Temperature Conversion Chart
Centigrade
Fahrenheit
Centigrade
Fahrenheit
34.0
34.2
34.4
34.6
34.8
35.0
35.2
35.4
35.6
35.8
36.0
36.2
36.4
36.6
36.8
37.0
37.2
37.4
37.6
37.8
38.0
38.2
38.4
93.2
93.6
93.9
94.3
94.6
95.0
95.4
95.7
96.1
96.4
96.8
97.2
97.5
97.9
98.2
98.6
99.0
99.3
99.7
100.0
100.4
100.8
101.1
38.6
38.8
39.0
39.2
39.4
39.6
39.8
40.0
40.2
40.4
40.6
40.8
41.0
41.2
41.4
41.6
41.8
42.0
42.2
42.4
42.6
42.8
43.0
101.5
101.8
102.2
102.6
102.9
103.3
103.6
104.0
104.4
104.7
105.1
105.4
105.8
106.2
106.5
106.9
107.2
107.6
108.0
108.3
108.7
109.0
109.4
Pain Assessment Guide
Pain Intensity 0-10
0 is no pain, 10 is worst imaginable
Words to Describe Pain
sharp, dull, burning, shooting, nagging
stabbing, aching, squeezing, deep
Aggravating and Alleviating Factors
How Does Pain affect:
sleep, ADLs, appetite, relationships, mood
Other Symptoms
Constipation, urinary retention, itching,
nausea, sleepiness
Check
V/S, medication history, pain knowledge,
Use of alternatives
Reassess and Document 60 minutes after PO
medication and 30 minutes after IV medication
interventions!
Measurement for PO Intake
Disposable Pitcher
10oz cup
12oz cup
14oz cup
Large Milkshake
Regular Milkshake
Coffee Mug
Small Juice Container
½ milk, juice, wine
Jello dish
Custard Cup
Soup Dish
Forta Shake
Ensure Shake
Forta Drink
Egg Nogg
Ensure
Clear/Styrofoam cup
800ml
300ml
360ml
420ml
420ml
240ml
210ml
120ml
120ml
100ml
100ml
180ml
240ml
240ml
240ml
240ml
240ml
210ml
REMEMBER: 1 Fluid oz = 30ml
Blue 100
“What to Do” Pocket Guide
The First 10 Steps
1. Check patient for unresponsiveness and call for help.
2. Check for absence of respiration and pulse. Begin CPR.
3. Initiate Blue 100 by having someone call 1-6666.
4. 2nd responder brings backboard. Begin 2 man CPR.
5. Other Responders, obtain equipment and set up the
following: crash cart, defibrillator/monitor, PMR bag,
oxygen and suction. Place intubation box at head of bed
for Respiratory Therapist
6. Provide patient history to the Code Team on arrival.
7. Assist Code Team as needed. Support family members
as needed.
8. Assist with transfer of patient to the ICU.
9. Document in nursing notes patient’s condition,
response to code and disposition of patient.
10. Restock crash cart.
Dosage Calculations/Abbreviations
Weight
Volume
Gram=g=1 gram
Milligram=mg=0.001gram
Microgram=mcg =0.001milligram
1000 mcg=1milligram
1000mg=1 gram
Liter=L=1L
Milliliter=ml=0.001L
1000 ml=1L
1 teaspoon (tsp)=5 ml
Amount to be Administered=Dosage Ordered X Quantity Available
Dose Available
Drip Rate=Volume to be infused X Drop Factor (Gtt/ml)
Total Time in Minutes
1 Kilogram(kg)= 2.2 Pounds (lbs)
1inch
=
2.54
centimeters
(cm
Vital Signs Info
Diastolic BP
< 85 Normal BP
85 - 89 High Normal
90 -104 Mild hypertension
105 - 114 Moderate hypertension
 115 Severe hypertension
Systolic BP with Diastolic <90
< 140 Normal BP
140-159 Borderline systolic hypertension
 160 Systolic hypertension
Normal Adult Respiratory Rate
14-18 breaths/minute
Normal Adult Pulse Rate
60-100 beats/minute (Average 80 beats/min)
Temperature Measurements
Oral Temp 98.6° F (37° C)
Rectal Temp 99.6° F (37.5° C)
Taking Orthostatic BPs;
Measures BP change with position changes.
Patient may become dizzy and/or faint with
position changes that lead to BP drop!!
1. Have patient lie down for at least 3
minutes; Take the BP write it down as
lying BP.
2. Assist the patient to sitting.
3. Take the BP after sitting 30 seconds.
Write it down as Sitting BP
4. Assist the patient to standing; be aware
the patient may become dizzy or faint.
5. Repeat the BP 30 seconds after standing.
Write it down as Standing BP.
Report values and any dizziness to the nurse
Key Resources
URMC Intranet:
http://intranet.urmc.rochester.edu/Highland
Will take you to sites for Highland:
Policy Manuals and Procedures
Downtime Procedures for Critical Applications
Environment of Care Policy Manuel
Hospital Policy Manual
Highland Promise
Human Resources Policy Manual
Infection Prevention Policy Manual
Nursing Policy and Procedure Manuals
Pharmacy Policy Manual
Departments
Clinical Engineering
Construction
Clinical Laboratories
