ICU HCMANE November 2025

HC-MANE Patient Monitoring Activity

Revalidation: November 2025

HC-MANE Revalidation November 2024

Choose your location below to start the case study:

CICU

CT ICU

Which assessment and documentation is not correct while the device is in place?

Your Admission:

A 61 YO female arrives to 7W01 post AVR & CABG x3 (LIMA to LAD, SVG to OM2, & SVG to PDA) with Dr. Smith. Shortly after arrival she arrests and returns back to the OR where the chest was re-explored and surgical repair of the aortic annulus was performed. The team decides to treat following the Post-Arrest Temperature Control protocol to ensure normothermia. The Arctic Sun Temperature management system is placed.

Every 4 hours assess around the pads and any pressure points; Assess underneath all pads once per shift.

Vital signs, including temperature from one central source every 15 min x 4, 30 min x 2, then every hour

Water flow & water temperature every 15 min x 4, 30 min x 2 then every hour

Temperature Management Post-Arrest

Temperature Management via External cooling system

Next up:

The second RN is getting your labs as you assess the patient. Chest tubes are to suction, OGT is to intermittent suction, 2A2V wires are secured and the foley is below the bladder. You level and zero your A-line and ensure that your alarm parameters are set appropriately and the volume is on. Next you complete your gtt check with your buddy. Your order is for dopamine 5mcg/kg/min. T.B. weighs 73.4 kg. You scan the dopamine and continue to the alaris pump:

Which is the correct Alaris pump guardrail for this patient?

What is the correct action for the 1115 am dose of VANCOMYCIN?

First - Draw the Trough. Second - check your med administration instructions Third - GIVE Vancomycin or HOLD

HOLD the dose & notify the provider

GIVE the dose

RN Participation in multidisciplinary rounds is an important action for patient care. What is NOT an appropriate way for the RN to ensure appropriate care delivery for the patient?

Perform a neuro assessment to relay updated data to the team during rounds.

Whew - what a start of the shift! The patient is doing much better and you continue to provide evidenced based care in the post-surgical period. It is now time for multidisciplinary rounds.

Wait to ask any questions until rounds are over.

Summarizing the plan of care for the day during rounds

You implement the hypoglycemia protocol and administer 25g of D50 IV x 1. What should you do with the insulin infusion?

Three hours later.....you are covering for your neighbor. During handoff, you are told that the patient is on an insulin infusion and the last BG was 111. You check a POC glucose on the hour & the glucometer results 46. You repeat the test to confirm, 46 again. You check your orders and see the Hypoglycemia Protocol ordered.

Temporarily stop the infusion. Perform POC BG in 30 minutes.

Stop the drip, notify the provider.

Great work! You stop the infusion and recheck a BG in 15 minutes, the results are 70. You treat again with 12.5g D50 (patient is not able to take oral). Recheck in 20 minutes is 87. You notify the provider and discuss starting D5, but you collaborate to monitor the patient for a bit. Base on your medication admin instructions, What is the frequency of monitoring with POC BG ?

Every hour, restarting the infusion at 50% when BG is >120.

Every 2 hours until thb BG is >100, then restart the infusion.

<-- Click here for the ADMIN INSTRUCTIONS Don't forget to document a hypoglycemia SmartPhrase in Maestro Care: .rnhypoglycemia

Sedation Narrator

What is the first action to start the documentation?

The next day during rounds, the team would like to perform a TEE to better assess valve function. You notify the charge nurse for assistance. Your buddy asks how they can help, and you ask them to document using the sedation narrator.

Staff Arrival

Sedation Start

Sedation Narrator

The narrative documentation is as follows: Patient weight: 65kg Sedation start: 1140 Time out performed at 1142 Propofol bolus of 30mg at 1145 by Dr. Whitecoat (Anesthesia) Second propofol bolus of 10mg at 1205 by Dr. Whitecoat (Anesthesia) Procedure end at 1215

Are the medications documented properly?

