Procedure: Wound VAC (Vacuum Assisted Closure) Device: Dressing Removal and Application

Policy statements:

#2. “Initial and/or subsequent” were added to the policy statement referencing who can change dressings and when.

#4. Dressing change frequency was changed from three times per week to “will be changed Monday, Wednesday, and Friday or per LIP’s orders, but no less than 3 times per week. (Exception: Wound VAC dressings used postoperatively after graft placement.”

#5. New policy statement- refers to some wounds being able to be changed using sterile technique, others using clean technique.

#6. Dressing change frequency for infected wounds was changed from Q24 hours to “may require more frequent dressing changes per LIP’s orders”.

#10 and #11- New policy statements.

Supportive Data:

This whole section is new. It describes what the VAC therapy is, as well as indications for usage, contraindications, and Use with Caution information.

Procedure:

The procedure has been divided into 2 different sections – procedure for Wound VAC dressing application and Wound VAC dressing removal.

Dressing Application:

Action #7 – “shave” hair deleted and “Clip” hair added.

Action #9 - wound measurements further described as: length x width x depth.

Points of Emphasis #11 – newly added

Points of Emphasis #12 – newly added

Action #15 – Deleted “barrier” and added “additional drape” to protective barriers to be used around wound edges if necessary.

Points of emphasis # 23 – added information about when to use a higher VAC pressure and when to use a lower VAC pressure.

Action #28 – deleted “date of next dressing change” under the documentation in the nursing progress notes section.

Dressing Removal:

Newly added to this procedure.

Reference: included the website/link to the July 2007 “V.A.C. Therapy Clinical Guidelines: A Reference Source for Clinicians”.

Appendix: Added #3 – definition of VAC GranuFoam Silver Dressing.

Added 3^rd column in the grid to include when the silver dressing can be used.

This document has been removed from the Nursing Practice Manual. 

• Page 4 #4: Transfusion of cryoprecipitate will use tubing provided by Blood Bank. 

• Page 2, #2: Compare the patient's name, medical record number and DOB on the requisition and patient's blood tube label. 
• Page 2 #3: The requisition information must match the blood tube label and identification band. 
• Page 2 #6a: The patient's blood tube label must contain the appropriate information listed.
• Page 3 #8: Has been moved to the Procedure for: Blood Components: Administration of Packed Cells, Autologous, Fresh Frozen Plasma, Granulocytes, Cryoprecipitate, Platelets and Blood Derivative Infusions.
• Page 3 #9: When a second specimen is required it must be drawn separately and at a different time than the original. 

Policy changes:

• Policy statement #1 has been changed to clarify that nurses do not insert feeding tubes. 
• Policy statement #5, 6, 7 are new to reflect updated practice per the article, Paduila, C.A. et. al. Enteral Feedings: What the Evidence Says.  AJN.  July 2004. 

Assessment and General Nursing Care from the old protocol have been combined:

• #2 - Deleted: "adding 2-5cc of blue food coloring to the tube feeding" in response to the FDA Public Health Advisory  September 29, 2003: Subject Reports of Blue Discoloration and Death in Patients Receiving Enteral Feedings Tinted with Dye, FD&C Blue no. 1. 
• #3 - regarding elevating the head, has been changed from 30 degrees to 30-45 degrees while the tube feeding is infusing and for 30-45 minutes after completion of the feeding.
• #4a - Change from residual "may" be returned to patient to "should" be returned to patient. 
• #5 - Now states "prior to initiating tube feeding and every 8 hours prn thereafter, assess for:"  Additionally, includes assessment for checking for placement of the tube via auscultation and aspiration of gastric contents. 
• #6 - added irrigating with tap water in addition to q 8 hours for continuous feedings to include also after each residual check, before and after each medication administration and before and after each intermittent bolus feeding.
• #6a - New statement: sterile water irrigation is recommended for critically ill or immunocompromised patients.
• #10 - from the old version of General Nursing Care has been deleted.

Reportable Conditions:

• #1 - has been changed to reflect notifying the MD of residual > 2x the hourly rate.  Greater than 100cc has been deleted. 

