Notes from orientation Flashcards
1
Q
Your phone extension is
A
74663
2
Q
If you need to print a work or school excuse note for a patient where do you go in the computer?
A
Add HOC
3
Q
the best way to search for a patient in MH is by using the ___ number
A
Fin
4
Q
when you add a staff note you should always include what?
A
your initials and time
5
Q
before you do an EKG what do you need to do when you put in the patient demographics?
A
change the age from 55 to actual age
6
Q
before you transfer a patient out of Woodbury what are two things that are needed first?
A
bed assignment and POC
7
Q
when the lobby is full, where does full triage take place in MH?
A
room 15
8
Q
what do you do before placing a urinary catheter in anyone?
A
use chlorhexidine wipes
9
Q
if you need an EKG and the Dr hasn’t written an order for one yet what do you do?
A
power nurse orders
10
Q
a patient asks for a disk for their radiology during their visit, what do you tell them?
A
they have to go through Patient Records and it may take 2 to 3 business days
11
Q
what are chlamydia tests called and how long do they take to result?
A
they are called Amamptima and they can take 48-72 hours
12
Q
when transferring a patient to MH from Woodbury the handoff is done through what?
A
discharge process
13
Q
For all transfer patients do the transfer note in ___ and include what? (5)
A
dispo AAOx3 # of belongings bags saline lock or running IV or n/a VS WNL or not stretcher or wheelchair
14
Q
before you take your transfer out of the system, be sure to wait for what?
A
the secretary to finish
15
Q
how do you document a patient medication refusal?
A
go to the med in red, right click,
patient refused to complete
duplicate task
16
Q
what are 4 things to remember about doing blood cultures?
A
1 do aerobic first, because the empty suction from the line won’t effect the result
2 aerobic is green like an O2 tank, the other is orange
3 Do not put the label over the QR code
4 do the 2 sets 5-10 minutes apart from and indicate site on the label
17
Q
what do you do different when drawing an ETOH level?
A
prep with betadine
18
Q
what is the in-house emergency number?
A
77777
five 7’s
19
Q
what is a code magenta?
A
radiation
20
Q
what do you do different when you draw a type and screen?
A
put date time and initials on the tube label
21
Q
what is a massive transfusion?
A
A massive transfusion is defined as an administration of 5 units of RBC’s in one hour or 8-10 units of RBC units in 24 hours.
22
Q
what are 5 things to remember when you need a massive transfusion
A
- Computer order for Emergent Blood Products
- Complete the release form (kept on stock in the ED, OR and L+D.
- Keep blood and plasma in cooler until infusion.
- Return any products that aren’t going to be used immediately or if over 4 hours from issue from BB.
- Cooler may stay with the patient if going to the OR only.
23
Q
What are the Massive transfusion ordering computer order sets
6 items
A
- MTP1 = 4 RBC, 4 FFP
- If need continues, MTP2= 4 RBC, 4 FFP, 1 single donor platelet
- If need continues, MTP3= 4 RBC, 4 FFP, 10 cryoprecipitate (2-5 packs) (pooled dose (?))
- This pattern is repeated in order until the MTP is discontinued
- Each full cycle completes 1 blood volume for the average adult
- Cryoprecipitate dose = 10 individual units pooled into either 2-5 packs or 1 10 pack.
24
Q
what are some considerations (things to assess for) when performing a massive transfusion?
A
Considerations during massive transfusion - hypothermia, citrate toxicity, air embolism, hyper/hypokalemia
25
This Phrase must be used every time you initiate a massive transfusion protocol and is non-negotiable.
Must use the phrase “Dr. _____ is initiating the Massive Transfusion Protocol and needs blood STAT”.
26
These Labs must be re-evaluated every 60 minutes and reorder lab tests as needed.
(Massive blood transfusion)
(8)
CBC, PT, PTT, Fibrinogen, D-dimer, CMP, Mg and Phos
27
when is a massive blood transfusion initiated and discontinued?
- MTP is activated when blood loss >150ml/minute or blood loss >50% in 1-3 hours.
- MTP is discontinued when bleeding <500mL / hour.
28
Autologous transfusions can be drawn up to __ days prior to the procedure unless the pt has been _____ or if transfused in the last __ months.
14
pregnant
3
29
what is the equipment setup for a blood transfusion?
