Triage
All pediatric patients, Stroke/ STEMI patients, and patients suspected to require titratable drips MUST have what documented in the EMR?
ACTUAL Weight
When should a Fall risk assessment be completed?
At Triage, every shift, with changes in patient status, after a fall, and with admission
What must be documented in Cerner during the "pre-procedure stage" in regards to assessment (in addition to vital signs) to determine the patient's baseline?
RASS or Comfort B AND Aldrete Score
How long does the RN have to complete the ED Initial Screening when assigned a patient.
1 hour
How often should high risk patients (Braden score of 16 or less) be repositioned?
Every 2 hours
Name 4 items that are considered Triage "must haves" (must be documented at triage)
Chief complaint, reason for visit, mode arrival, arrival date/time, triage acuity, V/S including pain and pain scale used
Name 3 fall risk interventions that should be documented in addition to the fall risk assessment.
Yellow socks, yellow arm band, utilization of wheelchair, bed rails up, call light within reach.
How often do we document vital signs: BP, HR, RR, O2, etCO2 & RASS or COMFORT-B during the procedure?
Every 5 minutes
How often should we complete focused assessments including skin?
Every 2 hours
Patients who are bed-bound, have pressure injuries to the trunk, or can only be turned to two positions MUST have what type of pressure redistribution support surface?
Air distribution mattress or an overlay (waffle mattress)
Children who require emergency stabilization or those who cannot be safely weighed can use ____ to estimate weight in kilograms?
Broselow Tape
What post fall management intervention is missing: head to toe assessment, vital signs, notify MD and Charge RN, complete post fall debrief form, complete IRIS
Critical event note
How often do we document vital signs: BP, HR, RR, O2, etCO2, PAIN & RASS or COMFORT-B Post Procedure?
Every 15 minutes until back to baseline
How often should we reassess vital signs including pain for stable patients?
Every 2 hours
State at least 3 HAPI prevention interventions that MUST be done and documented for a patient with a Braden Score of 16 or less.
2 RN skin check, Turning q2hrs, Skin assessments q2hrs, Waffle mattress, Heel boots, Braden Score every shift.
When should a rectal temperature be done at triage?
If a Childs course of treatment will be determined by a specific temperature (ex: febrile with neutropenia, infants less than 3 months)
All patients who are deemed a high fall risk should have a staff member assist them to the restroom. If the patient refuses, what do you do?
Educate the patient and document a refusal of care in adhoc
Name 4 requirements to meet discharge criteria after procedural sedation.
Aldrete score of 8 or back to baseline/ Unobstructed airway or normal RR rate/ Stable vital signs including pain/ Baseline RASS/ O2 >92%/ at least 30min post narcotics/ at least post 2 hours if reversal agents were given
How often should we assess vital signs for patients who are on Vasoactive drips?
How often for stable ICU patients?
At least q15min if titrating, 1 hour if stable.
If you discover a new wound on a patient, what should you do?
Order a new or additional wound care consult
The pediatric assessment triangle must be documented in triage (focused assessment area). This includes what 3 components?
General appearance
Work of breathing
Circulation to the skin
Are infants are considered a HIGH Fall Risk? True or False?
True- they should be placed in an infant bassinet
What must be done with the Team before the initiation of procedural sedation?
Time out- Must be documented
How often should you perform a focused ____ and comprehensive___ physical assessment for critical care patients?
Focused every 2 hours
Comprehensive every 4 hours
What should be done if a patient is found with a wound during the 2 RN skin check.
Take a picture & place a wound care consult