• Discontinuation of oral hypoglycemic agents that heighten the risk of lactic acidosis should occur 24 (not 48) hours prior to the scheduled procedure.
• Patients on insulin pumps are to maintain the basal rate of infusion as this is calculated based on NPO status.
• Step #5 regarding use of apple juice or Gatorade ® during transit from home to the procedure center was deleted from the procedure.
• Desired patient outcome: The goal for blood sugar is in the range of 100 to 150 mg/dL (previous version was 100 to 250 mg/dL).

• This document was updated to reflect the use of the electronic MAR (MAK).
• A new policy statement #4 was added based on recommendations of the Institute for Safe Medication Practices.  It reads "Patients will be asked to remove colored rubber wristbands upon admission due to the possibility of misinterpreting the patient's needs (e.g. the yellow Livestrong bands may be interpreted as a falls risk bracelet).  If a patient objects to removal of the wristbands and rationale for removal has been explained, the bands may be covered with tape.

This is a new document. 

This protocol incorporates content from the protocols for Coumadin and Heparin Infusion.  It now takes into consideration the fact that patients may receive anticoagulants for conditions other than venous thromboembolism.  Specific interventions for Heparin Infusion are part of the protocol with a notation that there are 2 standard order sets, one for Acute Coronary Syndrome and one for Deep Vein Thrombosis. 

1. New policy statements:
   1. Medication - specific antagonists are listed.
   2. Avoid Coumadin in pregnancy due to potential effects of fetal malformation and bleeding.
   3. If coagulation studies are drawn from Heparinized lines, check with the laboratory about the Hepabsorb assay. 
   4. Infuse Heparin on Alaris pump using guardrails.
   5. Heparin infusions require verification by a second RN - this was previously stated in the IV Fluid and Medication Administration procedure. 
2. Clinical Assessment and Care:
   1. Added #3, "Implement measures to protect from falls as per protocol for Falls: Risk Identification and Prevention Management". 

This is a new procedure that conforms to practice recommendations of the Institute for Safe Medication Practices and defines the procedural steps for independent double checks of high alert medications.  The medications that require double checks were pulled from various existing protocol.  The only new addition is Insulin by routes other than continuous infusion. 

At JDH, high alert medications are defined as:

• All Chemotherapy agents

• IV anticoagulants
• Insulin - both continuous and subcutaneous doses
• All narcotic infusions - including PCA
• Epidural infusions
• All NICU medications except oral vitamins

The procedure defines the steps for a double check of singe dose medications and for medications infused by continuous infusion.  One important step is that each licensed person independently calculates the medication dose or the rate of delivery. 

The double check will be documented on the MAR (or infusion record if in use): initials of RN administering the medication/initials of the RN performing the double check. 

1. New policy statements:
   1. Documentation of wound measurement is required weekly.  (This was moved from the documentation section). 
   2. At discharge, any wound or skin breakdown and care must be documented in the progress notes and the W-10/Clinical Resume. 
   3. All dressings are to be labeled with the date, time, and initials of the person doing the dressing change. 
2. Assessment - all patients require assessment every 24 hours (previously every 48 hours) for risk of potential or presence of actual skin breakdown.
3. Staging Skin Breakdown - new definitions were added.
4. General Nursing Care:
   1. Stage I - statement removed regarding use of transparent or hydrocolloid dressing; new statement added.
   2. Stage III - IV - items identified to be reported to LIP and consult with CNS. 
5. Algorithm for patient with skin breakdown - Low air loss/fluidized gel overlay (RIC) requires LIP order. 
6. Documentation (step 3) addition: "The flowsheet and care plan must be consistent in the reporting and care of any skin breakdown or wound."
7. Glossary

1. There was little change in content - mostly reorganized.
2. Interpretation of results removed from the procedure and will be located on the back of the form. 
3. The revised form HCH-578 (Skin Test Administration and Results) has been barcoded and is available from the copy center.  Definitions and interpretation of the results is on the back of the form.  

