Fall Prevention
What are fall prevention interventions for moderate fall risk (Yellow) patients?
All low-risk (green) interventions (non-slip footwear, belongings within reach, proper lighting, path free of clutter, call bell within reach, bed in low position and brakes locked, 2 side-rails up, fall risk assessment communicated during hand-off, purposeful rounding, and patient/family education regarding falls)
PLUS:
Place a yellow sign/Chiklet on the door (MH and VLD use Roomlink)
Apply a fall-risk bracelet
Initiate a bed/chair/stretcher alarm
Tele-Sitter where appropriate
Assist with toileting-stay within arms-reach of patient at all times, do not leave unattended
What is a dependent loop, and does it contribute to a CAUTI infection?
A dependent loop is when the Foley tubing is hanging off the side of the bed/stretcher below the drainage bag causing urine to pool in the tubing. It contributes to CAUTI infection by impeding bladder drainage.
When should a central line dressing be changed?
Every 7 days, or immediately if soiled, wet/bloody, or not intact.
Starting at what number on the Braden Scale Score is the patient determined to be at risk for developing a pressure injury?
18
What are 2 assessment findings of the SIRS Criteria?
Temperature >101 F (38.3 c) or <96.8 F (36 c)
HR >90
RR >20
WBC >12k or <4k, or >10% Bands
What are fall prevention interventions for high fall risk patients?
Initiate all green (low risk), and yellow (moderate risk) interventions, plus:
Red Chiklet or Roomlink icon
Verbally state at unit shift huddle all patients scored as red fall risk
Assess for enrollment in structured toileting program
Consider unit specific interventions protective devices (low beds, etc.)
What is Inspira's criteria that justifies Foley insertion/maintenance?
HORNO Criteria
H=Hemodynamic instability, OR
O=Obstruction
R=Retention
N=Neurologic
O=Other
If there is no blood return when you assess the patency of a central line, what is the next step you should take?
Do not use the device and notify the MD.
Who must you inform (and document) when a pressure injury is discovered?
The physician, the patient, and the family/caregiver if appropriate. Submit an RL6 so appropriate leaders are aware.
What are 2 indications of organ dysfunction?
SBP <90 or MAP <65, or SBP decrease >40 from baseline
Creatinine >2 mg/dl
Urine output <0.5 ml/kg/hr. for >2 hrs.
Lactate >2 mmol//L
INR >1.5 or a PTT >60 secs
Platelets <100k
Bilirubin >2 mg/dl
New need for mechanical ventilation or BIPAP/CPAP
Three patient conditions or history that elevates a patient's fall risk
Altered LOC or developmental delay, weakened or unsteady gait, restlessness/agitation, seizures, cardiac conditions, history of previous fall
What are 2 alternative urinary devices that can be used instead of a foley, and when would it be appropriate or inappropriate to use?
Female Purewick-
-Indications-incontinent patient to manage moisture, and possibly obtain urine output measurements.
-Contraindications-agitation/restlessness, retention, or obstruction.
Male Purewick-
-Indications-Incontinence, manage moisture, measure urine output, especially helpful for scrotal edema/difficult anatomy
Condom Catheter-
-Incontinence, manage moisture, and measure urine output
-Contraindications to Male Purewick & Condom Cath are retention and obstruction
Ultrasorb pad-
-Incontinence, manage moisture
-Contraindications-obstruction or retention
For continent patients use of a hat, bedpan, or commode bucket to measure urine output
What is the proper procedure for changing a Luer cap (Needless Connector) on a central venous catheter?
Wash hands, put on gloves, explain procedure to the patient.
Open the needless connector package maintaining sterility and aseptically attach a saline syringe and pre-prime.
Close the clamp on the catheter extension.
Remove the existing needless connector, swab the catheter hub for 5 seconds with an antiseptic pad and allow to dry.
Attach the new device, turn to tighten.
Unclamp extension, pull back to aspirate blood if not contraindicated, then flush with saline.
What is the process for obtaining photos of a pressure injury?
Cleanse wound
Ensure good lighting
Place the patient label (with personal identifiers) on a paper measuring tape
Write the date and wound location on the measuring tape
Take 2 photos, 1 close up and 1 farther away
(Double-check to make sure you are submitting to the correct patient record, and that the patient identifiers and wound are clear in the photo)
How is severe sepsis defined?
When the following 3 criteria occur within 6 hours of each other:
1. Known or suspected source of infection
2. SIRS Criteria (2 or more)
3. Any evidence of organ dysfunction (1 or more findings)
What is a structured toileting program, and what are the benefits?
Involves assisting the patient with toileting at pre-determined times of the day.
Works well for patients not capable of independent toileting. This program can improve quality of life, increase mobility, decrease skin breakdown, and DECREASE FALLS.
What are the set of interventions listed in Inspira's CAUTI Prevention Bundle?
1. Using the HORNO criteria
2. Hand hygiene and aseptic insertion technique
3. System maintenance: Keep the bag below the bladder and off the floor, avoid dependent loops, maintain closed system
4. Keep securement device in place
5. Daily review of catheter necessity by RN
What is the CDC definition of a CLABSI infection?
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site.
What is the required components of a wound/pressure injury assessment?
Open/document in a pressure injury or wound band:
Length
Width
Depth
Description of wound bed
Presence/location of tunneling and undermining if applicable
Drainage/odor if applicable
Stage (if pressure injury)
Septic shock "Time Zero" is the earliest time one of ___________(What Criteria) is met?
Lactic acid > or = to 4 mmol/dl
Severe sepsis with new onset or persistent hypotension present after fluid bolus (SBP<90, or MAP <65, or a decrease in SBP by >40 points from baseline
Who should be considered for the structured toileting program?
Are determined to be a high fall-risk
Are taking high-risk medication (Diuretics, sedatives, laxatives)
Are incontinent, have urinary frequency/urgency, or frequent stools
Are cognitively impaired (memory problems, impulsivity)
Consider other impairments (ambulatory dysfunction, visual impairment, tethers such as IV fluids/poles or chest tubes)
Any patient can be enrolled based on the nursing assessment
What is the definition of a CAUTI
A urinary tract infection that occurs in a patient who has or had an indwelling urinary catheter in place at the time of or within 48 hours prior to the onset of infection (Ferguson, 2018)
What are the set of interventions in Inspira's CLABSI Prevention Bundle?
1. Proper hand hygiene
2. Maximum barrier precautions
3. Chlorhexidine antimicrobial skin prep
4. Optimal catheter site selection
5. Daily review of the necessity for the central line
When should a pressure injury be assessed and documented, and photos be taken?
Upon admission if present
Upon discovery of a new wound
When receiving a transfer from another unit
Every Wednesday ("Wounded Wednesday")
Any time there is a change in the wound (worsening, improving, debridement,etc.)
At discharge (within 24 hrs. of discharge)
What interventions are included in the 3-hour bundle and 6-hour bundle?
3-Hour Bundle:
Measure Lactic Acid
Blood cultures (PRIOR to antibiotic administration)
Antibiotics
IV fluid bolus (30 ml/kg crystalloid) for hypotension or lactic acid > or = to 4mmol/L
Repeat Lactic Acid level if initial was >2
6-Hour Bundle:
Vasopressors if hypotension is persistent within 60 minutes after fluid bolus, or 2 consecutive MAP <65 or SBP <90
Reassessment exam (performed and documented by Physician/APN/PA-C)