- 18 or 20g IV, if 22 must be used then use caution to infuse slowly
- 250 ml NSS @ 20ml/hr
- ensure that the filter is primed with saline so that the saline is above the top of the filter
- if using a central line use the distal lumen (preferred)
30
-The only fluid compatible with Blood products is what?
| give 2 reasons
NSS 0.9%
No medications
- solutions with dextrose can lyse the red cells
- solutions containing calcium can cause clotting of the red cell component.
31
what are 4 things to you gotta do after a blood transfusion?
- Continue to observe patient for at least one hour
- Change tubing after 2 units or 4 hours
- Submit a copy of Transfusion Record to the BB
- Follow up instructions must be included in discharge instructions.
32
Key points about transfusions
Document what?
Infuse only _____ over the first 15 mins for ALL blood components (non-emergent)
VS __ minutes after starting transfusion
__ minutes remain with patient
pt education about S+S of transfusion reaction
15-30ml (up to rate of 120 an hour)
15
15
33
how long does it take for a transfusion reaction fever to take place?
can take as long as 4 hours after the transfusion is over
34
the most immediate and serious transfusion reaction is what?
ABO compatibility
35
what do you need to do after a transfusion reaction?
| 11 items
Stop transfusion
20ml/hr minimum NSS
Change tubing
Notify transfusion service
Place orders in computer per Transfusion Services Medical Director
Complete Transfusion Reaction form
Send blood bag/tubing to lab along with transfusion reaction form
Enter STAT order for Blood Transfusion Reaction into information system
Collect urine and send to Lab
Document in chart.
Blood may be restarted if; only hives (urticaria) appear and patient has been treated with an antihistamine and the hives disappeared, and physician gives order to restart.
36
What is a reason to NOT test for c-diff
Lab testing cannot distinguish between active c diff infection and colonization. Colonization occurs in 20% of hospitalized patients and 50% of LTCF patients.
37
When should you test for c-diff
| 4 items
- acute onset of diarrhea- greater than 3 episodes in 24 hours
- Any c diff risk factors
- The etiology of diarrhea is unknown
- Liquid or watery stools
38
what is the chest pain protocol?
EKG should be completed within __ minutes
EKG should be read by physician within __ minutes
Door to biomarker less than 60 minutes or what?
Door to device less than __ minutes
Serial Troponin strategy will be __, __, and __ hours.
6 minutes
10 minutes
Door to biomarker less than 60 minutes or TAT (Troponin turnaround time)
Door to device less than 70 minutes
Serial Troponin strategy will be 0, 3, and 6 hours.
39
The hallmark of the Third Universal Definition of MI is the detection of a rise and fall of cardiac biomarker values, with at least one of the values being elevated. In addition to the highly sensitive and specific cardiac biomarker of necrosis, Troponin, at least one of the following five diagnostic criteria should be met. What are they?
- Symptoms of ischemia
- New significant ST/T wave changes or left BBB
- Development of pathological Q waves on ECG
- Imaging evidence of new loss of viable myocardium or regional wall motion abnormality
- Identification of intracoronary thrombus by angiography or autopsy
40
If a patient cannot tolerate a treadmill stress test then a pharmacological test using
Adenosine, dobutamine or persantine infusion can be used.
41
what is the difference between an EKG and telemetry?
- Telemetry is “monitor” quality; determine the rate and rhythm only
- 12 lead ECG is “diagnostic” quality; determination of disease, infarction, infection
42
what do you have to do when you need to repeat an EKG?
All EKG's must that must be repeated have to be deleted by the EKG department. Do this by calling and leaving a message.
43
Inferior Wall MI
The inferior wall is supplied by the what?
ST elevations can be seen in what leads? (3)
Also be aware of possible
right coronary artery or RCA
II, III, and aVF
possible right ventricular infarct, can be determined with a right sided 12- lead
44
The anterior wall MI (slide saved)
The anterior wall is supplied by the
This type of MI is also known as the is known as the what?
left coronary artery or LCA
| widow maker
45
Septal Wall MI
Supplied by the what?
What should you look for?
Look for the lack of an R wave in V2
left anterior descending artery or LAD
| Look for the lack of an R wave in V2
46
Lateral wall MI
The lateral wall is supplied by what?
10% of the population has their ________ wall supplied by the LCX
mostly by the left circumflex artery or LCX
| 10% of the population has their inferior wall supplied by the LCX
47
Posterior wall MI
The lateral wall is supplied by what?