Yes

No

Your Admission:

T.B. is a 75 y/o Male who arrived to bed 5 post-PCI of the LAD from the Cath Lab (STEMI). PMH: CAD, hypertension, Type 2 diabetes , A1c 7.8%, former smoker, quit ~2 years ago Allergies: Heparin, ACE-i, NSR on tele, HR: 55, BP 85/63, RR 14 2L NC, SpO2 98%. PIV x 2, A&0 x 3. Complains of 3/10 chest pain. Patient received ticagrelor and aspirin in the cath lab. TR band with 10 ml air to right radial artery, clean, dry, intact, no hematoma.

Bedside handoff occurs with the cath lab and the CICU teams. What would need to be addressed with the cath lab team before ending handoff?

There are no post-cath orders in the EHR.

Post-Cath Diet Orders

You also talk about when to escalate to a provider related to drainage. When would you engage the provider right away?

Helping your neighbor

The patient is settled and your neighbor is admitting a patient from the cath lab, too! They are post-pericardial drain. They ask for your help with a quick refresher. You provide the following:

Sudden stop of drainage

• A stopcock is connected directly to the pigtail to facilitate flushing or sampling.
• Orders entered for frequency and amount of flush.

• The side arm of the sheath is capped and turned off to the patient.
• DO NOT flush, transduce or draw samples from the sheath.
• Verify the presence of negative pressure from the vacutainer (the green plunger is down)
• DO maintain the patient on bedrest while on continuous suction

When there is 30mL of drainage over 3 hours

Pericardial Drain

How frequently should you change out the vacutainer?

You help your buddy get the patient settled and they ask about the collection device connections. You assess the system with them, from the end of the pigtail to the vacutainer, ensuring a closed system with adequate negative pressure (suction). They ask about when to change out the vacutainer.

When the green suction indicator is extended

When the bottle is half full

Type and Screen

If one nurse is drawing the Type and Screen AND the Confirmatory ABO, what are the proper steps to ensure patient safety?

• You notice that the patient does not have an active type and screen. You escalate to the provider and they enter the order. The patient has not been seen at DUH previously, so will also need a Confirmatory ABO.

The two specimens must be collected at least 15 minutes apart

The two specimens must be sent to the lab at the same time

Don't forget to complete the collection in Epic!

Confirmatory ABO Supplemental Learning

Sedation Narrator

What is the first action to start the documentation?

The drain is patent and is draining slowly. However, about 30 minutes later the patient is in respiratory distress and has failed a trial of BiPap. The provider on for your shift is credentialed in RSI and would like to intubate the patient. You notify the charge nurse for assistance. Your buddy asks how they can help, and you ask them to document using the sedation narrator.

Staff Arrival

Sedation Start

Sedation Narrator

The narrative documentation is as follows: Patient weight: 65 kg Sedation start: 1140 Time out performed at 1142 Etomidate (0.3 mg/kg) at 1145 Succinylocholine (1.5mg/kg) at 1147 ETT 7.5 placed at 1150

Are the medications documented properly?

Yes

No

You help your buddy to correct the dose of etomidate to accurately reflect 0.3 mg/kg that was administered during RSI and you end the sedation event. The patient is started on a continuous infusion of propofol and fentanyl while intubated. The provider orders the PAD protocol to assist with Pain, Agitation and Delirium. You start the continuous infusions. 15 minutes later you assess the CPOT as 2 and RASS is +2. How should the medications be titrated?

Bolus dose of fentanyl and increase in propofol for CPOT and RASS

Increase in fentanyl for CPOT

Increase in propofol for RASS

Next up:

The patient is still hypotensive. The provider orders a dopamine infusion. Your order is for dopamine 5mcg/kg/min. T.B. weighs 73.4 kg. You scan the dopamine and continue to the alaris pump. It's not shift handoff - Time to handoff your drips!

