Blood Culture Collection

Date of Last Review: 4/07 Date of Last Review: 12/10/10

SME: Chief Nursing Officer

A primary concern of the blood collector for this test is preventing contamination of the blood culture by skin organisms. Procedure: Do not touch the venipuncture site after it has been prepared. Do not put unsterile gauze over venipuncture site until after blood is drawn. Apply the tourniquet to the patient's arm and select a site for the venipuncture. Remove the tourniquet. To prepare the patient's arm, cleanse the site with a betadine swab in a circular motion beginning at the center of the site selected for venipuncture. Allow the betadine solution to air dry. Cleanse the tops of blood culture collection bottles with betadine. Reapply the tourniquet. Obtain blood with a 10 ml vaccutainer and a 22 gauge or 20 gauge needle, pushing out all the air from the vaccutainer before drawing blood. Change needles and inject the blood into the tops of the previously prepared anaerobic (yellow) x1 and aerobic (blue) blood culture bottles x1 and denote whether obtained from (R) Right or Left (L) arm. Invert the bottles gently and label the usual patient name, date, and time of collection. After the patient's arm has stopped bleeding remove the betadine solution by wiping with a clean alcohol prep. Indicate on the requisition and on the bottles which culture (number) you have drawn if a series of blood cultures have been ordered. Blood cultures may not be ordered any less than one hour apart. If the doctor desires cultures more often, he must consult the supervisor of Microbiology of the testing laboratory

Death/Postmortem Care
Date of Last Review: 4/07 Date of Last Review: 12/10/2010

SME: Chief Nursing Officer

Guidelines for the care of patients who expire and for preparation of the body with respect and dignity for transportation to the funeral home or morgue, and to support the family in their time of grief.

Procedure: Nursing staff notifies the Physician/Resident who examines the patient. After the patient is pronounced dead by the physician, the nurse notifies the Director of Nursing/designee. TheNurse Manager/Supervisor notifies the Administrator/Administrator On-Call.

The Physician/Resident/designee contacts the family.

The Nursing Supervisor/designee asks the family if they want to be contacted by LifeGift Organ Donation Center. If no, do not contact LifeGift. If yes, the Nursing Supervisor/designee contacts LifeGift at 713-737-8111. Provides LifeGift the patients name, age, sex, race, admit date, time of death, diagnosis, and any other significant health history, next of kins name and phone number. Fills out the LifeGift Organ Donation Notification of Death form. The LifeGift Coordinator obtains consent and sends a copy to be placed in the chart.

The nurse gathers the following equipment and forms:

 Postmortem checklist Policy and Procedure regarding postmortem care Authority for Release of Body Form Shroud packs (adult or child)

Standard precautions will be used in postmortem care of all patients.

Communication to others outside UT-Harris County Psychiatric Center regarding special precautions needed is required if patient was diagnosed with one of the following diseases:

AIDS Anthrax Brucellosis HIV Infection Plaque Q Fever Rabies Rocky Mountain Spotted Fever Syphilis Tuberculosis Tularemia Viral Hemorrhagic Fever Viral Hepatitis (types A, B, D, Non-A/Non-B)

Following the death of a patient with a disease in the above category, personnel involved are to obtain two tags available in the Shroud Kit (Adult or Child). The name of the specific communicable disease is not written on the tags. Two tags from the Shroud Kit must be labeled: COMMUNICABLE DISEASE STANDARD PRECAUTIONS REQUIRED

 The name of the patient is written on each tag.

One labeled tag is attached to the foot of the deceased patient, (to the big toe whenever possible) and the second tag secured to the shroud. Personnel handling the deceased person shall follow these precautions:

Wear gown, mask, double gloves, and protective eye-covering when performing procedures involving contact with blood or body-fluids. Contaminated disposable needles and syringes shall be disposed of according to established policy. Contaminated articles are to be double-bagged with red bag. Spills of blood After pronouncement of death by a Physician/Resident, place body in horizontal position with a pillow under the head and close the eyes and mouth. Place dentures, if any, in mouth. If unable to do so, give dentures to family. Remove any jewelry and personal belongings and give to the family. If no family present, make a list of articles and send to funeral home or morgue. Allow family to be alone with the deceased, if desired. Place body in the examination room until body is released to Medical Examiner, funeral home, or LifeGift evaluation.

