Fall Prevention
Urinary
Chest Tubes
Hypoglycemia
MISC.
100
What should every room be equipped with to help prevent falls?
Bed and chair pad alarms
100
What is something you should be keeping an eye on throughout your shift? (NA and RN)
Patients urine output, making sure to document the amount!
100
(RN’s) Name the functions of the atrium x4
Suction indicator (explain how it works), suction turntable, water chamber, collection chamber
100
A diabetic patient is found lethargic and feeling lightheaded/dizzy, what would you do FIRST?
Check the blood sugar
100
When do you monitor for a transfusion reaction?
15 min after start of transfusion
Every hour during transfusion
1 hour after transfusion complete
*POLICY 2075*
200
What two visual displays can be posted as a reminder for patient's to call for assistance?
Verbiage written on the white board and the "call, don't fall" signs
200
How often should a patient be offered to use the restroom? Should they be left alone?
Every 2 hours and NEVER
200
What are three important things to remember when putting a patient with a chest tube back to bed or in the chair?
1. Make sure there are no dependent loops in the tubing
2. it's out of the patient's arm reach
3. is connected back to suction (if indicated).
200
(RNs) How often do you continue hypoglycemia treatment?
Continue treatment per protocol for BG >70 OR until alternate treatment orders are obtained from the physician
*POLICY 5115*
200
Name two patient safety identifiers that should be used prior to medication administration or specimen collections AND 2 reasons for the importance of barcode scanning
Name and MRN
1. To reliably identify the patient for whom the service or treatment is intended
2. To match the service or treatment to that patient
300
Name three tips to prevent accidental patient falls (3/3)
Room free of clutter (Clear the floor of all lines and tubing)
Non-skid footwear
Ensure easy access to necessary items like the call light, phone, and water
300
Patient had a foley removed at 1800, how long does the patient have to void?
6 hours
*Bladder scan earlier than six hours if pt complains of s/s of retention*
300
How do you determine if a patient should be to suction?
NA: ask RNs (specify which atrium if multiple)
RNs: Doctors order ONLY! Page out if order is not updated per assessment or MDs note.
300
Patient's blood sugar is >70 after treatment, do you recheck their blood glucose? If so, how long after?
Yes, Repeat BG one hour after treatment
*POLICY 5155*
300
What do the magenta visual alert magnets indicate?
Placed on patient's door to increase awareness in taking care of patients with behavioral risk (typically marked red in EPIC)
* FYI* Magnets are located near fall arm bands. These magnets ensure staff use a buddy system to enter and communicate with the patient to ensure team member safety
400
If a patient is refusing fall prevention interventions, what should be done?
Educate
Escalate (RN (for NAs) > charge nurse > manager > physician)
Document conversations had
*FYI* The refusal of treatment form cannot be used in this instance, but proper documentation will protect you should a fall occur
400
Name at least three signs and symptoms of possible urinary retention
Palpable Bladder
Bladder pressure “feeling of fullness”
Straining to void
Frequent small voids
*Form 4721-123595*
400
Your patient's atrium has been tipped over and there is drainage in multiple collection chambers, what do you do as the NA and RN?
NA: notify RN immediately (this impacts output data)
RN: change out atrium
400
What is best practice for checking ACHS blood sugars?
AC: with meals arrived on the unit
HS: bedtime (2100)
*FYI* Nurses have one hour from blood sugar check to give insulin. If more than one hour has passed, it needs to be rechecked prior to admin.
400
Create an SBAR report in 60 seconds or less
Patient name: Lucy Smith
Location: 7B05
Female, 60 years of age
Hx: DM, HTN, HLD, PAF, MVCAD
Admit dx: awaiting open heart surgery
Medications: Heparin running at 1000 units
Vitals: BP 88/85, HR 115, Temp 98.9, O2 90% on RA, RR 18
EKG: ST elevation in anterior leads (V1-V4)
Pain: 9/10 sharp chest pain that radiates to the R arm
(Situation) Hello Dr. Heart my name is … and I am the nurse for 60-year-old Lucy Smith in room 7B05. She is complaining of 9/10 sharp chest pain that radiates down her right arm. Please review the EKG I just obtained. (Background) She has a past medical history of MVCAD and is here on Heparin running at 1000 units, awaiting open heart surgery. (Assessment) Her current BP is 88/85, HR 115, and is sating 90% on RA. (Recommendations) I'm concerned she’s having a STEMI. I recommend we apply oxygen to maintain sats >92%, obtain labs, administer morphine IVP, an IV fluid bolus, and aspirin, and get her to surgery ASAP!
500
Demonstrate how to save a patient from an assisted fall
30 seconds or less
500
Who is allowed to place a patient's prima/primofit, what should be done each shift, and how often should it be changed?
RNs ONLY
Assess the skin
Every shift and as needed if soiled
500
(RNs) Explain how to change an atrium
Set up new atrium first
Clamp patient's chest tube
Connect chest tube tubing to new atrium
Unclamp patient's chest tube
500
Patient is alert enough to swallow with a blood sugar of 40. Name the 5 important things you are supposed to do
1. Add comment that you notified RN for NAs and MD for RNs
2. Document notification in EPIC
3. Recheck within 8 mins on SAME meter
4. Give 15 grams of an oral glucose
5. Repeat BG 15 minutes after treatment
*POLICY 5115*
500
What is the protocol for non-violent restraint application? (at least 4/7)
1. Apply restraints to prevent harm to self and others
2. Update POC
3. Page MD for order with exact restraint applied
4. New order every calendar day
5. Document every 2 hours contiNued use of restraints
6. Fluids/food, hygiene/toileting, skin integrity, ROM, circulation check of the restrained limbs, rights & dignity maintained
7. Key for locked restraints in Omnicell