Restraints & Insulin
What is Security's role in restraining a patient?
To appropriately use techniques to control the safety of the patient and others.
What is the expectation after you do your HD assessment and your patient scores a 22?
You put these interventions in place asap: Yellow armband, red signage at the door, nonskid socks, bed/chair alarm, fall mat. Maybe consider a baby monitor.
What does unstageable mean?
It means you cannot visualize the wound bed
It does not mean you are unsure of what it is
At what value does a lactic acid require a repeat?
2.1 or higher
To treat a patient with hyperkalemia, the physician must order the medication using what?
The Hyperkalemia order set
What type of insulin keeps blood sugars at a consistent level when you are not eating, but is not enough to cover glucose spikes after mealtime?
Basal insulin
You score your patient's HD at a 15, but the night nurse told you this patient is up independent, what are some things you should look at/consider?
15 is a high fall risk, look at why this patient is a high risk, assess the patient’s ability to call for assistance and wait to get up, assess the patient’s gait, balance and how they walk, are they attached to the IV pole or on oxygen (all trip hazards), educate them on why you need to put an alarm under them, fall mat on the floor, use nonskid socks.
If they truly refuse after educating them, then chart it.
If your Braden score is less than 18, what are 3 interventions that must be in place?
Q2 turns in bed
Frequent weight shifts in chair
TAP system/wedges
Incontinent- barrier cream/ Containment device
Soft care boots/ float heels
Initiate PIPP Protocol
Who is responsible for the overall management of the Trauma patient at HFWH?
The Trauma Surgeon
When should a specimen be labeled?
Immediately after collecting and at the bedside
Name 2 different restraint alternatives.
Lap belt with Velcro where patient can release it
Folding wash cloths
Skin sleeves
Activity apron...
When forming your HD care plan, which categories are you expected to chart on every shift?
Risk level, subcategories for sections that scored 2 or higher--(only pick interventions you are doing related to the subcategory)
Also you must complete a post fall if your patient has an inpatient fall
When MUST a 2 RN skin check be completed?
Upon transfer and admission
For a septic patient, at what value does a lactic acid require a 30 mL/kg sepsis bolus?
4 or higher
What do you need to add to the patient's eyes during post mortem care?
2 drops of sterile saline
Tape eyes closed with paper tape
Place a glove filled with ice and water to each eye
Elevate the head above the heart
What type of insulin is taken at mealtime and acts rapidly on the body, bringing down the high sugar levels following meals?
Prandial insulin
Why do we ask you to do a Hester Davis assessment each shift, with changes in condition, post fall, within 8 hours of admission?
This is a research based proven tool to predict whether a patient may fall on your shift, and gives you the interventions you should use based on the HD score to help prevent the fall and fall with injury.
If a hospital acquired pressure injury is found, what do I do?
Enter LDA
Stage the pressure injury
Measure the pressure injury
Consult wound care
Name one stroke risk factor.
afib, HTN, obesity, hyperlipemia, smoking, diabetes
How do you consult the ethics committee?
Place an order in Epic
Call the operator if you would like an anonymous consult
Halo the team
How often must an assessment be completed and documented on a Violent Self-Destructive (VSD) Behavior patient?
RN performs and documents in the EHR an hourly nursing assessment
Assistive staff monitors and documents in the EHR the patient every fifteen (15) minutes and helps collect data
Why do we have you fill out a post fall debrief form/huddle and why do we want you to be honest?
Gives other factors not known in a chart review: staffing issues, we may need to do a RCA and this tool gives us more information than the chart, the huddle lets the other staff on the floor know a patient fell, and keep them on everyone’s radar
When should you consult wound care? Name 2 instances.
1.Stage III, IV, unstageable pressure, deep tissue injury, device related, and/or mucosal
2.Non-healing pressure injuries
3. Deterioration of pressure injury
4. Any questions regarding the pressure injury treatment plan
5. Discovery of a hospital acquired pressure injury (HAPI >24 of admission )
If your patient develops stroke symptoms who do you call?
Rapid Response
What is the last sense to leave a dying patient?
Hearing