Vital Signs
What is the normal range for an adult heart rate?
60-100 bpm
HCA's & MHW's have an important role in skin injury prevention.
YES! 1000% HCA's are often taking patients to the bathroom and helping to reposition. If you see something on a patient's skin, escalate! Nothing is too small.
Hand Hygiene is one of the most important ways to prevent infections
True! Hands are the main pathways of germ transmission during healthcare.
Remember: Foam In & Foam Out!
If all my tasks are completed, I can work on my homework until a call light goes off.
No. There are many, many "unscheduled" tasks that could be completed. Passing ice water, ambulating with patients, stocking rooms, etc.
On my timecard, I should punch in with the preceptor code.
No. You must use the "Charge" code. If you choose preceptor, this will create a high exception on your timesheet.
A patient has a blood pressure of 210/110.
Recheck!
Let the RN know right away!
Document using the note function that RN was notified
The Braden score measures a patient's fall risk.
False! The Braden score measures risk of skin injury and is unique to each patient. A score of less than 18 is at risk for skin injury.
The Braden score should be a column on your EPIC worklist. Expect to reposition Q2H
Patients with foley catheters don't need peri care.
False! Foley cares need to be completed daily and after fecal incontinence. DOCUMENT!
False! All CHG baths are full body. Use all 6 clothes each time.
I can remain at the desk and wait for the orientee to ask me questions.
Temperature reading of 99.0 Fahrenheit.
Technically, this is in the "normal" range. Normal is 97.8 F to 99.1 F.
Patients at risk for skin injury need to be repositioned every 3 hours
False. Patients need to be repositioned every 2 hours
A patient has a central line. I should expect to do a CHG bath every day.
Blood sugar value is 40 mg/dL
Notify the RN immediately.
Expect the recheck frequently.
Completing the competency packet for the orientee is optional.
Nope. After each orientation shift, you should verify with the orientee what skills have been completed and sign off on the competency packet.
NO! Each patient needs respirations assessed with each set of vital signs
If a patient is incontinent, a brief can be used while in bed.
NO! Briefs increase the risk of skin injury and breakdown. Only 1 chux pad is needed.
False! The patient needs to have a clean gown and clean linen after each CHG bath. Remember to document in EPIC
It's breaktime! What do you need to do before leaving the floor?
Make sure all the RN's and other HCA's you are working with know you are leaving the floor. Tell them what time you will be back.
The orientee can take one side of the hallway and I can take the other side.
No. Approach the assignment as if you and the orientee are 1 person.
The first position when taking orthostatic vital signs.
Supine
Standing (if unable to stand, can do sitting)
Take the BP & HR immediately and again after a 2-minute wait time.
The MATS & Air Taps are the same tool.
False!
MATS are for lateral transfers and are recyclable.
Air TAPS are for repositioning, come with wedges and are NOT recyclable.
How do you know which is which?
Two of my patients are in contact isolation. If I'm going directly from one patient to the other, I can keep the same gown and gloves on.
NO! The gown and glove must be removed, and hand hygiene needs to be completed after leaving the room. When arriving at the next room, complete hand hygiene and don a new gown and pair of gloves.
All patients need vital signs completed every 8 hours.
Depends. Some patients will have an order for Q8H, others will have an order for Q4H. This should be on your EPIC patient list AND is located in the IP Snapshot.
All patients coming from a procedure need post operative vital signs completed (Q15min X 4, Q30 min X 2, Q1H X 2).
Tell your manager/CCS.
Escalate to charge nurse on off shifts.
Continue your role as preceptor throughout the shift.