Dr. C's Nursey Stuff - Home



Know the following about your patient:AllergiesCode statusWeightDiagnosis & plan of careI/OVSLabs: K+, Bun/Cr, WBC, H/HMeds-antibiotics, anticoagulantsNurses own:Infection controlSkinMobilitySafetyTeachingNursing Sensitive Indicators: (every patient, every shift, every day)RestraintsHAPU: Hospital acquired pressure ulcerCAUTI: catheter associated UTIFallsCLBSI: central line blood stream infectionHAI: hospital acquired infectionMDRO: multi drug resistant organismsVAP (VAE now): ventilator associated eventAccurate height and weightMedication reconciliationCore measuresHCAHPS (hospital consumer assessment of healthcare providers and systems)SBARMedication administrationPatient education with diversitySkilled communicationCore Measures:Heart failureVTESCIPPneumoniaImmunizationAMIStrokeNPSG (national patient safety goals):Patient identificationCommunicationMedication labelingInfection preventionUniversal protocol Report GuidelinesName, Age, DiagnosisAllergies, code statusRelevant history (past medical problems that impact current hospital stay, ie DM, HTN, COPD)Current problem (why are they here and are they on the appropriate unit)Assessment:Neuro (LOC, confusion)CV (fluid issues, EKG, BP, HR)Resp (lung sounds, oxygen amount, RR, CXR)GI (last BM, any abnormalities, NG)GU (voiding, BSC, foley, dialysis)Skin (wounds, ulcers, incisions, drains)Lines (IV, central line, PAC, fistula/shunt)Drips/FluidsPain med last dose/next doseMobility (type of assistance needed, OOB, turn q2, fall risk)DietAccuchecks (last BG, covered?)Abnormal labs (esp K, BUN/Cr, H/H, WBC, cultures)VTE (thromboguards, anticoagulant)Doctors To do’s (follow up items including labs, procedures, meds)Plan of careReview last 12 hours of orders\sCore MeasuresHospital InpatientAcute Myocardial Infarction (AMI)Aspirin (ASA) within 24 hours before or after arrivalASA/Beta Blocker prescribed at dischargeACEI or ARB at discharge for LV systolic dysfunction (LVSD) EF <40%PCI within 90 minutesHeart Failure (HF)Evaluation of Left Ventricular Systolic (LVS) FunctionACEI or ARB for Left Ventricular Systolic Dysfunction (LVSD) EF <40%Pneumonia (PNA)Blood culture in ED prior to antibioticAntibiotics selection ICU/non-ICUSurgical Care Improvement Project (SCIP)Antibiotic within 1 hour of surgical incisionAntibiotic selectionAntibiotic discontinued within 24 hours of end anesthesia time (EAT)Appropriate hair removalUrinary catheter removed by Postoperative Day (POD2)Perioperative temperature managementVenous thromboembolism (VTE) prophylaxis ordered & administered within 24 hours of end anesthesia timeBeta blocker taken prior to admission, document time last doseBeta blocker perioperative (24 hours before until POD 2)ImmunizationPneumococcal Age 65 and high risk Influenza Oct-MarPatients 6 months and olderStrokeVTE prophylaxisSwallow Eval before oral intakeDischarged on antithrombotic therapyAnticoagulation for A-Fib/A-FlutterThrombolytic therapyDischarged on statinStroke educationHead CT scan results for Stroke (acute ischemic or hemorrhagic) interpreted within 45 minutes of ArrivalNational Patient Safety GoalsIdentify patients correctly2 IdentifiersBlood transfusion-2 nurses verifyImprove staff communicationGet important test results to the right staff person on timeUse medications safelyLabel medicationsPrep medications where medicine and supplies are setupExtra care for blood thinnersMedication reconciliation Use alarms safelyEnsure alarms are appropriate, heard, responded to on timePrevent infectionHand hygieneAppropriate isolationCentral line infection preventionSurgical infection preventionUrinary tract infection from cathetersIdentify patient safety risksSuicide risk assessment and precautionsPrevent mistakes in surgeryProcedural pauseMark surgical site ................
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