Identification and Communication
Required prior to any medication administration, treatment, procedure, lab draws, and diagnostic tests
What is 2 patient identifiers
Completed upon entry and exit from a patient room.
What is hand hygiene?
In addition to confirming 2 patient identifiers, is required prior to opening medication packaging or spiking an IV infusion.
What is barcoding the medication?
A visual cue that a patient is a high fall risk.
What is a yellow gown?
Assessed for all patients at least once a shift or with every system assessment.
Level of Consciousness | Orientation X4 | Presence of chest pain | presence of peripheral pulses | capillary refill | edema
Repeating a verbal order or verbal assignment for clarification.
What is closed loop communication?
Completed before using any vascular accessing device
What is scrub the hub?
15 seconds, even if orange swab cap is used.
2 RN sign-off
What is required for high-risk medication administration?
PCA initiation and changes, IV anticoagulants, IV insulin, chemo, blood products
Appropriate dressing for a skin tear.
What is a non-adhesive absorbent dressing or an absorbent dressing with an adhesive border?
10 L/min.
What is the minimum flow rate for a non-rebreather mask?
The most appropriate flow rate is 12 L/min - 15 L/min, less than 10 L/hr turns the mask into a rebreather (of CO2)
A form of handoff report that evidence based to reduce errors, time, and increase patient satisfaction and/or awareness of the plan of care
What is bedside report?
Must be cleaned with purple top wipes or clorox wipes after every use in a patient room
What is:
Stethoscope? thermometer? dynamap? portable BP cuffs? glucometer? accuvein? Sara Stedy? lift equipment?
What steps are completed to ensure safe admin. of IV meds via pump?
Equipment in a hospital room that is considered a ligature risk.
(and one of the reasons a patient safety attendant is required for patients with a behavioral health crisis)
What is ceiling lift? telephone cords? tv cords? computer cords? patient gown? IV tubing? IV pump power cord? oxygen tubing? linens?
3 inpatient nursing interventions that needed for every surgical patient and are only not completed if a there is a specific order to not complete the tasks
What are:
Surgical prep
Incentive spirometer
Mobility
Printed for transport personnel who do when patient is leaving the unit.
Trip ticket
Aseptic non-touch technique
What is the insertion technique for an indwelling urinary catheter?
Every 1-2 hours for patients who cannot communicate discomfort or pain.
What is the frequency of IV site assessments when fluids are infusing?
Decreases nuisance alarms.
What is individualizing alarms? | What is changing the electrodes?
Is a sign of sepsis, acidosis, hyper or hypoglycemia, low cardiac output, hypotension, rising intracranial pressure, rising blood ammonia levels, rising uremia...
What is change in mental status or level consciousness?
Standardized, organized, and concise
What is an appropriate handoff report?
Is a high-infection risk and should be treated with alteplase (Cath-flo).
What is a central line that does not withdraw blood?
30 minutes
What is the maximum amount of time narcotics or the PCA key can be out of the pyxis without documenting what was used and what was wasted.
Valsalva, trendelenburg, petroleum ointment.
What are the air embolism prevention measures when removing a central line?
0.5 mL/Kg/Hour
What is the minimum urine output for adults?
55 Kg (121 lbs) = 28 mL/hr or 336 mL/shift
80 Kg (176 lbs) = 40 mL/hr or 480 mL/shift
100 Kg (220 lbs) = 50 mL/hour or 600 mL/shift