K/Mag/Phos
How long until repeat lab for IV replacement?
1 HOUR
Who do you notify to remove the sharps container?
Housekeeping
Is a lap belt considered a restraint?
No!
Where do you chart your heparin?
IV titration
Where do you document that you notified a MD of a critical result, or that you attempted to page/notify them?
-Under manage/notify in process interventions
What TWO places can you find your replacement protocol?
- in the emar
-in nursing orders
What does security do for the baker act patients?
- Wand the patient/visitors, assume care of their belongings & medications.
Can you chart in your patient's note - incident/vigilanz report done?
NO
How often are you required to get a PTT after making a titration adjustment?
Do you need to complete a vigilanz if someone leaves AMA?
YES
What two K levels do you have to notify the MD with?
K < 3 or > 6
Who is responsible for charting Q15 minutes on the observation tool?
-The sitter
If the patient hits their head upon fall, do you get an order for a CT w/ or w/o contrast?
WITHOUT
YES
Is it ever "that's the next shifts problem?"
wellllllllllll, NO :)
Which replacement require the pt to be on a cardiac monitor to administer?
How often is the RN required to fill out the observation tool?
Q2 Hours
What are some ways to prevent falls?
-bed alarm ON (bedside shift report)
-bedside tables and belongings in reach, call bell as well.
-keep bed in low position.
-nonskid socks
-the P's
Do we turn off the heparin when the bag is empty or when it is not "scheduled" for a second bag until a later time?
NO. NO. NO.
We add volume/get another bag.
WE CALL PHARMACY TO RETIME.
Is the patient required to sign the AMA paper?
No.
2 witnesses required.
How many hours after you give PO replacement do you need to recheck lab values?
3 HOURS
Can the patient use a phone? and have visitors?
Yes, and yes. May be restricted by the team if seen fit.
What do you need to complete after the fall?
- post fall assessment
-shift assessment
-patient note
-vigilanz report
-post fall debrief tool
What are the 3 things that we do after we make a heparin titration change based off the PTT?
1. Another PTT 6 hours post CHANGE.
2. Document IV titration w/co-signer.
3. We send a message/order to pharmacy on the change.
How often are vitals required on a blood transfusion? Bonus for what vital everyone forgets to chart typically?
Initial set before transfusion begins.
15 minutes after initiation.
At the completion of administration.
TEMPERATURE