Put this in the middle of chest if the Braden score is less than 18
What is a LEAF?
This is placed after a safety event has occurred. It helps guide potential policy and practice changes.
What is a SAFE?
0800/2000- Right, 1000/2200-Left, 1200/0000- Right, 1400/0200-Left 1600/0400-Right, 1800/0600- Left
What is Turning Schedule?
This performed within 24 hours of admission, post extubating, after OR, and post NIR procedure to determine if patient can have a diet.
What is the swallow screen?
Call this number when your patient is going to be terminally extubated or there is potential for brain death declaration.
Who is DNW/#1-800-553-6667?
This is done twice a shift to ensure that your patient does not get a catheter infection
What is Foley care?
Any manual method, physical or mechanical device, material, or equipment that restricts, immobilizes, or reduces the ability of a patient to move their arms, legs, body, or head freely that cannot be easily removed by the patient.
What is a Restraint?
This kind of turning requires two people on each side with arms overlapping and one person at the head of bed.
What is Log Roll?
This is vital sign is checked and documented before and after any vasoactive drip titration.
What is the Blood Pressure?
These patient specific stroke indicators are found in the provider H&P, admission documentation, and/or any lab results.
What is patient Risk Factors?
This is done Every Monday, within 24 hours of admission, before transfer/discharge, or if the patient is off the unit for greater than 1 hour.
What is 2 RN Skin Check?
This is done and documented under Flowsheets --> BOARDING UNIVERSAL PROTOCOL prior to any procedure that takes place at the bedside.
What is a TIMEOUT?
This procedure is completed after a failed urinary retention trail and requires another RN to be present.
What Foley Catheter Insertion?
This should be reviewed and documented, at least once a shift or with every rhythm change.
What is AirStrip/Telestrip?
This detrimental complication from a hemorrhagic stroke most often occurs 3-7 days but up to as many as 21 days post stroke.
What is vasospasm?
This an algorithm that you reference when discussing line necessity.
What is central line de-escalation?
This communication type is used in emergency situations to ensure the person receiving instruction or information repeats it back to make sure the message is understood clearly and correctly.
What is closed loop communication?
These occur every morning when the team collaborates with the bedside nurse to discuss the patient plan of care.
What is Interdisciplinary Rounds?
An example of this is sending a stool sample for CDIFF testing, when a newly admitted patient had one incidence of diarrhea.
What is Standardized Procedure?
A complication that should be aggressively treated to prevent worsening cerebral edema and infarct expansion after an acute ischemic stroke.
What is Fever?
These 6 elements need to be included on the measuring tape when taking a wound care photo.
What is the HIPPA NAME, MRN, PT DOB, LOCATION OF WOUND, DATE OF PHOTO, RN’S INITIAL?
This is what you activate when you identify escalating behaviors by patient, family, or a staff member.
What is DART?
This is recommended after a stressful situation like a code blue or emergency, to discuss team performance, opportunities for improvement, and provide positive feedback.
What is a Debrief?
This is done at the beginning and end of your shift to check for current or expired orders.
What is Chart Review?
A neurological disorder that occurs after correcting the sodium too quickly.
Central Pontine Myelinolysis (CPM)?