Stroke
must be completed on all stroke/TIA patients prior to consuming anything by mouth
What is a swallow screen? or What is a Dysphagia Screen?
three times a pain assessment should be completed on a patient
What is upon arrival to the unit, minimum of every 12 hours or once every shift, when a patient complains of pain, after any invasive procedure, before administering a as needed or prn medication for pain?
Number you call if someone falls
What is 211?
only person who should be staging a wound
What is a certified wound nurse?
if something is not documented
what is it was not done?
Five actions for stroke prevention
What is healthy diet, exercise or be active, stop tobacco use, limit alcohol, take medications as instructed, manage diabetes, manage high blood pressure, manage high cholesterol?
three parts of a pain assessment prior to intervention
What is pain score, pain location, and pain descriptors?
Five fall prevention interventions that nurses can do for patients
What are chair alarms, bed alarms, tele monitoring or remote monitoring, yellow grip socks, fall bracelet, stay with me sign on door, self-release belt, bed in the lowest position, table with frequently used items in reach, call bell in reach, room near nurse's station, gait belt use, ambulatory assistive devices, hourly rounding?
four appropriate skin protection measures
What is barrier creams, bed pressure redistribution surface selection, foam dressings to bony surfaces, heel boots, elbow protectors, cushion skin from medical devices, etc.?
IV site assessment should be documented
What is every 4 hours with a saline lock and 2 hours with a running infusion?
*** Double Jeopardy***
What are smoking, obesity, diabetes, high cholesterol, heart disease, irregular heart rate, heart valve disease, family history of heart disease, hypertension, previous stroke or TIA, unhealthy diet?
Two scores that need to be completed for assessment and reassessment when administering opioids
What are POSS (Pasero Opioid-induced Sedation Scale) and Pain scale?
On admission, every patient needs one of these done to help determine if the patient is a fall risk
What is the Morse?
all findings, abnormal and normal, need to be documented within
What is 24 hours of admission orders time stamp?
name some patient education that should be documented in the care plan activities
What is first dose of new medication(s), diagnosis, activity, activities, procedures?
*** DOUBLE JEOPARDY***
What is Balance, Eyes, Face, Arms, Speech, Time?
four non pharmaceutical interventions for pain
What are heat, ice, reposition, distraction, movement, music, pet therapy, art, pastoral counseling, exercise, companionship, meditation, aromatherapy, deep breathing?
The categories of a Morse Assessment
What are history of falls, secondary diagnosis, ambulatory aide, IV access, gait/transferring, Mental status?
all admissions and transfers require
What is a 4-eyed skin check?
Care planning and a progress note need to be documented this often
What is once a shift and as needed?
when you need to intervene for an O2 sat on a stroke patient (put oxygen on a patient)
What is less than 94%? (a stroke patient should always have an O2Sat of 94% or higher)
when a pain reassessment needs to be done by and what you need to do with the reassessment
What is document your reassessment for pain within 60 minutes?
the definition of a fall
What is A fall is a sudden, unintentional descent, with or without injury to the patient that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can).
during a 4-eyed skin check the patient's skin should be checked all over, especially the five focus areas, six in some situations, these are the areas
What are heels, elbows, toes (including between), spine, sacrum/coccyx, and if on O2 behind the ears?
A nursing progress note should be used to document
What is document significant events, changes, or communications?
(Policy states Document at least one progress note per shift to summarize patient's condition and progress in relation to their primary problem.)