Pharmacy Formulary
Department of Education
Provider Privileging
Environmental Services
Provider Orientation Guide
Family Medicine
Purchasing Department
Human Resources
Quality ManagementLibrary Services
JCAHO Readiness
Materials Management
Maintenance
Medical Imaging
Support Services
Nursing
Payroll
Pharmacy
Nutritional Services
Key Resources (cont)
Resources
Intranet Web Services-ISD
Infection Prevention
How to map a Network Drive?
Intranet FAQ
www.stronghealth.com Information on services at
Strong Health Affiliates, Strong Health providers and
patient teaching resources.
Highland Digital Library
http://eg.miner.rochester.edu/hhdig/hhdig.cgi
Micromedex: Access drug information and patient
medication teaching sheets. Access through
Highland Digital Library.
Check Provider’s Privileges:
E/Delineate user ID: nursehh
Password: nursehh
Diverse Patient Resources:
http://medlineplus.gov/spanish
http://www.cliconhealth.org
http://nihseniorhealth.gov
http://www.kidshealth.org
SPAN: Statewide Peer Assistance For Nurses: A resource
for Nurses affected by an alcohol or drug problem.
1-800-457-7261
Unlicensed Assistive Personnel May NOT!
■
Turn on, Adjust or Set oxygen flow
■
Administer Nebulizer treatments
■
Collect blood from Central lines
■
Start IV’s
■
Push PCA button to administer a
demand dose
■
Adjust IV pump
■
Silence alarms on any pump
■
Flush any IV line
■
Hang or flush any tube feeding
■
Deep endotracheal suction
■
Insert or discontinue a Foley catheter
■
Disconnect IV tubing for any reason,
including changing patient gown
■
Administer medications
Disconnect a chest tube from suction
Reportable Patient Findings For PCT to Nurse:
~A patient is experiencing difficulty breathing
~A patient is in pain
~Temperature is greater than 38.0C
~Heart rate less than 60 or greater than 100 bpm
~Systolic blood pressure less than 100, greater
than 180
~Oxygen Saturation less than 92%
~Respirations less than 16 or greater than 20 per
min.
~Urine output less than 250ml per shift or
<30ml/hr
~Inability to draw blood from a patient
~Blood Glucose greater than 250dl or less than
80dl
~A patient having difficulty with chewing/
swallowing
~A patient refused to : Eat
Get OOB
AM/HS Care Ambulate
EKG: Setting up the patient:
■
Enter the patient data prior to attaching leads
■
Check default settings on machine:
Speed – 25, Voltage – Full, Standard – Full
■
V1 and V2 should be approximately 2
finger-widths apart, on opposite sides of the
sternum
■
Place the electrodes in approximately the
same place on the opposite arms and legs
To Eliminate Artifact:
Check that the patient’s arms and legs are in a
relaxed, natural position
Place the electrodes on the upper arms and legs
Check the electrode representing the lead in which
you see artifact. For the limb leads check
LA for artifact in Leads I and aVL
LL for artifact in Leads II, III and aVF
RA for artifact in Lead aVR
*Make sure the filter is on
Documentation:
Make sure the EKG is labeled with the patient’s
name, Medical Record #, age, room number, and
operator ID #
Indicate on the requisition and the EKG if the patient
was sitting when the EKG was done
V1 - 4th Intercostal space, right sternal
border
V2 - 4th Intercostal space, left sternal
border
V3 - Mid way between V2 and V4
V4 - 5th Intercostal space, mid
clavicular line
V5 - Anterior axillary line, horizontal to
V4
V6 - Mid axillary line, horizontal to V4
and V5
Note - V4, 5 and 6 do not follow the 5th
intercostal space
Care of the
Pediatric Patient in
a
Disaster
Average Pediatric Vital Sign Ranges
Age Group
HR
RR
BP-S
Infant
80-150 25-35 65-100
Toddler
70-110 20-30 90-105
Preschool
65-110 20-25 95-110
School-age
60-95 14-22 100-120
Adolescent
55-85 12-18 110-135
BP-D
45-65
55-70
60-75
60-75
65-85
Pediatric Pulse Oximetry Ranges
Normal
95-100%
Mild hypoxia
91-94%
Mod hypoxia
86-90%
Severe hypoxia <86%
Pediatric Total Water Requirements/ 24 hours
Infant
500 -1300 ml
Child <6yrs
1150-2000ml
Child>6
2000-2700 ml
Pediatric Daily Urine Output/ 24 hours
0.5-2ml/kg/hr depending in age
and hydration status
Infant
350-550 ml
Child
500-1000ml
Adolescent
700-1400 ml
Fast Safety Assessment









