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INSTRUCTIONS FOR USE OF COMPETENCY BASED ORIENTATION PATHWAY (CBO)
DOCUMENTATION .2
WEEKLY OBJECTIVES 3
NURSING COMPETENCY BASED ORIENTATION PATHWAY13
GENERAL ASSESSMENT ....................................................................................... 13
NEUROLOGIC/BEHAVIORAL ................................................................................. 13
PULMONARY SYSTEM ............................................................................................ 15
CARDIOVASCULAR ................................................................................................. 18
GASTROINTESTINAL SYSTEM ............................................................................. 20
GENITO-URINARY SYSTEM .................................................................................. 23
ENDOCRINE & HEMATOLOGIC SYSTEMS ........................................................ 26
MUSCULOSKELETAL SYSTEM ............................................................................. 28
SKIN AND WOUND ................................................................................................... 32
PAIN/COMFORT ........................................................................................................ 35
SAFETY PRECAUTIONS ......................................................................................... 38
EMERGENCY RESPONSE ..................................................................................... 38
INTRAVENOUS THERAPY...................................................................................... 40
BLOOD ADMINISTRATION ..................................................................................... 41
AUTO TRANSFUSIONS ........................................................................................... 43
SPIRITUAL CARE/PSYCHOSOCIAL CARE ......................................................... 43
FOCUS AREAS .......................................................................................................... 44
RESTRAINTS AND SECLUSION ....................................................................... 44
COMMUNICATION ................................................................................................ 45
UNIT MANAGEMENT ........................................................................................... 46
PROFESSIONAL NURSE .................................................................................... 48
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UP-PGH CBO
Instructions for Use of Competency Based Orientation Pathway (CBO) Documentation
The purpose of this document is to assist the preceptor in providing a comprehensive and consistent orientation. It is intended to provide a foundation for practice
in the area of acute care to promote high standards of nursing practice.
It is the responsibility of individual acute care nurses to identify their practice parameters in accordance with Philippine nurse practice acts, professional codes,
professional practice standards, and their own competency.
The CBO guides the orientee in understanding the expectations of the University of the Philippines Philippine General Hospital Manila and documents the
orientation process received by new employees. It is intended to assist with the individualization of the orientation.
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UP-PGH CBO
Weekly Objectives for New Graduate Registered Nurse (Goal: 1 12 weeks, variable)
WEEK
1
PRIMARY OBJECTIVE
PLAN
On Unit:
Day 1
1. No patient assignment for orientee or preceptor
2. Tour of hospital, including library as appropriate, nursing administration, conference rooms,
HR, other units, pharmacy, lab, radiology, operating room, Central supply, cafeteria
3. Preceptor review purpose and function of Competency Based Orientation (CBO) Pathway;
orientee complete self assessment
4. Orientee given unit-specific orientation protocols by preceptor
5. Meet with supervisory personnel and preceptor
a. Supervisory personnel, preceptor, and orientee review CBO self assessment
i. Identify clinical strengths and weaknesses of orientee
ii. Develop orientation plan
b. Align preceptor and orientee schedules
i. To accommodate no more then than two preceptors per orientee
ii. Coordinate Continuous Education and necessary classes; e.g. CVAD, EEG,
PTE, temporary pacemakers, et al.
iii. Identify off-unit learning opportunities; i.e. OR observation, Infusion Center,
Cath Lab, etc.
6. Unit tour including, but not limited to:
a. Medication room
i. Delivery of meds
ii. Distribution/ location of meds
iii. Methods of interface with pharmacy
iv. Proper medication labeling
v. Proper medication storage
vi. Proper medication handling
b. Physical structure of unit
i. # Beds and rooms
ii. Private vs semi private rooms (A&B)
iii. Locations:
1. Code blue button
2. crash cart
3. med room
4. nursing lounge
5. physicians lounge
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UP-PGH CBO
7.
8.
9.
10.
