Documentation Standards
How long does a nurse have to complete admission documentation?
24 hours
Name a device that would be an alternative to a foley.
Straight catheterization, commode, urinal (male/female), External catheter (care dry/primo-fit), bed pan, incontinence pads
How long is prevantics scrub and dry time?
5 seconds each
What are ways to reduce pressure ulcers?
Order waffle mattress and/or boots, reposition every 2 hours, offload heals, avoid briefs, use barrier cream, optimize fluids and nutrition
What counts as compliant for CHG treatment documentation?
Bath (partial or complete) or shower and wipes, CHG or shower, CHG
Where would one document a fall?
Significant Events Navigator
How do we clean or prep the perineum prior to foley insertion?
Soap and water, or easiclens
When should you change a central line dressing?
Every 7 days OR if the edges are peeling up, moist/bloody under transparent film. And every 48 hours for gauze dressing.
Should you stage hospital acquired wounds?
No, the wound care nurse will stage the wound during their consultation.
When are you required to perform hand hygiene?
Upon entering and exiting the room, and if your hands are visibly soiled.
You receive a call of a critical lab. You document the critical value, provider notified, their name or PI# and any action taken. How long do you have to notify the provider and document in the same column?
60 minures
You remove a foley catheter at 1145. At what time would the patient need a bladder scan to evaluate post void residual?
3:45 or next void, whichever comes first.
Before drawing blood cultures from a central line, what do you need to scrub and exchange?
Needless connectors
How often do you need to document on a wound?
On admission and at least once a shift
What are 3 examples of medications you should assume care of in the EMR at the beginning of your shift?
PCA, Heparing gtt, TPN, insulin gtt, pain patches (buprenorphine)
What need to be charted on every 4 hours for a PCA?
RR, BP, HR, SpO2, ETCO2, and med rate verify (number of demands, delivered, total mg given and total volume infused)
What should you evaluate in the foley tubing between the patient and the collection bag?
No dependent loops and unobstructed
What does CHG line treatment entail?
Use a CHG wipe to clean over the transparent dressing and 6 inches down the line, once a day and document in the EMR.
What is the minimum documentation standard for wounds?
Wound/peri-wound assessments, treatments, dressing, skin intervention rows.
When a patient brings in medications from home and has no one to take them home, what should you do?
Take medications to central pharmacy to be locked up and document in EMR admission section, and hang the pink receipt on the patient board in the room as a visible reminder. Or, call pump tech and get a lock box for the bedside.
Ms. Smith is admitted after sitting on a gurney in the ED for days.During a skin assessment, you note quite a bit of skin breakdownto her coccyx/sacral area. It is non-blanching with a bit of skinbreakdown. What are 3 of the next things you should do?
Add pressure injury to LDA, take pictures, document assessment, accept BPA orders to order wound consult, eliminate/reduce source of pressure.
A doctor orders a urine analysis with culture for a foley that is 72 hours old. What should you do next?
Call the doctor to order a UA complete to evaluate WBC, replace foley if WBC are >10, and then collect UA with culture.
It is Wednesday at 2 PM, you are a smart and efficient nurse, you hang new tubing for your patient to receive a continuous TKO rate saline with their PCA. When would this tubing expire?
Sunday at 2 PM, 96 hours
What do you need to do if a patient develops a pressure ulcers in the hospital?
Notify MD, order wound care consult, take a picture and add to LDA, file IR.
What are the 5 P's of intentional rounding?
Pain, Potty, Pumps, Positioning, Personal space (belongings)