Which is the correct Alaris pump guardrail for this patient?

Falls Risk AssessmentHester Davis

John Doe, a 72-year-old male, was admitted to the hospital after experiencing chest pain at home. He was diagnosed with an NSTEMI John has a history of hypertension, type 2 diabetes, and hyperlipidemia and denies any prior falls.

Age: 0=<20 yo 1=20-40 yo 2=40-60 yo 3=>60 years Last Known Fall: 0=No falls 1= Within last year 2=Within last 6 months 3=Within last month 4=During the current hospitalization

Score is 3

Next

Mobility: 0-No limitations 1-Dizziness/generalized weakness 2-Immobilization/requires 1-person assistance 3-Use of assistive device/requires 2-person assistance 4-Hemiplegic, paraplegic, or quadriplegic Choose the correct mobility score to add to the total: **Don't forget to add all the appropriate selections@

Falls Risk AssessmentHester Davis

John is alert, wears glasses and has right-sided hemiparesis. His right arm shows markedly reduced motor strength (1/5), with minimal voluntary movement and absent functional use for ADLs. Right leg strength is slightly better (2/5), but unable to bear weight or assist in transfers. Sensation to light touch is diminished on the right, and he has difficulty with proprioceptive awareness. John requires total assistance with transfers using a mechanical lift or two-person assist. Non-ambulatory at this time. Physical therapy involved for positioning, contracture prevention, and early neuro rehab. He fatigues easily and demonstrates impaired balance and coordination.

Add 6

Add 5

Add 7

Falls Risk AssessmentHester Davis

Medication: 0=No meds 1=Cardiovascular or central nervous system meds 2=Cardiovascular and central nervous system meds 3=Diuretics 4=Chemotherapy in the last month What do you add for medication?

Amlodipine 10 mg daily Furosemide 20mg IV daily Metformin 500 mg BID Atorvastatin 40 mg nightly Aspirin 81 mg daily Lantus insulin per sliding scale

Add 2

Add 4

Add 3

Falls Risk AssessmentHester Davis

Mental status: 0=Awake, alert and oriented to date, place and person 1=Oriented to person and place 2=Lethargic/oriented to person only 3=Memory loss/confusion and requires reorienting 4=Unresponsive/nonpliance with instruction Choose the correct mobility score to add to the total:

John is oriented to person, place, and time, but experiences challenges with following complex instructions due to aphasia. He occasionally requires reorientation and additional time to process communication.

Add 1

Add 2

Add 3

Falls Risk AssessmentHester Davis

Behavior: 0=Appropriate behavior 1=Depression/anxiety 2=Behavioral noncompliance w/instruction 3=Ethanol/substance abuse 4=Impulsiveness What is his behavior score?

John is calm and cooperative, though he exhibits intermittent impulsivity attimes. (e.g., attempting to get out of bed unassisted despite safety reminders)

Add 2

Add 3

Add 1

Add 4

Falls Risk AssessmentHester Davis

What level of risk is John?

Great job assessing John! His total Hester Davis score is 29.

Low Risk

Medium Risk

High Risk

Congrats! You have completed one part of the November HC-Mane Revalidation Content! Don't forget to complete the LMS Module: CEPD 1155 Aligning Nursing Care Plans with Patient Needs and Documentation Standards Please click the link below to record completion for this section. LMS completion will be recorded in the LMS system.

Click here for Microsoft Forms

Try Again!

Go Back

RNs participate in rounds!

Nurses are an essential member of the team to help inform the plan for the day. Presentation of an accurate Neuro assessment and re-capping the overall care plan are two functions of the RN. Any questions should be asked during rounds when the team can address them in real-time!

Next

That's right!

Bolus doses should not be ordered as mcg/kg/min! This is for continuous infusion only! Help your buddy by editing the documentation to reflect a bolus dose, using the propofol mg/ml injection adminstration.

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