Gtts
What are the two lab values used to titrate heparin?
APTT and Xa
How often do you take vitals signs when infusing blood products?
Initiation, 15 minute check, and Completion of infusion
How soon do you need to notify a provider about a Sepsis BPA?
15 minutes
Turning and Positioning System
How often do non-violent and violent restraint orders need to be renewed?
24 hours-nonviolent
4 hours-violent
Which line should be connected to the IV site closest to the patient?
The saline or other fluids running with the medication
What temperature change is a sign of a transfusion reaction?
Greater than 1 degree Celsius
What lab is likely to be ordered to determine severe sepsis?
Lactic Acid
What Braden score indicates a patient is high risk for break down and require q2h repositioning?
Under 18
How often should the tubing and bottle be changed for tube feeds?
36-48 hours or new bottle
True or False: When calculating your patients insulin drip, it is okay to use the patients home monitor (CGM) to adjust the insulin drip.
FALSE. CGM's may only be used if the patient is on an insulin pump.
At what rate do you start a blood transfusion?
50 ml/hr based on the order placed by the doctor
What are signs/symptoms of sepsis? Name 5
Decreasing BP
Increasing HR
Increasing respirations
Fever
Pale/Sweating
Altered Mental Status
Faintness
How often should preventative mepilexes be changed?
Every 3 day or when soiled
What does "tidaling" refer to in terms of chest tubes?
the fluctuation of water level with respiration when there is no air leak. Can be minimal/nonexistent when connected to suction
How many milliliters of insulin need to be wasted when priming the tubing?
20-30mls
What information should be checked with a second nurse when hanging blood? (Name at least 4)
Pt Name and DOB
MRN
BBID
Unit Number
Expiration Date
Blood Type
Who is responsible for clearing a sepsis BPA if it is determined to not be sepsis?
A provider
Orange capped calazime cream
What intervention is performed if a CBI stops infusing/draining and pt complains of pressure and pain?
Forceful hand irrigation
Calculate the bolus needed for a patient weighing 243lbs ordered at 40units/kilo
(243/2.2)x40=4418 units
What is proper protocol with the blood if a transfusion reaction is suspected?
The blood bag and tubing must be placed in a red biohazard bag and walked back to the blood bank, cannot be sent through tubes!
What is Essentia's definition of sepsis?
life threatening organ dysfunction caused by disregulated host response to infection
What is the time frame that 4 Eyes on Skin should be completed from admission?
Under 8 hours
Which services can be consulted by the nurse on admission under a care support order?
Wound Care, Social Work, dietician, chaplain