Medications
Right Time. Right Resident. Right Route. Right Medication. Right Dose.
What are the 5 Rights of medications?
Regulatory Immunization. Every admission receives. Must be documented in two spots:1. Immunization tab in PCC (admin and read) 2. eMAR (admin and read)
What is TST?
Confirm order, place in communication book, verify order is in properly.
What is picking up lab orders?
Separate treatment supplies by resident and lock cart when not in use.
What is treatment care procedure?
What is Injuries Observed at Time of Incident?
"Injuries"
Date and Initial. Check placement every shift. Disposal must be witnessed by 2 nurses.
What are Transdermal Patches?
ex: CMP, TSH, Vit b 12, a1c, magnesium drawn from R antecubital, resident tolerated well.
What is a venipuncture progress note?
ex: CMP, TSH, Vit b 12, a1c, magnesium drawn from R antecubital, resident tolerated well.
Formulary Products, Guidelines for Use and Considerations.
Dressing Types, Product Name, Indications.
What is Wound Care Formulary Guide?
Nursing Description: Create a picture of the occurrence. Resident Description: State what they say only. Description of Action Taken: Immediate action taken r/t resident and this specific incident.
What is Incident Description?
"Details"
1. Properly position Resident (e.g. HOB elevated at least 35-40 degrees).
2. Check enteral feeding tube for placement and patency according to facility policy.
3. Apply gloves, cleanse end of tube w/ alcohol, flush tube w/ at least 30ml warm water before and after med pass.
4. Unless contraindicated, crush tablets into a fine powder and dissolve in 30ml water.
5. Prepare and administer all meds separately unless otherwise specified.
6. Administer flush and meds via gravity (if resistance is met, slowly and gently flush with syringe plunger. Cleanse end of tube w/ alcohol once med pass is complete.
What is Enteral Medication Pass?
Progress note describing: Body Location, Wound Type, Size/Description, Treatment/Interventions
What is a Wound/Skin Note?
Every wound must have a Wound/Skin Note when documenting. Even when documenting on SNF Skin Assessment Form. Document when you do your treatments.
Verbal Aggression, Alleged Abuse, Dignity concerns, Elopement, Skin Alterations, Self-inflicted Injury, Fall
What is risk management?
Anything out of the norm should be a risk management.
Must be done on all residents weekly. Even if they do not have any skin abnormalities, you must document it! Check yes in TAR and then open up the form in PCC.
What is SNF Skin Assessment form?
Predisposing Environment/Physiological/Situation
What are Factors?
Statement required by anyone who is not the nurse submitting the report or resident experiencing the incident.
What is a witness statement?
Even the person who found the resident down.