Sepsis
STAT labs for sepsis include Bl cultures, how often are these drawn?
15min apart x2
Bl cultures are drawn 15 min apart x2 and lab values are rechecked every 2hrs x3 if the initial lab values are abnormal
You would also draw lactic acid BEFORE administering ABX, CMP, Phosphorous & magnesium, CK-MB, Prolactin, Troponin, Urianalysis & microscopic urine and microbiology.
True or False:
When handling chemotherapy or patients' body excretes you must wear PPE.
True
Who should you notify if a visitor slips, trips or falls?
Security is who you should notify, and security will complete the appropriate forms.
SIRS is determined by Temp <96.8 or >100.9, HR of >90 bpm, RR >20/ PaCO2 <32mmHg and WBC >12,000 <4,000 or >10%bands how many of these does criteria does the pt have to meet to qualify as SIRS?
First SIRS is 2+ of the criteria, then progresses into Sepsis if we also have a suspected or confirmed infection, then Severe sepsis id one acute ran dysfunction or hypo perfusion (i.e. oliguria, ALOC, Respiratory Failure) then is progresses to Septic Shock is sepsis with hypotension despite adequate fluid recitation (but its who are on inotropes or vasopressors might not be hypotensive due to this false reading from medication action)
What color indicates chemotherapy precautions and how long does a patient stay on chemo precautions?
Orange, 48 hours.
Tool a nurse will use, to further assess and identify a patients fall risk?
What is the Morse Fall Risk Scale tool.
What other STAT orders would be indicated for sepsis?
Chest XR & 12-lead
Nurse is also responsible for initiating VTE prophylaxis & VAPP if the pt is ventilated and must record perfusion status by documenting VS, cardiopulmonary exam, cap refill, peripheral pulses and skin, CVP if they have a central live, bedside inferior venacava ultrasound, and have passive leg raise or fluids to restore volume.
1. Cover the toilet with disposable chux
2. Double flush the toilet
3. Remember to place signs in the restroom to remind pt and staff to double flush.
What position should the bed be in and what item should should be left in reach of client before exiting the room?
What is low position(for bed) and call light.
What is the goal CVP of a septic pt within 6hrs of arrival?
>8m
Ultimate goal is to maintain CVP of 8-12 if the pt has CVP monitoring in place.
Neutropenic Precautions, how do we protect our patients?
1. Hand hygiene (done gloves and mask, education visitors to do the same)
2. Place your patient in a single room (positive pressure room and keep the door closed if ordered by doctor)
3. Persons with a cold, flu, sore throat, open sores or infection should NOT enter this room
4. No fresh or dried flowers/plants/fruits/veggies (peel-able fruits or okay)
5. Patient must wear surgical mask when outside of room
6. STRICT aseptic technique with all lines and procedures
Name the first precedure/safety precaution that is used when transporting patients on a gurney.
What is side rails will be in the up position when patients are being transported on gurneys.
A central venous catheter is considered for hemodynamic monitoring in septic shock patients, name at least one indication
pt requires vasopressor for hypotension
no peripheral access has been secured
require massive fluid resuscitation
Contraindications invasive monitoring include: insertion of line would not change course of treatment, vascular access is not possible (i.e. bilateral clots), high risk for blessing, pt too unstable and code is imminent, high risk fr pneumothorax, pt refusing consent
How do you handle a chemotherapy spill?
1. Call a code orange
2. Evacuate everyone from room or area
3. Place chemo-spill sign near the spill
4. Don PPE (from skills kit)
5. Use absorbent towels and dispose in chemo waste can
6. Clean 3x with bleach wipes and dispose in chemo waste can
7. Clean 1x with water and dispose towel in chemo waste can
8. Dispose all PPE in chemo waste can
9. EVS to complete a final clean of the area.
10. Document everything and complete employee injury report (RIR), hazardous spill incidence form located in chemo cart, notify your manager.
Name two interventions you will implement after you initiate the "Fall Risk Protocol" for a patient with a Morse score 45 or higher.
What is...1 initate appropriate care plan(IPOC) with goal and interventions.2. initiate the Fall Risk Protocol Nursing Care Set. 3 Place yellow clip on pt. armband. 4. Place yellow non-slip socks on patient. 5. Post Fall Precautions sign over the patient's bed and at the room entry. 6 Pt. or pt.'s famiy to receive patient ecducation. 7. Place patient in bed with bed alarm if attempting to get out of bed without assist.