CAUTI
Before inserting an indwelling urinary catheter, these options—like bladder scans, external catheters, or scheduled toileting—should be considered.
What are alternatives to catheterization?
Hand hygiene must be performed before flushing and locking a central line, and can be done with this or soap and water.
What is alcohol-based hand sanitizer?
Pressure injuries most commonly develop over these bony areas of the body.
What are the sacrum, heels, and hips?
Along with completing the pre-op checklist by the nurse, this document must be signed by the patient and a witness before surgery can proceed.
What is informed consent?
When is a Suicide Risk Assessment completed for a patient in the acute care environment?
Upon admission
This team should be called for Behavioral Emergencies, such as escalating behaviors or violence.
What is BIRT Response?
This condition, along with bladder obstruction, is a key reason to insert an indwelling urinary catheter.
What is urinary retention?
This must be assessed and documented daily in the electronic health record to determine if a central line should remain in place.
What is central line necessity?
Moisture-associated skin damage from incontinence can increase the risk of pressure injuries. This type of product helps protect the skin.
What is a barrier cream or skin protectant?
The OR team should call within this time frame before requesting the patient for surgery.
What is 30 minutes to 1 hour?
Who evaluates a patient known or suspected to be suicidal within 24 hours?
Psychiatrist or Psychiatric Evaluation Nurse
This protocol should be utilized when an adult patient has new onset chest pain in an inpatient unit.
What is the SPRG Chest Pain Protocol?
CHG is used for peri-urethral cleansing in patients with indwelling catheters this often.
What is once every shift?
The insertion site should be cleaned using this motion with chlorhexidine for 30 seconds and allowed to dry when changing a central line dressing.
What is a back-and-forth motion?
This action should be taken by the nurse upon new finding of pressure injury or wound, or when a pressure injury is found upon admission.
What is Consult Skin team?
Patients should receive two CHG baths the night before surgery, unless contraindicated. These baths should be spaced this far apart.
What is 6 hours?
What action is triggered by any “yes” response on the Suicide Risk Assessment?
A Best Practice Alert and initiation of suicide precautions
This result on the Nova Meter would prompt unlicensed staff members to notify a nurse immediately and enter a comment with the nurse's name or badge scan before accepting.
What is a red/critical result? (less than 55 or greater than 400)
You are collecting a specimen from an existing foley catheter. You have ensured the foley has been inserted less that 72 hours. Before collecting the urine specimen, this must be done to the sample port.
What is scrub the hub with disinfectant?
IV tubing used for blood products, lipids, or TPN must be replaced within this time frame after starting the infusion.
What is 24 hours?
This surface is recommended for patients with high risk for developing PI or with existing pressure wounds.
What is specialty surface? (ie umano bed, agility bed, low air-loss mattress, dolphin bed, etc)
This type of antibiotic should be started when the OR calls for the patient.
What is the longest-duration preoperative antibiotic?
What items are patients on suicide precautions allowed to use for meals?
Paper dishes and plastic utensils only
Your patient with AMS (altered mental status) also has 2 of the following: Temp>100.9 or <96.8, HR>90/m, RR>20, WBC >12,000 or <4,000.
What is Meets sepsis criteria?
These are the three approved methods for collecting urine specimens according to Mercy policy.
What is clean-catch, intermittent/straight catheterization, and from an indwelling Foley catheter (inserted for less than 72 hours)?
This action occurs every 7 days or when becoming wet, loose or soiled.
What is change the central line dressing?
This can be present on wounds, which can be mistaken as purulent drainage as it can also be thick and yellow or milky in color.
What is Slough?
If a patient refuses CHG bathing, this must be done in addition to notifying the charge nurse and provider.
What is documenting the refusal in the patient’s chart?
How often must nurses round on patients under suicide precautions and document it in the EHR?
Every Hour
During these times, a paper telemetry strip must be printed, interpreted, signed and placed in the paperlite chart by a nurse. (Hint: there are 5)
Upon initiation
Upon Transfer
Every shift change
Acute changes
Upon discontinuation of tele monitoring
Under these circumstances a provider order required for a straight catheter urine specimen collection.
What is
Remember: You DO NOT need a physician order to perform a straight cath on a patient who cannot adequately provide a clean catch sample (i.e. confused). This can be done PER PROTOCOL.
These single-use items must be present on all unused ports and hubs to maintain disinfection for up to 7 days.
What are disinfection caps (e.g., SwabCap or SwabTip)?
As of June 2025, patients with this Braden score or lower require a daily photo of their coccyx documented in EPIC.
What is a Braden score of 18?
Nurses should begin this process upon admission to emphasize the importance of infection prevention.
What is patient education?
What must be done if a patient under suicide precautions needs to leave the nursing unit for diagnostic evaluation?
They must be accompanied by an assigned escort under continuous observation AND the transport personnel
This documentation is required at shift change, syringe change, dosage change, or discontinuation of PCA (Patient Controlled Analgesia).
What is a complete double-check by two nurses including volume to be infused, amount already infused, number of patient demands, number of boluses given, and verification by both?