Treat the Patient
Pt is talking to you but telemetry shows Asystole
Check patient/leads first
Instead of charting “patient is stable,” chart THIS.
Specific assessment findings.
Developed by an RN, who developed this scale to assess pressure injury risk.
Barbara Braden (and Nancy Bergstrom)
Your post-op patient suddenly becomes short of breath and tachycardic.
Assess immediately and escalate concern.
RAPID?
A dying patient becomes restless, agitated, confused, and repeatedly tries to get out of bed despite being very weak. What condition may the patient be experiencing?
Terminal restlessness (terminal agitation).
Lethal rhythm has no pulse and require immediate CPR and Defibrillation
V-fib or Vtach
Why is “patient resting comfortably” risky charting?
It is vague and subjective.
Developed by an RN, this scale helps assess fall risks
Janice M. Morse
You walk into a room and find oxygen disconnected. First action?
Reconnect and assess patient.
Your diabetic patient suddenly becomes sweaty, shaky, confused, and irritable. What should you check FIRST?
Check Blood glucose
You notice tall T-waves on telemetry. What electrolyte abnormality do you suspect?
Hyperkalemia
You gave pain medication. What MUST also be charted later?
Reassessment/response to intervention.
This WWII nurse became famous for helping establish modern air evacuation nursing and flight nursing practices.
Luther Christman: He did not hold a rank in the Army Nurse Corp because he was male. Later became the first male Dean of a nursing school in the US at Vanderbilt in 1967.
Your new admit patient scores a 48 on MORSE scale
Establish Fall precautions/safety interventions.
Your patient suddenly becomes difficult to wake up and has a decreased level of consciousness. What is your FIRST priority?
Assess ABCs/patient assessment/call for help as needed.
Rhythm often said to be "Regularly Irregular"
Atrial Fibrillation
Charting “doctor aware” is incomplete without THIS.
Time, provider name, and communication details.
This nurse narrowly avoided being killed during the Battle of Antietam when a bullet passed through her sleeve and killed the soldier she was treating. She later founded the American Red Cross.
Clara Barton
You suspect sepsis. Name one priority intervention.
Notify provider/get cultures/start fluids/lactate/etc.
A diabetic patient receiving narcotic pain medication suddenly becomes difficult to arouse. What two things should the nurse immediately consider checking or treating?
Respiratory depression/opioid overdose and hypoglycemia
OR
Blood glucose and need for Narcan (naloxone).
You walk into patient room, you see monitor alarming "leads off", but patient says, "I think I am going to pass out." What do you do?
Treat the patient, not the monitor
You charted something incorrectly in the EHR. What should you NEVER do?
Delete/falsify documentation.
This physician and former nurse became the first Black woman in space after beginning her career caring for patients.
Mae Jemison. Space Shuttle Endeavor 1992. She was such a Star Trek fan that she later appeared on Star Trek: Next Generation
Your patient says, “I just don’t feel right.” Vitals are normal.
Further assessment/trust your patient concern.
A patient says, “I feel like something is really wrong,” but vital signs are still normal. What should the nurse do?
Further assess/escalate concern/take the patient seriously.