Is child breathing?
Do you observe any signs of distress
*Follow the ABCs of CPR
What is the child’s color?
Is the child on a monitor?
*what is the rate and pattern
Any IVs?
*note type, rate, site
Note last set of VS
If abnl, check again
When was the last output?
Do you observe anything unusual
that needs immediate attention?
If yes, DO IT NOW
PEDIATRIC COMA SCALE
Pupils
Right
Left
Eyes Open
Spontaneously
To Speech
To pain
None
Size
Reaction
Size
Reaction
___
___
___
___
4
3
2
0
___
___
___
___
Best Motor Obeys Commands
6
Response:
Localizes pain
5
use best
Flexion Withdrawal
4
arm or leg Flexion Abnormal
3
or age
Extension
2
None
1
Best
Response
Age appropriate
Orientation
5
Confused
4
Inappropriate words
3
Incomprehensible words 2
None
1
Endotrach Tube or Trach T
___
___
___
___
___
___
___
___
___
___
___
___
Coma Scale Total (<7=Coma; <3 Deep Coma)
Pupil reaction: ++=brisk, +=sluggish, - = No reaction
C= eyes closed d/t swelling
Cardiac/Apnea Monitors for Pediatrics
ECG Monitor:
White color
right side of chest
Green color
(or red)
ground lower
abdomen
Black color
left side of chest
Apnea Monitor:
2 Electrodes
2 fingerbreadths
(1 each
side of chest) below nipple on
midaxillary line
Respiratory assessment
Cardinal Signs of Respiratory failure:

