Policies
At what intervals are post op vitals due?
Post-Operative Vital Sign Protocol #PC-0015
Initial set, 15min x 1, 1hr x 2, 4hr until 24hrs
What is the vital protocol for blood administration?
Blood Product Administration # PC-0030
Baseline vitals, x1 at 15 min, upon completion
The bellow of a chest tube will not expand to the window. What is the source of this complication?
Check your suction source, your suction isn't sealed or you may have to turn suction up
Which type of stroke is most common?
Ischemic Stroke
How high can a nasal cannula go before having to switch to a high flow?
6 Liters/minute
Within what time frame do you need to perform and document a physical assessment on a new admission?
Inpatient Nursing Standards of Care #PC-0020
4 hours
What orders must be in place for a blood transfusion order?
Blood Product Administration # PC-0030
Up to date type and screen, Blood product type, Nurse to transfuse order
Name 4 items that belong in the emergency equipment bag for chest tubes
Padded kelly clamps, sterile water, occlusive dressing, microfoam or medipore tape, gauze pads
You have a patient on SEWS who is scoring, you just gave 2mg Ativan, when do you need to recheck vital signs to assess if patient needs more medication?
1 hour
Name 3 strategies that can help with time management
Anticipate orders, clustering care, hourly rounding, early assessments
What team members respond to a rapid response?
Rapid Response Team #010-0019
ICU (Critical Care RN), RT, AOD
A patient has an order to manage insulin pump independently and has signed the consent. During their stay they have a rapid response and become unconscious, what do you need to do?
#020-0021
Remove their insulin pump and use hospital equipment for glucose management.
List 2 interventions for sepsis bundle and the time frame for which they should be done.
1 hour- initial lactate level, blood cx & urine cx (before abx), start antibiotics, fluid bolus
What type of stroke presents as a severe headache or “worst headache of my life”
What range of oxygen can you administer via Non-Rebreather Mask?
10-15 Liters/minute
How often do you have to chart patient ADL’s with non-violent restraints?
Restraints and Seclusions #020-0028
Every 2 hours (within a 15-minute window)
How long do violent restraint orders last?
Restraints and Seclusions #020-0028
4 hours
State 3 situations in which you would call a rapid response?
Unresponsive patient, new decreased LOC, extreme changes in vitals (severe hypo/hypertension, bradycardia/tachycardia, tachypnea), suspected stroke, seizure without prn medications
What 2 questions do you ask for level of consciousness on the NIH Scale
Your patient has a pressure injury to their coccyx which you can visually see fatty tissue in the wound bed. What would you stage this wound as?
Stage 3 (full-thickness skin loss)
List at least 3 types of violent restraints
Restraints and Seclusions #020-0028
Locking restraints, seclusion, chemical, physical hold, physical escort
If player 1 wins you get 500, if player 2 wins they get 250
Your patient has symptoms of dyspnea, tachypnea, hypotension, tachycardia, and cyanosis shortly after receiving 1 unit of blood. What type of reaction do you suspect?
Reminders: Hemolytic, Anaphylactic, Septic, TRALI, TACO
TRALI (Transfusion related acute lung injury)
When does stage 3 of Alcohol Withdrawal typically occur and what are 2 symptoms you should expect?
#RX-0023
48-72+ hours
Agitation, fever/chills, hallucinations, seizures
Name all items in the HAPI Bundle (5 items)
Optiview, waffle cushion, Z-flow positioner, comfort glide system, heel boots