Medical Examiner's Case:

The Physician/Resident, Supervisor, Nurse Manager or Charge Nurse must notify the Harris County Medical Examiner's Office in any of the following cases:

If death occurs within 24 hours after admission to the hospital. Patient involved in an accident leading to or contributing to death. Patient was suicide victim. Patient was homicide victim. Evidence or suspicion of foul play or child abuse exists. Dead On Arrival (D.O.A.).

Have the following information available when calling the Medical Examiner's office:

Patient's name, address, birthdate, age, diagnosis and apparent cause of death. History of illness and recent medical treatment. Next of kin and telephone number. Funeral home (if no funeral home is designated by the next of kin, the Medical Examiner may elect to dispatch a car to pick up the body). Indicate the name of the funeral home to which the Medical Examiner dispatches the body on the Authority for Release of Body form documenting that the funeral home is the Medical Examiner's choice (i.e., Johnstone Funeral Home per Medical Examiner). Advise that LifeGift has been called, if applicable.

The Release of Body Form shall indicate the following:

Name of the funeral home to which the body is to be released. Signature of next of kin and his/her relationship to the deceased. Two witnesses' signatures. Designate whether the body is or is not to be transported to the Medical Examiner's Office. Funeral Director's receipt must be signed by representative of the funeral home after proper identification of himself. Body must not be released until proper signatures have been obtained.

If the name of the funeral home has not been decided, have the ARelease of Body@ form signed by the next of kin or responsible party and write on the form that decision has been delayed.

Autopsy UTHCPC contacts the County Medical Examiners office and requests an autopsy in the following cases: Death occurs within 24 hours of admission Unnatural death

 Any unknown cause of death occurring during the patients hospital stay

If an autopsy is to be performed:

Autopsies ordered by the Medical Examiner do not require family signatures. All postmortem examinations ordered by the Medical Examiner are sent to the Harris County Morgue. Authority for Release of Body Form must be signed according to directions on the form and witnessed by two (2) persons.

Be sure patient's I.D. band is left on body.

Wrap body in shroud, tag body and shroud.

The name of the patient is written on each tag. One labeled tag is attached to the foot of the deceased patient (to the big toe whenever possible), and the second tag secured to the shroud.

Complete Death/Postmortem Care Checklist.

Document the following in the Progress Notes:

Apparent signs of death and time of occurrence. Time physician notified. Name of physician making pronouncement of death and time made. Note if family is present or has been notified. Time and route of disposition of body. Note if Medical Examiner was notified and if so, his/her name and to whom the body was released. Note if belongings were sent to morgue, funeral home or with family.

Unclaimed Body:

If unable to locate the next of kin or next of kin refuses responsibility for the body, contact the Nursing Supervisor and Administrator on-call. The Medical Examiner, when notified, decides: To arrange for transport of the body to the morgue Or Request that UTHCPC arrange for transport of the body to the morgue. The Administrator or designee notifies Harris County of Potential County Burial Patients.

Call Harris County Department of Social Services responsible for Harris County Burial Services (8:00 a.m.-5:00 p.m. Monday through Friday phone 713-696-7900; after 5:00 p.m., weekends or holidays call the County operator for assistance at 713-755-5000. The Chief Nurse Officer or designee notifies appropriate hospital departments, such as Case Management. Documentation of all attempts to contact family members and deliberation as to disposition of case should be indicated.

EKG Process
Summary Date of Last Review: 4/8/11 SME: Chief Nurse Officer EKG results are required to support quality patient care. UTHCPC has established guidelines for ordering an EKG (electrocardiogram) for patients. Requesting an EKG The physician enters an order for the EKG.

