Safety

Question 1

Fall: trigger

Answer 1

Morse scale

History of falling: 25

2. Secondary diagnosis: 15
3. Ambulatory aid

None/bed rest/nurse assist: 0

Crutches/cane/walker: 15

Furniture: 30

4. Intravenous therapy/saline lock: 20
5. Gait

Normal/bed rest/wheelchair: 0

Weak: 10

Impaired: 20

6. Mental status

Oriented to own ability: 0

Overestimates/forgets limitations: 15

Question 2

Morse scale

Answer 2

1. history of falling,
2. presence of 2 or more medical conditions,
3. intravenous medications,
4. gait assessment,
5. ambulatory aid, and
6. mental status. Patients are then classified into low-, moderate-, and high-risk categories.

Question 3

Delirium: risk factors

Answer 3

Age older than 70 years, cognitive impairment, sensory impairment such as vision or hearing loss, and functional dependence

physical comorbidity, psychiatric comorbidity, dehydration and malnutrition, and drug dependence

Question 4

CAM: specificity, sensitivity

Answer 4

sensitivity of 94 to 100 percent and a specificity of 90 to 95 percent

Question 5

Suspected Delirium: trigger

Answer 5

Compute CAM score

1. Acute and fluctuating course
2. Inattention
3. Disorganized thinking:

“rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?”

4. Decreased LOC: “Overall, how would you rate this patient’s level ofconsciousness?”
   
   1. Normal = alert
   2. Hyperalert = vigilant
   3. Drowsy, easily aroused = lethargic
   4. Difficult to arouse = stupor
   5. Unarousable = coma

Question 6

CAM: Level of consciousness component

Answer 6

Normal = alert

Hyperalert = vigilant

Drowsy, easily aroused = lethargic

Difficult to arouse = stupor

Unarousable = coma

Question 7

CAM: positive when

Answer 7

1. Acute onset, fluctuating course
2. Inattention
3. Disorganized thinking
4. Decreased LOC

The diagnosis of delirium requires the presence of features 1 AND 2 plus either 3 OR 4.

Question 8

Stress ulcer prophylaxis: indications

Answer 8

critically ill patients at high risk of bleeding:

1. coagulopathy (platelet count <50 × 103/µL, INR >1.5),
2. prolonged mechanical ventilation (more than 48 hours),
3. gastrointestinal ulcer or bleeding within the past year, or
4. severe burn injury and 2 or more minor criteria including sepsis,
5. stay longer than 1 week in the intensive care unit,
6. occult gastrointestinal bleeding for 6 or more days,
7. steroid therapy with more than 250 mg of hydrocortisone daily

Question 9

Braden scale

Answer 9

The Braden scale rates patients in six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear using scores ranging from 1 to 3 or 4.

The maximum score is 23; a score ≤18 is indicative of high risk.

Question 10

Non-blanching erythema on buttocks: Trigger

Answer 10

Pressure ulcer precautions

Question 11

Pressure ulcer risk mitigation

Answer 11

advanced static or dynamic support surface

if “high-risk,” regardless of whether the assessment was made clinically or with a structured scoring scale.

Question 12

Development of Stage 3 ulcer after admission: Trigger

Answer 12

considered a “never event” that must be reported to the Joint Commission.

Question 13

Pressure ulcer prevention: minimum strategies

Answer 13

1. formal institutional multicomponent strategy
2. protocols for scheduled turning and mobilization of at-risk patients,
3. education of physicians and nurses on recognition of early-stage ulcers,
4. designated “skin champion” who regularly evaluates patients and makes specific recommendations
5. regular audit and feedback of pressure ulcer rates.

Less evidence:

1. use of special mattresses and overlays to reduce skin pressure
2. championing by hospital leadership, although these strategies have less supporting evidence.
3. close attention to nutrition and hydration is important to prevent ulcers, no clear data show that targeting a specific serum albumin level is beneficial.

Question 14

Hypotension, tachycardia, mild abdominal/groin tenderness the day after cardiac cath

Answer 14

RP bleed

CT abdomen is the best test

Question 15

High Risk Meds

Answer 15

1. IV Adrenergic agonists
2. IV Adrenergic antagonists
3. Anesthetics, general + IV
4. IV antiarrhythmics
5. Anti-coagulants
6. thrombolytics (e.g., alteplase, reteplase, tenecteplase)
7. glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide)
8. Cardioplegics
9. Chemotherapy agents
10. Dextrose 20% or higher
11. Dialysis solutions, peritoneal and hemodialysis
12. epidural or intrathecal medications
13. hypoglycemics, oral
14. inotropic medications, IV (e.g., digoxin, milrinone)
15. insulin, subcutaneous and IV
16. liposomal forms of drugs (e.g., liposomal amphotericin B) and conventional counterparts (e.g., amphotericin B desoxycholate)
17. moderate sedation agents, IV (e.g., dexmedetomidine, midazolam)
18. moderate sedation agents, oral, for children (e.g., chloral hydrate)
19. narcotics/opioids
20. neuromuscular blocking agents (e.g., succinylcholine, rocuronium, vecuronium)
21. parenteral nutrition preparations
22. radiocontrast agents, IV
23. sterile water for injection, inhalation, and irrigation (excluding pour bottles) in containers of 100 mL or more
24. sodium chloride for injection, hypertonic, greater than 0.9% concentration

Question 16

Heparin induced thrombocytopenia: timescale

Answer 16

Drop in platelet count is seen after 5 to 10 days of exposure in patients not exposed to heparin in the last 3 months

Question 17

Drug induced lupus: drugs

Answer 17

1. procainamide,
2. hydralazine,
3. minocycline,
4. diltiazem,
5. penicillamine,
6. isoniazid (INH),
7. quinidine,
8. anti-tumor necrosis factor (TNF) alpha therapy (most commonly with infliximab and etanercept),
9. interferon-alfa,
10. methyldopa,
11. chlorpromazine, and
12. practolol [35-37].

Question 18

Drug induced lupus: Dx test

Answer 18

anti-histone

90% sensitive

Question 19

Anti-Smith for SLE: sensitivity

Answer 19

30%

Specificity: 55 to 100%

Question 20

anti-dsDNA in lupus: why useful?

Answer 20

1. Relatively High specificity
2. correlates with disease activity
3. association with active glomerulonephritis

Question 21

RCA

Answer 21

1. Interview
2. Identify proximate causes
3. Structured analysis:
   
   1. Communication structures
   2. Leadership
   3. Human resource issues
   4. Environmental issues
   5. Information management issues
4. Action plan