Screen Protectors
These are the severity level(s) requiring care plan & interventions for elopement risk
What are medium (4-6) and high risk (7-10) levels
Which is chemical restraint and why:
1. Daily po Zyprexa for Bipolar
2. One time IM Zyprexa injection for aggressive behavior
What is: One time IM Zyprexa injection for aggressive behavior
Because patient is exhibiting violent or self-destructive behaviors that jeopardize the immediate physical safety of the patient, staff, or others.
most common hand off nurses do
What is shift to shift
The Insulin pump patient info form; insulin pump flow sheet; and a photo of the insulin pump insertion site should be present in the EMR
What is the Insulin Pump Therapy Policy
Document foley cath care completion (or explain)
Demonstrate/explain documentation in IVIEW and care tracker
How do RNT's know patient precautions
Answers vary: white board, report from LPN/RN
Complete this screen for a positive response to the PHQ9 question regarding thoughts of harming self or better off dead
What is the C-SSRS (Columbia-Suicide Severity Risk Scale)
List 2 components that must be entered into the EMR upon administering an IM restraint medication
1. The order set. Titled "Restraint - IM Medication Behavioral Adult (18 yrs)
2. The Restrain IPOC. Titled Restraint - IM Medication - Adult (18 yrs)
This gets completed and sent with a patient to an outside appointment, then updated and scanned into the EMR misc folder upon patients return
What is the outside appointment SBAAR
1:1 nursing & the removal of harmful objects for patients that trigger until cleared by provider
What is Suicide Precautions Policy
Document PICC line dressing change and tubing change, and other line care completed during a dressing change/daily site check
Demonstrate documentation of the dressing change, cm markings (or external length), tubing change, saline flush, cap changes
Explain how to find the restraint policy
What is in HPOD icon on desktop, click on Nittany Valley, filter
Main purpose/action when completing the swallow screen
What is check for dysphagia & prevent aspiration; alert provider of concerns & obtain SLP swallow eval order
Vital Signs AND restraint monitoring should be taken at this interval for 1 hour following a restraint IM injection
What is every 15 minutes x 1 hour
Additional areas that need documented with shift to shift report
What is maintenance of any precautions (ensure precautions groups are created)
Since the discontinuation of the IV therapy protocol, each venous access device IPOC with care orders can be accessed here
Traci's shared folder
Create a spinal precautions group (no lifting >10 lbs, no twisting at waist)
Demonstrate how to create this group
Should the documentation for supplement intake be separate from total oral fluid intake?
Yes, supplement intake should not be counted in the oral fluid intake section
These are the exclusions to completing the swallowing screen
1. NPO prior to admission 2. Difficulty maintaining alertness 3. Unable to position upright 4. Modified diet 5. Tracheostomy tube
Following a restraint IM injection, these assessment(s) need completed at this interval by a trained RN
What are pulmonary, neurological, and cardiac assessments along with glucose check within the first hour following an IM injection (the order set will task these 45 minutes after the order set initiated)
Type of hand off done before & after a blood transfusion and where it's documented
What is a verbal hand off to and from MTU staff documented in the modified RN assessment or a progress note
This is preferred to occur upon starting the oxygen protocol to ensure correct orders and follow up
What is ENSURE Resp Therapy is notified via secure office phone message or office email
Demonstrate an education entry using interpreter service for Russian language on non pharmacologic pain modalities with patient able to verbalize understanding
Demonstrate this entry
These protocols are ordered on every patient and can be located where
What are chest pain, wound and skin, and oxygen protocols and are located in HOD under protocol tab or reference page next to protocol order
True or False & Why:
The level of risk on the C-SSRS assessment will determine if a patient needs suicide precautions
What is False - our policy states
"The risk assessment score of low, medium, or high does not affect the patient’s “at risk” status or suicide precautions".
This will occur hourly x3 after the first hour of restraint monitoring is completed
What is behavior monitoring (the order set tasks after the first hour)
List some elements shared when providing a verbal hand off to MTU
What are: Specifics of the order especially any medications ordered between units; any pertinent patient info that may have recently changed (isolation)
Aspects of this policy include: an order, signage, patient and family notification, and Q shift behavior monitoring
What is the video patient monitoring policy
Demonstrate how to access Traci's shared folder; what will you be retrieving from this folder today?
Demonstrate how to access and explain expectation to retrieve all revised venous access device IPOCs as well as chemical restraint order set & IPOC
Explain the action you are doing to ensure all meal % are documented
What is _________________________(any and all actions that will help)