Assessment & Reassessment
According to MRH policy, how often should a patient be assessed/reassessed and who can do this assessment?
See Nursing Assessment of a Patient policy:
1. M/S, ARU, L&D = 15mins
2. ICU, Oncology, PACU = On admission
3. SDS, OR = Prior to admission
4. ER = Triage
Only an RN can do an assessment. RN may be assisted in the assessment data collection by LPN, CNA, or EMT.
Reassessments are performed at the start of each shift, when a patient is transferred from one unit to another, during a therapeutic intervention, or as indicated based on a change in the patient’s condition.
Where is the patient’s written plan of care found?
Electronic Health Record
According to MRH policy, what are the two types of behavioral conditions used for the application or restraints at MRH?
Nonviolent/Non-Self-Destructive Behavior
Violent/Destructive Behavior
According to MRH policy, when is a patient assessed and reassessed for suicide risk?
All patients receiving care at the hospital will be assessed upon admission and reassessed each shift during their stay utilizing an evidence-based screening tool
OB department patients: will receive a suicide screening upon entry and periodically throughout their stay.
Patients who present to the ED will be screened by triage or primary care RN to determine the patient’s suicide risk factors and level of risk
According to MRH policy, what type of assessments and reassessments are required in the clinic setting?
Fall Risk, Suicide, & Pain assessment are required and should be performed at every visit.
According to MRH policy, how often should a patient be assessed and reassessed for fall risk?
Inpatient = On admission / reassessed each shift or when condition changes
Outpatient =
According to MRH policy, how often is the patient’s plan of care updated and who can update it?
Updated plan of care every shift.
RNs can update the plan of care. The RN may be assisted in the assessment data collection by other members of the healthcare team, such as the LPN and CNA, EMT/Clerk
Nursing Assessment of a Patient
According to MRH policy, when can a restraint be applied to a patient and how often should the order be renewed?
Restraint for Nonviolent/Non-Self-Destructive behavior: When alternatives are unsuccessful, restraints may be utilized to ensure that necessary medical or surgical treatment is provided or when patient behavior interferes with the delivery of care.
Restraint/Seclusion for Violent or Destructive Behavior: Restraint/Seclusion may be utilized immediately on the assessment of the trained Registered Nurse or Licensed Practitioner when less restrictive methods were not effective in controlling violent, aggressive, destructive, or threatening patient behavior and to protect the patient, staff and/or others from harm. This emergency use of restraint may be utilized in any treatment setting if a clear need exists. The placement of a patient in seclusion will only occur in the Emergency Department.
Order renewal:
Nonviolent/Non-Self-Destructive - 24 hours
Violent/Self-Destructive - Every 4 hours (18 yrs or older)
According to MRH policy, if a patient is identified as a suicide risk, what should be done immediately?
Staff will follow protocols and interventions based on the level of risk identified. Medical or obstetrical complaints shall be identified, addressed, and the patient medically stabilized prior to or during collaboration with psychiatric services.
For safety, all adult, adolescent, and pediatric patients with suicidal ideation will be monitored with safety observations. Prior to the patient being placed in a room, reasonable attempts will be made to create the safest possible room environment (Notifying food services that all meals will be served with paper and plastic eating utensils and without a saran wrap covering, restrict access to sharps/cables/cords/plastic bags/etc.)
Who can administer moderate sedation? Who can administer deep sedation?
Moderate sedation: Registered nurses (RN) and other allied health care professionals responsible for the care of patients receiving procedural sedation are trained in basic EKG/arrhythmia, have current ACLS/BLS for adults and PALS/BLS for pediatrics, and has satisfactorily completed an annual competency for moderate sedation.
Deep sedation: Licensed practitioners administering procedural moderate sedation must have the appropriate privileges and be qualified to rescue patients from deep sedation and must be competent to manage a compromised airway and to provide adequate oxygenation and ventilation
According to MRH policy, how often and when should a patient’s pain be assessed and reassessed?
Pain is assessed on admission, at the start of each shift, when pt transferred from one unit to another, during a therapeutic intervention, or as indicated based on a change in the patient's condition.
