Code White
Restraints
Suicide Prevention
Abbreviations
Addictions
100

True or False:

An incident report must be completed after a Code white has been called

True

100

Name 3 types of Restraints

physical, environmental and/or chemical

100

How many Mental Health Observation Levels are there?

4

100

What does NCI stand for?

Nonviolent Crisis Intervention 

100

What is the CIWA protocol?

Protocol that guides alcohol withdrawal symptom management

200

When should a Code White be called?

When there is a real or perceived risk of physical harm to a patient, staff member or property

200

True or False

An order from a physician is required for a wrist restraint?

An order from a Physician or Registered Nurse (RN) is required for a restraint. The order must include type of restraint and reason. If the order is placed by an RN, the Physician must co-sign the order within 24 hours

200

How often does a nurse need to round on a Constant Care (Level 1) observation?

Continuous and uninterrupted care of a patient by an assigned staff member with an unobstructed view of the patient at all times.

200

What does COWS stand for?

Clinical Opioid Withdrawal Scale (COWS)

200

True or False:

Nurses should ignore a Pt's substance use to respect autonomy 

False

300

True or False:

The use of physical interventions should be used to deescalate the the situation

Physical interventions are not in NVCI training and may lead to disciplinary action.

Physical interventions, pain-free and never coercive are limited to staff trained methods.

300

True or False

Restraints must be reassessed and reordered every 12 hours

False

Restraints must be reassessed and reordered every 24 hours

300

What is the name of the scale for suicide screening?

 COLUMBIA-SUICIDE SEVERITY RATING SCALE

300

What does the CIWA stand for?

Clinical Institute Withdrawal Assessment for Alcohol

300

True or False:

A nurse requires an order to complete a CIWA or COWS assessment?

False

400

What is the Team Leaders role?

Plan the interventions with other team members

Provide direction during the code

Request emergency service (police) be called to assist if needed

Act as the only responder speaking with the pt during the interventions

Facilitate the immediate pt debriefing session 

400

How often does a restraint Pt need to be monitored?

A restrained patient must be monitored 

i. Every 15 minutes x 4 initially and when patient behaviour is unstable

ii. Then every 30 minutes x 4 (x 2 hours)

iii. Then, every1hr until restraints discontinued

iv. Constant observation when using 4- or 5-point restraints

400

What should be removed from the environment for a patient at risk for suicide?

utensils, pencil/pen, strings, plastic bags, lighters, razors, scissors, call bell, chemicals, medications, anything that can cause harm.


400

What does NGASR stand for?

Nurses' Global Assessment of Suicide Risk

400

You have completed a CIWA assessment and the score is 50.  What Powerplan should be ordered for this Pt?

MED alcohol withdrawal (CIWA)  Adult admission Powerplan

500

What information should be added to the documentation for a Code White?

Demographics (e.g. date, time, location of incident; client involved, etc.)

· Description of incident

· Precipitating factors (or triggers) if known

· Behaviours witnessed (complaints; passive resistance; active resistance; assaultive, etc.)

· Type of intervention (e.g. standby; verbal de-escalation; escort; physical restraint;


mechanical restraint; environmental restraint, etc.)


· Medications administered

· Names of team members

· Staff injuries (if any occurred, staff need to document these on the appropriate workplace

injury report form)

· Names of other responders (e.g. police, security, etc.)

· Debriefing session

· Recommendations

500

A restraint may be used:

To prevent serious bodily harm to self or others

· To enhance freedom or enjoyment of life

· When it conforms with the authorized treatment plan and is consented to by the patient or Substitute Decision-Maker (SDM)

500

Where can a nurse find Resources for Patient's at risk of Suicide?

Cerner - Patient education - Search Suicide

500

What does BVC stand for?

Brøset Violence Checklist

500

You have completed a COWS assessment and the result is 20.  Is this a mild, moderate, moderately severe or Severe result?

Mild Withdrawal: 5 to12 

Moderate Withdrawal: 13 to 24 

Moderately Severe Withdrawal: 25 to 36 

Severe Withdrawal: greater than 36