Assessment, Safety and Documentation

What are the 4 assesment techniques?

Inspection

Palpation

Percussion

Auscultation

What is included in fall risk assessment tool?

Age

Fall history

Elimination, bowel, and urine

Medications

Patient care equipment

Mobility

Cognition

What are the different scoring categories for the fall risk assessment?

6-13 points = moderate fall risk

13+ points = high fall risk

What are nursing interventions to prevent falls in a health care facility?

Bed in low position

Leave call bell within patient's reach

Night light

Nonskid footwear

Leave belongings within reach

Lock bed/wheelchair

What is required before using restraints?

Order from dr

How often is monitoring required when using restraints?

Q15

What are some types of restraints?

Enclosure beds

Mitten restraints

Bed rails x4

Chemical restraints

What are the most common types of restraints?

Soft wrist restraints

Freedom splints

What are examples of chemical restraints?

Ativan, geodon, haldol

What are alternatives to restraints?

Move patient close to nurse station

Make environment similar to home

Invite family to bedside

Reduce stimulation

Offer activities

Bed alarm

Offer toileting frequently

Allow confused pts to walk freely in safe environment

What is sepsis?

Overwhelming systemic response to an infection that can cause vasodilation and shock

Late stages of sepsis can lead to..?

Organ failure and death

What is in the 1 hr sepsis bundle?

Vasopressors (if hypotensive)

30ml/kg saline IV bolus

Blood cultures then antibiotics

Measure lactate level

What lactate level is a sign of organ failure

greater than 2.0 mmol/L

Rules for documenting

Use black ink

Don't leave lines blank (put line through blank spaces)

Draw straight lines through errors and write "error", initial, then. proper documentation

Never document interventions before carrying them out

How to document

Military time

Objectively

Interventions and response

Time recorded and occurred

Incidences and assessments ASAP

When do you write a nursing note

To elaborate:

Admissions, transfers, discharges

When a procedure is performed

When receiving a postop patient

When communicating with provider

DAR format for nursing notes

Data - your assessments

Action - what did you do about it

Response - what happened after and what is the plan moving forward