Grasp-it

Teaching/Support

100

select this item when scheduled teaching with the patient and/or family is planned, or when nursing intervention is required to help manage a patient's/family's severe emotional distress or combativeness

What is "Planned teaching or extended emotional support"?

200

select this item for all children with a developmental age greater than 2 years

What is "diversional activities"?

300

select this item for all children under the age of 2 years, or children with special needs/developmental delay (developmental age <2 years).

What is "cuddling/rocking"?

400

select this intervention for infants < 9 months who are inconsolable due to drug withdrawal, colic, or unexplainable irritation. this intervention should not be selected in addition to cuddling/rocking

What is "inconsolable infant (birth to 9 months)?

500

select this intervention when there is a scheduled patient/family interdisciplinary team conference. this is not selected for daily rounds or discharge rounds.

What is "family/interdisciplinary team conference"?

Patient Safety and VS

100

the intervention appropriate for patients at high risk for falls because of Morse scale>60; only select for children over the age of 5 years with Morse Scale>60

What is "fall protocol (Morse scale >60)"?

200

Diagnosis of seizures and ongoing monitoring of seizures (more than 2 seizures per shift)

What is "seizure monitoring - complicated"?

300

diagnosis of seizures and requires ongoing monitoring for seizures (up to 2 seizures per shift). also includes the patient on video EEG monitoring.

What is "seizure monitoring - uncomplicated"?

400

intervention for patients who require more frequent neuro or csm checks (more often than with assessment). involves neuro assessment more than pupil check, and csm assessment more than pulse check.

What is "neurological checks" and "CSM checks"?

500

two interventions in the Vital Signs/Measurements section of the instrument which should NOT be selected when also selecting chemotherapy interventions

What is "strict intake and output" and "point of care testing"?

Medications and Chemo

100

select this intervention when meds must be crushed or added to food substance, administered through an enteral tube, or when administration is difficult due to patient resistance, or if the medication is given based on parameters

What is "special consideration with med administration"?

200

select this intervention when the patient has 2 or more IV "sites" or lumens AND requires site care, bottle/bag change, tubing changes, etc. (flushes for heparin locks are captured under the medication intervention)

What is "IV maintenance - 2 or more lines"?

300

select this intervention for patients receiving medications that require additional monitoring, e.g., heparin, insulin drip, amphotericin, ATGAM, albumin, local anesthetic infusions. the operational definition includes titration and additional VS monitoring

What is "special medications requiring additional monitoring"?

400

select this intervention for patients receiving chemotherapy that requires timed labs, point of care testing, post hydration fluids and rescue medications, and nursing evaluation and interpretation of lab values and adjustments based on those values. Time for point of care testing and strict I/O are included in this intervention

What is "chemotherapy interventions"?

500

this intervention applies to patients receiving induction chemotherapy (chemotherapy begun just after diagnosis) -- it includes the obtaining and monitoring of labs, specimen collection, and adjusting fluids. Chemotherapy simple or chemotherapy complex may also be chosen.

What is "chemotherapy - induction monitoring"?

Respiratory and Stuff

100

2 patient diagnoses for which individual interventions must now be selected.

What is "pediatric asthma pathway" and "RSV/bronchiolitis"?

200

Planned teaching Pulse oximetry Aerosol treatments/MDI by nursing staff Meds - oral (if applicable) Oxygen therapy (if applicable)

What are "interventions for the asthma pathway"?

300

Pulse oximetry Tracheal/oral/nasal suctioning >2-4 hours Oxygen therapy (if applicable) Aerosol treaments/MDI by nursing staff (if applicable) Isolation precautions (Only use isolation precautions - strict outbreak/airborne if isolation requires N95 respirator)

What is "RSV/Bronchiolitis interventions"?

400

--on list of patients, right click on patient --select instruments and then "attach instrument....." --from screen, select "next" --from pick list, select the instrument to attach attached instrument will now display on the patient list, and can be scored

What is "how to add and score the Davis 7 treatment room procedures tool"?

500

this is a projection of nursing care needs for the next two shifts (not your current shift, but the two subsequent ones)

What is the "grasp score"?

Ins/Outs and Others

100

select for patients without bowel or bladder control, and incontinence is a recurring event (not for occasional accidents) -- may include patient in diapers (not infant/toddler)

What is "incontinent care"?

200

intervention for "elimination" -- for infants and toddlers only

What is "Diaper change - infant/toddler"?

300

select this intervention for patients requiring a bladder training program -- applies to toileting and timed voids, and/or intermittent catheterization

What is "intermittent catheterization/bladder training"?

400

for the patient on complete bedrest and who cannot turn side to side independently

What is "bedrest/turn Q 2hours"?

500

for the patient who requires to be pulled up in bed or repositioned to maintain proper body alignment.

What is "reposition with assistance"?