ST depression will be seen in leads
either the LCA or the RCA
V1, V2, V3, and V4
Reposition leads and obtain a posterior 12 lead containing leads V7, V8, and V9 for the ST elevations
48
what are some things that can cause sinus arrest?
hypoxia, hyperkalemia, excessive digitalis or propranolol, quinidine toxicity, damage to SA node from AMI, acute myocarditis, degenerative fibrosis
49
which heart rhythm is associated with the word Wenkebach?
| has 2 names, name both of them
Mobitz Type 1
| 2nd degree AV block
50
what are the H's of the h's and t's?
```
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo/hyperkalemia
Hypothermia
```
51
what are the T's of the h's and t's?
Toxins (drug overdose, ingestion)
Tamponade (cardiac)
Tension pneumothorax
Thrombosis, coronary ACS
Thrombosis, pulmonary embolism The RN caring for the patient receiving moderate sedation should have no competing responsibilities that would compromise the continuous monitoring and assessment of the patient
- At time of discharge patient must have been returned to baseline.
52
What can be said for an RN who needs to be involved in a conscious sedation procedure?
The RN caring for the patient receiving moderate sedation should have no competing responsibilities that would compromise the continuous monitoring and assessment of the patient
- At time of discharge patient must have been returned to baseline.
53
What is a PCS and what is it used for?
PCS or Physician's Certification Statement.
| A form that states the need from a physician that a patient must be transported by stretcher
54
what is the definition of sepsis?
Defined; a life threatening condition that arises when a body’s response to an infection injures its own tissue and organs.
- Sir William Osler 1904
55
what does SIRS stand for?
SIRS- Systemic Inflammatory Response Syndrome: The clinical syndrome that results from a deregulated inflammatory response or to a non-infectious insult
56
Sepsis patients that are treated within the first hour have an __% survival rate. After 6 hours that rate drops down to __%.
80
| 30
57
what is the SIRS progression?
The progression is SIRS => Sepsis => Severe Sepsis => Septic Shock
The condition needs to be identified and treatment needs to be initiated at the point of sepsis.
58
what is the SIRS criteria?
| 5 items
- Temp above 101 F (38.3 C) or less than 96.8 F (36.0 C)
- Heart Rate greater than 90 BPM
- Respirations greater than 20 per minute
- WBC count greater than 12,000 per ml or less than 4000 per ml or 10% bands (immature WBC)
- Sepsis is the presence of 2 or more SIRS criteria AND a known or suspected infection.
59
```
Severe sepsis: the presence of sepsis along with any one sepsis induced organ dysfunction.
Hypop_____
Lactate greater than __mmol/dl
_________ urinary output
_________ platelets.
Acute altered mental status
_________ capillary refill
_________ creatinine
_________ coagulopathy
```
```
perfusion
2
decreased
decreased
decreased
increased
increased
```
60
Septic shock: severe sepsis AND tissue
SBP less than __ or a decrease greater than __mmhg from baseline
MAP less than __
Lactate greater than __ mmol/dl
```
tissue hypoperfusion despite fluid administration
90
40
65
4
```
61
what is time zero?
Time Zero- The time when the patient meets all of the criteria for severe sepsis is called Time Zero
-If the patient arrives with all criteria met then triage time is Time Zero
62
Time Zero is when the clock starts for __ hour and __ hour bundles
3
| 6
63
the sepsis 3 hour bundle should be completed within 3 hours of time zero and should consist of what?
6 items
- Measure lactate level; it is a tissue hypoperfusion marker
- Order “Initial Sepsis” and it will automatically re-order in 5 hours, if the result is greater than 2 mmol/l
- Obtain Blood cultures prior to administration of antibiotics
- Administer 30ml/kg crystalloid BOLUS
- Administer broad spectrum antibiotics (first than combo of needed)
- Document input and output
- Sepsis protocol Order set required.
64
6 Hour Bundle: Required for Septic Shock to be completed within 6 hours of time Zero.
Repeat what?
maintain a SBP of >__ or MAP of ___
apply what medications?
lactate (if lower than 2mmol/L)
90
65
vasopressors
65
- If the onset of symptoms or last known normal time is within 4.5 hour, triage as ESI level __
- If the inset of symptoms or last known normal time is greater than 4.5 hours, triage as level __.
