Documentation
Pharmacy is closed. You receive a telephone order for extra dose of a medication that already is in patient’s active med list in ADC and eMAR. How do you process it?
•Write telephone order on order sheet, read for physician
•To take med from ADC, in Active Med list , Select Override Med Order to create a new order in eMAR
• STK.MED.ONCE order will be created in eMAR
•Independent double check will be done by 2 nurses
•**if it is not a high alert med, add name of second nurse in comment.
•ACK the order
Do Not reject if order in eMAR is not matched with order on paper( Order will be documented as Non Admin: ADC Override Error)
***be very careful to pull under the correct patient to not create an STK on another patient***
Mrs. Smith is on Methotrexate tablet (CHD) 20 mg once a week. She can take whole tablets. Which protection should be used when preparing and administering Methotrexate to Mrs. Smith?
•Nitrile gloves
•Non touch technique
photo 1:
stage 3 Pressure Injury
- complete a head to toe, and wound assessment
- inform MD for a WC consult
- review previous dressing orders (apply dressing from sending facility)
Photo 2:
DTI
complete a head to toe, and wound assessment
inform MD for a WC consult
Offload the heel with pillows until able to get heel boots or other offloading equipment
- wasted in pharmaceutical bin, recorded on the NARCTOTIC & CONTROLLED DRUG RECORD - Leave of Absence (LOA) (both the MRN and a witness)
•Daily: Nursing ADL Assessment
•Weekly: Least Restraint order after assessing patient’s need
• Weekly: Least Restraint assessment
To find the medication, go to the main menu on the ADC, look under "report", select "Launch Omni Explorer", search "inventory list" and type the name of the medication then search
•Take the med form another unit ADC, Stocked med
•Check the night cupboard ADC
***be very careful to pull under the correct patient to not create an STK on another patient***
•Nitrile gloves and impermeable gown
•Red sharp container. Card board box in soiled utility room.
- continence care
- pain management
- intake
- turning and repositioning
- offloading (boots, pillows, wedges)
- therapeutic surfaces
What is a STK.MED.ONCE order?
What should we do before administering medication?
- There was a telephone order (One dose telephone order should be written in order sheet)
- Pharmacy was closed. Nurse took medication from Stocked medication in ADC
- This order was created in eMAR
- Before administered medication
Which of following interventions count as a restraint:
b) Tilt wheelchair to prevent patient gets out of the wheelchair
Pharmacy is closed: in the unit ADC, bin for one of patient’s active med is empty. What is the process to find the med?
- select the medication that is in gray, select "Yes" to do you want to see the medication order detail, select to check the item availability
go to another unit or the night cupboard, pulled from ACTIVE medication
***be very careful to pull under the correct patient to not create an STK on another patient***
•
it is a pressure that develops or worsens during the patient hospitalization
You have a patient that is displaying a new onset of confusion, although they have a history of dementia, this seems outside of their baseline.
What could be happening and what would your next steps be?
- complete at CAM to see if the patient is delirious
- inform the MD verbally, patient may need a delirium workup
- ensure other safety precautions are in place (for example fall prevention)
a) ePODS
b) Fall Risk Reduction Plan of Care
when you have a controlled medication discrepancies in ADC - the cycle count will solve it
False: that will only fix the count. You will still need to tell ADC why there was a discrepancy
Mr. Smith is taking a cytotoxic medication everyday. He has episode of vomiting in the gym. How should we do spill management?
•Take Chemo spill kit from the cabinet inside supply room .
• Display sign near spill area.
•Prevent the spill from spreading. Close off areas to patients, staff, volunteers and visitors
•Put on Personal Protective Equipment: gown, shoe coverings, mask, face shield,2 pairs of nitrile gloves
•Initial clean-up must be done by unit staff and then contact Environmental Services at ext 2120 for thorough cleaning.
Which of the following situation will be documented in SAFER?
A)Pressure injury stage 2 or greater developed in HBH
B)Pressure injury condition getting worse
C)Only pressure injury stage 3 and 4 developed in HBH
D)All pressure injuries
A) Pressure injury stage 2 or greater developed in HBH
B) Pressure injury stage 2 that has deteriorated to become a stage 3 or 4
- Take medication from ADC, Stocked Medications (ensure checking it is the right patient, right medication and right dose)
a) After doing recall value, review all documentation
d) Do not use Recall Value for Nursing ADL assessment or Vital Signs and Pain Intensity
False: you should solve the discrepancy within that shift
Sara, MRN for Mr. Smith, noticed a new stage 2 PI is on his right heel. What does she need to do now?
a)Add Stage 2 PI medical directive to patient care orders and follow instructions listed in the directive
b)Offload patient’s heel using a pillow
c)Communicate with team in wound safety huddles
d)Complete a SAFER report
e)Contact wound care team
f)A, B, C, and D
g)All of the above
A and B only
Pharmacy is closed. You received a telephone order for an extra dose (ex. insulin or Puffers) How do you processes it?
- in eMAR click on "Next Sched"
- In Next Sched, select Unscheduled Administration
*for insulin, 2 nurses must compare the order in eMAR with the Order sheet, and perform the independent double check