Sepsis
*What is included in the 3 hour sepsis bundle?
2 sets of blood cultures (prior to abx administration)
First lactic acid
Completion of fluid bolus
Initiation of antibiotic administration
*What is MNH ED's door to CT goal time?
< 15 minutes
Name 3 alternatives to placing a patient in restraints.
Medication
Move closer to nurses station
Verbal deescalation
Decrease environmental stimuli (dimming lights, decrease sound)
Chair / bed alarm
Frequent toileting
Sitter or family presence
Pain relief / comfort measures
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.
Demonstrate proper blood culture collection.
1. Clean blood culture bottles with alcohol swabs x15 sec.
2. Clean site with chloraprep x30 sec.
3. Draw first set of blood cultures, aerobic (blue) then anaerobic (purple) bottle with 9 ml blood.
4. Draw second set of blood cultures from second site, 10 minutes apart
5. Label lab sticker: initials, date, and time.
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 10+ years?
How often for patients 9 years and younger?
10+ years: every 2 hours
9 years and younger: every hour
*What should be stated in a timeout?
Corrent patient, procedure, site, & verification of signed/completed consent
When should you reassess a patient's pain level after giving IV/IN pain medication?
Within 30 minutes of administration.
*What should be done once the fluid bolus is completed?
Obtain repeat vitals x2 within 1 hour of completion of fluid bolus, 15 minutes apart.
*What should a patient's blood pressure be under prior to administering TNK?
<185/110
*How frequently should the RN monitor the 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.
A 75 year old patient is intubated due to achieving ROSC after a cardiac arrest. He is receiving Propofol for sedation and Norepinephrine for blood pressure management. Does this patient meet criteria for an indwelling Foley catheter?
No.
Think "are we changing any interventions based on urinary output?"
Demonstrate how to document blood culture collection times.
RN tasks and procedures-->Blood culture collection-->Add row-->Search "blood culture"-->Select "blood culture 1 drawn at"
*What is the treatment window for TNK?
If last known well is <4.5 hours
Name 3 types of non-violent restraints.
Soft limb restraint
Mittens
Lap belt
Enclosure bed
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
*Name 5 criteria that trigger the best practice advisory to start the sepsis clock
Selecting "yes" to suspected infection
Selecting "yes" to rigors present
Selecting "yes" to mental status changes
O2 sat < 90%
Temperature > 100.9 or < 96.8
Respirations >20
SBP < 90
HR >90
MAP <65
*A patient presents with stroke symptoms. He is in the window for TNK. He has a history of an intracranial bleed 1.5 years ago. Is he a candidate for TNK?
NO, exclusion criteria for TNK includes ANY history of intracranial bleed.
*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.
Name the actions of each ventilator setting (see picture)
1. Tidal volume: the volume of air delivered with each breath
2. PEEP (positive end expiratory pressure): the pressure left in the lungs at the end of exhalation to keep alveoli open
3. Rate: breaths per minute the ventilator delivers
4. Oxygen: concentration of oxygen upon inspiration