Blood Clot Prevention
(VTE Prophylaxis)
(VTE Prophylaxis)
What is one of the best ways to reduce the risk of blood clots?
Ambulation (walking)!
What is the normal range for a blood glucose level?
70-100
What is the purpose of telemetry?
Continuous cardiac monitoring - watching the patient's heart rate and rhythm
What does BEFASTT stand for?
B: balance E: eyes F: face A: arms S: speech
T: terrible headache T: time
Nurse assesses and scores - can be seen in flowsheet
What types of devices can be placed on legs/feet to help prevent blood clots?
SCDs and TED hose
What should you do if the patient's blood glucose is out of the normal range?
Below 70: stay with patient, alert nurse, check BG every 15 minutes until above 70.
Above 100: communicate with nurse (closed-loop!)
How do you know where to place electrodes?
Look on the back of the tele box for a reminder!
Other memory tricks (e.g., "clouds over grass, smoke over fire, chocolate close to the heart")
What kind of response do you call if you suspect a patient is having a stroke?
Neuro Response
What are some fall risk interventions that can be put in place for patients?
Bed/chair alarm, siderails up, bed in lowest position, bed wheels locked, call light within reach, personal belongings within reach, clutter-free room, nonskid socks, fall risk armband, toileting every 2 hours, gait belts, room close to nurse's station, safety companion (VSOP)
How do you document VTE prophylaxis?
In the Daily Care Flowsheet.
What comment should you enter on the Accuchek if a blood glucose is abnormal?
"RN notified"
You MUST still notify the RN.
How often should electrodes be changed?
Every 24 hours
What should you be prepared to do/check on a patient who may be having a stroke?
Stay with patient. Check BG and VS. Hand off any information (LKWT) to team. Help call UAB if needed.
What are the 4 Ps of Purposeful Rounding?
Pain
Potty
Position
Possessions
What should NOT be placed on a leg that has a DVT?
SCDs/TED hose
As a nursing assistant, can you initiate treatment for a low blood glucose?
No. The nurse must initiate treatment (e.g., ask NA to go get juice and crackers while they stay with patient).
What should you do if the red phone rings?
Answer it! Immediately give information to nearest nurse and check on patient.
How soon do SCDs need to be charted for a stroke patient?
By the end of day 2.
Do NOT chart "off" and notify nurse if patient refuses!
Why is bedside report important during shift change?
To visually confirming your patients are safe!
What are signs of a deep vein thrombosis (DVT)? What do you do if you notice these signs?
Redness, swelling, pain.
TELL THE NURSE!
DAILY DOUBLE!
What are signs of hypoglycemia?
What are signs of hyperglcyemia?
HYPOglycemia: sleepiness, sweating, pale color, uncoordinated, irritability, hungry, confusion, blurred vision, difficulty speaking/slurred speech
HYPERglycemia: dry mouth, increased thirst, blurred vision, weakness, headache, frequent urination
Can telemetry be removed for showering?
Yes, but ONLY WITH A DOCTOR'S ORDER.
How frequently should you get vital signs on a stroke patient? What is included in vital signs?
NO LATER than ordered (usually every 4 hours).
BP, HR, RR, SpO2, and temp.
How frequently do we document patient rounding?
Every 2 hours per role
(NAs on even hours; Nurses on odd hours)