Hbh--Icu Protocols

Front 1

Transfer pt. to other unit in HBH:

--Medication record for transfer/discharge
--Active order
--Belongings list (check each item before transfering)
--In-house transfer assignment
--I/O form
--Restrains sheet
--

Back 1

Accept pt. from other unit:

-- listen to the report from the other unit.
-- do the shift assessment
-- chart in the computer for shift accessment
-- chart in "patient note"
-- continue monitoring the patient.

Front 2

Pt. Admission
-- prepare the bed ( sheet, blanket, pillowcase, pillow)
-- raise the bed up.
-- set up the monitor
* zero the system
* input the patient's name and
medical record number

--
-- print out the admission packet in the computer
--- get the MRSA form from the drawer.
-- print out the patient's name lables.

-- prepare the name band, fall risk band, allergy band etc.

-- add "care plan" into the computer "process interventions"
in case of needed, add new interventions to the list.

After pt. comes:
-- do physical assessment
-- go through each question in the "admiss data", initial assessment and initial history assessment in the computer.
-- Chart the "initial assessment"

Back 2

Doctor's new order:

-- Medication:
* FAX to pharmacy, Stamp
* copy to MAR, D/C old one if necessary.

-- Lab / Procedure
* copy into MegTech
* Mark "m" on paper chart.

Front 3

IV bag

-- changed q24 hr

Back 3

PICC line
-- Flush q12 hr ( 5ml NS, then 250 unit heparin)

-- Dressing change
24 hr after
* weekly with Biopatch.

Front 4

Triple lumen Catheters

-- flush daily (5ml NS, then 250 units heparin)

-- Dressing change: Weekly with Biopatch.

Back 4

Pressure bags and tubings of NS with 1000 u heparin:

-- Changed Q72 hr.

Front 5

IV tubings

-- Change Q72 hr

Back 5

TPN & Intralipid tubings

-- change Q24 hr.

Front 6

Propofol bottle and tubing

-- Change Q12 hr
--- documented on MARS

Back 6

Glass bottles

-- peel off the label
-- throw into the container at the nurse station.

Front 7

NEW MARS

-- printed out at night,
-- Checked and signed by the night shift nurse (compare and updating with old MAR)

Back 7

arm bands

--- white: name band
--- yellow: Fall risk
--- Red: Allergy
--- pink: Avoid using it for IV, BP, or blood draw.
-- Orange with blue label: received blood products.

Front 8

Pillows in pt's room should be less than 3 to 4.

Back 8

Chart completely:

-- Acuity sheet
-- Rhythm Strip Sheet
-- Medication Sheet
---Restrain Sheet
--- Wound Sheet
--- Computer Documentation.

Front 9

early enteral nutrition (within 24-48 hours following admission to ICU) in critically ill patients

Back 9

Tylenol -- liver damage

Front 10

MEC

Back 10

Potency
--

Front 11

Tachyphylaxis
--reduction in responsiveness brought on by repeated doses in short period of time. Rapid tolerance

Back 11

Synergistic Effect
--

Front 12

Penicillin G: IV or IV only aqueous preparations may be given IV.

Penicillin V: Only Oral

Back 12

All antibiotics have potential for renal toxicity, diarrhea, and hypersensitivity

Front 13

Penicillin pt teaching:

-- Take most PCN on empty stomach.
--- Take each dose with full glass of water.
-- Shake liquid well.
-- If allergic, stop using.

Back 13

Peak and Trough Values
--Determine dose and time drug is to
be given based on the therapeutic levels.

Front 14

Lanoxin indications:

--Heart failure
--artial arrhythmias

Back 14

Lanoxin Toxicity is caused by"

-- rapid loading / digitalization (in order to reach plateau )
-- impaired renal function
-- age extremes
-- electrolyte imbalance
( especially Low K+, Low Mg2+ and High Ca2+)

Front 15

Lanoxin S/S of toxicity:

-- N/V/, Diarrhea, Visual changes (colored halo), arrhythmia.