Attachment: HCH-578: Skin Test Administration and Results

Revised documents were incorporated into the Falls Self Learning Packet

Protocol: 1:1 Observation/Constant Observation: Monitoring of Acute Medical/Surgical

Protocol: Restraints, Behavioral: Care of the Patient In

Revised documents were incorporated into Restraint Self Learning Packet

New point of emphasis added regarding the use of the alcohol swab that comes in the central line dressing kit.  This may be used to remove old blood or other debris from the catheter prior to applying the CHG antiseptic.  The CHG must remain on the skin once applied because it provides a lasting antimicrobial effect. 

Med-Surg 5 listed as an exception to the requirement of charting every 7 days on Discharge Planning.

Smaller syringe and flush volume are needed for neonatal patients.

Updated to reflect medication practices for units using POE. 

Military time added to the appendix of standard medication times and as relevant throughout the documentation.

Automatic rewrites changed from every 14 days to every 30 days (as per revised HAM policy) with exceptions as listed for DEA schedule II, NICU and patients on Psychiatry. 

Secondary infusion sets are to be changed at the same time as the primary IV infusion set.

Reference made to HAM policy 06-004 (Automatic Stop Orders) regarding transfer order.

Statements added re: need for completion of medication reconciliation at the time of transfer.

Content re: nursing documentation moved from a policy statement to steps in the procedure.

Transportation department may be called to effect the transfer.

Rapid Response Team and action nurses may be called in the event of urgent transfer to the ICU. 

The list of indications for referral to a dietician has been expanded and service availability has been modified. 

The appendix was revised to reflect the steps in hanging a replacement infusion bag on the new pumps that are used for epidural infusions.  Step 11 of the protocol text (clinical assessment and care) reflects the same content. 

This is a new document that describes the nursing care and procedural steps for giving IV push medications. 

Final review and minor working changes have been made.  This is no longer a draft. 

1. Step # 1 of old procedure was made a policy statement. 
2. Addition to point of emphasis # 4: "Medication reconciliation is done at this time. ( Refer to HAM policy for Medication Reconciliation.)"
3. Procedural steps 6 and 8 were removed. 
4. Addition to point of emphasis # 8: "APRNs and PAs may be able to sign in select circumstances depending on payors or the agency to which the patient is referred."   

1. FLACC and Abbey Pain scales were added as appendices to the procedure. 
2. New policy statement # 3 added: "Nursing care associates may question patients about their pain score and report patients' subjective data to the RN/LPN."

1. Percutaneous umbilical cord blood sampling (PUBS) and intrauterine fetal transfusion were added to the list of indications for RhoGam. 
2. The label of the blood collection tube for a RhoGam screen requires the patient's name, medical record number, date and legible signature (not initials) of the person drawing the blood. 

This is a new document; however, content was moved for the procedure for IV Medication Administration.

1. Policy statement #1 is new: No IV potassium infusions will be reconstituted on the nursing units.
2. Policy statement #5 is new: Infusion pumps are required for all intermittent or continuous potassium infusions. 
3. Administration guidelines were placed in tabular format.
4. Clinical aspects of patient care such as assessing for signs of hypokalemia and risk factors are new.  These are listed in the "Clinical Assessment and Care" section. 
5. The section "Actions in Event of Hyperkalemia" is new. 

NEW PROTOCOL:  Protocol for Chart Review and Audits

1. This is a new protocol to be reviewed in its entirety. 

1. New standardized assessment scales for pulse volume/force/amplitude have been added.  These are to be used as a reference pending flowsheet revisions. 
2. Nutrition screening page has been revised:
   1. Patients on all inpatient units (except 1, 3 and 5) are screened by a dietician within 24 hours of admission (previous stated 72 hours) and are seen within 72 hours. 
   2. Additions to the indicators for referral are open wounds and GI disorders/malabsorbtion issues. 

1. Additions to equipment list: core data base, patient and family teaching record, standard care plan/care path/treatment plan
2. Point of emphasis #1 added: "On admission, the data base should be completed to the best of the admitting nurse's ability given the ability of the patient to communicate, the availability of the family, and the impact of hospitalization."

