Pressure Injury
How often patients lying in bed should be repositioned.
What is every 2 hours?
The areas of the body that must be avoided during a CHG bath.
What is the internal mucosa?
The nurse should do this if a patient refuses SCDs.
Escalate through the chain of command
Aside from admissions and transfers, these are the times when fall risk assessments should occur and also be documented.
What is every shift, change in patient condition, or post-fall?
The time in which antibiotics should be started after receiving an order.
What is One Hour?
The three times during patient care when two RNs should assess the skin.
What is admission, transfer, and discharge?
Comfort, Hemodynamic Monitoring, Obstruction, Retention, Urologic, and Surgery
What is CHORUS?
True/False: The patient should transfer with the SCD machine.
What is False?
This is a sudden, unintentional descent that results in the patient coming to rest on the floor, or against some other surface, another person, or an object.
What are falls?
Upon suspicion of sepsis, after contacting the Sepsis Team, the nurse should complete this in Epic.
Complete the Nursing Sepsis Management Order Set in Epic
The stage of a wound with a pink and intact wound bed with no visible adipose or deep tissue.
What is Stage 2?
The frequency of CHG central line dressing changes.
What is every 7 days and as needed?
These TWO kinds of prophylaxis must be addressed if a patient is high-risk for VTE.
What are pharmacological and mechanical prophylaxis?
A patient that needs a fall mat and bedside commode has this score or higher on the Hester Davis Fall Risk Assessment.
What is 15?
Hypo/hyperthermia, tachycardia, tachypnea, leukocytosis/leukopenia are all signs of this syndrome.
What is Systemic inflammatory response syndrome (SIRS)?
A patient with an existing pressure injury should only have this amount of chair time.
What is One Hour?
This action involves scrubbing an access port with CHG for 5 seconds and letting it dry for 5 seconds.
What is Scrub-the-Hub?
A patient who has just had surgery is a moderate risk for VTE, and therefore needs this kind of prophylaxis.
What is Pharmacological prophylaxis?
When a fall occurs, these are the people that must be notified.
Who are the family, attending, and chain of command?
Family, Attending Charge/Manager,TAPs
The three important EARLY signs of sepsis.
What are Tachypnea, tachycardia, and Altered Mental Status?
A wound bed that is obscured by eschar.
What is an Unstageable Pressure Ulcer?
This, in hours, is how often Primary tubing is changed.
What is every 96 hours?
True/False: Calf cuffs for SCDs are one size fits all.
What is False?
Every 4 hours and before moving
What is the requirement for subglottic suction?
The definition of Severe Sepsis.
What is Sepsis with organ dysfunction, hypoperfusion, and hypotension?