Restraints
To reduce risk of skin injury, the RN needs to check under soft and locked restraints this often
What is every 2 hours
A risk assessment tool used to predict the likelihood of pressure ulcers
What is Braden Score (lower number = higher risk)
When helping a patient who is unstable, impulsive, has cognitive impairment, or is a risk for injury from fall to the bathroom, they are a __
What is a STAR patient
This level of urine in foley bag means it is too full
What is 1/2 full
Which key are we always looking for on 6MB?
The closet key
Patients arriving from the ED or ICU in restraints need this redone
What is a new order
Where on the nose should the new clear nasogastric securement device be placed?
The side of the nose (please do not place on the middle of the nose)
Bedside commodes and bedside walkers should be kept here
What is next to the bed and within reach of the patient
This antimicrobial dressing helps prevent CLABSIs and needs to be changed every Saturday
What is a chlorohexidine dressing
(ALSO: 24hrs after line placement, change to chlorohexidine dressing.)
What object do we never touch near the charge front desk?
Lorri's crystals
When increasing or decreasing the number of restraints, you need a new order & to chart this section
What the pre-restraint assessment
Number of layers that are allowed to be under patient
What is 3
This is not considered a bleeding risk on the Risk of Injury ABC's Scale
What is prophylactic medications, such as heparin, lovenox, aspirin
This care needs to be done every 24 hours for patients with Central Line, PICC, or HD line
What is CHG bath
(Wash up to the chin and don't forget to chart! For CHG allergies, use purple wipes.)
This should be charted in the restraint flowsheet and nursing note for restraint justification
What is patient specific behavior
This device should be used for any patient unable to lift or move their head
What is Z-flo pillow
(Call to order from Med Stores!)
Acronym for patients who need hands on supervision during toileting. This is anyone with cognitive impairment, impulsivity, recent falls, or risk for injury from a fall
STAR
(these patients need yellow blanket, yellow socks, yellow sign outside door, and yellow bracelet)
Needleless Access Devices should be changed after these 2 events
What are blood draws and dressing changes
(Don't forget to chart!)
This flowsheet section is not charted on acute care units
What is q15min visual check OR the debrief for violent restraints
Head to toe assessment that needs to be done every shift - focuses on the skin overlying bony prominences, inside skin folds, and under medical devices
What is Complete Skin Assessment (CSA)
(Use good lighting and make sure the skin is clean and moisturized. )
Two items that must be ordered if patient has had a fall this hospitalization
What are low bed and fall mats
(This can be ordered by RN)
This should be avoided to encourage proper urine drainage and prevent urine backup into the bladder
What is dependent loops