Code White
True or False:
An incident report must be completed after a Code white has been called
True
Name 3 types of Restraints
physical, environmental and/or chemical
How many Mental Health Observation Levels are there?
4
What does NCI stand for?
Nonviolent Crisis Intervention
What is the CIWA protocol?
Protocol that guides alcohol withdrawal symptom management
When should a Code White be called?
When there is a real or perceived risk of physical harm to a patient, staff member or property
True or False
An order from a physician is required for a wrist restraint?
An order from a Physician or Registered Nurse (RN) is required for a restraint. The order must include type of restraint and reason. If the order is placed by an RN, the Physician must co-sign the order within 24 hours
How often does a nurse need to round on a Constant Care (Level 1) observation?
Continuous and uninterrupted care of a patient by an assigned staff member with an unobstructed view of the patient at all times.
What does COWS stand for?
Clinical Opioid Withdrawal Scale (COWS)
True or False:
Nurses should ignore a Pt's substance use to respect autonomy
False
True or False:
The use of physical interventions should be used to deescalate the the situation
Physical interventions are not in NVCI training and may lead to disciplinary action.
Physical interventions, pain-free and never coercive are limited to staff trained methods.
True or False
Restraints must be reassessed and reordered every 12 hours
False
Restraints must be reassessed and reordered every 24 hours
What is the name of the scale for suicide screening?
COLUMBIA-SUICIDE SEVERITY RATING SCALE
What does the CIWA stand for?
Clinical Institute Withdrawal Assessment for Alcohol
True or False:
A nurse requires an order to complete a CIWA or COWS assessment?
False
What is the Team Leaders role?
Plan the interventions with other team members
Provide direction during the code
Request emergency service (police) be called to assist if needed
Act as the only responder speaking with the pt during the interventions
Facilitate the immediate pt debriefing session
How often does a restraint Pt need to be monitored?
A restrained patient must be monitored
i. Every 15 minutes x 4 initially and when patient behaviour is unstable
ii. Then every 30 minutes x 4 (x 2 hours)
iii. Then, every1hr until restraints discontinued
iv. Constant observation when using 4- or 5-point restraints
What should be removed from the environment for a patient at risk for suicide?
utensils, pencil/pen, strings, plastic bags, lighters, razors, scissors, call bell, chemicals, medications, anything that can cause harm.
What does NGASR stand for?
Nurses' Global Assessment of Suicide Risk
You have completed a CIWA assessment and the score is 50. What Powerplan should be ordered for this Pt?
MED alcohol withdrawal (CIWA) Adult admission Powerplan
What information should be added to the documentation for a Code White?
Demographics (e.g. date, time, location of incident; client involved, etc.)
· Description of incident
· Precipitating factors (or triggers) if known
· Behaviours witnessed (complaints; passive resistance; active resistance; assaultive, etc.)
· Type of intervention (e.g. standby; verbal de-escalation; escort; physical restraint;
mechanical restraint; environmental restraint, etc.)
· Medications administered
· Names of team members
· Staff injuries (if any occurred, staff need to document these on the appropriate workplace
injury report form)
· Names of other responders (e.g. police, security, etc.)
· Debriefing session
· Recommendations
A restraint may be used:
To prevent serious bodily harm to self or others
· To enhance freedom or enjoyment of life
· When it conforms with the authorized treatment plan and is consented to by the patient or Substitute Decision-Maker (SDM)
Where can a nurse find Resources for Patient's at risk of Suicide?
Cerner - Patient education - Search Suicide
What does BVC stand for?
Brøset Violence Checklist
You have completed a COWS assessment and the result is 20. Is this a mild, moderate, moderately severe or Severe result?
Mild Withdrawal: 5 to12
Moderate Withdrawal: 13 to 24
Moderately Severe Withdrawal: 25 to 36
Severe Withdrawal: greater than 36