NSIs
Your patient arrives to your unit with a NG in place. What is the preferred method of securement?
What is the Omega method
Always treat ____ before agitation
What is Pain?
Patients are screened for delirium every ____ hours
12
Mobility should occur how often?
As soon as possible and a minimum of twice daily.
This excludes PT/OT's work
Your patient has been assisted to the toilet. What is required to keep your patient safe from falls?
What is stay within arms reach of the patient. Do not leave unattended
Patients with a NG tube should have their nares assessed and NG repositioned every ____ hours?
What is 12
When do you reassess pain?
What is within one hour after any intervention (pharmacological and non pharmacological)?
When screening for delirium in the acute care patient, if there is not an acute change from baseline or if the patient’s mental status has not fluctuated over the past 24 hours, do all of the other 4 components of the b-CAM need to be completed?
Yes all 5 components must be completed (including the RASS)
These measures are taken if your patient refuses mobility
Re-educate the patient on the importance of mobility
Document the refusal and re-education in SCM
Escalate to the provider,CNS, DCN, and/or PCM/APCM
These measures are taken after a patient falls.
What is obtain initial set of vital signs and complete nursing assessment--include neurological checks, recheck in 15 min, then every hour for 2 hours
notify--Provider, DCN, HOA, and Manager
Complete online incident report AND post fall Huddle form (with DCN and/or HOA)
Ensure the patient has fall risk identification and all safety measures are in place.
The turn team turned your patient. You know it is an effective turn by your ability to do what?
What is slide your hand under the coccyx.
The following are reasons for _______:
Need to urinate or BM
Uncomfortable position
hypoxia
sleep deprivation
inability to communicate
need for personal items (glasses, hearing aid)
drug withdrawal
frustration, fear
What is agitation
Name at least two non-pharmacological treatments for delirium:
Avoid restraints
Promote sleep (lights on til 9p, sunlight during day, cluster care)
Early mobility
Purposeful hourly rounding (reorientation to person, place, time)
Provide personal items
Establish trusting relationship
SCDs should not be off longer than what time frame?
How often do you document SCDs in place?
What is should be worn at all times, even when up in chair. SCDs should not be off more than 90 minutes?
SCDs should be documented every 4 hours
The patient is scheduled for OR in the AM. Enoxaparin is ordered. Should this be held for surgery?
NO!! Unless there is an order to do so or unless the active order has been documented.
If the Braden Score is <18 or the Jackson Cubbin is <35, this product will be applied to the heels
What is allyven.
The RASS (Richmond Agitation Sedation Scale) goal for light sedation.
What is -2 to 0
The scale used to assess delirium in the ICU patient
What is ICDSC (Intensive care delirium screening checklist)
This is a non-pharmacological treatment for delirium, decreases length of stay, and improves patient outcomes
What is early mobility
This should be set on ALL patients
High Fall Risk patients will be set in which zone
ibed awareness
2
Daily care of the patient with a CVAD includes what elements?
What is assess the necessity of central line
Monitor/assess the site daily
Daily CHG treatment (within 24 hours) CHG treatments do not replace soap and water
Flush port(s) q 12 hours with 10 ml of normal saline using pulsatile flush technique?
The action you take if RASS is out of -2 to 0 Range
What is titrate drip according to order set until patient is within ordered goal range
Which scale is used to assess delirium in the acute/progressive care areas
What is bCAM (brief confusion assessment method)
Your patient has not been mobilized in the last 24 hours. What is your next step?
Notify Provider and CNS of immobility. Mobilize patient as soon as possible!
Who do you call when the 37 pin cable is missing from the Stryker Bed?
Patient transport