1. Policy statement #2 added.  "A progress note is required a minimum of every 24 hours.  Exceptions are well newborns on the care path with no variances and women on OB care paths for vaginal and Cesarean section deliveries. 
2. The following were added to the list of events that require a progress note:
   1. Examples for post procedures are PICC placement, interventional radiology procedure
   2. Failure to meet expected outcomes on the care path or care plan

1. Policy statement #1 revised to read: On a daily basis, each RN or LPN is responsible for initiating, reviewing, updating, and/or revising the SCP for each assigned patient.  This review will be documented on the daily chart check sheets. 

1. The following "exclusions" were removed from the definition of fall: position changes caused by spontaneous medical diagnosis (e.g. seizure, stroke, syncopal episode). 

1. Details about specimen tubes were removed - refer to the Laboratory Specimen Manual and the Transfusion Reaction Evaluation Form for details. 

1. To the procedural steps for procurement of blood components, point of emphasis #4 was added.  "A size 20 gauge catheter or larger is preferred because flow of blood through a smaller gauge catheter may damage the RBCs."

Deleted from the manual. 

The relevant content has been incorporated into the procedure for Medication Administration and Use of the MAR

The procedures for medication administration and the guideline for the use of the MAR have been combined into a single procedure with a new title. 

1. Some content that was in the procedural steps has been moved to become policy statements (policy #3, 5, 8, 9, 11) in the administration section.
2. Policies: Administration
   1. Policy #4 changes so that scheduled medications should be given within 1 hour before or after the scheduled time.
   2. Policy statements 6 and 7 were added from a Price Waterhouse Cooper (PWC) work group.
   3. Policy statements 11 to 15 are new.
3. Policies: Transcription and Documentation
   1. Policy #1 has a new point of emphasis: Medications are to be transcribed exactly as written in the order. 
   2. Policy #2 contains new content.  The appendix with standard medication times is attached.
      1. Steps for mid-day daily drug order came from PWC work group.
   3. Policy #3 is from the PWC work group.
   4. Policy #9 is new: Verbal and telephone orders for medications may be transcribed by the HUCs/MAs. 
   5. Policies 5 to 8 and 10 to 11 moved from the MAR guideline.
4. Policies: Reordering Medications
   1. #4 MAR rewrites moved from MAR guideline.
5. Policies: Self Administration or Administration by a Significant Other
   1. No changes.
6. Policies: Storage of Medications
   1. No changes.
7. Procedure for use of the MAR
   1. This section has been edited/streamlined to include only those steps that are not self-explanatory by the use of the form.  Redundancies have been removed.
   2. Step #8 is new from the PWC work group.
8. Procedural Steps for Medication Administration
   1. No changes. 

Procedure: Peak and Trough Levels: Medication

1. Content was reorganized so that statements that were previously listed as “points of emphasis are now policy statements.

2. Cross-reference was made to the Laboratory Specimen Manual for the volume of blood and the type of collection tube.

3. Content was put into tabular format for ease of reading.

   • Option for IV Vancomycin over 1 hour was removed (per pharmacy and P&T committee minutes of 8/31/05

   • Footnote was added regarding Vancomycin peak levels

   • “Once daily” aminoglycoside option was addressed

Protocol:  Immune Globulin: Intravenous Administration

1. Assessment:  Frequency of vital signs added  as follows:  just prior to infusion, after each rate change or am minimum of every 30 minutes while the rate is being increased, after the maximum rate is reached, then every 60 minutes for the duration of the infusion.
2. Because there are several different preparations if immune globulin, “Communicate with the unit pharmacist about the infusion rate of the product to be infused”. 

Protocol: Pre-operative Care

Deleted from the manual. 

This protocol is redundant because the majority of the content is included in the Inpatient Pre-operative Checklist.

Protocol:  Pain (Acute): Care of the Patient Receiving   Narcotics via PCA Pump

IV must remain in place for 4 hours after discontinuation of the infusion (prior version stated 6 hours).  Four hours is consistent with the PCA order sheet.