Daily directory The daily directory is a report generated by the EKG machine which lists the EKG's performed daily. Generating results Nursing staff proceeds with the process of reporting EKG results as follows: Stage 1 Description Receives the physician's order requesting an EKG. A requisition with an order is generated Staff signs out and obtains the EKG machine from the lab, room 1A66. The Licensed Nurse or Senior Psych Tech performs the EKG using the guide on the machine for placement of electrodes and leads and for data entry. Upon completion of the EKG, the Registered Nurse reviews the rhythm strip and informs the physician of any abnormal finding(s). Notification shall be documented in the Nursing Progress Notes. Nursing staff files a copy of the rhythm strip in the medical record. Ancillary staff transmits the rhythm strip to a cardiologist for interpretation. Within 48-72 hours, ancillary staff receives a formal report and places it in the medical record.

Inquiries Inquiries about EKG reports can be directed to extension 741-7854 between the hours of 8:00 a.m. and 2:00 p.m., Monday through Friday and to the Nursing Supervisor after hours and weekend.

EEG/Lab Emergency Preparedness

Introduction
Date of Last Review 4/8/11 SME: Chief Nurse Officer

In an emergency situation, the Chief Nursing Officer or designee implements Emergency Preparedness guidelines for department employees. External alert conditions In the event of an external emergency, the Chief Nursing Officer or designee uses certain guidelines according to the following timeframes of the emergency notification: Condition V - 48-hour notice

Condition IV - 36-hour notice

Condition III - 24-hour notice

Condition II - 12-hour notice

Condition I - 8-hour notice

Condition V, IV, III The Chief Nursing Officer or designee ensures that adequate staff and services are available during a disaster by doing the following: EEG The Chief Nursing Officer contacts the EEG contract technician and relays instructions.

The EEG contract technician completes all ordered EEG's as soon as possible so that all current orders are completed prior to the identified emergency. Lab The Chief Nursing Officer or designee contacts the lab technician and relays instructions.

The lab technician processes and delivers any currently pending lab orders or results. Condition II - 12 hour notice The Nursing Operations Coordinator ensures that adequate services are available during a condition II, follow instructions for condition V: If the hospital goes to emergency staffing levels, cancels all outside appointments scheduled during the expected disaster and /or reschedules as appropriate.

Alerts working personnel and waits on special assignments. Condition I 8-hour notice The Chief Nursing Officer or designee ensures that adequate staff and services are available during a condition I: Secures work areas as needed.

Covers and secures all equipment in anticipation of ceiling leaks and window damage.

Unplugs all electrical equipment.

Emergency Oxygen Administration

Date of Last Review: 01/21/2011 SME: Chief Nursing Officer

Oxygen description

Oxygen is a colorless, odorless, tasteless, gas used to treat disorders that may cause hypoxemia. Oxygen also supports combustion and presents a possible fire hazard. Emergency supplemental oxygen is used in conditions that may cause hypoxemia. Such conditions include, but are not limited to: Airway obstruction Pulmonary edema Acute respiratory failure Cardiac disorders Metabolic disorders Shock

When is oxygen used?

Who orders emergency oxygen use?

An R.N. may initiate emergency oxygen with a flow of no more than 2-2.5 liters/minute. A physicians order must be obtained after initiating oxygen and must be documented in the medical record.

Who may administer Oxygen may be administered by a: oxygen? Physician Registered Nurse

Where are oxygen tanks stored? Oxygen fire prevention

Emergency supplemental oxygen (O2) tanks are located in each treatment room between all of the units in the hospital. Prior to use of oxygen, the following preventive measures are taken to reduce the risk of fire: Assure that all electric plugs and electrical equipment are properly grounded Do not allow smoking in the presence of oxygen Refrain from the use of spark-producing electrical appliances Never use oil on oxygen equipment. Note: If lubricants are necessary, use a water-based lubricant jelly

Required signage

All areas that house oxygen must have a universal oxygen hazardous material sign. (These areas are identified by the sign on the door)

Seizure Management
Date of SME: Chief Nurse Officer Last Review: 02/11/2011

Purpose:

To protect the patient during seizure activity To provide guidelines for observations of seizures To provide guidelines for nursing interventions Policy: Patients experiencing seizures should be protected from harm, observed during activity, and have a clear airway maintained.

