Signature Assigment Flashcards
Environmental Survey
Bedrails up, bed in low position, brakes locked, clear floors, personal items within reach, bed alarm PRN, well-lit room
Ethics
Ethics team available to consult, made up of nurses and Docs, can consult a lawyer
Collaboration
Teams you can collaborate with
- PT/OT
- Ethics Team
- Case Manager/Discharge Planner
- Social Worker
- Speech
- Rapid Response
- Music Therapy/Pet Therapy
- Respiratory
- Interpreter
- Chaplain
- Dietitian
- Pharmacy
- Housekeeping/Unit Manager/HOA
Isolation Protocols
- Contact D
- Contact
- Airborne
- Droplet
and know PPE for each one
Contact D
C-diff and norovirus, gown, gloves, and handwashing (soap and water)
Contact
Gown and gloves, can use hand sanitizer
- Ex: MRSA, herpes simplex, varicella zoster, scabies, closed shingles
Airborne
N95, hand sanitizer
- covid, measles, chickenpox, TB, disseminated herpes zoster, open shingles
Droplet
Surgical mask, hand sanitizer
- flu, pertussis, rhinovirus, mumps, rubella, adenovirus, group A strep
Alternatives to Restraints
- Folding washcloths
- Move near nurses station
- Treat the cause
- TV/Mobile Device
- Encourage family to visit
- Nursing student to talk with pt
- Telesitter
- Bed/chair alarms
- Disguise equipment - posey activity blanket, abdominal binder
Negative Outcomes from Restraints
- Loss of circulation
- Impaired skin and tissue integrity
- Incontinence
- Mental status changes
- Difficulty breathing
- Pneumonia
- Impaired hydration and nutrition
- Aspiration
- Strangulation/Entrapment
- Muscle Atrophy/reduced bone mass/contracture
- Fractures
- Death
Restraint Checks
-
1 kg
2.2 lbs
1 cup
240 mL or 8 oz
1 lb
16 oz
1 oz
30 mL
1 tsp
5 mL
1 tbs
15 mL
1 pint
2 cups, 500 mL
Sitaution
Hello HCP. This is ____ (name), student nurse. I am calling you about ____ (pt name) in ____ (room #). As you recall, pt. was admitted (date) for _____ (admission dx). I am calling you now because I am concerned about ____ (the reason you picked up the phone).
Background
The _____ (above concern) is concerning because _____ (backgroun support)
- assessment findings
- medical/social hx
- medications (home and current)
- labs/dx tests
Assessment
I think the problem may be ______
- this is what you think is happening, not a time for cues, it is time for conclusion. Can be nursing or medical diagnosis. Even if you say unsure, try to draw a conclusion.
Recommendations
I think the patient needs _____ (intervention, an order, next action, a change in treatment plan, HCP to come see the patient)
Independent
- turning the pt
Dependent
- giving meds
Interdependent
- consulting with another team
IV Charting
gauge, location, dressing clean/dry/intact, what is hooked up to it, s/s (signs and symptoms) of phlebitis or infiltration
- Ex - 22g in the left hand, tegaderm dressing clean dry and intact, IV patent with no s/s of infiltration or phlebitis, if hooked up to fluids - what rate are they infusing at, or saline locked, tubing expiration
Saingenous dressing
bloody IV dressing
Visible redness, swelling (erythema)
don’t flush
Blood in extension tubing
no s/s of infiltration or phlebitis, need to flush to determine patency
