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Nursing Practice Manual

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Clinical protocols and procedures are in bold print.


Structure Standard Department of Nursing Structure Standard

 

Appendix 1: General Nursing Standards

Appendix 2: Philosophy of Nursing

Appendix 3: Clinical Affairs Organization Chart

Appendix 4: Department of Nursing Organization Chart

Appendix 5: Nurse Staffing Plan
Protocol: Abuse: Child Physical Abuse, Neglect, Sexual Abuse

 

Appendix A - DCF Form 136a
Protocol: Abuse: Domestic Violence
Protocol: Abuse: Elderly Abuse
Procedure: Allergies: Identification of Patient Allergies
Protocol: Anticoagulation Therapy
Procedure: Assessment: Scope of Nursing Physical Assessment: Adult Inpatient - DRAFT
Procedure: Attendance – Sick Leave

Protocol: Blanket (Solution) Warmers: Care of the Patient Using Supplies Stored in
  Appendix: Daily Temperature Log - Warmer
Protocol: Blanketrol II: Hypo/Hyperthermia Blanket
Procedure: Blood Components: Acquisition from the Blood Bank and Transport to the Units
Procedure: Blood Components: Administration of Packed Cells, Autologous, Fresh Frozen Plasma, Granulocytes, Cryoprecipitate, Platelets, and Blood Derivative Infusions
Procedure: Blood Components: Emergency Release
Procedure: Blood Components: Transfusion Reaction
Procedure: Blood Components: Type and Screen/Type and Cross-Match for Transfusion Purposes

Procedure: Calorie Counts
Procedure: Central Lines: Alteplase (Cathflo Activase®) Instillation for Catheter Clearance
Procedure: Central Lines: Blood Drawing
Procedure: Central Lines (and Implanted Ports): Heparin/Normal Saline Flush
Procedure: Central Lines (and Implanted Ports): Intravenous Fluid Administration
Procedure: Central Lines: Dressing/Catheter Site Care
Procedure: Central Lines: Implanted Port: Accessing Port with Huber Needle
Protocol: Central Lines: Patient Care
Procedure: Certification Bonus
Procedure: Change in Patient Condition - Chain of Command Notification
Protocol: Charge Nurse Responsibilities
Protocol: Chart Review and Audits (Inpatient)
Protocol: Chest Tube: Care of the Patient with
Policy: Code Blue Documentation
Policy: Code Pink Infant or Child Abduction (Hospital Administrative Manual)
Policy: Code Strong (Hospital Administrative Manual)
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: Crimes: Management of Crimes Committed

Protocol: Decentralized Lab Testing (will be moving to the Hospital Administrative Manual)
Procedure: Decentralized Lab Testing
Protocol: Delirium: Care of the Patient with
Protocol: Diabetes Mellitus Management: Periprocedural Care

Addendum: Guidelines for the Preoperative Preparation of the Surgical Patient
Protocol: Discharge Planning: Nursing Responsibilities for Preparing Inpatients for Discharge (and Referrals for Post-Hospital Support/Services
Procedure: Documentation: Admission (Inpatients)
Procedure: Documentation: Discharge (Inpatients)
Procedure: Documentation: Patient Care Plan
Procedure: Documentation: Progress Notes
Procedure: Documentation: Standard Care Plan (SCP)
Procedure: Dress Code

Procedure: Education – Mandatory In-service
Procedure: Equipment – Malfunction
Procedure: Evaluation – Staff
Protocol: Exploratory Laparotomy: Care of the Post-Operative Patient

Protocol: Falls: Risk Identification, Prevention Management and Treatment

 

Appendix A: Falls Flowsheet (DRAFT)
  Patient Education Handout

Procedure/ Protocol: Hand Off Communication
Protocol: Heimlich Valve: Care of the Patient with
 Protocol: Hypertension
 
