This describes what must be documented if a patient exhibits a weight gain of +/- 3kg
What is a reweigh?
100
This must be administered to all patients greater 65 years old or 5-65 with a high risk diagnosis of COPD, ESRD, HIV, Heart Failure, Diabetes, Asthma, Nephrotic Syndrome, Asplenia
What is the pneumonia vaccine
100
IV Assessment & Care Intervention
What is every 4 hours?
100
This must be entered in the I & O even if a chest tube as had no output during your shift
What is zero?
100
Picture 1
What is the Hygiene Intervention
200
This "I Did it" intervention is present to ensure a restraint order is received every calendar day
What is the Restraint Order Received Intervention
200
A physician has ordered to change your patients fluids from normal saline to D51/2 NS. At 1045 you make these changes. Other than in the patient's EMAR, where does this exchange need to be documented?
What is the IV Titration Intervention
200
Restraints Intervention
What is every 2 hours?
200
Along with amount of assistance used, this must also be documented when describing the reposition of a patient
What is their position?
200
Picture 2
What is the Discharge/Transfer Orders
300
Upon initiating a Fentanyl PCA pump, this must be done and documented by a second RN
What is an independent double check?
300
If an antibiotic is ordered on a new admission at 2300 on 5/5 but is not administered until 0030 on 5/6, what two componants must be checked to ensure correct documentation of this administration?
What is date & time?
300
Foley Catheter Intervention
What is BID?
300
This is written anytime there is a change in patient condition, transfer to another area, admission or discharge etc.
What is a narrative note?
300
Picture 3
What is the Death Record Intervention
400
These individuals are needed to administer a drug highlighted in yellow on the hazardous drug list
What is 2 chemotherapy trained nurses
400
What two places must you document the date of a a central line dressing change
What is in the IV Assessment & Care intervention and on the dressing
400
Medication Double Check Intervention
What is anytime you initiate, change the rate, or hang a new bag of a high risk medication?
400
Name four cares that must be documented, when completing the restraints intervention every 2 hours
What is CMS checks, repositioning, fluids, food, bathroom, repositioning, skin checks, hygiene
400
Picture 4
What is the Medication Double Check Intervention
500
If no proper primary indication for a foley catheter is present, one must have one of these to mark Dr's Reason Present
What is a foley catheter continuation order or a reason for continuation in a physician progress note
500
Name 4 of the 6 teaching components that are mandatory in the CHF Education Record Intervention
What is medications, diet & nutrition, activity & exercise, tracking weight, warning signs/HF zones, Follow up Appt
500
Braden Score for Pressure Ulcer Risk
What is 0700, 1500, 1900?
500
If a patient is receiving lovenox, this would be the reason for exclusion in the VTE intervention