Restlessness, Altered LOC

Tachypnea/tachycardia

Increased work of breathing
-grunting, flaring, retracting

Cyanosis

Diaphoresis
Abnormal breath sounds or findings

Crackles-air through fluid

Wheezes-air through narrow passage

Stridor-high pitched noise d/t upper
airway obstruction (mucus/foreign body)

Head bobbing-sign of dyspnea
Vesicular Breath Sounds

Heard over entire lung surface

Inspiration is louder, longer and higher
pitched than expiration

Sound is soft swishing sound
Bronchovesicular Breath Sounds

Heard over manubrium where
trachea and bronchi bifurcate

Inspiration is louder and higher
pitched than vesicular breathing
Bronchial breath Sounds

Heard only over trachea

Inspiratory phase is short and
expiratory phase is long
Pediatric Assessment of Appearance
Tone
Interactivity
Consolability
Look/Gaze
Speech/Cry
Questions to be answered
Is there vigorous movement with
good muscle tone, or is the child
limp?
Is the child alert and attentive to
surroundings, or apathetic?
Will the child reach for a toy?
Does the child respond to people,
objects, and sounds?
Does comforting the child alleviate
agitation and crying?
Do the child’s eyes follow your
movement, or is there a vacant
gaze?
Are vocalizations strong, or are
they weak, muffled, or hoarse?
DEVELOPMENTAL DIFFERENCES IN
CHILDREN RELATED TO PAIN
AGE
COMMENTS
Infants
Preverbal Signs of possible
pain:
fisting,
Young Child
with
pain
regression,
withdrawal,
Older Child
may
types of
signs of pain
Diffuse body movements, highpitched Cry, stiff posture,
worried facial expressions, eyes
tightly closed
Limited vocabulary interferes
verbal expression of pain; uses
words like “owie”
Can not describe intensity of
Signs of possible pain:
thrashing arms/legs,
clinging, screaming
Use pain scale for this group;
have trouble distinguishing
pain such as sharp or dull. May
show fewer overt
PEDIATRIC MEDICATION ADMINISTRATION
Determining Dosage and Route
 Variations based on age, weight, body
surface area
and kidney and liver maturity and function
 Require provider order specifying wgt.,
dosage
calculation, dosage, route and frequency
Routes of Administration
 PO: use calibrated dropper, syringe or cup
Prevent aspiration: elevate head, place
med
in cheek near back of mouth. Do not
dilute
med
 NG or OG: crush pills finely, check tube
placement and infuse slowly. Flush tube to
clear
 IM or SQ: use sm. syringe &sm gauge (2523G x 5/8”-1”) based on size. Anticipate
resistance: get assistance.
Preferred sites: Infants & toddlers: vastus
lateralis
Older children: deltoid
 IV: assure patency of line, administer
through pump or soluset
PEDIATRIC MEDICATION ADMINISTRATION
CONT.
Administration
 Check for safety of dose and route
 Check for drug allergy
 Have 2 RN check drug calculation and
dose
 Use 2 patient identifiers prior
to administration (don’t count on child
for verbal info)
 If po med, give choices when possible
(water or juice)
 Ask parent, if present, suggestions for
Giving the med. If po, allow the parent to
give
 Never leave meds at bedside
Standard Precautions
Blood and body fluids of ALL persons must be
considered dangerous. The blood of anyone may be
infected with bloodborne pathogens including hepatitis B
virus, hepatitis C virus, or HIV, the virus that causes
AIDS. Standard Precautions apply to ALL
PATIENTS.




Hand Hygiene: Done before and after contact with
every patient, after handling blood or body
fluids,after having contact with the patient’s
environment or before an aseptic procedures.
Alcohol-based waterless hand rub should be the
primary method except:
After using the restroom
When there is visible soil on the hands
Before eating.

Gloves: Worn when there is a risk of contact with
blood or body fluids. Hands must be sanitized after
removing gloves.

Gowns/Aprons: Worn when there is a risk of soiling
clothing with blood or body fluids or when splashing
or splattering of blood/body fluids may occur.

Face masks/goggles: Worn when splashing,
splattering, or spraying of blood/body fluids may
occur.
Phlebotomy Quick Reference
1. Always confirm patient's identification:
~Always use 2 means of patient ID
~ Correctly Label Specimen at the bedside.
2. Correct Order of Draw:
1.
2.
3.
4.
5.
6.
7.
8.
Blood Cultures or Isolator Tubes
Light blue
Red (plain, no gel)
Gold gel tubes
Green top tubes (gel or plain),
Lavender
Pink
Royal blue tops
3. Hemoconcentration:
a. A tourniquet left on for more than one
minute may alter lab values
b. Release tourniquet for 2 minutes and
reapply before collecting blood specimens
c. Gently tap a vein to encourage fill
d. Opening and closing a fist may alter lab
(over)
Phlebotomy Quick Reference( con’t)
4. Hemodilution:
a. Never draw above a running IV
5. Quantity Not Sufficient (QNS):
a. Difficult draw may not allow sample to be
analyzed by lab if QNS.
b. Patient will need to be redrawn if QNS
6. Clotted Specimens:
a. Difficult draw - perform only 2 attempts
b. Gently invert specimen tubes end to end to
mix any tubes with additives 8X.
7. Hemolyzed Specimens:
a. Alcohol prep not allowed to air dry
b. Difficult draw
c. Tourniquet on too long or too tight
d. Too small a needle and too large a tube
Blue 100 Documentation Tips
Code Log Check Sheet:
Be sure the following is completely
filled out on the log:








