Vital Signs
How often do you take vital signs on patients
Every four hours
What does the glucometer show >
The patients' blood sugar reading
How often do you document on a 1:1 patient
Every 15 minues
Where do you document vital signs in Epic
Flow sheet
What do you do if blood sugar is too low
Notify RN immediately and offer orange juice with sugar (if not NPO)
What is low blood pressure?
<90/50
How often do you clean the glucometer
After every patient or if soiled
Where do you document in Epic for a 1:1
Close observation
Where do you document ADL's in Epic
Patient care/safety flowsheet
What do you do if the blood pressure is too high
Document, notify RN immediately and recheck in 15 minutes
What is high blood pressure?
> 150/90
What can you do if using the glucometer on an isolation patient
Place in clear bag prior to entering the room
What must you do while sitting on 1:1's
Offer food, drinks, and bathroom privileges
What must you do if a patient is a fall risk
Yellow socks, highlighted in Epic and sign on door
Can a patient that is 302 go AMA
not until cleared by psychiatry
When would you not use a certain arm for blood pressure?
Renal patients and mastectomy patients
What is a low blood sugar
<50
Who removes the patient from a 1:1 need
The nurse or physician may down grade the patient
Where do you document Intake and output in Epic
Flow sheet
Can a patient being discharged be allowed to leave AMA
Yes, but we try to get them to wait for discharge papers
When do you need to change blood pressure cuffs to a different size?
If patient is obese or very small. The cuff needs to fit the patient adequately
What is a high blood sugar
180-200
Are 1:1 patients ever in restraints
Yes. Sometimes soft and sometimes locked
What type of output do you document in Epic
All urine, foley, drains, pure wicks, emesis
What must you do and the beginning and end of every shift
Sign in and accept your patient assignments