What do I do?
You searched for a medication on night shift, it's not in your patient's bin, or in the night cupboard stock list. What next?
Call pharmacy on-call through locating or find on Sunnynet Paging
Routine trach care
06. 14. 22. and PRN
Your patient has a tracheostomy. They are coughing and their SpO2 remains at 87% even after you suction. What are your next actions?
Call a rapid response or Code Blue (if the patient deteriorates further, not improving with increased oxygenation)
Your patient's family is calling frequently about test results. You explain that you are not permitted to provide them with this information over the phone. Where can you do to ensure they get the info they need?
Refer them to access MyChart - patient/family has access to all results
Inform family that you will tell Doctor to call the family with an update
Your patient is confused and trying to climb out of bed. You have no observer right now. What do you do?
Prevention strategies: floor mat, call bell, bed alarm, distractions, bed in lowest position, frequent checks, lights on/off depending on time, move patient closer to nursing station or to a room with a shared observer, assess for new confusion/delirium, collaborate with externs on the floor for increased monitoring
The telemetry nurse calls you and says the patient's heart rhythm has changed and they are now in a-fib, at 115. What next?
Assess patient first. Vitals. Page MD to inform of change. Does patient have any symptoms?
Documentation: Always write: "As per telemetry nurse". You are not accountable for this change as you are not viewing the rhythm strips. MD may order ECG, bloodwork.
Your patient has a CBI. How often do you document? What do you include in your documentation?
q2h. Input, output, colour of urine, blood? blood clots? irrigation required? bladder scan required?
Separate documentation CBI tool
Your patient has a STAT CXR ordered.
Enter the CXR order in sunnycare as STAT and portable. Call 744 on phone, and/or page 1191 for X-ray. They will call the unit back and you tell them you need a stat portable CXR to your unit, room number, patient name
There is Insulin novorapid ordered for 2200 for your patient. Where can you confirm this?
Check the Doctor's orders - Insulin orderset
The orderset states NOT to give short-acting insulin at HS. The grey areas in the nurse's blood sugar documentation form gives you a clue that you shouldn't be administering short-acting insulin at this time. Page MD to clarify.
You are doing your MAR to MAR check at HS shift. You notice a medication is missing on the new printed pharmacy copy MAR. Why would this happen?
Always check the chart back at least 24 hours. If the order was written later in the day, the pharmacy may not have received it in time to print on the new MAR. Re-write the medication that was missing on a new blank MAR sheet. Always double check any medications that have been hand written, or medications that have been discontinued/changed.
Your patient has a tracheostomy, and they are requiring suctioning q1hour for the last 2 hours due to ++ secretions. What can you do next?
Continue suctioning, + trach care as needed. Elevate head of bed. Ensure O2 sat is appropriate and respiratory assessment is completed. Inform MD of ++ secretions. Anticipate patient requiring CXR. May need medication to decrease secretions. May need increased observation. Connect with RT if increased oxygenation is needed.
When do you bring the MAR to the bedside?
Every time you administer medications
Your post-op patient is complaining of worsening pain. His MRP is orthopedics. He is being followed by APS. Who do you call?
APS - manages pain, and should have a separate APS orderset.
Don't give any analgesics ordered by MRP, unless clarified and confirmed. Only follow APS orders for pain management
Your patient had bloodwork ordered and entered on the previous shift. Where can you look to see if the bloodwork was completed?
Blood board - phlebotomists sign off when they complete the bloodwork.
Sunnycare - patients blood work results, or see if the lab has "received" the sample
Your patient's ileostomy keeps leaking. You have changed it once already on your shift. Why?
Ensure skin is clean and dry surrounding stoma. Ensure the appliance size is correct. Ensure the cut out is the accurate size and fits snugly around the stoma. If too much weight/pressure for appliance, you can apply the appliance while pt is sitting up, instead of laying down. Check if it needs a different type of appliance (flat, convex), or an eakin ring.
Call wound care nurse for assistance.
Your patient is post-operative abdominal surgery. They have an epidural and foley-cather in-situ. The MD orders to discontinue the foley. What do you do next?
Question the order, as the patient still has an epidural and there is no order from APS to d/c the epidural. Patients with an epidural should continue to have foley in-situ.
Your patient is on NG feeds. When do you replace the feeding tube bag, and how often?
Approx 0600 on night shift, q24hours
Your GIM patient has some suggestion orders from Respirology. Who do you call?
MRP - to co-sign the order
Before you transcribe or acknowledge the order.
Exception: APS and palliative orders
Do you need an independent double check for subcutaneous insulin?
Independent double check policy on sunnynet
No. Only for IV insulin or if you are retrieving a new insulin pen from the fridge/night cupboard.
Other high alert meds that need IDC: IV ketamine, IV heparin, IV insulin
You are assigned to C6 when you leave your house in the morning. You arrive and your name is not on the assignment. Why?
Check RESP on the unit to see where you are assigned as it may have changed. Call scheduling to confirm if necessary. Go to assigned unit as shown on RESP (this can happen as ACNRT so don't be alarmed!)
Your post-op total hysterectomy patient has an IV PCA + continuous infusion. On assessment, the patient is sleepy/unable to keep their eyes open with a respiratory rate of 9 respirations/min. What are your next actions?
Turn off IV PCA pump. Ask for help & call/page the MRP and APS and to inform. Prepare and administer naloxone as ordered on the APS order-set (remember to dilute with NS in syringe). Remain with patient, monitoring for changes in GCS and respiratory rate.
Can you clamp the patient's NG tube that is being used for decompression?
Never!!
If giving medications is required via NG - put to straight drainage x30 min post medication admin.
Clarify order with MD, are medications allowed to be given?
Your patient has bloodwork ordered at 2pm. Your patient has a PICC. Who do you call?
IV RN - can draw blood from PICC or find a staff member certified in blood draw.
Phlebotomy - doesn't draw blood from PICC
Your new admission/post-op patient arrives on C5 in +++ pain. You notice that their PCA pump is turned off. What are your next actions?
Check the APS orders any analgesic related issues; disregard analgesic orders from MRP. Page APS/sending unit to find out why pump is turned off. File an incident report. Turn pump on as ordered. Independent double check for setting up PCA pump with one other nurse.
Your patient has a T2-S1 epidural block. The patient can wiggle their toes & lift their legs but reports ankle numbness, saying that they can't feel the coldness of the ice check. Why is this happening? What do you do next?
The epidural block is extended down their legs, meaning either it may be too much medication for the patient and creating a larger block. Assess the patient's pain level. Slow down the rate of epidural infusion as ordered in the range. Or inform patient to not use as much of the PCA. Inform APS as needed if block not improving.