Fall Risks
Night lights, yellow non skid socks, fall bands, hourly rounding, fall lights, belongings close by, frequent potty breaks
What are standard items used to prevent falls
Push IV meds, initiate blood alone.
What are things an LPN can not do?
What is timely, accurate documentation?
On admission, every 7 days, at discharge.
What are wound photos?
High/Low vitals, mental status, BG, HR, BP, change in condition.
What data that needs to be reported to the nurse, HS and doctor?
These things are assessed after a fall
vitals, skin, fall risk score, neuro checks
ADLs, toileting, rounding, pass trays, notify other staff, answer call lights, take vitals.
What are things all nursing staff can do?
Vitals, weight (weekly!), I&Os, nursing assistant shift assessment, patient rounding.
What is required documentation from the CNA?
Assess, change, document, discuss with provider, enter verbal orders.
Who are all nurses.
Any nurse can do this, using SBAR format, it is not the HS responsibility to inform the provider of changes in condition.
Who can communicate data to a provider?
This item is loud and alerts us that a patient is trying to get out of bed.
What is a bed alarm?
Document admission assessments, initiate blood transfusions, IV push medications.
Who is the RN.
Shift assessment, patient rounding, review POC, MAR, TAR, critical results, events, notifications from talking to providers, discharge instructions, education, wound care.
What is required documentation from any nurse?
Clinical documentation, Wound Care, Add
How do add a wound in the EMR?
4 hours
How much time before the start of your shift do you need to call off?
Any unanticipated change in elevation where the patient lands on the floor
What is the definition of a fall?
Assess, monitor, communicate changes, delegate to CNA, patient care, educate, discharge, collect labs, enter orders from MD, collect vitals, wound care, initiate blood with an RN, speak to providers.
What are things an LPN can do?
Functional scoring for the first 2 days after admission that must be completed each assessment.
What are GGs? On shift assessment: Is this the patient first 1-2 days of admission: YES!
Time, date, initial
What needs to be marked on the dressing?
Falls, LOAs, deaths, AMA, codes, abuse and neglect, anything else outside the norm.
What are events that need to be communicated to MD, AOC, CNO, Family, HS etc.
The doctor, family and AOC/CNO
Who should be called after a fall?
Initiate a plan of care on admission, declare death.
What are things LPNs can not do?
"The patient fell because day shift wasn't doing what they were supposed to do, that one CNA never does her job"
What is an inappropriate statement in the EMR?/What is an SUBJECTIVE statement.
Frequency, steps, location, items needed, also located on the TAR, and to be completed as ordered.
What are wound care orders, wound care treatments?
Being aware of tone of voice, body language, others perception. Being helpful, not condescending, not swearing, being polite always. Controlling your reaction.
What is respectful, professional communication?