Sepsis
With sepsis when must antibiotics be administered?
Within 3 hours of activation and after blood culture collection.
What is the Max Dose for TNK?
Besides a violent restraint order what other orders need to be placed?
- Manual Hold Order
- PSA 1:1
How frequent should vitals be during a procedure?
Every 5 minutes
*When should you reassess a patient's pain level after giving PO/IM pain medication?
Within 1 hour after administration (must document pain score and POSS).
Why does a sepsis watch OPA fire? What color is it? What do you do?
- At least 2 SIRS criteria met
- Yellow
- If infection suspected- activate sepsis watch. If not, check do not suspect infection (will not fire again)
When should the swallow screening be completed on a patient who is a rule out stroke?
Prior to administering PO medication.
*How often do you need to obtain a violent restraint order for patients who are 11 years?
9-17: every 2 hours
*What should be stated in a timeout?
Correct patient, procedure/laterality, & verification of signed/completed consent. (Timeout should occur immediately before medication is administered).
When should you reassess a patient's pain level after giving IV/IN pain medication?
Within 30 minutes of administration (must document pain score and POSS)
What prompts sepsis warning to fire? What color is it? What do you do ?
- 2 or more SIRS criteria met, suspected infection, and organ dysfunction.
- RED
- IF IT FIRES YOU MUST ACTIVATE! and document provider notification (same practice as in Legacy)
*What should a patient's blood pressure be under prior to administering TNK?
<185/110
*How frequently should the RN monitor AND document on a patient while in violent restraints?
Every 15 minutes
*Why do we monitor ETCO2 during a sedation?
Frist indication of respiratory depression when giving sedative medications.
What are the components of a complete medication titration order?
- Medication
- Starting dose
- Titration frequency
-Goal (B/P and/or MAP or RASS)
When should blood cultures be collected? How should they be collected? Documented?
- Prior to antibiotic administration
- Two different clean sites, 8-10ml blood, blue before purple. Not from established IV!
- x 2 10 minutes apart, site
What are the inclusion criteria for TNK?
- last known well is <4.5 hours
- B/P < 185/110
- No hemorrhage on CT
- Exam + for focal neuro deficit
- No exclusion criteria ( BS < 50, no active bleed or within 21 days, no intracranial bleed ever, no hx of ischemic stroke, head or spine sx in last 3 months)
What needs to be charted prior to violent restraint start? At restraint start?
-Least restrictive alternative & risk factors.
- Manual hold, VS, EDUCATION (dc criteria, explanation, patient response, family notification),clinical justification, reassessment for release, Restraint Monitoring, Restraint Type (all or nothing), sedation scale if medication used.
A 5 year old is going to receive IV push Ativan to help relax him prior going for CT scans. He responds to painful stimuli, but not verbal. Is this considered a moderate sedation?
YES, BUT it depends on how the medication affects the child and the intent of use.
Minimal sedation: "Anxiolysis" is a drug induced state during which the patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, ventilatory, and cardiovascular functions are unaffected.
Moderate sedation: drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation (reflex withdrawal from a painful stimulus is NOT considered a purposeful response). No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
*A patient is being intubated, and was administered Etomidate and Succinylcholine prior to intubation. Approximately 15 minutes after intubation, the patient is clenching his jaw, becomes flush, and becomes tachycardic. What are we concerned for?
Malignant hyperthermia
What should be done once fluid bolus is completed?
Document stop time in real time and obtain two sets of full vitals 15 minutes apart within 1 hour of completion.
*A 54 y.o. patient presents with stroke symptoms. He is in the window for TNK. He is s/p spinal fusion of C5-C6 76 days ago. Is he a candidate for TNK?
NO, exclusion criteria for TNK includes history of ischemic stroke, head or spinal surgery within the last 3 months.
*A patient is taken out of violent restraints at 0900. The patient is calm at this time. At 0915, the patient attempts to elope and is placed back in violent restraints. Do you need a new violent restraint order or can you use the previous order?
You need a new order. This would be considered a PRN order, which is not allowed with restraints.
**A 35 year old patient is having a chest tube placed in the emergency department. He received 25mg Fentanyl IV for pain. His pain is controlled and GCS 15. Is this considered a moderate sedation?
No
BUT if the patient becomes sedated to where he is no longer appropriately interactive or responds to verbal commands, moderate sedation has been achieved and must care/chart for accordingly.
In what order do you administer hyperkalemic medications?
- Calcium
- Dextrose
- Insulin
- Bicarb
- Lokelma
(Albuterol-- if difficulty obtaining IV access start with Albuterol!)