All patients are assessed to identify any risk for seizure. The following criteria are considered:
A patient with a history of seizure activity A patient who has had a head injury due to falling, fighting or accident A patient who has had a craniotomy A patient with a history of paint sniffing or ingestion with possible lead poisoning Patients addicted to substances, such as alcohol or sedatives, which cause seizures during the withdrawal process

The patient will be assessed by the R.N. at a minimum of every 2 hours to assess for any seizure activity (see Precautions and Special Observation procedure).

Special observation for seizure activity may be ordered by the physician or R.N. as an independent nursing intervention. Patients who are at risk for seizure may attend off-unit activities.

Procedure if seizure occurs:

Protect the patient from injury while the seizure continues, but don't forcefully restrain movements. Whenever possible, try to lay the patient on a soft surface and turn on one side. Place something flat and soft under the head; loosen clothing around the neck.

 Do not place anything in the mouth. As the jerking slows down, make sure breathing is unobstructed and returning to normal. Do not try to give medicine or fluids until the patient is fully awake and aware. Reassure the patient and gently help re-orient him or her as consciousness returns. Do not attempt CPR while the patient is having a seizure. Documentation in the progress notes includes, but is not limited to:

The time of the seizure onset The time of seizure termination Total duration of the seizure Any additional treatment/orders from the physician

Characteristics of the seizure: Tonic- muscles in rigid contraction (respiration may be suspended with development of cyanosis, often eyes open and pupils dialated). Clonic- jerky movements (saliva may blow from the mouth creating froth, urinary, fecal incontinence may occur) Focal- (Localized) (Jacksonian) convulsive twitching, jerking in one part of the body, may then spread to other areas. Petit Mal- Brief lapse or loss of consciousness, person may suddenly stop whatever he/she is doing, seldom falls, but may lose bladder control. Patient's orientation after the seizure

Patient will be monitored and assessed per physician order.

Related Standards The Joint Commission-Provision of Care, Treatment, and Services Center of Medicare/Medicaid Services (CMS) Conditions of Participation

Search, Unit
Date of SME: Chief Nursing Officer Last Review: 02/11/11

Unit searches are necessary to ensure a safe environment for all and will not include body searches without an individual physician order.

Procedure:

A unit search will be initiated whenever there is a reason to believe that there are contraband or restricted items for patients on the unit (see "Patient and Patient Visitor Entrance Screening" procedure) The Nurse Manager, and/or supervisor will be notified of the need for a search.

The procedure and reason for the search will be fully explained to the community members in a community meeting before the search. The environment will be searched in the presence of the community by staff members under the supervision of a registered nurse. If restricted or illegal items (see HCPC Contraband List) are found, notify the physician to obtain a recommendation for processing with the patient(s).

In addition, restricted items shall be turned over to Patient Registration to be returned to the patient upon transfer/discharge. A Valuables Release Form will be completed for all items sent to the Property Room. Illegal items shall be turned over to UT Police for disposition. An Occurrence Report form will be completed describing the search, the reason for the search and the results.

Staff members will process the event with the patients in a community meeting or individually, and the appropriate nursing interventions will be initiated and documented.

Urine Collection, 24-Hour Specimen

Date of SME: Chief Nurse Officer Last Review: 3/18/11

All 24-hour urine collections shall be collected in a consistent manner to minimize risk of contamination.

Procedure:

The order for a 24-hour urine collection shall be entered into Sunrise. The nursing staff shall:

Obtain the appropriate collection container(s) (with or without preservative) Place the patient's name on the container(s) (use patient addressograph imprinted labels) Place the container(s) on ice in a locked area as designated Obtain the appropriate urine collection device (collection container will be labeled with the patient's name) Males will use urinals Females will use "Fireman's Caps" Instruct the patient in use of the urine collection device Assign a specific nursing staff member to assist with the collection of the urine

All collections shall be started at 6:00 a.m.

