Hypoglycemia and Hyperglycemia
What is the initial method of choice for correction of hypoglycemia?
Oral route! Give 15 grams of carbs and re-test glucose in 15 minutes. Continue replacement until glucose is above 70.
What is considered a fall?
A Fall is an unplanned, undirected descent to the floor (or extension of the floor, e.g., trash can or other equipment) with or without injury to the patient, occurring in any location.
Is it within your scope of practice if you have not completed education to safely perform the activity?
Where should paper with patient identifiers be thrown away?
Shred bin
Who would the FLACC Scale be appropriate for?
Infants: 0-4 years of age: unable to self report. EXCEPTION: NICU uses a specialized tool for pain assessment. In cognitively impaired or developmentally delayed patients use the FLACC or CPOT scale to assess pain in intubated or unconscious patients
Is it ok to hold basal insulin (Lantus)?
NO! Never hold basal insulin without a providers order. Without basal insulin, your patient could go into DKA or have hyperglycemia.
What are some examples of Universal Safety Precautions (prevention measures that should be used for all patients)?
-Orient patient/family to room.
-Call light within reach & answered in timely manner.
-Bed in low position with wheels locked. Upper side rails of bed raised.
-Wheelchair and stretcher brakes locked when stationary.
-Ensure floor surfaces are clean and dry & Maintain patient care areas free from clutter.
-Ensure necessary items are within patient reach.
-Encourage patient/family to call for assistance with patient ambulation and other needs.
-Complete purposeful proactive visits (hourly rounding) to address patient needs.
Should you post a picture with patient identifiers in the background?
No!
If you have a law enforcement officer wanting to see a patient who is NOT under arrest, what should you do?
Patient determines if they want to see law enforcement just like any other visitor.
When would the Faces Scale be utilized?
Children 4-13 years of age Patients with language or cultural difference from health care team
What oral options are considered 15 grams of carbs?
120 mL of juice, 3 graham crackers, 6 saltine crackers, or 4 glucose tablets, or 1 glucose gel package.
If a patient is considered to be high risk for falls, what extra interventions should we include?
Yellow fall risk claps on ID band.
Place yellow or electronic signage in visible location in patient’s room/door.
Initiate Fall Risk Care Plan and interventions based on your assessment.
The physician asks the RN to administer propofol IV push for the patient to have a bedside procedure, is this within the nurses scope of practice?
No, RN's are unable to push propofol
If you have a patient who is under arrest, what information is ok to give law enforcement?
Free to disclose anything that LE needs to know to provide post discharge care to patient, keep LE safe and keep other prisoners safe. Think of parent/child relationship =“in custody of”
Who would the Numeric Scale be used for?
Children 13 and older and Adults. Adults with dementia should utilize the PainAD scale.
Per Baptist policy, what is considered a critical blood glucose result (high & low) for anyone ages 1 year or older?
Less than 55 or more than 500
What does a falling star represent?
The patient is a fall risk
Should you share a patient story on social media?
It is best practice to not share anything work related.
Who can be a healthcare agent?
Any person the patient trusts to make medical decisions when patient is unable to make decisions for self.
At what level should pain be treated?
Pain levels of 4 or more should always be treated based on severity. Mild pain is 1-3, moderate is 4-6, and severe pain is 7-10
Is it ok to hold corrective insulin for a blood glucose of 180 because the patient is NPO?
NO! Insulin should not be held unless you have a MD order. Hyperglycemia can occur in patients with infections, using medication such as steroids or immunosuppressants, having surgery, experiencing stress.
How often should Fall Risk Screening Assessments be completed?
Upon ED assessment, upon admission, every shift, upon transfer to another level of care(Complete shift assessment), and post fall.
If the nurse is not willing to accept accountability for the activity and intervention they are about to perform, should the nurse perform the activity?
No, the nurse must be ready to accept accountability for the activity, intervention, or role and the related outcomes
Would it be a breach in HIPAA if you enter your patient's room (who has a room full of visitors) and start talking about their diagnosis?
Yes it could be! Always give the patient a meaningful opportunity to object before disclosing information when entering the room.
What are the 8 Rights of Medication Administration?
The Eight (8) Rights for Medication Administration are:
Right patient, Right medication, Right dose, Right route, Right time, Right documentation, Right of patient to know what medications they are receiving, Right of patient to refuse medication.