Pain is reassessed post pain intervention (preferred within 30 minutes of IV/IM medication, within 1 hour of PO medication)
How would a diabetic patients nutritional plan of care be established?
Nutrition assessments are completed on the following patients if triggered during the screening or re-screening process, or ordered by a physician: 1. High based on GLIM or ASPEN guidelines below 2. Low and Moderate Risk (based on GLIM or ASPEN guidelines) who have intake <50% of meals >5 days. 3. All patients on nutrition support. 4. Patients who are NPO/CL >5-7 days
Nutrition assessments are complete within 72 hours of a nursing screen or physician order
According to MRH policy, when can a restraint be discontinued?
Restraint use is discontinued per criteria from restraint order from the LP and when the patient meets the safety criteria:
1. Improved mental status
2. Patient agreeable to comply with expected behavior (use of call light, cooperative with medical treatment, maintains self-control)
3. Improved ability to ambulate without risk of falling
4. Follows simple instructions
5. Can discuss and follow plan for safety
6. Not removing medically necessary equipment
7. Meets expected outcomes:
a. Patient remains free from injury
b. Staff and others remain free from injury
c. Medical treatment is not interrupted
What room(s) in the ED and throughout the hospital can a patient with a suicide risk be placed?
ED: Per Policy, "The patient shall be moved to the most appropriate bed for monitoring ". First preference in room 7
Inpatient: ICU first consideration, if not available then Med/Surg or OB. Continuous monitoring with direct observation REQUIRED regardless of room/floor placement
According to MRH, what is the process for giving blood to a patient?
Blood Transfusion Policy:
1. Blood products may be electronically ordered by the physician or nursing staff
2. Before transfusion, obtain an “Informed Consent for Blood Transfusion” form and give to the patient or patient’s authorized representative. The form must be signed and dated by the patient or patient's authorized representative, a witness must sign and date and the patient's provider must sign and date the form.
3. Patient Preparation: Assemble needed equipment, 18 ga IV preferred, educate patient on S/S of transfusion reaction.
4. Obtain blood product from blood bank
5. Return unused blood products to blood bank.
6. Transfusion of blood products: Verification of blood product and patient by two healthcare professionals before transfusion begins; one of the two healthcare professionals must be the person who is administering the blood product (transfusionist). If there are any discrepancies, DO NOT TRANSFUSE THE BLOOD until resolved. Contact the Blood Bank immediately at ext. 7223.
According to MRH policy, when should the H & P be completed before surgery and when should it be updated?
For a medical H&P examination which was completed within 30 days prior to registration or inpatient admission, an “updated H&P” documenting any changes in the patient's condition must be completed within 24 hours after registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services by a Member/APP. This update may be documented in a progress note in the patient’s medical record.
It is the responsibility of the surgery nursing staff to verify that the H&P is in the medical record prior to a procedure and is within a 30-day timeframe
History and Physical Policy
How is interdisciplinary, collaborative care, treatment, and services provided at MRH?
See Policy "Provision of Care, Treatment and Services with Scope of Services "
According to MRH policy, how often should a patient in restraints be assessed/documented on?
Nonviolent/Non-Self-Destructive: At the initiation of restraint and every two hours thereafter
Violent/Self-Destructive: at the initiation of restraint/seclusion and every 15-minutes thereafter
If a patient in a clinic setting is identified as a suicide risk, what should be done?
According to MRH policy, what is the process for handling tissue specimens after a surgical procedure?
For tissue (Histology), follow "Histology Specimen Collection" policy/procedure for "All surgical specimens, excluding exempt Surgical Specimens." The list of exemptions is found on the "Exempt Surgical Specimens" policy.
For fluid (Cytology), follow "Cytology General Collection Table"
True or False
In the ED, there is no requirement for reassessment after pain administration.
False
True or False
A written plan of care is not required on observation patients.
False
True or False
MRH practices seclusion.
Per MRH Policy, "The placement of a patient in seclusion will only occur in the Emergency Department".
True or False
It is state reportable if patient attempts suicide in the hospital/clinic setting but is not successful.
False
"Occurrence Manual"
True or False
When performing high level disinfection on instruments at the department level, if the instruments are washed there is no need to use enzymatic cleaner.
Cleaning and Disinfection Guidelines