Documentation dos
Where do you document when you have given a patient a bath?
Daily Cares Flowsheet under hygiene.
The patient refuses their CHG bath. You leave the necessary supplies at bedside and document supplies at bedside. What is wrong with this?
Need to document the patient's refusal, inform nurse regarding refusal and check with the patient again later
How often do QCs need to be performed on the glucometers?
Vital signs are:
BP: 87/56, HR: 134, Resp: 22, Temp: 98.7
What do you do?
Notify the nurse regarding the low blood pressure and high heart rate
RE-check bp manually
How many pumps should be used when giving a CHG bath?
4 pumps
The patient ate their entire lunch tray. They drank 150 mL of juice. How and where do you document that information?
Document under I/O flowsheet
Put under correct meal and enter the % eaten and enter the intake in liquids as well.
You did your q2h rounds on all your patients throughout your shift. When should you document completion?
One of your patients is ambulatory and did not need anything from you the entire shift, so you do not document anything. Is this correct?
As you complete them or as soon as you are done.
NO, you should document the completion of rounds.
You just checked a patient's blood sugar before going into another patient's room, what do you need to do?
Clean the glucometer with approved cleaners. Should clean after every use
When doing your hourly rounds on patients you look at the suction for a purewick and find it to be set to 200.
Is this correct?
No- suction should not be higher 120 mmHg
Correct the suction, ensure correct placement of purewick and verify no skin injury
As a NA are you allowed to disconnect patient's from medical equipment such as a IV pump or feeding tubes?
When providing foley care to a patient where should you document it and how often?
Daily Cares flowsheet under hygiene-perineal care (catheter care completed)
Q Shift and prn
Your patient has a foley catheter you empty the bag at 0800 and then again at 1400. Which is incorrect?
a.) You document as 1 occurence
b.) You document the volume emptied each time
c.) You tell the nurse how much was emptied but do not document.
a.) or c.)
When performing controls on the glucometers you need to make sure you are also checking what?
That the glucometers are clean along with the charging stands.
What value is abnormal:
BP: 115/65
HR: 120
Resp: 16
HR >100
A patient should be offered a bath daily?
T/F
A CHG bath counts as a bath?
T/F
True, true
Your patient has q2h turn order. What do you need to make sure you document with the turn?
Use of wedge and positioning equipment, any care provided, previous position
Epic update November 17th
Your patient has a purewick in place. A new cannister is in place at the start of the shift. When doing your I/O later in the shift. You forget to document so you just mark it as an occurrence. Is this correct?
No. Need as accurate as possible amount documented. Mark on cannister when you record output. If purewick has become dislodged then you can document as an occurrence.
If cannister is full and needs to be changed make sure to use solidifier and dispose of in patient's trash. Take to dirty supply room when done.
How long are the controls good for? How long are the strips good for?
Controls: 3 months
Strips: 6 months
Your patient has not had any urine output in 8 hours, but they are not complaining of any pain. What do you do?
Notify RN, assist patient to restroom/bedside commode
At what time should all patients have a bed alarm turned on?
Yes, always notify the nurse regarding any abnormal vital signs or complaints the patient may have.
When checking a patient's blood sugar it is found to be 54. The patient is still alert and talking. You leave the room and continue to check blood sugars. What is wrong with this?
Document that nurse is notified in glucometer and Epic, get the patient juice (if alert), and re-check the blood sugar in 15 minutes
The glucometer should be wiped down with a orange wipe and then a purple wipe.
True
A patient is complaining of a severe headache and blood pressure is found to be 189/110. What do you do?
Push the RRT button, notify the nurse, check bp manually
You are walking by a patient's room and you see their foley catheter sitting on the floor. What do you do?
a.) Keep walking not in my assignment
b.) Go in room and hang on bed not touching floor
c.) Notify the nurse/aide caring for that patient
d.) Dance
B.