable neuro

Neuro Page

• Chart pupil size after adjustment to ambient room light

• Continue to use previous codes:

Brisk

= Fixed

- Sluggish

STANDARD:• Monitor and chart q1h and prn for

patients with neurological injury.

• Pressure on 3rd cranial nerve causes loss of ability to constrict on the side of the lesion (or loss of the parasympathetic response). Pupil becomes dilated and non-reactive. 3rd cranial nerve is located at top of brainstem; new finding suggests brainstem compression.

• Sympathetic control of pupil is located in pons; injury here causes loss of ability to dilate (pupil becomes pinpoint and non-reactive).

Neuro Page

• Chart eye opening, verbal and motor response.

• Total each score.

• Trend important.

STANDARD:• Chart q shift for all patients

• Chart q1-4h for all patients with neurological alteration

• Chart BEST response; GCS is an assessment of the BEST cerebral function not symmetry

• Provide best estimate of verbal response.

•If intubated patient able to write or communicate appropriately, give a 5 (or 4).

• Do not mark “T” unless the patient could be better.

Steven is a 26 year old who sustained a head injury. He opens his eyes to pain only, is intubated and plays with his foley catheter with his right hand.

He has abnormal posturing with his left arm and no movement in his legs.

What is his GCS?

Eye Verbal Motor6 obeys

5 oriented 5 localizes

4 spontaneous 4 confused 4 withdraws

3 voice 3 inappropriate 3 flexion

2 pain 2 incomprehensible 2 extension

1 none 1 none 1 none

4 5 6

Because he is not communicating, his verbal score is “1”. If you think he might be able to make verbal sounds if extubated, you can give him a 1T (total score 8T) to indicate he is at least an 8, possibly higher.

Tom has a C3 cord injury. He opens his eyes spontaneously, is ventilated, has flaccid paralysis X 4 and blinks to

command.

Eye Verbal Motor6 obeys

5 oriented 5 localizes

4 spontaneous 4 confused 4 withdraws

3 voice 3 inappropriate 3 flexion

2 pain 2 incomprehensible 2 extension

1 none 1 none 1 none

4 5 6His inability to move is not related to his brain. GCS identifies his best cerebral function. Within the limits of his cord injury and ETT, he is able to obey and communicate. His score is 15. DO NOT add a “T” to his verbal or total score, as you have already given the highest verbal score possible. “T” indicates the score could be higher.

Neuro Page

• Identify differences in each limb

STANDARD:• Record L (localizing), W (withdrawal), F (flexion)

or E (extension). “O” means “no movement” (NOT obeying). Can use + or – if localizingbilaterally with obvious weakness.

• If patient obeys, a numerical score using 0-5/5 motor score is required.

• If patient has uncleared CTL spines or is a post-op aneurysm repair, a spinal cord record must be used and chart q1h until clear.

Motor Score5. normal strength (muscle contraction

against resistance)4. mild weakness (weakly against resistance)3. support limb against gravity but not

against examiner’s resistance2. able to move but not against gravity1. flicker but no movement0. no movement

12-hour Vital Signs Pages

Charting of BP, HR and temperature unchanged

• Chart high and low alarm limit settings or “off”

• ExampleECG: 50-130

STANDARD:• ECG and BP alarms are on

and set appropriately

• If you chart “off”, rationale and troubleshooting must be documented in AI record

50-130

12-hour Vital Signs Pages

• Chart SVO2 (drawn from PA tip) or ScvO2 (drawn from right atrial sample drawn from IJ or SC)

STANDARD:• Venous oxygen saturation is measured

to examine adequacy of cardiac output (it is not a pulmonary assessment)

• Measure to evaluate adequacy of CV resuscitation, BP or CV drug support

• Decreased levels indicate inadequate oxygen delivery (need to optimize CO, arterial saturation and/or hemoglobin)

• Normal SVO2 60-80% (PVO2 = 40)

• In absence of PA, use SC or IJ blood gas sample (normal > 70%)

ScvO2 .58

12-hour Vital Signs Pages

• Chart “L” or “Z”

• Chart “L” to indicate that the level has been confirmed or adjusted

STANDARD:

• Check “L” at 0700/1900 hrs and with each hemodynamic data collection set

• Chart “L” to confirm placement at 0700/1900 hrs, q6h, when level is adjusted, and to confirm placement when CVP or PWP is measured

• Strips must be posted for CVP and PWP recordings

• Zero with initial setup and prn

L

12-hour Vital Signs Pages

• Chart total respiratory rate

STANDARD:

• Chart hourly or when changed

12-hour Vital Signs Pages

• Chart actual highest and lowest pressure (not set PS/PC and PEEP)

21/5

STANDARD:

• Chart hourly or when changed

12-hour Vital Signs Pages

• Chart total minute volume (VE), at rest

• Chart total minute volume at time blood gases are drawn

STANDARD:

• Chart hourly or when changed

• CO2 clearance is related to VE

• Increased at rest VE indicates increased MR (e.g., fever, sepsis, pain, removal of sedatives)

12-hour Vital Signs Pages

• Chart set parameter

STANDARD:

• Chart hourly or when changed

12-hour Vital Signs Pages

STANDARD:

• Chart hourly or when changed

• Chart set parameter

12-hour Vital Signs Pages

• Chart set parameter

.4/5

STANDARD:

• Chart hourly or when changed

12-hour Vital Signs Pages

• Chart infusions here

• Do not chart insulin here

• Chart ml/hr over dose/hr OR dose only (dose on bottom)

• Identify type of dose in first column (e.g, mg/hr, mcg/min, mcg/kg/min)

