Care plans
Do not leave me unsupervised in my wheelchair in my bedroom. I like to have my call light clipped to my shirt when I'm in bed, and I'm not to have a turn sheet in my bed. Who am I?
Ruth F
I am to be charted on three times a day. I am important as I show if there is a trend in gains or loss. Knowing my results can allow those who audit me to see if there needs to be changes during this activity that is to be charted on. What am I?
Meals / Supplements
My vitals are as follows:
BP 200/95, Pulse 75, Spo2 95% RA, RR 20
What happens next?
BP is to be done manually
PCP needs faxed of out of range BP
Progress note needs to be written that PCP was faxed and out of range BP
I was getting resident A up from bed and upon standing she complained of dizziness, what do I do next?
Where are personal cell phones to be located at?
either in CS1 or in staff members mailbox
Encourage me to wear log sleeves or jacket, apply lotion to me, I should have ace wraps on arms of my wheelchair and left arm of my wheelchair is padded. I'm also care planned to wear tubi-grips to my forearms. Who am I
If you don't chart on me this could cause PRN's to be given that I don't need. If I was to receive a PRN that I don't need, this could cause discomfort and anxiousness from myself and others. What am I?
Bowels
My Vitals are as follows:
BP 135/64, P67, RR20, Spo2 RA 85%
What next?
Re-attempt Spo2 reading, if correct, apply oxygen per standing order and put in orders, notify PCP, write progress note, continue monitoring resident
You notice that during meals, I'm coughing a lot after I take drinks of my fluids during my meals. What do you do next?
Notify charge nurse, offer thickened liquids and remove regular liquids.
Charge nurse to assess vitals and lung sounds. If aspiration is believed to have occurred, monitor Spo2 and temp - Spo2 lowers and temp rises.
Notify kitchen to give nectar thickened liquids as a trial.
Notify PCP or complaint, vital and lung sounds, request ST evaluation, update plan of care of trial, educate staff on update, notify DPOA, and chart in progress notes
How often should a resident who isn't independent with toileting be toileted?
At least every 2 hours.
I am to be toileted upon awakening, before and/or after meals, between 1900-2100 and PRN. Who am I
Janell N
When charting this, you should never put opinions only facts, you should never chart a staff members full name and you should chart in me when a fall occurs, vitals out of range , skin impairments, new orders, faxes received, etc. What am I
Progress notes
How do you know if a vital is out of range?
It states after entering vital and is in red
If your a CMA on the cart you must notify your charge nurse right away
You notice that I'm starting to decline in my ADL's such as I was able to mostly assist with dressing myself and now I need more assistance. My gait has become more unsteady. What do I do next?
Notify Charge nurse.
Charge nurse - Assess resident - pain related?
Notify PCP and request PT/OT evaluation and restorative nurse of decline.
Goal is to keep residents at baseline and independent for as long as they can be and put programs in place if need be.
How often should ice water be passed along with snacks?
Typical time would be for water at 10am and then water and snacks at 2-3pm and 7pm.
My child will be a care assistant this summer and will be starting to pass snacks at 10am as well.
You shouldn't wear your jewelry around me. I also need to be repositioned every 1-2 hours per my care plan. Who am I
Jean O
Skin
Elopement
Pain
My vitals are as follows:
BP 1854/90, P80, Spo2 RA 95%, RR 18
What next
Nothing vitals are within range
I just had a fall and I hit my head. I have complaints of pain to my left wrist with slight swelling. What do I do next?
If pain is persistent post fall an x-ray should be done right away.
Fall observation to be done, neuros as directed along with vitals, order put in to do neuros and vitals along with a fall follow up progress note every shift while on fall follow up. Fall check list to be completed and an intervention is to be put in right away based on results of why fall occurred.
If you are asked to do something by your supervisor what should you do? What do you do if you disagree with request?
Do what is asked out of you. If you disagree with request, go to supervisor and ask why request is being made and if you still disagree state facts of disagreement in a professional manor and respect the decision that is made by your supervisor.
I have times where I believe I have "Friends" in my room that I talk to that are not visual to others. When this is observed ask if there is anything I need or ask if everything is alright to ensure that my delusions / hallucinations are not causing dis-harm to my mental state. Who am I?
Sandy W
When a resident is admitted they are to have a TB skin test done, where do you chart that a TB skin test was given.
Preventative health records
What are the typical range for the following vitals:
(some residents may have specific ranges)
Temperature, Pulse, Blood pressure, Respirations, Oxygen
Temperature 96-100.5
Pulse 50-120
Respirations 10-30
BP Systolic 90-180 / Diastolic 50-90
Oxygen 88%-100%
You here the fire alarm go off. What do you do next?
Find the direct contact person and find out where fire is located. If you find the fire first you are to activate fire alarms and let someone know where the fire is at so they can direct staff and activate 911. If you are able to put out fire with fire extinguisher you are to attempt to do this if safe. All residents must be behind fire doors. If a fire is in a residents bedroom, residents beside that room, across that room and adjacent to that room must be removed. Safe tags are to be placed lowered on doorframe with door shut to indicate that resident is safe. If fire is unable to be extinguished with fire alarm you are to shut the door and proceed with evacuation of residents.
Chain of command. If you have an issue that arises who do you contact first?
CNA's - if staff to staff conflict attempt to resolve matter with staff member first, if no resolution is obtainable then go to charge nurse, if this results in no resolution then go to DON
Charge nurses - same as above with staff to staff conflict. If no resolution then go to DON
Administrator should never be the first person you go to in conflict or disagreements. After the charge nurse it would be DON. If unable to resolve conflict then a meeting would be made with person with complaint, DON and HR. Administrator would only be notified of conflict, discussion and result by HR or DON. Administrator would only be involved in conflict if and only if it is last option available.
All calls and text messages of work issues after hours need to be directed to DON only and not administrator. Administrator will be notified by DON if Administrator needs to be involved.