Heparin Drips
This must be done when a bag is initiated, a new bag is hung, when a rate, dose, or setting is changed, with a bolus dose, and at care handoff.
What is an independent double check?
The color of tubing that should be utilized for all epidurals.
What is yellow?
This is the emergency number that must be called in addition to utilizing the "Code Blue lever" on the Hill Rom station.
What is 8-5555?
A lactate greater than this is one sign of acute organ dysfunction.
What is a lactate greater than 2 mmol/L?
At this blood glucose level, the patient is considered hypoglycemic and requires immediate treatment by the RN and the provider must be notified.
What is less than 70 mg/dL?
Remember, document this as provider communication of a critical result!
This must be ordered if an Anti-Xa is not therapeutic.
What is a timed lab draw (6 hours from the non-therapeutic lab draw)?
This describes the specific skin surface area innervated by a single spinal nerve or a group of nerves and should be assessed Q4 hours with a bag of ice.
What is a dermatome?
This is a lifesaving procedure for a victim who has signs of cardiac arrest (i.e., unresponsive, no normal breathing, and no pulse).
What is high quality CPR?
Push hard, push fast.
A temperature > 38.3 OR < 36, HR > 90, RR > 20, and WBC > 12K or < 4K are examples of this.
What is SIRS criteria?
(Two or more SIRS criteria, with a suspected or known infection, and new associated acute organ dysfunction meets criteria for sepsis)
Within this time frame, the hypoglycemic patient's blood glucose should be rechecked post treatment.
What is within 15 minutes?
Remember to document your intervention in the I&O tab in Epic under "Oral Carbs for Hypoglycemia."
You need this many therapeutic Anti-Xa levels before you change the Anti-Xa lab draw to QAM.
If this anti-coagulant has been ordered for a patient with an epidural, you should call the provider before administering.
What is Lovenox or a heparin drip?
These should be applied to the patient immediately and should "sandwich" the heart.
What are defibrillation pads?
A Sepsis Alert has been initiated. Under the Nurse Driven Protocol, these two labs can be ordered by the RN.
What is a CBC w/ Diff and a lactate?
This device is not approved for use in the hospital setting for insulin treatment decisions.
What is a Continuous Glucose Monitor (CGM)?
When drawing an Anti-Xa from a PICC line, it is best practice to pause the medication and wait this long before flushing w/ 20 ml of normal saline, wasting 5-10 ml and then drawing your sample.
What is 2-5 minutes?
When this happens, respiratory rate and sedation level must be monitored Q30 min x2.
What is when the dose is increased, the lockout frequency is decreased or a bolus is given.
While there are many roles to fill during a code blue, these are the main 4 roles that must be filled during a code. (Think - before the code team arrives)
What are Airway, Compressions, Code Cart and Recorder?
This exam occurs after the fluid bolus is started, often in collaboration with the Virtual Health Center (VHC).
What is the Reperfusion exam?
RNs should use clinical judgement when repeating glucose meter tests. If LO or HI is displayed on the glucometer, the RN should do this.
What is order a stat serum lab draw?
If a PICC line is not drawing back blood, the RN should advocate for this before attempting Cath Flo.
What is a chest x-ray?
(To ensure the catheter is not malpositioned)
Your patient has an epidural catheter. You should be monitoring for these five side effects.
What is respiratory depression, urinary retention, pruritus, nausea/vomiting, and lower extremity weakness?
Initially, the BLS prepared staff member turns the defibrillator on to which setting?
What is Defib? (Remember, it is red on our Zolls. Red = Dead)
These 4 bundle elements must be completed within one hour of calling a sepsis alert.
What is drawing an initial lactate, blood cultures, starting IV antibiotics, and a initiating a fluid bolus?
The long acting night time insulin should be questioned before administration for this type of patient.
What is a patient with reduced oral intake?
Think: NPO at midnight, N/V, TPN/TF were recently stopped.