Patient Addressograph
Date/Time
Initial Assessment of Patient
Total IV fluid
Time Resuscitation Stopped
Signatures
Rhythm Strips
Nurses’ Note Completed
(over)
Blue 100 Documentation Tips (con’t)
PAR note should include:

Patient condition prior to code

Last time patient was seen and
patient condition

How patient was found

Who found the patient

Time Code Blue was initiated

Outcome of code: if transferred
to ICU, what time
Rhythm Strips to include on log:





Initial rhythm strip
Any changes in the rhythm strip
Any defibrillation and post defib
rhythms
Any rhythms if patient regained
a pulse at any time
End of code rhythm
Commonly Used Words and Phrases
English to Spanish
Arm = el brazo
Bathroom = cuarto de bano
Body = el cuerpo
Blood = sangre
Blood Pressure = presion de sangre
Chest = el pecho
Discharge to home = dar de alto a
su casa
Eye = el ojo
Foot = el pie
Hand = la
mano
Injection = inyeccion Left = izquierdo
Leg = la
pierna
Mouth = la boca
Nose = la nariz
Pill = pildora
derecho
Skin = la piel
vena
Out of bed = Fuera de la cama
Pain = Dolor
Right =
Urine – orina
Vein = la
Good Morning = Buenas Dias
Do you speak English = Habla ingles?
I am a nurse = Soy la enfermera
What is your name? = Como se llama?
Where is your Pain? = Donde tiene su dolor?
Are you nauseated? = Tiene nauseas?
Take a deep breath = Respira hondo
QUICK EVALUATION OF A SICK CHILD
Observation
Normal
Mod Impairment
Severe impairment
Cry
Strong
Normal tone
Whimper or
Sob
Weak, moaning
high pitched
Reaction to
Parents
Cries briefly
then content
State
Variation
If awake,
Wakes with
stays awake.
prolonged
If asleep,
stimulation
Wakes easily
Color
Hydration
Pink
Cries off/on
Continual cry
Will not rouse
or falls to
sleep
Pale hands,
Pale or blue
Feet or acroor gray or
cyanosis
mottled
Skin warm Skin & eyes
& dry. Eyes&
nl, mouth
Mouth moist
slightly dry
Skin doughy
or tented &
eyes sunken
Pediatric FLACC Pain Assessment Tool
Rating
0
Face
No particular
expression or
smile
1
Occasional
grimace or
frown, withdrawn
Uneasy, tense
restless
2_________
Frequent to constant
frown, clenched jaw
quivering chin
Activity Quiet, moves
Easily
Squirms,
tense, shifts
back & forth
Arched back,
rigid or
jerking
Cry
Moans or
whimpers
Crying steadily,
screams or sobs
Reassured
by touch,
hug or talking
Difficult to
console or comfort
Legs
Nl position or
relaxed
No cry (awake
Or asleep)
Consol- Content,
ability relaxed
Age of use 2 mo to 7 yr
Nursing 23(3): 293-297
Kicking, legs
drawn up
Scoring 0= no pain, 10= worstFrom: Pediatric
Key Points for Pediatric CPR
Assess
Responsiveness
Open Airway/
Assess breathing
___<1 yr
1-8 yr
> 8 yr_to puberty__
For sudden witnessed collapse and unresponsive: activate EMS
For unwitnessed collapse: Activate EMS after 5 cycles of CPR
Look, listen, feel <10 sec.
If no trauma suspected, do head-tilt/chin lift. If trauma, use
jaw thrust only. Open airway and give 2 breaths. If 1 st breath
does not go in, retilt head & try again
Perform rescue
Breathing: Give
2 breaths then:
12-20 breaths per min. Approximately 1 breath q 3-5 sec
for rescue breathing without CPR
8-10 breaths/ min with advanced airway with CPR
Assess pulse
Provide
Compressions
Brachial or femoral
Carotid
Carotid
1 finger below nipple Heel of 1-2 hands
Heel of hands
line with 2 fingers
lower ½ sternum
Center of chest
---------Depress 1/3 to ½ the depth of the chest-----------------100/min
100/min
100/min
Compression/
Ventilation ratio
15:2- 2 person
30:2- 1 person
15:2 -2 person
30:2 -1 person
