Skin
What braden score and below requires a LAL mattress to be ordered
17
How often should you change the inner cannula?
new stomas (less than 7 days old) every 8 hours and PRN
healed stomas daily and PRN
How long are tube feed bottles good for?
24 hours, must be date timed and initialed
How long is a restraint order good for?
24 hours
When should admission documentation be completed
* admission history and note should be completed by admitting nurse no matter the time they get here
* assessment does should be completed if patient arrives more than 30 minutes prior to end of shift by admitting nurse
How often to preventative mepilex's need to be changed
7 days
Is trach suctioning a sterile technique? do you need an order to suction?
yes and yes
How often should a chest tube/pigtail dressing be changed?
every 48 hours and PRN
no, needs a new order
When should IV lines and oxygen tubing be changed?
Every Sunday into Monday and every Wednesday into Thursday
What product should be used on a chair to prevent skin breakdown
How often should bubble bottles be changed
on line change days and prn when empty
State the steps to change a chest tube dressing
1. with clean gloves, remove prior dressing
2. don sterile gloves and clean with chlorahexadine scrub
3. wrap site with occlusive dressing
4. apply drain sponges in same direction
5. place cover sponge
6. secure with medipore tape and DTI
How frequent should you be documenting on restraints
every 30 minutes for observations, RN assessment every 2 hours, and release every 2 hours
When should patients be receiving good oral care?
Anyone who is NPO or unable to swab their mouths themselves
What is the best way to prevent pressure injury with an ngt?
spiral wrap with 1/2 inch white tape making sure the tube is not touching the septum
Who do you call if a patient de-cannulates themself?
respiratory!
How often should foley care be done?
Q8 hours and PRN with every bowel movement
Do mitts not tied down count as restraints?
No
What number do you call for a code, rapid response, stroke alert and stat security
5-STAT (5-7828)
5-2222
5-2222
13
How often should an ostomy appliance be changed?
5-7 days or PRN
Name three things that should be at the bedside at all times with trach patients
1. current and one size smaller trach set up and lube
2. sterile post trach kit
3. ambu bag
4. trach ties
5. scissors
6. inner cannulas
7. suction set up
What do you do if a patient self removes a chest tube?
apply occlusive dressing and cover sponge, tape 3 sides with medipore tape, page provider
Re-orientation
Mitts
Medication review
Prevent delirium
60/hr for 15 minutes