Procedure: Intravenous (IV) Fluids with Additives/Medications: Preparation and Administration

1. Addition to policy statement #1 regarding use of infusion pump “using guardrails as applicable”.

2. Policy statement #2 rewritten to read:  The pharmacy is responsible for the preparation of large volume parenterals with medication.  The pharmacist should be paged when a new order is written.   In the event that a medication is needed urgently. The RN or LPN must consult with the pharmacist prior to adding any medication to a large volume parenteral solution.

3. Infusions (not an inclusive list) that require double check by a second RN or LPN moved to become a policy statement.

4. Policy statement added about the need to use a filter needle when withdrawing medication from a glass ampule.

5. Content about specific medication concentrations was removed – these are addressed in resources that are available on the units.

6. The KCL content will go into a new protocol entitled Potassium: IV Infusion.  This protocol is not yet completed.

7. Addition to procedural steps: After the medication is added: “Agitate the bag or bottle to ensure uniform distribution of the medication and prevent possible pooling and bolus infusion”

• Policy #3 re-written to read: "The dietitian will collaborate with the nursing staff about how much food and beverage any patient on a calorie count may have consumed after the calorie count has been completed.  The dietitian will calculate the calorie count."
• Point of emphasis #5: the duration of the calorie count is generally 3 days/72 hours

• New policy statements were added:

   

  1. "Continuous IV insulin infusions are to be run on an infusion pump using the guardrails."
  2. "Insulin infusions must be checked by a second RN or LPN for correct medication, dose and rate of infusion."

   

• Clinical Assessment and Care: The standard dilution for insulin is 1.0 unit per ml.

• Title changed to Medication: Patients' Personal Medications
• Point of Emphasis #1: "Patients may be encouraged to bring personal medications to the hospital for the purpose of identifying what medications they are on.  They are to be discouraged from storing medications in the hospital."
• Point of Emphasis #4: Unclaimed medications that are stored in the pharmacy are destroyed after 30 days.  (Previous version stated 6 months.)

• CNS, in addition to dietician, may be contacted to give advice regarding diet.
• Interventions added for skin care:
  1. Irritation: Cavilon No Sting Skin Barrier
  2. Weeping/excoriated: Stoma Powder
  3. Dimpling/creases/irregularity: Stoma paste

• Clinical Assessment and Care: "Report changes from baseline" added to assessments post seizure: LOC and vital signs, skin, muscle strength and ability to move all extremities, and speech.
• Content reorganized to put similar items together.
• Patient teaching: "if applicable" added to statement about the use of Medic Alert bracelet

• "Acceptable alternative scale" (such as the Abbey Scale) was added to the equipment list and throughout all documents to be used when objective assessment is needed for patients who are unable to use the numeric or faces scale.
• Documentation of the pain score was added as a procedural step, rather than within a "documentation section").  The documentation section was deleted.

• The assessment section was separated into "Initial Assessment" and "Ongoing Assessment"
• The pain scale in use must be documented on the flowsheet.
• Pharmacological Management: "and following intervention" added to the indications for assessing the effectiveness of medications.
• The sedation scale for all pain documents has changed so that the language and the direction of the scale is the same as that used for patients receiving conscious sedation.  The parameters are

• Awake (4): Awake, alert

• Minimal (3): Ptosis, slight slurring of speech

• *Moderate (2): Spontaneous eye closure, delayed response to verbal commands, appropriate response to verbal/tactile stimulation

• *Deep (1): Responds only to repeated or painful stimulation

• *Unresponsive (0): No response to painful stimulation

• For items with *, there must be an attempt to arouse the patient.
• Sedation score of 2 or less must be reported.

