Restraints
Nurses can enter violent restraints as a verbal order
What is False
Sit, stand, march and walk.
What is the mobility challenge?
Timing of pain reassessment after pain medication administration
What is within 60 min?
English is second language, lack of transportation to follow up appointment, past history of sexual assault.
What are social determinants of health and trauma informed care considerations when developing care plans.
Timing of vital signs prior to start of blood products
What is less than 15 min PRIOR to blood administration but cannot be at the exact blood start time?
The nursing assessment of patients in non-violent restraints is completed and documented, how often?
What is every 2 hours +/- 10 min
Using the gait belt, being on standby with patient using the bathroom, using patient's walker.
What are interventions to prevent a patient fall?
Patient reports "no pain" when conducting your reassessment after pain meds were administered.
What is 0 on the Numeric Pain Scale?
Patients must be assessed for their risk for self-harm when arriving to your unit
What is True
Frequency of vital signs during blood administration
What 15 min. after start of infusion and when transfusion is completed?
For patients in violent restraints a Face-to-Face Evaluation must be completed within 1 hour of restraints by
Hospitalist, ED provider, or Intensivist
What is the 4 eyes skin assessment?
List 3 of 5 pain qualities documented in EPIC after med administration
What is Intensity, Quality, Location, Duration, Response to Treatment?
Must be assessed upon admission on patients 8 years or older.
What are thoughts of harm to self or others?
Associate verifies this prior to administering any blood product
What is the blood consent in EPIC?
Alternatives to consider before putting a patient in restraints.
What are
Foam border dressing applied to prevent pressure injury
What is an Allevyn dressing?
Turning, repositioning, or applying ice.
What are nonpharmacological interventions for pain management?
Care Plans will be individualized to each patient, aligning their diagnosis and other patient safety focuses
What is True
When remainder of blood and tubing should be returned to the blood bank
What is when a blood transfusion reaction occurs and blood administration is stopped prior to completion?