Back 15

Lanoxin related labs:

-- Digoxin level,
-- BUN
-- creatitine
-- Electrolytes (K+, Mg2+ etc)

Front 16

Digoxin toxicity

-- therapeutic range 0.8--2.0 ng/ml

Back 16

Digoxin antangonist:

-- Digibind, Digoxin immune falb.

Front 17

captopril side effects:

Back 17

--dry hacking cough
(sensitivity in cough center)

-- first dose syncope

-- hyperkalemia

Front 18

Captopril Toxic Effects:

--Angioedema --Swelling of mucosa and submucosa in face, lips, tongue and potentially hands.

Back 18

Captopril nursing implication:

-- Administer 1 hr before meals.

-- monitor bp for first dose syncope

-- instruct pt to lie down after first dose or after rapid increase in dose

-- adequate hydration

-- Monitor K level

Front 19

Metoporol

-- can cause hypoglycemia
and bradycardia, airway resistence/ pulmonary edema etc.

-- Abrupt withdrawal can lead to rebound HTN.

Back 19

Lasix -- side effects:

- Ototoxicity (ringing)

-- Hypokalemia
-- hypotension
-- photosensitivity
-- diarrhea

-- muscle spasm

Front 20

Heparin Antagonist

Back 20

-- protamine sulfate

Front 21

Tube feeding
-- hold tube feeding if residual over 100 ml, recheck in 2 hours.

Back 21

Tube feeding
-- pt on tube feeding need free water, ask MD for order if pt not getting free water flush.

Front 22

flush NG/G tube if feeding on hold.

Back 22

VAP prophylaxis

-- Oral care Q4hr
-- HOB 30 degree or higher.
--daily "sedation Vacation", ask
RT to check weaning parameters to see if pt OK to off from ventilator.
-- Stress ulcer prophylaxis
-- DVT prophylaxis

Front 23

Bedside irrigation kit (for tube feeding) should be changed DAILY
(labeled with date)

Back 23

Wound Vac:
-- main purpose: granulation
-- Change 3 times/week
-- if the machine if off more than 2 hours. replace sponge dressing.

Front 24

Wound vac:

-- after pt admission, remove sponge dressings, take pictures, and replace with hydrogel, then wet to dry dressing til wound care sees pt.
-- Dr's order needed for a wound vac machine.

Back 24

Change canister/liner for NGT drainage Q shift.

Front 25

Change Canister / liner and tubing Daily for ET/trach suction

Back 25

5150:

-- only Apply to ER pt.
-- it will be null and void once pt is admitted to inpatient
-- if pt on 24 hours medical hold, after that time he wants to leave (but not medically clear), he can sign AMA (if pt A/OX3).
-- after pt leaves, call police and family and inform them.

Front 26

Extravasation (infiltration) management:

-- 1. stop IV immediately.
--2. slowly aspirate as much of the drug as possible. Do not apply pressure to the site.
-- 3. Remove IV access while aspirating. (Do not use this site for IV)
-- 4. inform physician.
-- 5. elevate the area for 48 hours to minimize swelling.
-- 6. Initiate substance-specific measures.

-- document and pt education

Back 26

Dobutamine, dopamine IV infilration:
Levophed, phenylephrine
-- Treatment: Given phentolamine SQ injection.

Front 27

--Amphadase (bovine),
Vitrase (ovine) SQ or intradermal used for IV infiltration.

-- Regitine SQ

-- Used to treat the IV infiltration (extravasation)

Back 27

Mylanta

-- usually given for MI patient on admission for epigastric pain.

Front 28

Pre-Op antibiotic:

Ancef (cefazolin ) is one very common antibiotic. ( 1 gm IVPB q8hr X2 doses)

Back 28

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Front 29

new policy about handwash

Back 29

handwash before enter pt's room