Flowsheet --> Daily Cares/Safety --> Humpty Dumpty or Morse
100
When charting a critical lab value/notification, what needs to be included?
Test name and critical result, Provider name, Date and time of notification, action taken, any comments
100
How often do you chart education?
Any time an education topic has been taught to a family or patient, but no less than once a shift.
100
How often and when do you chart pain assessments?
With vital signs, on admission, when a patient c/o pain, 1 hour after intervention as been provded (even if its a scheduled pain medication), every 2 hours while on a PCA, and at the beginning of your shift.
100
How long does it take for Super Sani-Wipes and Bleach Wipes to be effective (how long must the surface stay wet for)?
Super Sani-Wipes (Purple top) - 2 min
Bleach Wipes - 3 mins
How long should you be doing hand hygiene for in order for it to be effective?
15 seconds
300
How long do you have to chart/notify providers of a critical lab value?
1 hour
300
How often must you renew orders for Violent/Non-Violent restraints?
Non-Violent - every 24 hours
Violent - q4 hours if > 18 y/o
q2 hours for 9- 17 y/o
q1 hour for < 9 y/o
300
How do we individualize Care Plans?
Update the nursing care plan once a shift, update our RN-to-RN handoff in Epic with active most updated information, and discuss the POC during family centered rounds.
300
Where are narcotic and other medications stored on the unit?
Meds are locked in our med carts, narcotic box in our locked med room, refrigerator in our locked med room.
300
What do we do as a hospital to ensure patient safety?
Mission zero, iCares, bundle rounds, etc
400
How often must a fall/braden assessment be charted?
Once a shift, upon a fall or skin breakdown noted, on Admission
400
What are the 5 critical steps of a Universal Protocol?
1) Open chart with Universal Protocol checklist
2) Collect supplies and have staff at bedside
3) Call "Time Out" before performing procedure
4) Complete Universal Protocol check list
5) Perform correct procedure on correct patient
400
When does the Care Plan and Education Assessment need to be initiated and how often is it updated?
Care Plan/Education Assessment must be initiated within 24 hours of admission and charted on once a shift.
400
When is the plan for pain management communicated to the care team?
During multidisciplinary rounds
400
What is the cut off to be considered at risk for either skin breakdown (Braden) or Fall Risk (Humpty Dumpty or Morse)?
Braden < 19, Humpty Dumpty > 12, Morse > 45
500
How often do you chart Safety and interventions for a patient with non-violent or violent restraints?
Non-Violent - every hour
Violent - safety q 15 min, and interventions every hour
**Although the sitters or NA's may ne the ones charting these safety and intervention checks, it is the RN responsibility that it is completed**
500
Name some interventions for patients who are on High Fall Risk?
Humpty Dumpty sign by the bed or on the door
Educate the patient and families
Assess a need for 1:1 sitter
Evaluate medications
Appropriate size bed and bed is locked in low position
non-skit footwear
500
Where can you view your care plan and education in EPIC?
Chart Review --> Care Plan/Pt Ed tab
500
What is wrong with this order...
Acetaminophen 650mg, PO, Q6, PRN
There is no indication for this medication.
500
What is your responsibility as a staff nurse during multidisciplinary rounds?
Present patient, provide an update on how the POC has been working for patient, VS trends