SCDs & TED Hose
Is a provider order required for SCDs?
Yes, SCDs are a medical intervention that requires an order
True or False: You should turn off the bed alarm when the patient is not in bed.
False- alarm should be silenced by pressing on the bell. Alarm will default to ON when patient gets back into bed.
Who should be notified after a fall occurs?
provider, charge nurse and supervisor
What is the purpose of CHG bathing?
Decrease healthcare associated infection
What should you do if a patient has no urine output for 8 hours post-op?
Assess bladder with bladder scanner for urinary retention, notify provider
What is the purpose of sequential compression devices (SCDs)?
Prevent venous thromboembolism (VTE) by promoting venous return by reducing venous stasis
What are contraindications to getting a patient out of bed?
Bed rest order, new neuro deficits, hemodynamic instability, excessive sedation
What are universal fall precautions?
Precautions in place for all patients, regardless of their risk for falls
Orient patient to environment- call light
Educate patient and family on fall risks – request assistance
Correct use of assistive devices
Items in reach
How and when should a CHG bath be completed post-op?
Daily for 3 days
What are signs of postoperative ileus?
What are contraindications for SCD use?
Active DVT, severe PAD, severe edema/CHF, skin breakdown
How often should the Morse Fall Scale be completed?
On admission, every shift, and with any change in patient condition
What should you do if you find a patient on the floor?
Complete assessment and notify provider. Assist patient back to bed if no major injury suspected (head injury, fracture, etc.) If
major injury suspected,
call a rapid response.
What areas should be avoided or used cautiously with CHG?
What is the expected time frame for a patient to void after Foley removal?
no more than 6 hours
How long can TED hose remain on a patient?
Should be removed before bed and removed once per shift for skin assessment. Continuous pressure increases risk of skin breakdown
What interventions should be implemented when the Morse Fall Scale is >45?
Bed alarm, frequent rounding, assist with all mobility, non slip socks/footwear
What should be completed post a fall?
Notify MD/Hospitalist/Patient contact person.
Perform Post fall huddle.
Document post fall note in VISTA (every shift for 72hrs) & update Plan of Care.
Complete JPSR
How often should patients with central lines receive a CHG bath?
once a shift every M, W, F
What is the next step if the patient cannot void?
Straight cath
How often should the skin be assessed under TED hose?
Once per shift as part of comprehensive skin assessment
This intervention must remain active for high fall-risk patients, should not be disabled when the patient is out of bed, and is critical for injury prevention.
Bed alarm
When should you call a RRT after a fall?
When major injury is suspected, when patient states they hit their head and when the fall is unwitnessed
What is the correct approach for CHG bathing?
Wipe 1 – neck, shoulders, chest
Wipe 2- arms, hands, webbed spaces, and axilla
Wipe 3- abdomen, groin
Wipe 4- right leg and foot
Wipe 5- left leg and foot
Wipe 6- back of neck, back and buttocks
What is a common complication of anterior cervical spine surgery?
Answer: 30ml/hour