Stroke
Your stroke patient suddenly becomes more difficult to arouse during your assessment. What is your priority nursing intervention?
Perform an immediate neurological assessment, obtain vital signs, and notify the provider/activate appropriate escalation process.
What is the single most important nursing intervention that improves patient outcomes?
Mobility!!!! Get your patient moving, you do NOT have to wait for physical therapy to mobilize your patient! Even dangling helps!!
What equipment should always be readily available for a patient on seizure precautions?
Suction equipment and oxygen.
Name two patient characteristics that increase the risk of developing a pressure injury and what nursing actions you can take to decrease these risks.
Immobility-implement q2 turns and frequent mobilization assistance
Poor nutrition-consult dietitian
Moisture/incontinence-frequent bed changes, assessment for incontinence
Decreased sensation- educate patient on importance of frequent mobility, remind and assist when it's time to turn, document if refusals
How do you know your bed alarm is turned on and working?
It's flashing green
A patient with a recent stroke has coughed every time they've taken a sip of water during breakfast. What should you do next?
Stop oral intake, keep the patient NPO, and request Speech Therapy evaluation as appropriate.
It is Post Op Day 2, and your spine surgery patient is nauseated, vomiting, has no interest in food, and their belly is very distended. What do you do?
Listen for bowel sounds, are they passing gas? If not, notify provider ASAP and ask for KUB to rule out post-operative ileus
Consider mobility, PRN laxatives (suppository, enema)
The period immediately after a seizure is called:
What are nursing interventions you can do for your patient during this time?
Post Ictal Phase
Reassure, emotional support, reorient to environment, check vitals, assess for post-ictal injury and incontinence
This dysphagia-related quality measure helps prevent aspiration in stroke patients
When does it need to be completed?
Bedside Swallow Screen
Before medication or oral intake
On admission
Name 3 items for fall prevention that you could document under your Daily Cares Section in EPIC
Fall socks, fall arm band, fall mat in place, side rails, bed locked, bed in lowest position, call light within reach, etc.
Your patient becomes frustrated because they know what they want to say but can't get the words out. What post-stroke deficit are they most likely experiencing?
How are you going to respond?
Expressive aphasia.
Provide extra time, try to ask yes or no questions, give options if needed, acknowledge the frustration, speak slowly to allow for more time to process, provide communication tools if needed
What do you do 4 hours after a foley has been removed if they haven’t urinated yet?
Bladder scan!
Get the patient out of bed to bedside commode/toilet and prompt them to urinate.
Then follow NURP.
A seizure lasting greater that 5 minutes is known as:
How do you treat on the floor?
Status Epilepticus
Maintain ABCs, give medication per order, notify neurology, press EEG event button if patient is connected to EEG
What do you do if your patient's central line does not have blood return?
Why would you need to restore blood return in the line?
Request Cathflo from MD, give Cathflo per MAR instructions
Clots hold on to bacteria and can create central line infections.
If your patient is a high fall risk and impulsive, what are active nursing interventions you can do to help prevent a fall?
Hint: Not precautions, actual nursing interventions
Sitting near your patient room, moving patient closer to the nurse's station, assessing need for restraints or sitter
Your patient is prescribed blood pressure medication every morning. During medication administration, they state, "My blood pressure was normal yesterday, so I don't need it today." How should the nurse respond?
Blood pressure medications work best when taken consistently. Skipping doses can increase the risk of another stroke and other cardiovascular complications.
Name 3 items that should be at the bedside if you have a spine surgery patient
SCDs, Incentive Spirometer, Education packet, Tens unit if ordered, chewing gum
After a seizure, what are the most important things to document? Name 3
The seizure start time, duration, movements observed, level of awareness, and postictal symptoms.
Your patient asks why you're using CHG wipes on their entire body when the central line is only in one area. How do you explain the purpose of a full-body CHG bath?
CHG works by reducing bacteria across the entire skin surface. Because germs can travel from other parts of the body to the central line site, bathing only around the line would not provide the same protection against CLABSI.
For example: if you touched your leg and then touched the arm with your central line, you've pulled all of the bacteria on your leg over to your arm
What platform would you use to determine IV compatibility before you hang two medications together?
Micromedix under IV compatibility tab
If your patient has new stroke symptoms, what is the in-house code stroke process?
What is your role in that process?
What information do you need to know about your patient?
1. call RRT 52345 to assess the patient
2. assist RRT in assessment, supplies and prepping pt for transport to CT
4. assist with transport to CT
5. Resume care if patient is stable or assist with handoff to higher level of care
Vital signs, last known well, past medical history, blood glucose, new symptoms, family contact
Name a way that patients can understand more about their pain medications
Updating the pain board in the room to include meds and time available for next dose.
Assess the patient’s pain when you enter the room, it is always kind to ask the patient about their pain if the patient is nearing the time for the next dose
Consider use of muscle relaxers if not scheduled
Your patient with a known seizure disorder is made NPO for a procedure. During chart review, you notice their scheduled antiepileptic medication was not administered, and no alternative route was ordered. What is your priority nursing action?
Contact the provider immediately to clarify how the antiepileptic medication should be administered while the patient is NPO. Missing doses can increase the risk of breakthrough seizures.
Name two commonly missed areas of a skin assessment where skin breakdown can occur
behind ears, underneath feeding tubes, elbows, shoulder blades, heels
Name the specific platform that you can use to look up diagnoses, procedures, diagnostic tests, care plans and more.
Lippincott Advisor