Safety & Fall Risk
A score of greater than or equal to 51 indicates a high risk of...
What are Falls, From the Morse Fall Scale?
Right circumstance, right direction, right communication, right person, right task
What are the five rights of delegation?
Vitals that are within normal limits (WNL) for an adult
Pulse: 60-100
Temp: 96.8-100.4 (taken after 30 min)
Resp: 12-20
BP: less than 120/80 (taken with legs uncrossed and no movement/talking)
Pulse ox: 95-100%
A process in which actions are used by clinicians and patients to collaboratively achieve identified healthcare outcomes
What is therapeutic communication?
The most reliable way to assess the details of a patient's reported pain
What is to ask the patient for a pain description and rating on a pain scale appropriate for age?
Call light within reach, tray table within reach, bed in lowest/locked position, nonskid socks, 2 side rails up, and frequent purposeful rounding
What are ways to decrease falls?
The law which describes what tasks can/cannot be delegated by the RN
What is the Nurse Practice Act (NPA)?
A theory based on the premise that higher level needs be addressed before lower level needs in prioritizing care
What is Maslow's Hierarchy of Needs (ABCs)?
The verbal and nonverbal interaction that occurs between human beings; begins at birth and continues through the lifespan
What is interpersonal communication?
The best indicator that a patient's pain is being well managed
What is to ask the patient to rate the level of pain after medicating?
Improving patient safety, preventing wrongful surgeries, reducing medical errors--all by requiring health care facilities to focus on certain safety measures
What are the National Patient Safety Goals (NPSGs) of the Joint Commission?
Activities that require nursing judgment: Assessing, diagnosing, planning, evaluating (as well as patient education). Hint: We can only do this for a task involved in nursing care
What are things that should not be delegated to the LPN by the RN?
Minimum infection prevention steps as defined by the CDC: Used to avoid the transmission of infection
What are standard precautions?
A common process for handoff reporting, used between nurses as well as between nurse & provider
What is the SBAR?
A scale of 0-10, FACES, FLACC (for those unable to communicate), CRIES, and COMFORT
What are the commonly used pain scales?
An unexpected occurrence resulting in patient death, serious injury, or the risk thereof
What is a sentinel event?
Teaching, supervising patient care, delegating, assessing patient status
What is the practice of a registered nurse, per the OBN?
Contact, bloodborne, and droplet: Each with its own type of PPE used to prevent the spread of infection
What are isolation precautions?
An expectation of all nurses: The act of speaking for others to assist them in meeting their needs
What is patient advocacy?
The nurse asking the patient about location, intensity, quality, onset/duration, alleviating factors, effect on quality/function of life, and comfort goal
What is a pain assessment?
The patient's name and date of birth
What are examples of two patient identifiers, used always when giving care, for safety?
High-risk pregnancies, preterm infants, special needs children, frail and elderly, transitional care, mental illness, and end-of-life care
What are exemplars of populations most in need of care coordination?
An infection developed/contracted while a patient is hospitalized and under our care
What are health care-associated (nosocomial) infections?
Observation, open-ended questions, leading question, back channeling, probing, direct closed-ended questions
What are nursing interview techniques?
Information that is subject to opinion (or patient's verbal description) vs factual and measurable
What are subjective and objective data? (sidenote: patient statements/descriptions are subjective)