VITALS
When do you take baseline vitals?
Time of admission
Transfer to a different unit
Returning from a procedure that required sedation
Name 3 things that should be included in hand off report.
Safety risks
Bed alarm Falls Restraints
Priority turns Specimens NPO
Fluid restrictions Feeding assistance
Daily weights Vital sign issues
Glucometer
What is a diagnosis that requires Incentive Spirometry?
Abdominal or chest surgery
Rib fracture
Pneumonia
COPD
Cystic Fibrosis
What 2 Hester Davis categories scoring a 2 or more tells you to ensure a bed/chair alarm and fall mat are present and on in your patient’s room when the patient is a moderate fall risk (11-14)?
Mobility and mental status
How should a stump from a BKA/AKA be positioned in bed?
Flat
If a patient has an elevated oral temperature, how often will you retake the temperature?
Minimum of every 4 hours
Name 3 hygiene activities that are done daily.
Bathing, shaving, incontinence care, bed linen change, oral care, hair care, skin care, pericare
2 things that you should do for a patient on bedrest are?
Use a TAP system
Turn every 2 hours
Float heels
Use soft care boots
What are the universal fall risk precautions and who gets them?
Bed in lowest position, call light within reach, bed or wheelchair wheels locked, room well-lit and free of clutter, slip resistant footwear, side rails up x2
and everyone gets them!
Name 2 things that are not the responsibility of a PSA (Patient Safety Assistant).
Bed baths, foley care, wound care, blood sugar checks, vital signs, restraints
After obtaining vital signs, when should the values should be documented in Epic?
Immediately or as soon as possible to reflect real time
When should you label a specimen?
At the bedside before leaving the patient's room
Name one thing that puts your patients at risk for a pressure injury.
◦Spend most of the day in a bed or a chair with minimal movement
◦They are overweight or underweight
◦They are unable to control their bowels or bladder
◦Have decreased feeling in an area of the body
◦Spend a lot of time in one position
What are you going to wrench in on your patient list to help determine the patient’s fall risk and interventions needed?
Hester Davis score
Name 2 behaviors of aggression.
Increased agitation, focused threats, increased profanity, yelling, kicking, biting, hitting, spitting
How do you obtain an accurate count of respirations?
Counting the times the patient breathes in one minute
How often should dentures/oral care be completed?
Twice a day
Name an activity that should be done several times a day for non weight bearing patients?
Dangle or sit at side of bed 2-3 times a day for 5-30 minutes
Your patient scores a 12 on their Hester Davis assessment according to your patient list column – what interventions will you ensure the patient has, and if they don’t you will go get?
All the universal fall risk precautions, fall risk armband, yellow socks, and I will check to see if they have a 2 or higher score under mobility or mental status – if they do I will place a fall mat, and bed/chair alarm and inform the nurse.
What is the last of the 5 senses, to leave a dying patient?
Hearing
In what positions do you take orthostatic blood pressure measurements?
Lying and standing
Name 3 tasks that belong to a NA/MHA?
Admission/discharge set up, daily care, vital signs, hygiene, specimen collection, feeding, ambulation, elimination needs, PSA duties
Name 2 areas on the body that are high risk for pressure injuries?
Heels and ankles
Knees
Hips
Spine
Tailbone area
Elbows
Shoulders and shoulder blades
Back of the head
Ears
My patient who has a Hester Davis score of 18 wants to go to the bathroom. Is it OK for me to leave them in the bathroom after instructing them to use the call light cord and wait for assistance before getting up?
No
Name 3 examples of a ligature risk.
Shower rails, coat hooks, plumbing, bedframes, window and door frames, handles, fixtures, door knobs, hand rails, shower curtain, power cords---etc.