Fall Prevention
What are fall prevention measures for low-risk patients?
Green Chiklet on the door or Roomlink icon
Non-skid socks
Call light and valuables within reach
Bed in low position, brakes locked
Side-rails up x 2
Appropriate lighting (nightlight as needed)
Educate patient and family
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?
Red Chiklet or Roomlink icon
Yellow band on patient's wrist
Initiate and maintain bed/chair/pad alarm
Patient may not be left alone unless an alarm is in place
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
Creatinine >2 mg/dl
Lactate >2 mmol
INR >1.5
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
What are 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
When removing a central line or changing luer-caps, what position must the patient be in, and what additional step is involved at the moment of removal? (To prevent air-embolism)
Place the patient in Trendelenburg position (or flat if high ICP, recent MI) prior to removal. Have the patient perform a Valsalva maneuver (bear down and hold breath) as you remove the line.
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)
Is it permissible to leave the patient alone while using the toilet if they are at high risk for falls?
Patients should not be left alone while toileting if they are at high-risk for 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 >4 mmol/L
Severe sepsis with new onset or persistent hypotension present after fluid bolus
Physician documentation of septic shock
What is the National Database of Nursing Quality Indicators (NDNQI) definition of a fall?
*A fall is defined by the NDNQI as a sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can).NDNQI counts only falls that occur on an eligible inpatient or ambulatory unit that reports falls* When a patient rolls off a low bed onto a mat or is found on a surface where you would not expect to find a patient, this is considered a fall. If a patient who is attempting to stand or sit falls back onto a bed, chair, or commode, this is only counted as a fall if the patient is injured. * Entrapment is defined as: An event in which a patient is caught, trapped, or entangled in the spaces in or about the bed
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 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?
Lactic acid
Blood cultures
Antibiotics
Repeat lactic acid
IV fluid bolus for hypotension or lactic acid >4mmol/L
6-Hour Bundle:
Vasopressors if hypotensive after fluids
Perfusion exam (performed and documented by Physician/APN/PA-C)