• This document previously also covered narcotics by continuous infusion.  These 2 concepts have been separated into 2 separate protocols - Narcotics via PCA and Continuous Narcotic Infusion.
• An addendum was made to the policy statement that a basal infusion must not be initiated with the PCA.  "Patients treated with chronic opioids may require continuous infusion dosing.  In these cases, contact the pharmacist for further guidance."  This is the same language that is on the pain pocket guide.
• Vital signs to assess patient response: Dosage decrease (except for weaning) also requires an increased frequency of monitoring.
• Patient Education: "Instruct the patient/family that only the patient should push the control button."
• A sedation score of 2 or less must be reported.  the revised sedation scale is consistent through all documents.

• This is a new protocol.  Content mirrors that of the protocol for Narcotics via PCA.
• Assessment parameters for response to narcotic administration do not apply to patients near the end of life for whom the frequency of assessments will be determined by the MD or LIP.
• Vital sign parameters differ for continuous infusion than PCA.
• Reportable conditions:

• Patient instruction will be done by the department of anesthesiology

• Actions to be taken in the event of suspected narcotic dosage are comparable to those listed in the PCA protocol.

• Policy statements added that are in other documents (availability of resuscitation bag and mask, pain level of 5/10 or greater or any level that is unacceptable to the patient requires further assessment and review).
• Revised sedation scale with reportable score of 2 or less
• Bladder scanner may be used to assess for bladder distention (by staff with established competency in its use).
• If an increase in epidural dose is needed, RR, BP, HR, sedation score are to be done q15 minutes X2, then first 24 hour assessments are to be continued.

• New policy statement #3 added: "No medications or solutions, with the exception of normal saline (0.9% NaCl) may be infused simultaneously through the same tubing with blood or blood components".

• This document is new to the nursing practice manual.  It was previously in the perioperative nursing manuals.

• This document is being deleted from the manual due to general nature and lack of specificity of content.

• Precaution changed to read: "Medications and equipment to support cardiorespiratory function during a severe allergic reaction and located in emergency carts on the unit"

• Statement in Safety measures about not restarting the machine if it has been stopped for more than 2 hours was changed to a policy statement.  Some wording was also changed to improve clarity.

• Statement removed regarding notifying clinical engineering of any machine malfunction.  This is applicable to all equipment and is not specific to this device.  This topic is covered in the Hospital Administration Manual.

Clinical Assessment and Care:

• Step 1: Changed to add assessment of patency every 4 hours (in addition to functioning).  The description of "fluttering" with or without pneumothorax has changed.
• Step 5: Related to disconnection of the chest tube and the Heimlich valve reworded to "place the end of the chest tube in a cup of water to maintain a water seal" from "place in 2cm sterile water."
• Step 6: Related to chest tube falling out, new sentence added.  "Continue to monitor patient tolerance and report any signs and symptoms of respiratory distress.  Notify MD/LIP."

• Checking the pharmacy worksheet was deleted - RNs do not have a copy for comparison.
• If there are discrepancies - page the unit pharmacist instead of returning the solution to the pharmacy.
• Pharmacy does not need to be notified of rate decreases, only increases that my affect fluid availability.
• Removed "observation for protein allergy."
• Removed "positive urine acetone and BP changes as reportable conditions."

No substantive changes - predominantly clarity and reorganization of content.

• Deleted step about checking the infusion pump every 4 hours for a continuous infusion.
• Reportable condition #3 was changed to read: "Phlebitis or infiltration score of 2 or greater or infection at peripheral insertion site."

• Deleted from the manual.  The same document is in the Hospital Administration Manual (08-051).

• Policy statement #1 separated into 2 distinct policy statements.

1. Student nurses must be supervised by a  staff nurse preceptor or faculty member when giving medications.

2. Student nurses may not give IV push medications.

• Step #3 regarding family viewing of the body was changed to be more open ended, recognizing that some individuals may not want to touch/talk to the body.
• Policy statement #4 regarding jewelry or other patient valuables changed to read that they may be given to a "spouse or next-of-kin as documented in patient registration, unless there are known concerns.  Refer to Hospital Administration Manual (HAM) policy "Patient Valuables."
• Procedural steps in the body preparation divided into adults and infants.  Infant content was added and the NICU unit-specific procedure is being deleted.