The assigned nurse shall assure that:

The patient voids into his/her own device. The urine shall be emptied into the 24-hour container. The containers shall remain iced at all times. Output is monitored. The physician is notified, as clincally indicated.

Upon completion of the 24-hour urine collection, the requisitions shall be completed and sent to the laboratory.

Use of PRN/NOW Psychoactive Medications

Introduction

Date of Last Review: 02/25/2011 SME: Chief Nursing Officer

UTHCPC has developed guidelines for PRN/NOW Psychoactive Medication usage. Crisis intervention for the agitated patient When a patient is agitated, staff:

Use less intrusive treatment Example: Verbal redirection as taught in SAMA training.

If less intrusive treatment is not effective, administer PRN/NOW psychoactive medication as indicated. Agitated patient treatment If no contraindications for psychoactive medication use exist, the physician does the following when treating a patient with the medication: Consider giving the patient benzodiazepine (even for substance abuse patients)

If the benzodiazepine does not help or is not indicated consider giving the patient a second dose of benzodiazepine, a dose of an antipsychotic, or a combination of a benzodiazepine and an antipsychotic

For severe agitation, a combination of benzodiazepine and an antipsychotic may be the first line of medication choice. Example: Patient throwing chairs Indication for any PRN should be specified and should not duplicate the indication for another medication written as a PRN. Consent The patient must consent to the administration of PRN psychoactive medications. Exception: NOW orders, see below. NOW orders The physician may issue a "NOW" order to administer psychoactive medication without the patient's consent in an emergency as follows: See Consent to Treatment with Psychoactive Medication for an explanation of what constitutes an emergency

The physician documents the order on the following form NOW Order for

Involuntary Emergency Administration of Psychoactive Medication within 1 hour Algorithm for managing agitated patient This table describes how the patient's agitation can progress and how nursing staff responds: Stage Description 1 The patient is visibly emotionally or subjectively distressed. Signs and symptoms may include but not limited to the following:

Staring, tone of voice (i.e., threats, yelling, swearing, etc) anxiety (i.e., clutching body, grimacing, clinching fist, tense posture, etc.) mumbling pacing sleep disturbance self report of agitation 2

Assess the reason for distress and treat appropriately or with other nursing (nonpharmacologic) least restrictive interventions. Interventions may include but not be limited to:

Assess cause of agitation and anxiety Move patient to quiet area Reduce milieu noise/activity level as possible (i.e. television/radio volume, etc.) Remove objects that can be used as weapons Attend to concern supportively without delay Verbal de-escalation in a calm manner with a non-threatening stance Acknowledge behavior and/or level of stress and discomfort Maintain a safe distance 3

Does the patient respond and become less distressed and agitated? If yes, the process ends.

If no, s/he becomes visibly agitated Response: Utilize less intrusive interventions Example: Ask the patient to go to a room for a more focused period of rest/relaxation, and offer PO PRN lorazepam or other non-neuroleptic antianxiety agent. 4 Does the patient respond and become less agitated?

If no, s/he becomes severely agitated and verbally abusive or threatening Response: Give verbal redirection and offer the patient PRN (PO/IM)lorazepam or other benzodiazepine and the process continues to stage 5. 5 Does the patient respond and become less agitated?

If no, s/he becomes severely agitated and his/her action begins to escalate to physical aggression toward property or staff Response: Call a special team Request a physician consider a "NOW" order. If needed, seclude and/or restrain the patient

PRN order The physician may consider a PRN order for an antiparkisonian agent or give a "NOW" dose of one with the IM (intramuscular) injections of lorazepam and haloperidol. S/he should consider using the same IM neuroleptic as the scheduled one where possible.

General suggestion Staff should note that the preceding information is a general suggestion. Not all patients follow this progression and may require significant interventions earlier. Staff and physicians must use their clinical judgment. Related standards Related to regulatory standards

Venipuncture
Date of SME: Chief Nursing Officer Last Review: 3/18/2011

Strict adherence to venipuncture procedures is essential to obtain accurate blood test results. The Registered Nurse, Licensed Vocational Nurse, and Senior Psych Tech IV function as phlebotomists.

