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Nursing Practice Manual

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Clinical protocols and procedures are in bold print.

Please Note: These policies, procedures and protocols are provided for informational purposes only for the staff of John Dempsey Hospital.  The owner and authors assume no liability whatsoever in connection with the use of the information contained within.

The Lippincott Manual of Nursing Practice should be used for nursing procedures not found in the Nursing Practice or Unit Practice Manual’s. Procedures in the Nursing Practice Manual or Unit Practice Manuals supersede the Lippincott reference.



Structure Standard
  Click to Expand
Procedure: Allergies: Identification of Patient Allergies
Procedure: Ambulatory Patient Summary List
Protocol: Anticoagulation Therapy
Protocol: Aspiration Precautions: Adult
Procedure: Assessment: Scope of Nursing Physical Assessment: Adult Inpatient
  Addendum: Within Defined Limits
Procedure: Attendance: Sick Leave
Procedure: Attendance: Staff Call-Out Procedure

Procedure: Bladder Scanner
Procedure: Blood Cell Exchange (RBC) Transfusion via a Peripheral Stick
Blood Cell Exchange (RBC) Transfusion via a Central Line or Peripheral IV
Procedure: Blood Components: Acquisition from the Blood Bank and Transport to the Units
Procedure: Blood Components: Administration of
Procedure: Blood Components: Emergency Release
Procedure: Blood Components: Type and Screen/Type and Cross-Match for Transfusion Purposes

Procedure: Calorie Counts
Clinical: Chemotherapy (Cancer Therapy) Administration
  • See HAM policy 08-41 for additional Chemotherapy standards
Protocol: Capnography - Care of the Patient Receiving Combination End Tidal C02 (EtCO2) and Simultaneous Continuous Pulse Oximetery (SpO2) Monitoring
Protocol: Cardiac Catheterization - Post Procedure
Protocol: Cardiac Monitoring - Care of the Patient on Cardiac Monitoring
Procedure: Certification Bonus
Procedure: Change in Patient Condition - Chain of Command Notification
Protocol: Charge Nurse Responsibilities
Protocol: Chart Review (Inpatient)
Protocol: Chest Tube: Care of the Patient with
Protocol: CIWA-Ar: Alcohol Withdrawal Assessment Protocol
Procedure: Code Blue Documentation
Protocol: Competency Checklist: Completion of for Permanent Nursing Staff, Contract Nursing Staff and Nurse PROs
Procedure: Conference Time for UHP Professional Staff in the Dept of Nursing
Protocol: Congestive Heart Failure (CHF): Care of the Patient with
Procedure: CPAP and BiPAP Units: For Use During Hospital Stay

Procedure: Decentralized Lab Testing: Quality Control Checks
Protocol: Deep Vein Thrombosis (DVT): Care of the Patient with Upper or Lower Extremity Deep Vein Thrombosis
Protocol: Delirium: Care of the Patient with
Protocol/ Procedure: Department of Corrections (DOC): Interdepartmental Communication
Protocol: Diabetes Mellitus Management: Periprocedural Care
  Addendum: Guidelines for the Preoperative Preparation of the Surgical Patient
Protocol: Discharge Planning and Documentation: Nursing Responsibilities for Preparing Inpatients for Discharge (and Referrals for Post-Hospital Support/Services
Procedure: Documentation: Admission (Inpatients)
Procedure: Documentation: Patient Care Plan
Procedure: Documentation: Progress Notes
Procedure: Dress Code

Procedure: Education: Mandatory In-service
Procedure: Electronic Triage (E-Triage) Application: Use of in JDH Clinics
Procedure: Evaluation: Staff

Protocol: Falls (Inpatients): Risk Identification, Prevention Management and Treatment
  Patient Education Handout
Protocol: Fall Screening and Prevention (Hospital-Based Ambulatory Areas) - DRAFT
Procedure/ Protocol:

Fecal Incontinence Management Using the Flexi-Seal Fecal Incontinence System Signal (FMS)

  Click to Expand

Procedure/ Protocol: Hand Off Communication
Protocol: Heimlich Valve: Care of the Patient with
Protocol: Hemodynamic Monitoring
Protocol: Hypertension
Protocol: Hypo-Hyperthermia Blanket

Protocol: Individual Coping Impaired: Extended Hospital Stay
Procedure: Infiltration, Extravasation: Care of the Patient with Peripheral IV
Procedure: Infusion Therapy: Accessing Implanted Central Venous Access Port with Huber Needle
Procedure: Infusion Therapy: Subcutaneous Needle Insertion for Continuous Infusions
Procedure: Infusion Therapy: Alteplase Instillation for Central Venous Access Catheter Clearance
Procedure: Infusion Therapy: Blood Draws from Central Venous Access Devices
Protocol: Infusion Therapy: Device Selection and Placement
Procedure: Infusion Therapy: Dressing and Catheter Site Care for Central Venous Access Devices
Protocol: Infusion Therapy: Equipment and Use of
Protocol: Infusion Therapy: General Care, Education and Documentation
Protocol: Infusion Therapy: Infection Prevention and Safety Compliance
Protocol: Infusion Therapy: Management of Complications
Procedure: Infusion Therapy: Preparation and Administration of Fluids with Additives / Medications
Appendices: Appendices: Flushes for Central Venous Access Devices
Procedure: Insulin, Regular U500: Use of
IV Push Medications