Procedure: Identification of Patients (Adult and Children)
Protocol: Immune Globulin: Intravenous Administration
Guideline: Infusion Record
Protocol: Insulin: Continuous IV Administration
Policy: Interfacility Transfer: Guidelines for the Safe Transfer of Patients Between Acute Care Facilities (Hospital Administrative Manual Policy)
Procedure: Interventional Radiology Patient Recovery: RN Coverage After Hours / Weekends
Procedure: Intraperitoneal Instillation of Medications (pending transfer to Oncology Unit Practice Manual)
Procedure: Intravenous (IV) Fluids with Additives/Medications: Preparation and Administration
Procedure/ Protocol: Intravenous (IV) Therapy: Peripheral
Procedure/ Protocol: IV Push Medications

Procedure/ Protocol: Lipids Administration

Procedure: Medical Order Writing
Protocol: Medication Administration: Investigational Drugs: Inpatient Utilization of (see Medication References/Pharmacy)
Procedure: Medication Administration: Pyxis for Controlled Substance Security
Procedure: Medication Administration: Student Nurses
Procedure: Medication Administration: Therapeutic Interchange of Medications
  Appendix - Therapeutic Interchange List
Procedure: Medication Administration and Use of the Medication Administration Record (MAR)
Teaching Plan: Medication Teaching
Procedure: Medication: Double Checks
Procedure: Medication: Patients' Personal Medications

Protocol/ Procedure: Neurologic Assessment of the Adult Inpatient - DRAFT
Protocol: Night Bonus Payment

Protocol: 1:1 Observation/Constant Observation: Monitoring
Protocol: Orthostatic (Postural) Vital Sign Measurement
Protocol: Ostomy Care
Teaching Care Plan:

Ostomy Care of the Adult Patient

Appendix A: Best Practice for Clinicians: Discharge Planning for a Patient with a New Ostomy
  Attachment: Patient Education Handout - Patient Discharge Instructions - Colostomy / Ileostomy
  Attachment: Patient Education Handout - Patient Discharge Instructions - Urostomy
Procedure: Overtime – Approval

Protocol: Pain: Care of the Adult Patient with (and Use of Pain Scales)
Protocol: Pain (Acute): Care of the Patient Receiving Continuous Narcotic Infusion
Protocol: Pain (Acute): Care of the Patient Receiving IV or SC Narcotics via PCA Pump
Protocol: Pain: Epidural Infusion and Patient Controlled Epidural Analgesia (PCEA): Care of the Patient Receiving
Procedure/ Protocol: Parenteral Nutrition Administration
Procedure: Patient Care – Private Duty Nursing Care
Procedure: Peak and Trough Levels: Medications
Procedure: Peritoneal Dialysis: Acute, Stay Safe CAPD Exchange Procedure
Procedure: Physicians Orders – Questioning
Procedure: Police Response to Calls for Assistance
Procedure: Post-Mortem Care
Protocol: Potassium: IV Infusion (Adult)

Protocol: Respiratory Compromise, Acute: Patient Assessment and Care
Protocol: Restraint Use in the Inpatient and Outpatient Setting
  Attachment: Restraint Flow Diagrams
Procedure: RhoGAM
Procedure: Rotation Bonus Payment

Procedure: Scheduling – Staffing 12 Hour Shifts
Procedure: Scheduling Practices
Protocol: Seizures: Care of the Patient at Risk and Actual
Protocol: Skin Care: General Preventative Care of the Hospitalized Adult Patient
Protocol: Skin Care: Pressure Ulcer Prevention and Management
Protocol: Skin Care: Skin Tear and Abrasion Prevention and Management
Procedure: Skin Tests: Administration of HCH-578: Skin Test Administration and Results
Protocol: Sleep Pattern Disturbance: Care of the Patient
Procedure: Staffing – Assignment of Personnel
Procedure: Staffing Practices
Protocol: Standards Development and Approval
Procedure: Standards of Administrative/Clinical Practice: Review Process
Protocol: Standards of Clinical Practice: Development, Approval and Posting
Procedure: Supplemental – Nurse PROs

Procedure: Transfer Process: In-House
Procedure: Transportation – Deceased Patients
Procedure: Transportation: Inpatients (Ticket to Ride)
  Addendum: Ticket to Ride Information
Protocol: Tube Feedings (Adult)

Policy: Vaccinations - See Hospital Administrative Manual Policy 8-064
Protocol: Volunteers - See Hospital Administrative Manual Policy 2-006

Procedure: Wound V.A.C. (Vacuum Assisted Closure) Device

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