General Monitoring
How often should vital signs be taken?
What is every hour? Every 2 hours for stable patients. Temp every 4 hours.
All pressure monitoring (ABP, CVP, PAP) must be leveled at ______ and when?
All bedsides should have what regardless of the patient's condition?
Ambu bag with face mask, O2 flow meter, and airway suction set up.
Dressing q7days and as needed (NEW CENTRAL LINE DRESSING CART)
Tubing q4days
If a continuous drip rate is less than 10cc/hr what should be done to ensure the medication reaches the patient?
Setting up a 5-10cc/hr KVO with a stopcock.
Arterial line alarms should be turned off if the waveform is poor?
False. Arterial alarms should never be turned off. Set higher parameters to decrease alarms or remove the a-line.
When a patient has a SWAN or FLOTRAC device what should be documented and how often?
CO, CI, SV, and SVO2. every 2 hours and as needed
Low continuous/intermittent wall suction should be set to what one the wall suction?
No greater then 120 mmHG for airway suction. 80mmg for NGT
Blood administration tubing should be changed when?
after 4 hours of use.
Prior to patient transport of an intubated patient what safety measures should be completed?
Test adequacy of ventilation supine tolerance. sedation needs, appropriate monitors
How do you set heart rate alarm limits for a patient?
20 bpm below or above the patient's baseline or as the patient's condition changes.
Arterial line pressures should be compared to manual cuff pressures q15min?
False. Once a shift, then as needed.
A patient with a tracheostomy should have what a the bedside.
Extra trach one size smaller and the same size. Obturator Disposable inner cannulas. Ambu bag attached to O2
How should the nurse safely manage a fecal management system?
Flush and deflate the balloon qshift.
Document how much is in the balloon qshift.
Consider removal every shift.
Do not insert in patients with known rectal bleeding and low platelets.
What patients qualify for telemetry transport?
Stable drips, ready for the floor. RNs have to go to every procedural area if patient is coming back to the ICU.
Post-operative vital signs are completed at what intervals.
What is q15min for 1hr, q30min for 1hr, q1hr
CVP are measured on which port of the central line?
Distal port.
All medical equipment should be plugged into which outlet.
The red outlet. Connected to the backup generator.
Soap and water should be used for all ICU patients during baths.
False CHG.
How do you safely secure a PA catheter?
Rate/dose verify should be completed when?
Change of shift, every hour for cont meds, q15 for titration.
If your arterial waveform is dampened, the FLOTRAC monitor is accurate?
False. You need an adequate waveform for adequate FLOTRAC monitoring.
All monitor alarms should be checked and documented when?
qshift and when there is a change.
CAUTI prevention techniques include what?
Pericare with CHG q4hr
Securement
Bag below bladder and on opposite sides of GI drainage bags.
Early removal
You should Y-site all continuous drips.
No. Manifolds and stopcocks should be used with appropriate labels.