Protocol: Jewelry: Wearing of Jewelry and Body Piercings by Patients  During Operative and Invasive Procedures

Procedure: Medication Administration IV Guidelines: Medications Not Listed in JDH IV Medication Guidelines
Procedure: Medication Administration: Student Nurses
Procedure: Medication Administration: Pyxis for Controlled Substance Security
Protocol: Medication: Documentation of New Orders and Rate Changes for Continuous Medication Infusions
Procedure: Medication Documentation: Using the Medication Documentation Check (MAK) for Inpatient Units
Teaching Plan: Medication Teaching
Procedure: Medication: High Alert, Double Check
Procedure: Medication: Inpatients' Personal Medications

Procedure: Negative Pressure Wound Therapy (NPWT/Wound V.A.C.) Device: Dressing Removal and Application
Protocol/ Procedure: Neurologic Assessment of the Adult Inpatient
Neurovascular Assessments/Checks
Protocol: Night Bonus Payment
Protocol: Nursing Standards (Policies, Procedures, Protocols): Exceptions to

Protocol: 1:1 Observation/Constant Observation: Monitoring
Protocol: Orthostatic (Postural) Vital Sign Measurement
Protocol: Ostomy Care
Procedure: Overtime: Approval

Protocol: Pain (Acute) - Continuous Opioid and PCA Infusions: Care of the Patient Receiving
  Attachment: PCA Pocket Guide
  Alaris PCA Instruction Manual
Protocol: Pain: Care of the Patient
Attachment: Pain Scales
Protocol: Pain: Epidural Infusion and Patient Controlled Epidural Analgesia (PCEA): Care of the Patient Receiving
Parenteral Nutrition (PN) and Intravenous Fat Emulsion Administration (IVFE) in Adults
Procedure: Patient Care: Private Duty Nursing Care
Protocol: Patient-Owned Pumps: Management of (Internal or External)
Procedure: Patient's Property, Valuables/Transfers/ Discharge
Procedure: Peritoneal Dialysis: Acute, Stay Safe CAPD Exchange Procedure
  Attachment: CAPD Stay Safe Procedure Card
  Reference: Using Fresenius Stay safe set with BAXTER catheter
Procedure: Post-Mortem Care
Protocol: Post-Operative Care: General Care of the Post-Operative Patient
Protocol: Preceptor Responsibilities
Procedure: Prescription Refill Procedure for Registered Nurses and Medical Assistants in JDH Clincs

Protocol: Respiratory Compromise, Acute: Patient Assessment and Care
Protocol: Restraint Use for Non-Violent / Non-Self Destructive
Protocol: Restraint Use for Violent / Self Destructive
Appendix A
Appendix B
Procedure: RhoGAM
Procedure: Rotation Bonus Payment

Procedure: Scheduling: Practices
Protocol: Seizures: Care of the Patient
Protocol: Self Injurious Behavior: Care of the Patient on a Non-Psychiatric Unit
Protocol: Sensory Perception, Altered
Procedure: Sickle Cell Pain: Pain Management Using High Dose Continuous & PCA Narcotic Infusions
Protocol: Skin Care: Pressure Ulcer Prevention, Management and Treatment - Adults
Protocol: Skin Care: Skin Tear and Abrasion Prevention and Management
Procedure: Skin Care: Wound Management
Procedure: Skin Tests: Administration of
  HCH-578: Skin Test Administration and Results
Procedure: Staffing: Permanent and Per Diem (NursePRO and Contract) Personnel
Procedure: Staffing: Supplemental NursePROS
Procedure: Standards of Administrative/Clinical Practice: Review Process
Protocol: Standards of Clinical Practice: Development, Approval and Posting

Procedure: Therapeutic Phlebotomy via a Peripheral Access & Therapeutic Phlebotomy via a Central Line
Procedure: Transfer Process: In-House
Procedure: Transportation: Inpatients
  Addendum: Ticket to Ride Information
Protocol: Tube Feedings (Adult)

Procedure: Urinary Catheter (Indwelling): Care of the Adult Inpatient

Protocol: Warmers, Blanket and Solution: Care of the Patient Using Supplies Stored in
  Appendix: Daily Temperature Log - Warmer
Procedure: Weights: Admission and Daily
Protocol: Wristband Standardization: Allergy, Latex Allergy, Fall Risk, DNR, Protected Limb Wristbands


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