6. supply rooms
7. dirty utility room
8. nurses mailboxes
9. nurses station
c. Bed functions
i. Call lights
ii. Bed lights
iii. Positioning (trendelenberg, reverse trendelenbeg), degree of elevation
iv. Special bed indications and resources
d. Document storage (paper)
e. Patient medical record
f. Medication Administration Records (paper and electronic)
g. Nursing unit white boards
Safety procedures
a. Fire
b. Gas shut off valves
c. Evacuation route
d. Yellow name badge card
e. Codes
f. Evacuation devices
Administrative functions
a. Telephone etiquette
b. How to transfer a call
c. Red phones
d. Nondisclosure status
e. Work schedule: location and procedure
f. Process for vacation request, missed break or meal
Communication
a. Chain of Command
b. Paging protocol
c. Physician privileges
d. CPAR
e. Elements of Nursing Report
f. Who to Call/ MD coverage
g. Paging via WebRef
h. Primary vs consulting physician services
i. Physician ID numbers (PID)
j. UP-PGH phone book
i. Paper
ii. WebRef
iii. Blink
PCIS
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UP-PGH CBO
a. Printing of PCARS
b. Charting assessments
c. Charting Point of Care testing
d. Charting Care Plan
e. Charting PADB
f. Review report/results (lab, procedures, consults)
11. Resources
a. Nursing colleagues
i. Nurse Manager
ii. Assistant Nurse Manager
iii. Charge Nurse
iv. Preceptor
v. Interdisciplinary team
vi. Co-workers
vii. Superusers
viii. Nursing Education, Development, and Research
ix. Case Managers
x. Wound and ostomy nurses
xi. Vascular access nurses
b. Interdisciplinary colleagues
i. PT
ii. OT
iii. MD, NA, MW
iv. Nutrition
v. Speech
vi. RT
c. Pocket Reference Cards
i. Patient Safety Goals
ii. Phone numbers
iii. Core Values
iv. Pillars of Excellence
v. Clinical resources
d. Unit-specific resource binders
e. WebRef
i. MCPs (have new hire find blood administration MCP)
ii. Care Notes
iii. CP online
iv. Infection Control
v. Library
f. Lift team and/or lift devices
12. Equipment
a. Vital sign machines
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UP-PGH CBO
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
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UP-PGH CBO
Week 2
through
4
Two patient assignment with direct preceptor oversight. May assist with admit or
discharge, transportation of patient, administer blood etc
1. Perform general assessment
2. Completes system focused assessment (neuro, CV, GI per patient diagnosis, needs
assessment as correlated with vital signs, I&O, labs, signs & symptoms)
3. Follow clinical pathways
4. Develop/ revise plan of care
5. Document with preceptor audit
A midpoint meeting should be scheduled at the end of week four.
Participants: 1) Nurse Manager, 2) Preceptor, 3) Educator, 4) Orientee
Focus: Review progress and accomplishments of the orientee toward orientation goals.
Bring to the meeting: 1) Nursing Competency Based Orientation Pathway and 2) Planning Guide
Objectives:
Review orientee strengths and accomplishments
Establish plan to support and encourage the orientee to achieve independent and
interdependent practitioner roles
Determine if orientation is meeting orientees needs
Realign orientation plan to meet orientees needs
Discuss orientees integration into unit culture
Insure that CBO document is up to date, identify elements for follow up on the CBO document
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UP-PGH CBO
Week 5
3.
2.
4.
Continue with previous bedside objectives
and skill acquisition and expand per CBO
Pathway and as patient assignment
allows.
Week 6
Week 7
5.
5.
3.
5.
4.
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UP-PGH CBO
and skill acquisition and expand per CBO
Pathway and as patient assignment
allows.
Identify what duties can be appropriately
delegated to other members of the
healthcare team.
Week 8
Week 9
Bring to meeting: 1) Patient assessment, 2) plan of care, 3) vital signs, etc. for a full day of
patient care and the 4) CBO document.
Objectives:
Review orientee strengths and accomplishments
Establish plan to support and encourage the orientee to achieve independent and
interdependent practitioner roles
Determine if orientation is meeting orientees needs
Realign orientation plan to meet orientees needs
Discuss orientees integration into unit culture
Insure that CBO document is up to date, identify elements for follow up on the CBO
document
Evaluate documentation consistency within UP-PGH guidelines. If documentation issues
are identified, they will be shared with the orientee
Evaluate readiness to complete orientation, determine future planning
Develop mechanism for ongoing support, e.g. mentor, buddy
1.
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UP-PGH CBO
and skill acquisition and expand per CBO
Pathway and as patient assignment
allows.
2.
3.
Week 10
4.
5.
1.
2.
3.
Week 11
4.
5.
1.
2.
3.
Week 12
4.
5.
1.
2.
3.
4.
5.
