-
Stable (8)
- Use of word stable
- Chronic
- Post op more than 12 hours
- Local/regional anesthesia
- Lab abnormalities A/B
- Ready/ to be discharged, admitted longer than 24 hours ago
- unchanged assessment
- expected s/sx
-
Unstable (8)
- Use of word unstable
- acute
- post up less than 12 hours
- general anesthesia
- Lab abnormalities C/D
- newly admitted/diagnosed, admitted less than 24hr ago
- changed assessment
- unexpected s/sx
-
always unstable (4)
- hemorrhage
- hypoglycemia
- fever over 104
- pulselessness/breathlessness
-
tie breaker- vital organs
- Brain
- Lung
- Heart
- Liver
- Kidney
- Pancreas
- Black Lipstick Has Left Kisses Passionately
-
NO LPN
IV, unstable pt, admin, discharge, first, blood transfusion, plan of care
-
NO UAP
meds, assessments, treatments, firsts
-
Is staff doing something illegal ?
tell supervisor
-
Is pt or staff in harms way ?
intervene immediately
-
Is it just inappropriate ?
council later on
-
K (D)(C)
- 6 or above
- Hold K, assess heart, prepare D5W insulin/kayexelate, Call MD
- C: 5s
- TL: 3.5-5
-
-
CO2 (D)(C)
- 60s
- assess resp, do pursed lip breathing, prepare to intubate, Call RT/MD
- C: 50s
- TL: 35-45
-
P02 (D)(C)
- 60 or under
- Assess resp, give O2, prepare to intubate, Call RT/MD
- C: 70-77
- TL: 78-100
-
Platelets (D)(C)
- under 40K
- Assess for bleeding, prepare platelet transfusion, Call MD
- C: under 90K
- TL: 150K-400K
-
INR (C)
- 4
- Hold warfarin, assess for bleeding, prepare vit K, call MD
-
Hemoglobin (C)(B)
- under 8
- assess for bleeding, prepare for transfusion, call MD
- B: 8-11
- TL: 12-18
-
SAO2 (C)
- under 93
- assess resp, give 02
- TL: 93-100
-
Neutropenic (WBC, ANC, CD4)
- WBC: Under 5K (5K-11K)
- ANC: Under 500
- CD4: under 200
-
-
BUN
- 8-30
- elevated = (B) check for dehydration
-
-
NA
- 135-145
- B monitor for dehydration
- C change in Neuro
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