Documentation
The following interventions need to be added if anew admitted patient has a balloon feeding tube:
•Enteral Feeding Tube Assessment
•Intake and Out Put after clearing the pump
•Changing water inside the balloon
Pharmacy is closed. You receive a telephone order for extra dose of a medication that already is in patient’s active med list in ADC and eMAR. How do you process it?
•Write telephone order on order sheet, read for physician
•To take med from ADC, in Active Med list , Select Override Med Order to create a new order in eMAR
• STK.MED.ONCE order will be created in eMAR
•Independent double check will be done by 2 nurses
•**if it is not a high alert med, add name of second nurse in comment.
•ACK the order
Do Not reject if order in eMAR is not matched with order on paper( Order will be documented as Non Admin: ADC Override Error)
***be very careful to pull under the correct patient to not create an STK on another patient***
Mrs. Smith is on Methotrexate tablet (CHD) 20 mg once a week. She can take whole tablets. Which protection should be used when preparing and administering Methotrexate to Mrs. Smith?
•Nitrile gloves
•Non touch technique
What are the main causes of a pressure injury?
- pressure
- moisture
- decreased subcutaneous fat
- malnutrition
- friction and shearing
- pre-existing PI
When a patient returns from a LOA - what process do you need to follow to return a controlled medication?
*****
-Unused controlled release medications are wasted in pharmaceutical bin and recorded on the NARCTOTIC & CONTROLLED DRUG RECORD – Leave of Absence (LOA) by the MRN and a witness nurse.
Which documentation will be done for patient who is on restraint?
Daily documentation:
Weekly documentation:
•Daily: Nursing ADL Assessment
•Weekly: Least Restraint order after assessing patient’s need
• Weekly: Least Restraint assessment
Pharmacy is closed: A new medication is ordered.
Medication is not available in your unit ADC. What is the process to find the med?
To find the medication, go to the main menu on the ADC, look under "report", select "Launch Omni Explorer", search "inventory list" and type the name of the medication then search
•Take the med form another unit ADC, Stocked med
•Check the night cupboard ADC
***be very careful to pull under the correct patient to not create an STK on another patient***
Mr. Yong is on Methotrexate (CHD) 25 mg IM once a week. Which PPE is needed when you prepare and administer Methotrexate to Mr. Yong?
Where would you dispose the used needle and syringe?
•Nitrile gloves and impermeable gown
•Red sharp container. Card board box in soiled utility room.
How can we prevent/manage pressure injuries?
- continence care
- pain management
- intake
- turning and repositioning
- offloading (boots, pillows, wedges)
- therapeutic surfaces
What is a STK.MED.ONCE order?
What should we do before administering medication?
-There was a telephone order. (One dose telephone order should be written in order sheet)
-pharmacy was closed. Nurse took med from Stocked med in ADC
-This order was created in eMAR
Before administering medication:
-2 nurses independently will Compare order in eMAR with order sheet
-ACK the order (Do Not reject if order in eMAR is not matched with order on paper (Order will be documented as Non-Admin: ADC Override Error)
Which of following interventions count as a restraint:
a) Tilt wheelchair to remove pressure from coccyx area
b) Tilt wheelchair to prevent patient gets out of the wheelchair
c) Use 4 bed side rails up to transfer patient from hemodialysis room to their room
d) Use bed exit alarm for a fall risk patient
b) Tilt wheelchair to prevent patient gets out of the wheelchair
Pharmacy is closed: in unit ADC, bin for one of patient’s active med is empty. What is the process to find the med?
- select the medication that is in gray, select "Yes" to do you want to see the medication order detail, select to check the item availability
go to another unit or the night cupboard, pulled from Active medication
***be very careful to pull under the correct patient to not create an STK on another patient***
Mr. Lee is on Gefitinib (CHD) tablet 250 mg once a day via G. Tube. Which PPE is needed when you prepare and administer Gefitinib for Mr. Lee?
**Gefitinib, tablet will dissolve in water. Do not crush hazardous med in the unit.
•Nitrile gloves, impermeable gown, face shield
True or False: When a patient is admitted with a Pressure injury, it is still considered a Hospital Acquired PI if not documented within the first 24 hours after admission
True: if it is not documented within in the first 24 hours, there is no way to prove the PI was there on admission
You have a patient that is displaying a new onset of confusion, although they have a history of dementia, this seems outside of their baseline.
What could be happening and what would your next steps be?
- complete at CAM to see if the patient is delirious
- inform the MD verbally, patient may need a delirium workup
- ensure other safety precautions are in place (for example fall prevention)
For which of the following documentations you must do recall Value:
a) ePODS
b) Fall Risk Reduction Plan of Care
c) Nursing ADL assessment
d) Vital Signs and Pain Intensity
a) ePODS
b) Fall Risk Reduction Plan of Care
True or False:
when you have a controlled medication discrepancies in ADC - the cycle count will solve it
False: that will only fix the count. You will still need to tell ADC why there was a discrepancy
Mr. Smith is taking a cytotoxic medication everyday. He has episode of vomiting in the gym. How should we do spill management?
•Take Chemo spill kit from the cabinet inside supply room .
• Display sign near spill area.
•Prevent the spill from spreading. Close off areas to patients, staff, volunteers and visitors
•Put on Personal Protective Equipment: gown, shoe coverings, mask, face shield,2 pairs of nitrile gloves
•Initial clean-up must be done by unit staff and then contact Environmental Services at ext 2120 for thorough cleaning.
Which of the following situation will be documented in SAFER?
A) Pressure injury stage 2 or greater developed in HBH
B)Pressure injury stage 2 deteriorates to become a stage 3 or 4
C)Only pressure injury stage 3 and 4 developed in HBH
D)All pressure injuries
A) Pressure injury stage 2 or greater developed in HBH
B) Pressure injury stage 2 deteriorates to become a stage 3 or 4
Pharmacy is closed. You have an Unverified medication in eMAR. How do you process it?
-Take med from ADC, Stoked meds (right patient, right med, right dose)
Related to Recall Value, which statement is NOT correct :
a) After doing recall value, review all documentation
c) Recall value, recall your last documentation
d) Do not use Recall Value for Nursing ADL assessment and Vital Signs and Pain Intensity
a) After doing recall value, review all documentation
d) Do not use Recall Value for Nursing ADL assessment or Vital Signs and Pain Intensity
True or false:
When there is a discrepancy in the ADC, you do not need to solve it until the manager asks you to
False: you should solve the discrepancy within that shift
What is the process you will need to follow when your patient is new on a HD medication
- put the signage up and proper PPE at the door
- follow specific precautions required (including when handling the medication and bodily fluids)
-Add HD Care plan to patient's Kardex
True or false:
Nurses have a medical directive to prevent PIs and manage a stage 1 PI
True
Pharmacy is closed. You receive a telephone order for extra dose of a multi-dose medication (puffer, Insulin…). How do you process it?
-Write telephone order on order sheet, read for physician
-in eMAR click on “Next Sched”
-In Next Sched, select Unscheduled Administration
*For insulin, 2 nurses must compare order in eMAR with order sheet. Independent double check
**if it is not a high alert med, add name of second nurse in comment.