Name that Precaution
Did I do that?
Nursing Care
Say what??
100
What type of precaution is this for?
Anterior Hip Precautions
100
What percentage of pulmonary embolisms develop in the lower extremities?
90%--prevention is key! especially in ortho patients
•EARLY MOBILITY
•Please make sure these are on TEDS/SCDS
•Foot pumps
•Anticoagulants
100
Alcohol withdrawal peaks in what stage?
Stage 2
(1-3 days after last drink)
100
What should all CHF patients have documented in the cardiac education chapter
60 minutes of CHF education
include education on heart healthy diet
provide CHF booklet (located on 4N& 6N)
200
What type of precaution is this?
Posterior Hip Precautions
No bending over
Make sure when sitting hip is is not bent past 90 degrees (pillow on chair)
Use elevated commode/Toilet chair
200
What might you be involved in after a code?
A Debrief
200
Who should you call prior to starting cardizem gtt/bolus?
Telemetry tech
200
What do I do with the AM-PAC score?
Use it to determine the patient's mobility level
300
What precaution is this for?
Knee Replacement
No pillows directly under knee (place under calf to keep knee extended)
Foot stool when sitting to prevent knee from bending
300
What should you give patient's prior to PT?
Pain medicine
300
When do we take off a patient's insulin pump?
Patient is not alert and oriented
Patient unable to self test pump
Patient doesn't have supplies to maintain pump
300
What must be placed on hoverjack to get patient into bed?
hovermatt
Patient must be centered, be sure each chamber is fully inflated prior to moving to next chamber
holds 1200lbs/39" wide vs standard 35"
One kept on 4S/4M/5S
400
What precautions is this for?
Anterior precautions
400
What happens if you pass a light on the floor?
400
Patient voids 200ml in 8 hours
Nurse bladder scans for 300ml
What should you do?
Call and request for a straight cath not a foley
400
What should you do if your patient's serum glucose is 64 when you look at your labs?
Go check a FS, if >70 document in the hypoglycemia chart FS and result.
If FS < 70 follow hypoglycemia protocol and document in hypoglycemia chapter
500
What precaution is this for?
Posterior hip precautions
Remember this when patient turning-think little steps keeping feet facing forward
Do not cross legs/pillow between legs in bed
500
All CHF patients must have ________ documented at discharge
an outpatient cardiology appt. --appt needs to be within 7 days from discharge
date/time of appt should be documented on d/c instructions
500
What atrial arrythmia is irregularly irregular?
Atrial fibrillation
500
What is the penumbra?
The part of the brain tissue temporarily derived of blood flow but has not yet suffered irreversible damage
"Time Lost is Brain Lost"