HF NE Exam Review

role of NE

• all practice must be under supervision and/or delegated by preceptor

• documentation must be cosigned by preceptor

• gather relevant data, contribute, and implement care plan

• perform nursing care delegated by RN

HF policies

• service excellence

• attendance

• confidentiality

• meet or exceed customer service standards

purposeful rounding 4 P’s

• Pain

• Personal needs (Potty)

• Positioning

• Possessions

hourly rounding using AIDET

• Acknowledge pt by preferred name

• Introduce self and role

• Duration

• Explain what you are checking on

• Thank pt

SBAR

• situation → pt and personal name, unit, reason for calling

• background → dx, admission date, pertinent changes, important changes

• assessment → of pt

• recommendation

• response → agree what action to take

IPASS

• Illness severity → pt status, code status

• Pt story → PMH, admission, dx, ROS, transition of care

• Action list → changes during next shift, items to be finished

• Situational awareness → past complaints, future plans

• Synthesis → confirm understanding

SAFETY

• Stand at bedside → introduce new nurse and update whiteboard

• Assess pt → LDA, IV, ROS, meds

• Fall risk

• Explain plan of care → explain upcoming tests, meds, procedures, etc.

• Try to involve pt → teachback!

• Y (why) → pt verbalizes understanding

pt ID band colors

• yellow = fall risk

• red = allergy

• pink = limb alert

• white with black airway = difficult to intubate

• purple = indicates DNR

• blue = guardianship

pt handoff

encompasses clinical status, current condition, recent or anticipated tx, must be opportunity to ask and respond to questions

• can be written or verbal transmission

ticket to ride function

• pts room number/location CANNOT be used as pt id in any setting

• responsibility of nurse to ensure pt has ID band and is stable for transfer

• mobility status will be flagged indicating 2+ assistance needed

when should baseline vitals be completed and documented

within 30 - 60 minutes of admission, upon transfer, after procedure → always documented in real time

BP

report immediately systolic <100 or >140 and diastolic <60 or >90

HR

report of <60 or >100 bpm

RR

report <10 or >20

temperature

report oral of greater than 38C or less than 36C

pulse ox

report less than 92

• COPD pts between 88 and 92

weight

report changes greater than 0.5 kg

skin decolonization - 2% CHG wipes

• provided to pts in ICU and those in GPU with central line daily

• decreases bacteria on skin and decreases risk of CLABSI

• only use below jawline and NO soap (can deactivate)

• okay to go over occlusive dressings/closed incision and 6 inches of LDAs nearest pt

• good in warmer for up to 84 hours

contact precautions

used for MDROs, suspected bed bugs/lice/chickenpox, RSV in peds, candida auris

• gown, gloves, HH

contact plus precautions

used for C Diff and COVID

• gown, gloves, HH (soap and water ONLY), clean with bleach

  • no clorox/sanitizers

droplet precautions

used for flu, bacterial meningitis, rubella, mumps

• mask, HH

droplet plus precautions

used for Mpox

• N95, eye protection, gown, gloves, HH, door closed

• all trash is red bag waste

airborne precautions

used for active TB, measles, localized shingles in immunocompromised pt until dissemination r/o

• N95, HH, door closed

airborne plus precautions

used for MERS, SARS, ebola

• N95, HH, door closed, eye protection, gown, gloves

aerosol-generting procedures

procedures that result in the production of airborne particles; intubation, vents, insertion/removal of trach, chest physiotherapy, CPR, endoscopy, TEE, ERCP

• N95 required for all pts with AGPs already in precautions

• + or - pressure rooms wait 35 minutes

• neutral pressure rooms wait 2 hours

C. Diff testing

• upon admission or during first 3 days of admission if one episode of diarrhea

  • RN can place order

• after 3 days of admission if >3 episodes of diarrhea

  • provider must place order

phlebotomy notes

• 19-23 G needles (21 most common)

• 15 degree angle of insertion (30 is lots of adipose tissue)

• adhere to order of draw to avoid cross contamination of additives

• must waste first light blue tube if using butterfly needle due to air

• clean site with 70% alc pad and allow to dry completely

• gently invert 180 degrees → do NOT shake

• label should be vertical with accession # on top and window

tourniquets

purpose is to enlarge the veins and make easier to feel

• do not leave on pts arm for greater than a minute → may cause hemolysis

• always use new tourniquet and discard soiled one

optimal sites for venipuncture

• cephalic vein

• basilic vein

• median cubital → most commonly used

• best area is in antecubital fossa area

if good vein cannot be found…

• ask pt for best site

• check other arm

• ask pt to make fist

• apply warm compress to venipuncture site

• lower arm over bedside

• use vein finder if available

blood cultures

• should be drawn prior to initiation of antimicrobial therapy

• central and PICC lines not used due to high colonization and false positives

  • must be drawn using butterfly needle

• aerobic then anaerobic (GO)

• cleanse site with chlorhexidine

collecting a urine sample

must be sent to lab within 30 minutes of collection

routine sample

• use urinal, bedpan, or hat

clean catch midstream

• urinate small amount into toilet first then begin collecting stream

indwelling cath

• clamp Cath below collection port for 15-20 minutes

• withdraw urine into syringe or adaptor

• unclamp cath

24 hour urine

• collecting begins when pt wakes up

• first specimen NOT saved

non violent, non self-destructive behavior

restraint which is applied when the primary reason for use is to protect the safety of the pt and directly supports medical healing; use in this case presumes all other appropriate alternatives have been exhausted

violent self-destructive behavior

restraint may be utilized for emergency management due to pts violent, uncontrolled and self-destructive behavior

drug induced restraint

a drug or med that is not a standard tx or dose for the pts condition and is used as a restriction to manage the pts behavior or restrict pts freedom of movement or to control behavior in an emergency

human physical hold

the involuntary holding down of a pt against their will with the express intent of preventing them from free access to body/env, from leaving, or for administering meds against wishes; constitutes episode of violent restraint

seclusion

involuntary confinement of pt alone in a room or area in which the pt is physically prevented from leaving; can only be used for mgmt of violent/self destructive behavior that jeopardizes immediate safety of pt, staff, or others

restraint procedure

• must be ordered by provider

• RN initiates

• should not be ordered to both legs only, arm/leg unilaterally, over pts head, or to pt in prone position

• removal for self care activities is not considered discontinuation

face to face restraint assessment

NVNSD

• face to face within 24 hours;

• must be renewed each day with every other day being face to face

• complete nursing assessment every 2 hours

VSD

• f t f required within one hour of admin; new order every 4 hours

• complete PA every hour

• q 15 minute checks

partial/non rebreather face mask

• high O2 concentration but allows for some rebreathing of exhaled air (partial) or no rebreathing (non)

• O2 rate >= 10 L/min

• bag needs to remain 2/3 full during inhalation

• non = 70-100% oxygen

nebulizer

turns liquid medicine into mist that can be easily inhaled thru mask of mouthpiece

• initiate gas flow at 6-8 L/minute

tracheostomy tubes/O2

• trach collar delivers humidified O2 to pt to prevent mucus plug and bypass nose

• routine trach care q8 hours or PRN

• passy muir valve does not allow air to exit; increased O2 and secretion mgmt; facilitates weaning to decannulation; allows pt to speak