Medicine team
The nurse you call when your patient is really sick
CCOT
Occasions when nurse needs to accompany patient to tests.
Air leak present, chest tube inserted in last 24 hours, drainage exceeds (sanguineous drainage over 100 ml/hr, serous fluid over 1000 ml/hr), suction required, chest tube is clamped for less than 24 hours
Resource used to create wound care plans
Wound care grid, CLWK
Purpose of order to draw
Each coloured blood tube contains additives that can affect the next tube and can cause inaccurate results
Order that you can use to leave reminders for your nursing colleagues
Nurse Reminder Order
Nurse leader who is involved with patient care and discharge planning
CML (Care Management Leader)
Purpose of the 500 ml of sterile water in the emergency kit
chest tube disconnection - immerse the tube connected to the patient 5 cm below the surface to establish water seal and prepare new Pleur-Evac
Tasks not within the role of the NSWOC
Doing routine dressing changes, changing orders for surgical services that had a specific care plan, arranging discharges to home health
Differences in blood draw with blood cultures
Do not flush and aspirate blood, change the max plus port
Required AdHoc form that should be filled prior to OR or procedures
Pre-procedure checklist
The nurse you contact if you are unsure about the approach to care for your patient with mental health concerns.
CIRT
Frequency of chest tube assessments
Q 15 min x 1 hour, Q 30 min x 1 hour, Q 1 hour x 4 hours, Q 4 hours x 24 hours, Q 6 hours and PRN until removed
Components of wound assessment
Exudate (colour, consistency, amount of drainage), periwound skin (macerated, red, indurated/firm because of inflammation), odour assessed after cleaning, pain, measurements (widest, deepest, undermining using clock)
Meaning of blood cultures x 2
1 set is one orange and one green bottle. You need 2 sets drawn ideally from 2 different areas (PICC or CVC and peripheral lab draw)
Area to remove precautions in the Cerner Banner Bar
Process Alerts
The nurse you call to get in contact with AMCT Peer Support Workers
ALN (AMCT Liaison Nurse)
Required orders after patient has a chest tube inserted
Chest Tube Insertion Post Procedure (Module) PowerPlan: vital signs and monitoring, dressing changes, location, suction/gravity, activity orders, oxygen therapy
Action after completing wound care no matter how minor the wound is
Documentation!
Action to do when drawing blood when the patient has TPN infusing
Pause the TPN, Flush CVC with 20 ml NS, draw from the line without the TPN infusing
Area to communicate messages to the team
Actions or Situational Awareness
Nurse in charge of patient flow, patient assignments, skills mix, general unit concerns
CNL (Clinical Nurse Leader)
Safety equipment that should be with the patient at all times
2 clamps, 4x4 gauze, 500 ml bottle of sterile water, Adaptic
Difference between arterial and venous wounds
Arterial wounds stem from poor blood flow and venous wounds are due to leaking/dysfunctional valves in our veins that result in impaired venous return and persistent high pressures
How to determine how much blood to draw for each tube?
Each tube has a predetermined vacuum that allows required volume of blood to be drawn. Each tube also has an indicated # of mls.
What to review on night shift orders checking
Reviewing any orders that need to be initiated or discontinued, clarify orders you don't understand, labwork ordered appropriately, check for duplicate orders, appropriate consults, communication orders, MAR stop dates and med times, review actions and situational awareness notes, complete any orders that are done