1
| 2
66
what are the initial stroke protocols?
| 10 items
```
Check capillary glucose
STAT non-contrast Brain CT (ordered by MD)
Assessment ABC’s, vital signs
EKG
Labs; CBC, platelet, PT, PTT, BMP
NIH stroke scale
t-PA inclusion / exclusion criteria (MD)
Swallow screen before anything PO
Elevate head of bed
Patent IV access
```
67
what is Tikosyn?
A class III antiarrhythmic indicated for the conversion of a-fib and a-flutter to NSR and keep it that way
68
what conditions have to be in place to initiate treatment with Tikosyn?
and why?
must be initiated in a critical care setting.
can cause life threatening arrhythmias
-The occurrence of prolonged QT is directly linked to plasma concentrations and therefore the dose has to be adjusted based on creatinine clearance and to avoid certain drug interactions.
69
the name of the nursing union is what?
HPAE
70
Before a blood transfusion, check for pre-existing symptoms that may be mistaken for a transfusion reaction such as; (6) chills, rash, itching, hematuria, muscle aches, or breathing abnormalities.
chills, rash, itching, hematuria, muscle aches, or breathing abnormalities.
71
what are 4 things you should make sure you do when performing a blood transfusion?
Document pt education about S+S of transfusion reaction
Infuse only 15-30 ml over the first 15 mins for ALL blood components (non-emergent)
VS 15 minutes after starting transfusion
15 minutes remain with patient
72
what are 4 things to make sure you do AFTER a blood transfusion?
- Continue to observe patient for at least one hour
- Change tubing after 2 units or 4 hours
- Submit a copy of Transfusion Record to the BB
- Follow up instructions must be included in discharge instructions.
73
What is a PCS? What does PCS stand for?
Physicians certification Statement
A form that states the need from a physician that a patient must be transported by stretcher
-Forms are required for all scheduled and nonscheduled patients that will be covered by Medicare or any other Federally funded programs, including Medicare HMO’s that are administered by commercial carriers.
PCS forms are not required for wheelchair transports.
74
this lab value is a marker of tissue hypoperfusion
lactate greater than 2
75
when should you give an ESI level of 1 or 2 with a stroke patient?
if the last known normal is within 4.5 hours, level 1
| if the last known normal is greater than 4.5 hours, level 2
76
name 4 things the Dr needs to do when you have a stroke patient?
- Order required testing; CT/CBG
- Perform initial NIHSS
- Consult with neuro/teleneuro
- Order t-PA/ BP control medications
77
what do you need to do when an HCG test is borderline?
order a serum Beta Quant to confirm
78
what are the 4 medications in the headache cocktail?
Toradol, Benedryl, Decadron, Reglan
79
mix this medication in a 50 cc bag to prevent crotch burn
Decadron
80
what NSAID should you NOT give to pregnant women?
Toradol
81
when you draw a subsequent troponin, what should you also do?
repeat EKG
82
ABG values: pH
7.35-7.45.
83
ABG values: Partial pressure of oxygen (PaO2):
75 to 100 mmHg.
84
ABG values: Partial pressure of carbon dioxide (PaCO2)
35-45 mmHg
85
ABG values: Bicarbonate (HCO3):
22-26 mEq/L.
86
the little balloon at the end of an ET tube where you inject the air, not the balloon that holds it in the patient, is called the what?
pilot balloon
87
what are the 7 P's of Rapid Sequence Intubation?
```
preparation,
pre-oxygenation,
pretreatment,
paralysis and induction,
positioning,
placement and confirmation and following these,
post-intubation management
```
88
what should you look out for if you revive someone with narcan?
flash pulmonary edema
89
vent settings; AC stands for what
| what does it do?
Assist control
the vent allows the patient to control when breaths are taken and given a set pressure breath ie 8ml/kg
*narmally used with a backup rate (such as 12) in case the patient doesn't take a breath
90
PV= nRT is the formula for what?
lung compliance
P= pressure
V= volume
91
C pap is like non invasive what?
PEEP
| they are both set at around 5-20 centimeters of water pressure
92
what does PEEP stand for?
Positive end expiratory pressure
93
what are the 4 things that should be included in a vent order and give an example of each
Mode / AC 16
Tidal Volume / 550 ml
FiO2 50%
PEEP 5
94
what does FiO2 stand for?
fractional inspiration of O2
