Trouble Shooting
BP is reading low on the wall monitor. Name 3 things to determine accuracy of result.
Recheck BP on other arm. Recheck with another machine. Manual BP. Assess if patient is symptomatic (headache, dizziness).
The "normal" range for heart rate
60-100bpm
Your patient is complaining of pain. What focused assessment would you do, and what interventions would you perform?
Do a full pain assessment (PQRSTU). Provide PRN analgesic, or non-pharmacological methods of pain management (warm blanket, distraction, etc.)
Precaution signage, PPE, and cleaning required for MRSA
Contact Precautions. Gown and gloves. Hand sanitizer and regular sani-wipes
Initiation and titration of oxygen
Green column
HR is bouncing up and down on the monitor. What should we assess to determine accuracy of result, and name one reason why HR may be fluctuating.
Obtain a manual radial HR or Apical HR for one full minute. Does patient have Atrial Fibrillation?
The "normal" range for O2 sats
>92%, 88-92% for COPD patients
Your patients Respirator rate is 24 and O2 saturations are 86% on RA. What focused assessment would you do, and what interventions would you perform?
Respiratory assessment. Auscultate lungs. Assess if patient is SOB, using accessory muscles, etc. Perform deep breathing. Try positioning. Apply oxygen via nasal cannula
Precaution signage, PPE, and cleaning required for Influenza
Contact/Droplet. Gown, gloves, face shield, surgical mask. Hand sanitizer and regular sani-wipes. Don't forget your flu shots! :)
Medication administration
Green column for PO,SC, IM, Topical. Red Column for IV
Oral temperature is not reading on the tempadot. Why might this be occurring? Name 2ways we can obtain an accurate temperature.
Patients mouth is dry. Expired or faulty tempadots. Take auxillary temp. Try a tympanic or forehead temp if available on the unit. These temperatures typically read half a degree lower than oral.
The "normal" range for temperature
36.0-38.0. 37.5-37.9 considered a low grade fever
Your patient has had a fall. What focused assessment would you do, and what interventions would you perform?
Pain assessment and skin assessment/injuries sustained. Obtain vitals. Discuss incident leading to fall. Help patient back into bed. Fill out an RLS. Call doctor.
Precaution signage, PPE, and cleaning required for COVID
Modified. Gown gloves, face shield, N95. Hand sanitizer and regular sani-wipes.
Nasopharyngeal (NP swabs)
Red column.
O2 saturations are reading low on patient. Name 1 way we can assess accuracy of the monitor. What could we assess for on the patient?
Try reading on another monitor. Try reading on own finger. Can try on ear but mixed reviews on accuracy of result. Assess if patients hands are cold. Cyanosis of lips or fingertips.
The "normal" range for respirations
12-20 breaths per min
Your patient is lethargic and drowsy. What focused assessments would you perform?
Obtain vitals. Check blood sugar. Do a GCS/neuro assessment
Precaution signage, PPE, and cleaning required for C-Diff
Contact/Sporicidal precautions. Gloves and gown. Bleach wipes and soap and water
Insertion of a clysis/HDC/ SC site for fluid therapy
Green column.
Respiratory rate for patient is low. How can we determine accuracy of our finding?
Ask a nurse or your instructor to assess!
The "normal" range for Blood Pressure (systolic and diastolic)
120/80. Systolic 90-140. Diastolic 60-80.
Your patient is complaining of chest pain. What further questions might you ask? What tests would likely be ordered?
Do a full pain assessment. Importance on if pain is radiating to shoulder. Ask patient to point to pain. Ask if it feels like heart burn. With or without respirations. Doctor will order an ECG, and bloodwork (troponin level)
Precaution signage, PPE, and cleaning required for Chicken Pox or shingles
Airborne and Contact. Gown, gloves, face shield, N95. Hand sanitizer and regular sani-wipes. Patient must be in a negative pressure room
Transferring of patients with a mechanical lift
Yellow column