| Sunday Bloody Sunday - BPAM | It Wasn't Me- Falls | I'd Rather Have Nothing- C. Diff | State of Confusion- Delirium/ CAM/ ACE unit | My Heart Will Go On - Cardiac |
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What are 2 things you must do to fully complete a transfusion?
Document transfusion completed as "yes" and right click in pink header.
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What is zeroing the bed and weigh your patient on admission?
How to ensure bed alarms activate properly for different-size patients.
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What is stool characteristics for the lab to accept the specimen?
Liquid/loose stool that conforms to the specimen cup.
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What are patients the CAM must be completed on?
65 or older, previous hx of delirium, prior hx of delirium with hospitalizations, & PRN.
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What do you do with a patient experiencing chest pain?
STAT EKG
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What is the time you must stay with the patient once the transfusion begins?
For the first 15 Minutes.
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What is the distance between you and the patient while toileting in the bathroom or bedside commode?
Within arm's reach.
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What are the initial steps when a patient has the first unexplained loose/liquid stool?
Document amount and characteristics in H/C, place patient on Contact + isolation, document under critical alerts "other", and notify the doctor.
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When does CAM assessment need to be documented?
Document twice a day, day and evening shift & PRN
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What is always notify the physician of rhythm change?
Your patient has a hx of A-fib, has been in NSR, and now has new onset A-fib.
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What is the three pre-transfusion verification options you must document for ALL blood products?
The Appropriate Consents, Blood Products, Patient 2 ID's.
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What are fall risk factors?
Recent fall within 1 year, delirium, weakness, stroke, syncope, orthostatic changes, surgical procedures, CNS effecting meds.
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What is disposable items for an isolation room which must be removed when a patient is discharged?
Stethoscope, BP Cuff, thermometer, pulse oximeter finger probe, & pill crusher.
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What is how to accurately perform the CAM?
Answer all questions and use standardized question prompts listed in H/C.
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What is the nurses responsibility during their shift.
Verify your patient's tele strips from the Monitor Tech within the first 2 hours of our shift.
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What is the window of time you must document "yes" or "no" to transfusion reaction?
Within 15 minutes of transfusion start.
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What are ways to check patient's current mobility status and progress?
PLOF, CLOF, recent pain medication, balance, strength, ability to follow commands, and sign on patient's wall.
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What is explained loose stool definitions?
Colon or small bowel surgery, new tube feed start, bowel prep, laxative, & enema.
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What is inclusion criteria for the ACE unit?
75 and older, ambulatory @ baseline & medical diagnosis.
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What is check the order in the PER for transport status?
How you know if you need to transport your patient on a monitor to a procedure, accompanied by a tele nurse.
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What are PRBCs, FFP, & Platelets, with EVERY unit given.
These blood products need pre-transfusion verification, this often.
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What is where do you easily find the PLOF?
It's in the HealthConnect Brain.
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What must be included when sending 3rd liquid/loose stool to the lab?
Checklist filled out and signed by ANM.
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What is exclusion criteria for the ACE unit?
Tele monitoring, Stroke/TIA, Isolation precautions, ETOH abuse/withdrawal, *active delirium, with disruptive behavior, *Dementia with behavioral problems/non redirectable, *1:1 sitter, long term care or placement issue, or comfort care.
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What is when you call RRT and anticipate a heart alert?
Patient is clammy, pale, and c/o "bad heartburn". HR 120. Twelve lead EKG shows new left bundle branch block.
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