Venipuncture shall be performed in designated areas (treatment rooms and designated venipuncture stations (with venipuncture chairs on the nursing units). Venipuncture shall not take place at the nursing station. Staff performing venipuncture shall comply with the following: All supplies and equipment are maintained in a secured location The Sharps container is fixed in a way that it cannot be tipped or knocked over (use stabilizer dish)

 Ensure patient confidentiality during the procedure Wash hands before and after procedure. Use approved disinfectant to sanitize the drawing area Use approved disinfectant to sanitize the drawing area Wear gloves when performing venipuncture

Procedure:

Check the physician's order for blood tests required. Assemble required materials.

Assemble required matierials. (Refer to the lab compendium manual on each unit for specimen collection materials.

Identify the patient utilizing at least (2) patient identifiers.

Explain the procedure to the patient, including why it is necessary

Apply tourniquet above the area of the venipuncture site

Cleanse the venipuncture site with alcohol swab prior to insertion of the needle. Allow site to air dry.

While applying slight pressure below the puncture site to draw the skin taut, enter the vein with the needle (held bevel side up).

Upon filling each test tube with the desired amount of blood for testing, release the tourniquet, and withdraw the needle.

Place a dry 2 X 2 on puncture site after procedure. Apply immediate pressure for three minutes at the site of venipuncture.

Support the patient.

Rotate all test tubes (except red top tubes) to decrease the likelihood of the blood specimen clotting.

Affix patient label to the collection tube.

Place the specimen in a specimen collection bag and take it to the centralized are (for placement in the refrigerator and pickup by the lab).

Vital Sign Monitoring

Introduction
Date of Last Review: 5/19/08

Last Revised: 12/10/10 SME: Chief Nursing Officer

This procedure provides guidelines for monitoring, reporting and documenting patient vital signs. What vital signs are monitored? Monitoring of vital signs includes checking the patients temperature, pulse, respiration, and blood pressure. As required, neurological checks may be ordered. Neurologic checks will include but are not limited to assessment of pupils, level of consciousness, movement and speech. When are vital signs monitored? Vital signs (with the exception of pain) are monitored and recorded on all patients a minimum of once daily or more often per nurse/physician order. Note: The RN will notify the physician if more frequent or special vital sign monitoring is indicated, based on patient's condition. Entering orders The physician/nurse enters orders for vital signs monitoring, which prints on the nursing shift report. Assigning monitoring duties The shift leader uses the assignment sheet to designate the nursing staff member responsible for monitoring and recording vital signs. Duties of assigned staff Unlicensed staff verbally report the following to licensed staff immediately: All abnormal vital signs (see Abnormal parameters below) Patient refusal to have vital signs taken Any other concerns noted during the monitoring process Abnormal parameters Abnormal vital sign parameters are listed below: Pulse > 110 or < 60 Systolic > 160 or < 100 Diastolic > 100 or < 60 Respiration > 25 or < 15 Temperature > 100 Pain Rating > 1 Note: The physician or nurse may designate other parameters as needed. Duties of licensed staff

Based on reports of abnormal vital signs, refusals, or other concerns, licensed staff perform the following: Assess the patient immediately Re-monitor abnormal vital signs as clinically indicated Notify physician immediately of: Abnormal vital signs Information regarding patient baseline Other pertinent symptoms/modalities Document intervention and response . The treatment team will address patient refusals and plan of care Nursing staff documentation Nursing staff enter vital signs/neuro checks into Sunrise.

Age

Normal heart rate (beats per minute)[14] 100-160

[16]

Normal respiratory rate (breaths per minute)[15] 30-50

Newborn 05 months 612 months 13 years 35 years 610 years 1114 years 14+ years

90-150

25-40

80-140

20-30

80-130 80-120 70-110

20-30 20-30 15-30

60-105

12-20

60-100

12-20