LDAs/CAUTI/CLABSI
How often should you perform Foley hygiene care? Central Line hygiene care?
Foley Care = every shift/ prn
Central line care = daily / prn
How often do you need to document vitals/I&Os/ Assessments on PCU? (bare minimum).
Bare minimum documentation
Vitals= Q4
I&Os = Q8
Assessments= Q6
Being resident/fellow in the program, are you ever allowed to administer ANY medication by yourself?
Nope! must have preceptor with you during all and any medication administrations. Even with Tylenol.
How often do you need to update or chart on the care plan?
Once a shift or PRN.
After AM labs were collected, you receive a call from laboratory to report to you of a critical K=2.6. What actions would you take?
First, page provider!
Under the critical lab tab, document your lab value and the provider you notified with their ID.
However, what if your provider 1st call did not call back within 5 minutes? How do you proceed?
For Foley Stat locks / Central line dressings, how often do you change them?
Foley Stat Locks = change every Saturday, Q7 days, or PRN.
Central Line Dressings = change every Saturday, Q7 days, or PRN.
What is the documentation process for 1:1 sitters or patient safety attendant (PSA)?
Documentation on sitters need to have Q1 documentation on Epic. Discuss with your sitter to document odd hours and RNs documents even hours.
Purple sheet for PSA q15 minutes.
How often should the CBG machine be cleaned for POCT?
In between uses.
Also, must go to "maintenance", click on "cleaning", and then hit the green check mark twice.
What do you need to do to every care plan or patient education?
Needs to be patient specific and individualized.
Where do you find your first call provider?
In patient chart, under team. It should have your providers listed.
What do you need prior to using Peg Tube, NGT, DHT, Central Lines?
You need a clear for use order from provider.
Documentation for Restraints
Needs to be documented on every 2 hours/ even hours.
Patient has 1 IV, has new order for 2 antibiotics but you are not sure they are compatible. What is a resource you can use?
Lexicome and look in IV compatibilities.
Where do you document a medication's first dose education?
Go to "education" tab and in "first dose" section document under the medication you gave education on.
OR
Document on the MAR with the little book marker in the right-hand corner.
How do you page RAT?
Under directory, can type in RAT and page the Rapid Assessment Team. Give SBAR.
How often do you assess your lines? (foley, central).
Foley = minimum of Q4 hours
Central = with assessments and prior to use.
For PCU, how often and when do you interpret EKG strips?
Needs to be completed by 0900/2100 as part of your initial assessment must have PR, QRS, QT intervals, analysis of rhythm documented on strip and placed in paper chart.
You are taking care of your 3 patients, but you hear another rooms bed alarm going off. Do you go and check it or wait for the other nurse to check on their patient?
Always respond to any alarm, no matter what!
You never know what is happening and it could save a life.
How often do you chart a patient's stated goal?
Once per shift.
How do you call for a code blue?
On 5 MPCU because we are on a Pilot Process for Code Blue, you just need to press code blue button and announce wayfinding number and what is going on.
OR
If you're off unit, you can call 911 and give wayfinding number.
How often do you document on your LDAs
With assessments on most LDAs or per provider orders.
when you access for medication administration (PIVs)
How often do you get CBGs for insulin gtt/ Anti Xa for heparin?
Insulin gtts require hourly CBGs
Heparin gtt require Q 6 unless there are 2 therapeutic levels back to back and then it is Q 12.
You are taking care of your 3 patients. You notice one of your patients has an abnormal HR and arrythmia. Who can you grab to get a second pair of eyes on the situation?
Your preceptor!
Your neighbor nurse
Resource RN
Charge RN
AUM/ANM (weekdays)
When starting your shift, what is the importance of reviewing Professional Exchange Report (PER)?
When starting your shift, it is important to review PER with off-going shift to discuss the goals of continuity of care and what should be the daily objective in patient care.
How do you document you notified a provider?
In the critical value tab, there is a section for notified provider.