Physical Assessment
Grunting, nasal flaring, use of accessory muscles, tachypnea, desaturation, worried looked
What is Respiratory distress
•Digoxin elixir
•Insulin
•Morphine
•Warfarin
•Transdermal patches
•DDAVP-subcutaneous
What are High Alert Medications.
When resident is:
Being bathed
Having the diaper changed
Being dressed
Being given a rectal medication
What are times to close the curtains
Localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device.
What is a Pressure Injury
At a minimum of 90 Days
When are Care Plans reviewed/updated
This occurs when air flows rapidly through bronchi that are narrowed nearly to the point of closure
What is Wheezing
Sticker that states “Directions changed, refer to patient chart”)
What is placed on Medications that according to directions do not reflect patient’s current MAR but are still usable ( correct med, strength and valid expiration date)
Never leave the resident in the bed with these down.
What are Side Rails
Full-thickness skin loss when slough is present.
What is a Stage 3 Pressure Injury.
Are completed quarterly and at resolution of an issue.
What is Outcome Evaluation
Presents with Abnormal flexion with Arms flexed, legs extended
What is Decorticate posturing
Applied to resident, covered with tegaderm, and witnessed by two RN's
What is a Transdermal Patch.
Need to reset at bedside after rendering care and before leaving bedside
What are bed alarms.
Obscured full-thickness skin and tissue loss.
What is an Unstageable Pressure Injury.
Care Plans to be completed by this date.
What is Plan of Care date.
Signs and symptoms of Dysautonomia
HR up to 200+ beats/minute
RR up to 80 breaths/minute
Temperature to 107.6 F
Arterial BP of 170/120 mmHg
Sweating
Second Nurse checks dose prior to administering medication. Assigned nurse writes note to state dose verified by two Nurses
How to verify New or Changed Medication orders when pharmacy is closed.
Time for charge nurse to inform nurses and cnas of any important information about the residents.
What are Change of shift/ safety huddles
Times you measure a wound
When is Weekly and upon discovery
Should be discipline specific, resident specific, and relate to the problem being addressed.
What are Interventions