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UP-PGH CBO
Weekly Objectives for Experienced Registered Nurse (Goal: 2 4 weeks orientation, variable)
WEEK
1
PRIMARY OBJECTIVE
PLAN
On Unit:
Day 1
No patient assignment for orientee the first 4 hours. Can be spent with preceptor or charge.
1. Complete CBO self assessment
2. Schedule weekly CBO Pathway progress meeting/ review reports
3. Tour of hospital
4. Scavenger hunt
5. Co-assignment with preceptor
a. Blood draws
6. Orientee to locate and review protocols for
a. Central line
b. Falls
c. Restraints
7. Patient co-assignment with preceptor for remaining 8 hours of shift.
a. Communication
i. CPAR
ii. Chain of command
Day 2
Full assignment between orientee and preceptor.
a. Expand skill acquisition including documentation per CBO Pathway and as patient
assignment allows
b. At the end of each day, review progress and establish goals for the next day
Day 3
Full assignment between orientee and preceptor.
a. Mid-day # 3, schedule time for weekly progress evaluation
b. Completion of CBO documentation
c. Proactively develop the plan of care for assigned patients with minimal assistance
from preceptor
Week 2 next page
Day 4, 5, 6
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UP-PGH CBO
Orientee takes full assignment with preceptor.
a. Preceptor oversight seeking out learning experiences, commensurate with
orientees assignment.
b. Identify what duties can be appropriately delegated to other members of the
healthcare team.
Mid-day, day 6
a. Weekly progress evaluation
b. Meet with Nurse Manager to make competency recommendation
c. Complete CBO Pathway documentation
3-4
Week 3 4
Take full assignment.
a. Continue with previous bedside objectives and skill acquisition
b. Expand per CBO Pathway and as patient assignment allows
Meet with Nurse Manager, Educator to make competency recommendation, unit fitness
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UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
EVALUATOR
ASSESSMENT
Met
Date
Initials
GENERAL ASSESSMENT
Obtains head to toe assessment every shift (q12h)
and prn changes in patient condition or per MD order
Reviews history and physical, medical record, and
pertinent nursing documentation on admission
Assesses overall general appearance
Obtains, assesses and trends vital signs per routine,
prn changes in patient condition or per MD order
Assesses patient response to illness and treatment:
changes in body image, self concept, role
performance
Identifies problems from the assessment and
formulates a plan of care
Collaborates with patient/family to identify expected
outcomes
NEUROLOGIC/BEHAVIORAL
Assesses mental status, orientation using Glacow
Coma Scale (GCS)
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Self Assess
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Follow up:
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Met
Date
Initials
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Self Assess
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Initials
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Self Assess
PROCEDURE OR SKILL
Follow up:
EVALUATOR
ASSESSMENT
Met
Date
Initials
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Self Assess
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Self Assess
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Initials
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Self Assess
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Date
Initials
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Self Assess
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Date
Initials
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UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
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ASSESSMENT
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Date
Initials
nare.
Ongoing assessment for nasal feeding tubes: verifies
that marking is at nare, tube is not coiled at back of
throat.
Assesses for watery eyes, coughing and changes in
vocal quality which indicates incorrect tube placement
Performs Interventions
Inserts and maintains nasogastric tube for suctioning
and/or small bore feeding tubes for nutrition
Maintains patency of feeding tubes. Flushes with NS
q 4-6 hr, & before and after medications
Uses aseptic technique when handling enteral
feeding: washes hands, dons non sterile gloves when
setting up tube feeding, administering meds, checking
residual.Uses med administration port when giving
meds or checking residual.
Administers medications via a gastric or nasogastric
tube
Confirms placement of nasogastric tube by
auscultation of injected air and aspiration of stomach
contents (if able).
