Restraint
Frequent re-orientation, sitter, medication evaluation, and distraction techniques are examples of this possible course of action
What are alternatives to restraints?
Amount of time an order needs to be renewed for non-violent restraint
What is daily?
The minimum time needed to wash your hands with soap and water after caring for this patient and/or before leaving the room
What is 20 seconds?
Within 4 hours of admission, every shift, transfer from another unit/department and day of discharge
What is a head-to-toe skin assessment by an RN?
To be administered within 3 hours for a patient who meets severe sepsis without shock
What is an antibiotic?
If deemed necessary based on a Practitioner’s clinical judgement, which member of the clinical team can be present with a patient who is restrained for violent behaviors.
What is safety attendant?
Amount of time an order needs to be renewed for a violent restraint of an adult.
What is 4 hours?
(For adults age 18 and older)
Donning gown and gloves, washing hands with soap and water, and having dedicated equipment are all necessary for this type of isolation.
What is Enteric Contact Isolation/Precautions?
A head-to-toe skin assessment that must occur by 2 licensed clinicians within 4 hours of admission, upon discovery of suspected pressure injury, and when transferred from another unit/department
What is "4 eyes on the skin"?
Patient has 2 or more SIRS criteria
What is initiate the sepsis resuscitation bundle?
Movements which threaten to disrupt medically necessary dressings or invasive medical equipment or the lack of understanding to comply with safety directions
What is non-violent behavior justifying the use of restraints.
Timing for restraint orders to be received in an emergency situation
What is as soon as possible after application?
Bristol Stool Classification of 7
What is the appropriate type of stool for testing? Conforms to the inside of specimen cup.
The skin risk assessment performed
What is The Braden Scale?
Labs that can be ordered STAT under the Sepsis Power Hour.
What is Lactic Acid, CBC with Diff, CMP, Blood Cultures X 2?
A sudden, violent, unexpected and aggressive outburst presenting an immediate and or serious danger to patient, safety of others, or the property of others
What is violent behavior justifying the use of restraints.
Visual/Safety observation
Skin
Circulation, sensation and movement
Level of consciousness
Toilet offered
Fluid/Nourishment offered
Patient Response
What are all things that must be assessed and documented at least every 2 hours for a patient in non-violent restraints and at least every 1 hour in violent restraints?
Previous negative C-Diff within 7 days?
Positive C-Diff within the last 30 days?
Patient is asymptomatic with formed stool?
Patient had laxatives within 48 hours?
What are the reasons not to test?
Repositioning should occur
What is at least every 2 hours or more frequently based on patient condition and risk factors?
Communication through Cerner that patient is at risk of sepsis
What is a sepsis alert?
A release from non-violent restraint to address patient daily care needs
What is a temporary release of restraints. (no new order is needed as long as you stay in the room).
Must be reported in adherence with CMS guidelines
What is reporting a death in restraints?
Time frame for early testing for C-diff & isolation of symptomatic patients present on admission
What is the first three days of admission (or before the 4th day)?
Pressure injury staging will be completed and documented by
What is the wound care clinician?
Called when patient has:
Suspected infection + 2 SIRS + organ dysfunction
What is activate a Code Sepsis?