Assessments
What is the timeframe to complete admission assessments?
Four hours from admission to unit.
IV Dilaudid is given for pain. Pain will be reassessed in ____________.
In 15-30 mins after administering IV pain medications.
Care plans are updated ______________.
Every shift at least, and if patient's needs change.
Patients with foleys or central lines need this type of bath done and documented to be compliant with infection prevention.
CHG bath
What are the indications for activating the Rapid Response Team?
Concerns for decline, change in vital signs, change in LOC, uncontrolled bleeding, urine output less than 120mls in 4 hrs,
The timeframe to reassess pain after a PO pain medication.
Pain needs reassessed one hour after PO administration of PRN pain medications.
The patient reports pain of a 3/10 but wants a medication ordered for severe pain. Can this be administered?
NO, Patient preference is not acceptable for stronger potent medications if the pain assessed does not meet order requirements.
What fall care plan should be utilized for all patients?
Hester Davis fall care plan
Dressings for central lines should be changed every _____ days.
Every seven days and if loose or soiled.
The key points in time when vital signs are required for blood administration.
Pre-transfusion, after 15 mins of start, every hour during transfusion, post-transfusion
Patient education is documented in this timeframe.
Every shift, after new medication administration, and as needed.
What are the numeric score ranges for mild, moderate, & severe pain?
Mild: 1-3
Moderate: 4-6
Severe: 7-10
Care plans need to be __________ to patients.
Individualized
The timeframe for completing foley care.
Foley care needs done and documented every shift and after every bowel movement.
When are fall risk assessments required to be completed/reassessed?
Addmission, change in condition, Qshift, after any fall, after transfer to another unit
A head-to-toe to toe assessment is performed in this timeframe after admission to the unit.
In one hour, there needs to be a head-to-toe assessment documented with vitals, pain, height, and weight.
If a patient reports their pain is a 7/10 but requests to have a lesser potent medication, can it be administered? How do you document this?
It is acceptable to give a lesser potent medication for pain. Document patient's preference to take less potent medication in MAR comment.
All care plans should have ___________.
Expected end date usually expected date of discharge.
What is the upkeep for patients with a central line?
Flush all lumens at least Q shift, caps on all unused lumens and tubing ports, labeled tubing 96 hours for continuous fluids, 24 for intermittent medications, change saline locks after blood draws.
The 6 initial documentation requirements for Non-violent restraint.
1. Order including restraint type
2. Justification
3. Assessment
4. Patient Education
5. Care plan added
6. Monitoring and assessment every 2 hours
Key assessments/screenings of admission are...
ADL screening, abuse, pain, fall risk assessment, skin assessment, suicide risk, nutrition screening, and learning.
The different pain scales that can be used and for what kind of patients.
The numeric pain scale- 0-10 is used for patients who can communicate.
FACES- for children or older adults to point at face expressing pain felt.
PAINAD- non-verbal, cognitive impairment, based on behavior/observation.
CPOT- Critically ill/intubated- measures the presence of pain
A patient is admitted to the floor. What is the timeframe for starting the Care plan?
Care plans need to be initiated within 4 hours of admission.
Intake and outpt for a patient with a foley catheter need documented every _______ hours.
At least every 8 hours and with vitals.
For violent or self-destructive restraints, what are the 3 assessments required (including the time frames)?
Q 15-minute observation, Face to face with provider within 1 hour, assess for removal minimum of every 2 hours