HAPI
These assessments are completed at least once per shift.
Head-to-toe skin assessment and Braden QD score.
ACT is an acronym for ____.
Assess, Compare, Touch
Humpty Dumpty screening must be completed every ___.
shift and when the patient's status changes
RNs must scrub the hub for ___ seconds and let dry for ___ seconds.
15; 15
When administering medications, you must follow the ___ rights of medication administration.
8
Patients must be turned or repositioned every __ hours.
When assessing a PIV, it is important to remove the ___.
Armboard and doghouse
fall risks and prevention measures including maintaining a safe environment, calling before getting out of bed, and proper footwear for patient
Cap changes must be completed every ___ hours.
96
When administering IV medications, we must check the 3 Cs which are:
Connection, Clamps, and Confirm
Pulse ox probes are rotated at least every __ hours.
8
When a red vesicant is infusing, I must assess the PIV every ___ minutes.
30
signage, armbands, communication at handoff and transfer of care, communication with other disciplines (PT/OT/Child Life)
As part of the CLABSI Prevention Bundle, this must be completed daily for each patient with a CVL unless contraindicated.
CHG bath and linen change
When administering a high-alert medication, the RN must:
Have a 2nd RN independently verify the 8 rights and 3Cs and sign off
Examples of moisture management/barrier and wicking products include ___.
Hydra guard, Z-guard, stoma powder, and no-sting barrier spray.
Providing education to family about ACT and PIVIE symptoms should be completed and documented ___.
every shift
It is important to make sure this item is close to the patient to avoid falls.
Call light
This should be used when completing a CVL dressing change to ensure we are following the same process.
Standard of work
When administering medications, the RN must verify it's the right patient by using at least ___ patient identifiers.
2
Assess under EEG head wraps every ___ hours ensuring you can place two finger-widths space between the skin and the wrap.
4
When a PIVIE is found, the RN must do the following:
- Notify VAT (or extravasation resource RN if VAT unavailable) and provider within 30 minutes
- Conduct post PIVIE huddle with VAT/extravasation resource and charge RN, measure with 2 RNs
- Follow steps in PIVIE Classifications and Measurement QRG depending on if PIVIE is "clinically significant" or "other"
If there is a change in patient condition, the RN should:
Re-screen the patient for fall risk using the Humpty Dumpty assessment tool and implement individualized interventions to prevent falls.
When performing a dressing change, you must clean the site with CHG for this long.
30 seconds for dry sites (arm, chest) and 2 minutes for moist sites (femoral).
List the 8 rights of medication administration.
Right Patient, Medication, Dose, Route, Time, Reason, Documentation, and Response