Everything's bubblin'
What items do you need at bedside when a chest tube is present?
2 rubber tipped hemostats
2 vaseline guaze
Your patient has a purewick and the provider has ordered a urinalysis. How would you collect your sample?
Have patient void in sterile collection cup
Get order for In & Out cath
What zone should bed alarms be placed in?
Intake and Output should be recorded how often
Every 8 hours (0600, 1400, 2200) and end of your shift
When changing a port dressing on Friday what else should be changed?
Needle needs to be exchanged
How often do you need to assess and document a chest tube?
Assess insertion site, respirations, amount and color of drainage, suction and vital signs at least every 4 hours
Your patient has had 5 watery stools in the past 24 hours, the provider has placed an order to test for C. Diff. When should we not test?
If patient has had laxatives or stool softeners in the last 48 hours
Newly started on tube feedings
Negative c.diff test within past 7 days
Positive c. diff test within past 14 days
What are some preventative measures we can use to prevent falls?
Bed alarms, non-skid socks, bed low/locked, at least 2 siderails up, call bell within reach, purposeful rounds, keep needed items close to bed, leave night light on in room, avoid clutter, educate patient/family
Foley bags should be emptied when they are ____________.
2/3 of the way full
Your patient needs to go to the bathroom, they are able to bear weight but are weak. What smart moves equipment would you use?
Sara Steady or Gait belt
The chest tube collection chamber should be?
Below the patient's chest and in upright position
You receive the following results for a patient for rule out for C.Diff:
PCR screen: Positive, toxin test will be performed
C. Diff Toxin Confirmatory:
Toxin Negative-Colonization
Can isolation be removed from this patient.
No, they are colonized and must remain on isolation at least 30 days.
You are completing your q2h rounds and find your patient on the floor. What should you do?
Assess patient, complete post fall huddle immediately after including patient and family if available, document post fall huddle/assessment in Epic
*Post fall reassessment must be documented within 24 hours or before same-day discharge
Your patient has a foley in place and has not been emptied during your shift. During your 2am/pm round you notice there is no output. What do you do?
Perform a bladder scan, notify provider, obtain order for foley irrigation (if needed)
Your patient has a foley catheter in place and it is time for foley care. What wipes should you use?
Green package, use all!!
When are the only times you should clamp a chest tube without a provider's order?
To change the collection chamber
To diagnose source of bubbling (start at insertion site and work you way down)
When collecting a sputum sample, what will you do with the container prior to being sent to lab?
Break down the container. Only the inner cylinder with lid firmly in place can be sent down.
What tool is available in Epic to assess for a patient's fall risk?
EFI (Epic Falls Index)
updates every 4 hours and relies upon current documentation for patient, becomes visible as soon as it begins collecting data and stabilizes at 12 hours
What is the recommended way to document IV fluid intake?
How should you document IV fluid intake?
Start and stop in Epic, to reflect times
Use IV pump to get more accurate amounts
What smart moves equipment should you use if a patient has fallen and you need to get them up?
Maxi Move
Your patient has a chest tube and when you enter the room you see vigorous bubbling, what do you do?
Start at insertion site and cross clamp with rubber tipped hemostats, if bubbling stops issue is in patient's thorax or at insertion site-notify provider immediately
If bubbling stops when moving away from insertion site issue with tubing, replace tubing or secure connections
If bubbling continues as near Atrium, change atrium
When collecting labs from a central line what must you replace after obtaining your blood sample?
Needleless connector
Scrub needleless connector for 5 seconds and flush w/ 10 mL NS (replace needleless connector if drawing blood cultues), attach empty syringe and draw off discard amount, scrub hub and place 2nd syringe draw amount of blood needed for sample, scrub hub and flush 10mL NS
45 or greater
You are reviewing your patient's intake and output values and find that their output is greater than their input. What are you concerned about and how should you assess the patient?
Dehydration, check vital signs, check for tenting of skin, encourage fluids (if able to drink) and notify provider
Your patient is Suicidal and has a sitter. What items do you need to remove from the room?
Gloves, extra linens, phone, sharps container, toiletries items, curtain if in room, trash bag should be paper, meal tray should be a safety tray