STANDARD:• Can “arrow dose/hr over” until

changed

• Rate is only charted if it makes it easier to calculate dose

• Chart drug/solution (D5W or 0.9) on I/O

• Chart concentration/solution on MAR

• At each hour, chart the dose received over the previous hour

NE mcg/minMS mg/hr

20/54

5

Intake and Output

• Chart 0600-0600

• Chart flush solutions/IV meds

• Chart dialysis

STANDARD:• Identify each infusion by listing drug and

solution (e.g., NE in 0.9 NaCl)

• I and O tracks the volume of each solution (and needs to reflect total D5W versus 0.9 NaCl)

• Concentration MUST be signed for on MAR

• Flush feeding tube with STERILE WATER before and after meds, q6h and prn

Care Routines

• Chart PA position at entry to introducer

• Chart when tubing is changed

• Document significant findings (use AI record if needed)

STANDARD:• Chart the PA catheter marking at the

start of each shift

• List each intravascular site

• means WNL for infusion, site, lok

• Initial your assessment

• Change tubing q96 hrs (C or P), q12h for propofol, q24 hr for TPN or lipids, and after 2 units or q24 hr for blood tubing

• Label the tubing and kardex! (sticker in pt drawers)

Care Routines

• More options for charting activity

• Chart HOB in degrees

• Chart activity

STANDARD:• Maintain HOB elevation >30

degrees for all patient with ETT, unless contraindicated

• If not elevated, document reason HOB < 30 degrees in AI record; reassess/reattempt q4h

• Reposition q2h

• Goal: earlier ambulation

Care Routines

• Chart tubing changes

• Chart “new bag” on I/O

• Chart flush on I/O

STANDARD:

• Change tubing q 4 hours when feeds are changed for open system

• Change tubing q 24 hours for closed system

Care Routines

• Chart stool using code

• Chart impaction check

• Chart when bowel routine applied

STANDARD:

• Check for impaction q3days if no BM

• REMEMBER TO CHART LAXATIVES ON MAR

Care Routines

• Chart hourly insulin dose in units/hr

• Chart glucose checks

• Chart administration of 50% dextrose to provide tracking

• Do not chart insulin in infusion section of graphic

STANDARD:

• REMEMBER TO CHART INSULIN SYRINGE CHANGES ON MAR

• Change syringe daily at 1600 hrs

• CHART 50% DEXTROSE ON MAR

• Chart insulin/solution on I/O

Care Routines

• Chart VAMASS

• Chart pain assessment (0-10/10 or subjective criteria)

STANDARD:• Chart VAMASS q4h for awake, comfortable

patients

• Chart MASS if unventilated

• Chart VAMASS q1h for continuous sedation (infusions or regular doses), or for patients requiring prn sedation

• Chart VAMASS on MAR at time prn dose given

• Document comfort assessment (pain, anxiety) at start of each shift and track q4h on AI record

Care Routines

STANDARD:• Document consent in AI record and Kardex

• If consent refused, family must sign release form

• Assess CSM q15X4, then q1h

• Remove and reapply q2h. Chart q2h. Monitor alignment (especially shoulder stretch)

• ROM q12h

• Reassess q shift and document reason for ongoing need

• Document interventions used to avoid restraints. Least restraint policy

• Q shift, assess and document response to restraints off

• Chart use, removal and limb color, sensation and movement

Care Routines

• Chart when catheter inserted or changed

• Chart type of catheter used

• Chart drainage bag change

STANDARD:

• Change standard catheter q7days or prn

• Change silicone q monthly

• Change drainage bags q7days

Care Routines

• Chart type of care

• Chart skin inspection

STANDARD:• Hair wash bags appropriate when hair

washing is contraindicated; wash hair once tray can be used

• Bath q 24 hr and prn; coordinate to promote sleep

• Peri/catheter care q 6-12 hr

• Assess skin q shift. Document findings, interventions and response to treatment in AI record

Care Routines

• Chart type of oral care provided

• If inspection not WNL identify with * and document in AI record

• Add H202 to “other”

STANDARD:

• Mouth care q4h and prn

• Brush teeth q shift and prn

• Order required for chlorhexidine (consider for patients with poor oral hygiene, +secretions, halitosis)

Care Routines

• Chart eye lubricant using D = drops; O = ointment

• Chart eye patch or other

STANDARD:

• Eyes must be closed if patient is unconscious or NMB in use

• Lubricating ung may be all that is required to keep eyes shut

• If patches used, be sure eyes are closed under patches

• Chart meds on MAR

Care Routines

• Chart shave

STANDARD:

• Shave male patient’s daily

Care Routines

• Chart color care, splints on and off, ROM

• Chart abnormal findings in AI record

STANDARD:

• Collar care and inspection q shift

• Splints on and off q2h unless otherwise ordered

• ROM q 6-12 hr

Care Routines

• Chart TEDS/SCD on with +

• Record that skin care is given and inspection performed once per shift

• * and DAR findings not WNL

STANDARD:

• TEDS off once per shift for skin care and inspection only (not “off” for 20 minutes)

• SCDs should go to scan or to OR

• If off > 30 minutes, physician needs to decide whether a Doppler study is needed and document

Care Routines

• Chart when suctioned

STANDARD:

• Suction prn.

• Suction at least twice per shift with assisted cough for C-spine and NMB

• Document copious, purulent or bloody secretions in AI record

• Flush suction catheter after each suctioning episode

• Do not routinely instill saline

Care Routines

• Chart rotation and vibration therapy

STANDARD:

• Bed use for patients meeting criteria

Care Routines

• Chart dressing changes

• Chart changes in chest drainage unit

STANDARD:

• Chart abnormal findings in AI record

• Change chest tube dressings q2days and prn

• Trach dressings q shift and prn

• Change chest drainage unit q 7 days