| 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 is 2 things you must do to complete a transfusion?
Document transfusion complete as "yes" and right click in pink header.
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What is zero bed and weigh your patient in the bed on admission?
How to ensure bed alarms activate properly with 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 is 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 is necessary when your patient has chest pain.
Stat EKG
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What you must do for the first 15 minutes once transfusion begins.
Stay with the patient.
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What is the distance between you and the patient while toileting in the bathroom or bedside commode?
Policy states within arm's reach.
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What is 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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What is times to document the CAM?
Document 2 x a day during day and eve shift & PRN.
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What is when to notify physician of rhythm change?
Patient has a hx of A Fib, has been in NSR this hospitalization, now has Afib.
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What is the three pre-transfusion verification options you must document for ALL blood products?
Appropriate Consents, Blood Products, Patient 2 Ids.
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What is 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 used and then disposed of when a patient is discharged?
Stethoscope, BP Cuff, thermometer, pulse oximeter finger probe.
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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 tele nurses responsibility?
Verify your tele strips from the monitor tech within the 1st two hours of our shift.
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What is the window of time you must document "yes" or "no" to a transfusion reaction?
Document within the first 15 minutes, anytime necessary, or at least before ending the transfusion.
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What are ways to determine patient's ability to mobilize?
PLOF, CLOF, recent pain medication, balance, strength, ability to follow commands.
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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 how to determine if your patient needs a tele nurse and to be placed on a portable monitor when transporting off the unit for a procedure?
Transport orders in the PER.
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What is when you document VS?
Pre, during and post.
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What is lights at the end of the bed that show if bed safety features are activated. iBed
Red and green light on end of the bed.
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What is the 3rd liquid/loose stool within 24 hours?
Which stool and when you send specimen to the lab.
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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 patient is symptomatic- pale, diaphoretic, c/o chest pain, dizzy, ALOC, worsening VS?
Call RRT and anticipate Heart Alert.
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