Gravity Always Wins
What is the assessment we use to determine someone's fall risk called?
Hester Davis
What is the criteria for meeting the Braden Bundle?
A Braden skin score of 18 or less
How often is the C-SSRS performed?
On admission or if concerns develop/are mentioned
Who meets criteria for a Chlorhexidine Bath?
Anyone with a central line (accessed port, hemodialysis catheter or PICC) and all vented patients
What do you do if a patient is declining pertinent medical care or nursing interventions?
use the .refusal smart phrase at least once a shift and document appropriately in the flowsheets. This must include acknowledging education was provided
What indicates the need for a bed alarm?
Anyone who is not independent
Who meets criteria for a LEAF sensor? (2 parts you must get)
Braden of 15 or less and all vented patients
What intervention is required if a patient is awaiting psych placement or came from a psych facility (with expectation to return)?
1:1 observation and safe room checklist q shift or room change
How many wipes are used in a complete CHG bath and how often should it be performed?
6 wipes, daily (day shift preferred)
How often do you need a new order for non-violent restraints?
Every 24 hours
What does a fall risk score need to be in order to be eligible for a TUG test?
10 or less
Explain a 2-person skin check and how it is documented
Done on all admissions or transfers to the floor, 2 staff members (PCA is ok), documented under assessment of integumentary system, free text witness and flag for significance
What intervention is required if a CSSRS scores anything other than NO RISK?
Immediate 1:1 observation and prompt assessment by mental health professional (Social worker, PRT, psych)
How often should foley and peri care be performed?
Every shift and anytime the tube is contaminated from stool
What is the desire of turn degree for a turn, indicated by green on the LEAF sensor
at least 20*
What is the fall risk score that requires fall mats on the floor?
15 or greater
What should you do if you find a coccyx that is reddened but blanchable?
Take a photo and upload to media, apply a foam dressing for prevention, consult wound, and reposition at least every 2 hours
What intervention is required if the SAFET results in MODERATE RISK?
Video Monitoring and Safe Room Checklist (q shift or room change)
What is the name of the tool nursing can use when determining if a patient's indwelling cath can be taken out?
Nurse Driven Removal Protocol
What should you do if you are getting an air leak with a Bipap machine?
Leave it! :) If pt is not tolerating, you may adjust but do not tighten. Call RT if not resolved
What are the necessary documentation pieces to be completed following a fall?
Post fall progress note using .phrase
Post Fall Huddle Form
MIDAS
Name at least 4 interventions from the Braden Skin Bundle
1. Start the Braden Bundle
2. Reposition and remove layers
3. Assess and document, consult for concerns
4. Devices and dressings- remove devices to assess and apply preventative foams
5. Excoriation protection- apply z-guard
6. Nutrition consult- document % of intake for every meal
Where/how do you document when a safe room checklist has been completed?
Daily Cares Flowsheet- Safe Environment Initiated/Maintained- free text "Safe Room Checklist Complete"
Describe what your orders will look like if you can use the NDRP?
Linked orders between insert, catheter care and removal per protocol (look for comment or nursing communication order to say otherwise)
Name some things that should be removed to perform an adequate skin assessment (at least 3) and must occur daily at minimum
socks, c collar, brace, knee immobilizer, foam dressings