| Restraints | Falls | Shared Governance | Skin | Sepsis |
|---|---|---|---|---|
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What is NO!
Do you need a 1:1 for a patient in restraints?
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What is: The initial set, 30 minutes, 60 minutes and 90 minutes
How often are VS and Neuro checks done post fall?
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What is: CPC
This committee reviews the most up to date policies and procedures.
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What is: Turning and repositioning.
Other interventions to prevent skin breakdown include: elevating heels, getting patients OOB into a recliner, ambulating 6-8 times per day, make sure skin is clean and dry, barrier cream, skin prep
Your patient is bedbound, what intervention are you doing most frequently?
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What is: Anything! Pneumonia, UTI, Meningitis, Skin/Soft tissue infections, appendicitis
What can cause sepsis?
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What is Q2H
How often do you assess CMS, toileting and continues use of restraints?
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What is: All present in the fall and the staff members on the unit at the time of the fall including nursing supervisor.
Who should be present for the post fall huddle?
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What is: Baystate Region Eastern Wellness
What does the B.R.E.W Crew stand for?
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What is: Xerofrom and DSD
What dressings would you place on a skin tear?
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What is: Temp >100, HR >100, BP <100
What is the Rule of 100?
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What is the bed frame. Restraints are NOT attached to the side rails.
Where do you attach the restraints?
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What is: Everyone!
Who’s responsibility is it when a Posey alarm is going off?
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What is: The Staffing Advisory
This committee reviews exit survey data with HR.
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What is: Synergy bed. Patient’s label should be placed in the binder next to the OA. This order should be discontinued upon discharge and Hilrom should be called to get it picked up.
This type of bed requires an order.
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What is: less than 2
What is a normal lactate?
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What is a Mitten Restraint
This type of restraint prevents patient from dislodging invasive equipment, removing dressings, or scratching.
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What is: Accidental.
Other types of falls include: Anticipated Physiological: The pt has physiological conditions with which a fall is anticipated: related to age and decreased functional ability, diseases, previous falls, weak/impaired gait, or lack of realistic assessment of own ability. Intentional: A fall that is done or performed with specific purpose or intent. Unanticipated Physiological: May be attributed to physiological causes, but created by conditions that can’t be predicted; new onset stroke, seizure, MI for instance.
This type of fall related to environmental factors; includes spills, slips etc.
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What is: The Night Council
This council is held at night.
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What is: RN: length, width, depth. Epithelization tissue, granulation tissue, slough, eschar. Wound base, odor, undermining, drainage (color), surrounding skin, dressing.
PCTs: notify the RN, document patient care.
Your patient has a wound, what are you documenting?
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What is: IVF and broad spectrum abx
Name two things you would see if your patient is septic?
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What is No. “Side rails are not considered a restraint if used for patient safety and if they meet any of the following patient assessed needs: patient request, sedated patients, including pre and postoperatively, situations where the bed must be in high position, patients in special beds, patient uses the side rails for leverage when turning, patient on seizure precautions, patient semi or comatose.”
Are side rails considered a restraint?
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What is:No. For a witnessed fall: “If no change from baseline, with no neuro deficit, evidence of fracture of pain; if patient follows commands & reports no neck, hip leg or arm pain, & there is no evidence of head injury, then patient may be move back to bed.
According to our policy for an unwitnessed fall: “if they are unable to communicate events of the falls or there is a change in baseline with evidence of head injury, neuro deficit or neck pain, DO NOT MOVE THE PATIETN UNTIL FULL ASSESSMENT IS COMPLETE & HARD COLLAR APPLEID”
Do you C-Collar all patients when they fall?
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What is: Help me advance on the clinical ladder.
Broaden my knowledgebase Promote change
Name one thing attending Shared Governance day will do for you.
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What is: Mepiliex! These dressings are used to prevent skin breakdown but also can be used on open wounds.
What dressing can you remove and reapply?
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What is: SIRS
What is the body’s immune response to infection and criteria?
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