Administers medications to alleviate constipation and/
or diarrhea
Collaborates with MD and institutes a bowel
management program
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Date
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Initials
Acute Care
Guidelines of
Care
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Self Assess
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Met
Date
Initials
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Date
Initials
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speech, moon-face
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Initials
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Initials
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Initials
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and contacts MD
Documents appliances, devices, mobility status
Documents skin integrity
Documents neuromuscular and vascular status
Documents and trends labs (Hgb and Hct, PT, PTT,
INR) Documents reporting abnormalities to MD
Documents nutritional intake and output
Documents patient's adherence to mobility restrictions
Documents non pharmacological interventions for
comfort
Documents patients mood
SKIN AND WOUND
Performs Assessment
Assesses skin for intactness, integrity, moisture,
dryness, edema
Assesses need for specialty bed
Inspects hair, nails, and skin for cleanliness
Determines pressure ulcer risk using Braden Scale on
admission, every shift and changes in patient
condition
Assesses skin closures for sutures, staples, and other
skin closures
Assesses intactness and appropriateness of dressing
and drainage q shift, prn and changes in patient
condition
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Date
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Initials
9
9
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Initials
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Self Assess
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The Nursing
Practice Act
Section 2725
(B)(1)
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MCP 380
MCP 380.1
MCP 305.1
MCP 380.1
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victim
Selects IV catheter size according to patient need
Assesses for presence of central and peripheral
venous access; identifies infiltration, occlusion and
dislodgement of catheters
Performs venipuncture according to policy
Maintains & changes dressings per standards
Maintains & utilizes saline locks according to
standards
Utilizes non free-flow devices with all infusion pumps.
Demonstrates free-flow check.
Utilizes/maintains pumps per manufacturer guideline
States/demonstrates proper procedure for D/C IV
BLOOD ADMINISTRATION
Assessments
Verifies MD order for transfusion of blood product,
differentiates that an order for a type and cross match
is not an order to transfuse
Verbalizes indication for transfusion
Verifies consent for blood transfusion is present in
chart, if not notifies MD
Verbalizes that each blood administration tubing is
good for 4 hours or 2 units of blood products
whichever occurs first
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Initials
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Performs Interventions
Verbalizes indications for contacting Social Work and
Pastoral Care
Demonstrates ability to access Social Work and
Pastoral Care
Provides means to meet spiritual needs
Considers spiritual needs when providing care
Addresses spiritual needs in Plan of Care
Advocates for patient's requests for
chaplaincy/spiritual counsel
Focus Areas
Restraints and Seclusion
Performs Assessment
Initiates alternative measures to use of restraints: e.g.
de-escalating behavior, moving bed closer to nurses
station, family members at bedside, judicious use of
medications, distraction techniques
Identifies patients at risk for needing restraint
Differentiates between the need for medical vs.
behavioral restraint
Applies and maintains restraints, obtains MD order
within 12 hours of applying restraint
Reassesses need for continuing restraints every 2
hours
Properly applies restraints
Monitors restrained patient at required time intervals
Documents Assessment, Problems &
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PROCEDURE OR SKILL
Follow up:
EVALUATOR
ASSESSMENT
Met
Date
Initials
Interventions
Checks presence and timeliness of MD order and
renewal order
Completes restraint seclusion documentation form
frequency?
Appropriately enters patient data in Unit log book
COMMUNICATION
Communicates clearly and concisely
Gives change of shift /hand off report that includes
patient age, dx, problems, plan of care treatments,
interventions, response to care and progress in
attaining goals
Prioritizes care using critical thinking, trending of vital
signs, data, monitoring, timeline strategies and
specified goals. Evaluates and communicates results.
Demonstrates paging system including phone page,
emergency page.
Delegates tasks and assignments appropriately to
members of the team to include: NA, INTERNS, RN,
other clinical staff
Makes shift change rounds with on-coming RN
Verbalizes how and when to obtain intepreter
services: must be used for consent, relaying of
diagnoses and assessment
Identifies needs of diverse populations, cultures and
custodial patients
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Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
EVALUATOR
ASSESSMENT
Met
Date
Initials
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Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
EVALUATOR
ASSESSMENT
Met
Date
Initials
trained
Locates oxygen shut off valve and verbalizes how to
shut off if instructed to do so
Locates emergency exits and reviews emergency
evacuation routes
INTERVENTION
Activates code system and demonstrates use of code
alerts:
ADAM
= abducted or missing infant/child
BLUE
= medical emergency response
ORANGE
= internal hospital emergency
PINK
= maternal/child emergency
RED
= fire response
TEN
= bomb threat
GREY
= disruptive or violent behavior
TRIAGE
= mass casualty STROKE CODE=new
onset stroke symptoms
TAN
= Bomb Threat
GREY
TRIAGE
STROKE
Follow up:
= Disruptive Behavior
= Mass casualty
= New onset of stroke symptoms
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ASSESSMENT
Date
Initials
UP-PGH CBO
Self Assess
PROCEDURE OR SKILL
Follow up:
EVALUATOR
ASSESSMENT
Met
Date
Initials
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ASSESSMENT
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Initials
Page 49