Adult Sepsis
It is very important to catch sepsis early to prevent this fatal outcome called MODS. What are MODS stands for?
Answer: Multi Organ Dysfunction System
Usually associated with high mortality rate and often leads to irreversible damage.
Renewal of Adult restraints for Non-Violent and Violent orders?
Answer: Non-Violent orders - every 24 hours
Violent orders - every 4 hours
Is it ever acceptable to re-advance a Central/PICC line if it slightly pulled out from the original insertion length during a dressing change? Give at least one 1 reason.
Answer: NO!!
Risk of embolism, infection risk, damage to vessel or catheter, loss of proper position, regulatory and clinical guidelines
What are the 4 Ps of hourly rounding
Answer: Pain, potty, position and proximity
Do you need physicians order to remove ACE wraps, compression devices, walking boots when assessing the skin?
Answer: Yes
RN should contact the physician for an order to remove the device and follow the physicians order with regards to replacement.
What is the most common organ failure found in sepsis.
Answer: Kidney Failure
Reduced blood flow - due to hypotension and decreased perfusion
Toxins and Waste accumulation - in sepsis bacterial toxins are released to blood stream that can damage kidneys
Disruption of Glomerular Filtration
Lack of oxygen - tissue hypoxia can damage renal cells
Within how many hours of Violent restraint application that a Physician must conduct a face-to-face evaluation to the patient.
Answer: within 1 hour
To assure patient safety, rule out underlying factors, assess for physical and psychiatric condition and decision to continue necessity.
How many mls of N/S of pulsatile flush do you need after TPN/Lipid or blood transfusion and give at least 1 reason why.
Answer: 20 mls
To prevent from catheter occlusion, clearing residual fluids, ensure proper function of the line, preventing from fluid/drug interaction, maintaining line sterility
Give at least 5 universal safety measures to prevent fall
Answer: Call light, lowest position of bed with wheels locked up and side rails up, non- skid footwear, personal items within reach, hourly rounding, educate patient and family to call for assistance, clean and tidy room
Wound measurement and photos are done when?
Answer:
On admission
Weekly on Wednesdays
What is the most common cause of Sepsis?
Answer: Pneumonia
Impact of pneumonia on the immune system, lungs have the large number of blood vessels when lungs is infected it can easily cause bloodstream infection leading to sepsis.
Give at least 5 assessment and monitoring carried out by nurses while patient is on restraints.
Answer:
Offer Food and Fluid if not NPO
Range of motion
Skin integrity and redness
Cognitive function
Offer toileting
Assess the need for continuity or removal
How often do you change needless connectors when patient is on TPN/PPN or lipid infusion? Give at least 1 reason why?
Answer: Every 24 hours
Prevent Infection, maintaining sterility, preventing catheter occlusion, reducing the risk of clot formation, avoiding compatibility issues, guidelines and best practices
What documentations are required after a patient had a fall? Give at least 3
Answer:
1. PSR
2. Significant event
3. Update care plan
4.Update fall risk status
The patient was admitted 5 days ago and immobile. If a new wound is present, the RN must:
Answer:
1. Notify the medical provider
2. Consult wound specialist
3. Complete the LDA/WALDO
4. Take photos of the wound
5. Fill out PSR
Give at least 3 complications that can result from sepsis.
Answer: Renal Failure, Respiratory failure, Cardiovascular decompensation, DVT, DIC, GI bleeding/stress gastritis, anemia, electrolytes abnormalities, ARDS,
At least every how many hours is the monitoring and ongoing assessment of Non-Violent and Violent patient?
Answer:
Non-violent: every 2 hours or more often if indicated
Violent: RNs must assess a patient at least every hour and document in medical record. Monitoring at least every 15min utilizing flowsheet
When do you remove a bad PIV?
a. Once a new PIV is established just in case of emergency
b. Immediately
c. As soon as possible
d. A and C
Answer: Immediately
To prevent complications such as infections, infiltration/extravasation, phlebitis, clot formation/thrombosis, patient comfort
What are your immediate actions for post fall event?
Answer:
1. Activate Code falling star
2. RNs must assess the patient at the time of incident
3. RN will determine the safest way to move the patient back to safe location, based on mobility assessment
4. Notify the physician in SBAR
5. Notify the family as appropriate
When performing assessment, 2 RNs are required to co-sign on what criteria.
Answer:
Braden Score of 18 or less
All new admits
All new transfers
What are the 4 phases that sepsis progresses through and what are the sepsis bundle time?
1. Answer: SIRS - SEPSIS - SEVERE SEPSIS - SEPTIC SHOCK
2. Answer:
0-1 hr, 3-hour, 6-hour - lactate, blood cultures prior to IV ABX, IV fluid bolus
What are the documentation requirements for discontinued restraints? Give at least 2
Answer:
1. Complete the care plan
2. Document date, time, patient behavior and condition of the patient
3. Make sure that the order is discontinued by physician
If a patient has PICC line and it has migrated out 2 cm from the initial insertion external catheter length. What is your next step?
a. Leave it as it is because 2 cm is not that much
b. Notify MD to request chest x-ray to confirm tip location
c. Re-insert back
d. Request order to remove PICC line
Answer: Notify MD to request chest x-ray to confirm tip location
Ensuring correct placement, prevent complications, guidance for malposition, standard of care and guidelines
Fall Risk Assessment: Initial and ongoing
Every patient will be screened by a Registered Nurse (RN) for risk of falls using the EHR screening tool at the following intervals: Give at least 3.
Answer:
1. Upon admission
2. As part of every shift assessment
3. Upon transfer to another unit
4. Change in condition
5. After a Fall
For patient with Braden score of 18 and less, how many hours repositioning/turning is recommended.
Answer: every 2 hours or more often as needed