15:2 2 person
30:2 1 person
Vascular Device Tips
Central Venous Catheters
Non-Tunneled Catheters
~Flush with 10ml NS before each use.
~Flush with 10ml NS and 5ml
heparin (10units/ml) after each use.
~Unused lumens flush q8hrs with
10ml NS and 5ml Heparin(10units/ml)
Tunneled Catheter
Hickman/Broviac
~Flush with 10ml NS before each use.
~Flush with 10ml NS and 2.5ml
heparin (10units/ml) after each use
~Unused lumens flush everyday with 10ml
NS and 2.5ml Heparin (10units/ml).
~ Day shift is responsible to flush all
unused lumens during that shift
Groshong
~Flush with 10ml NS before each use.
~Flush with 10ml NS after each use.
~Unused lumens flush every 7 days with
10ml NS
(over)
Vascular Device Tips (cont)
Tunneled Catheters (cont)
Hohn
~Flush with 10ml NS before each use
~Flush with 10ml NS and 5ml heparin
after each use (10units/ml)
~Flush each lumen with 10ml NS
followed by 5ml heparin every 8h (10units/ml)
IVAD
~ Before each use aspirate for blood return and flush
with 10ml NS.
~After each use flush with 10ml NS and 5ml
heparin(10units/ml) No heparin if continuous IV started.
~Unused port flush everyday with 10ml NS and instill
5ml heparin (10units/ml)
~Deaccessing Flush with 10ml NS and instill 5ml
heparin (100units/ml)
PIC/PICC
~Before each use Flush with 10ml NS
~Groshong PICC
After use flush with 10ml NS
Unused line flush every 24hrs with 10ml NS
~Midlines and PIC/PICC
After each use flush with 10ml NS and 5ml
Heparin (10units/ml)
Unused lines flush q8hrs with 10ml NS and 5ml
Heparin (10units/ml)
Blood Transfusion Reaction
Blood Transfusion Reaction Symptoms:
Fever/Shaking Chills
Low Back Pain
Nausea/Vomiting
Hypotension
Chest Pain/SOB
Hematuria
If your patient develops a blood transfusion reaction:
~Stop the transfusion at once and notify physician
~Obtain vital signs
~Change IV tubing
~Treat Symptoms
~Notify Blood Bank
~Draw 1 Purple and 1 red top tube from opposite arm
~Fill out transfusion reaction form
~Return form, blood specimens & unused blood in bag to
Blood bank immediately
~Send first urine passed to urinalysis laboratory
Latex Allergy Tips
1. Apply red allergy band
2. Post Signs in room and on chart.
3. Remove all latex gloves and products from
patient room/care area.
4. Notify pharmacy of allergy to obtain premixed
medications/IV solutions if possible.
5. If meds must be drawn through rubber
stopper, puncture the stopper only once and
withdraw the required amount. Discard the
needle after drawing up the med and
before mixing/administering the med.
6. Use kling or stockinet to protect patient from
possible contact to latex items i.e. BP cuffs.
*Current research shows that the micron filter is
ineffective in filtering latex protein particles.
There is no reason to be using the micron filter.
Common Lab Draws
Tube
Common Labs
Red
ETOH, acetaminophen,
glucose
Light Blue
Coagulants/Hematology
Green
Troponin/Ionized Ca
Lavender
CBC, Diff and Platelets,
Ammonia level
Pink
Blood Bank
Gold top
Chemistry
Point of Care Testing Questions:
(stool occult blood, blood glucose)
Contact Kristeen Messore 341-8458
ABG NORMALS
PH
7.35-7.45
PaCO2
35-45mm Hg
PaO2
80-100mm Hg
HCO3
21-27 mEq/L
O2Sat
95-98%
Base Excess
+2 mEq/L
ABBOTT EPIDURAL
Press ON/OFF (unlock keypad prn)
Press YES to CLEAR HISTORY
Press YES for EPIDURAL MODE
Press 1,2 or 3 to select delivery mode.
Press YES for ML ONLY
Set RATE. Press ENTER
Press YES or NO for loading dose. (follow prompts)
If BOLUS DOSE is desired, set BOLUS DOSE and
press ENTER or follow prompts to set BOLUS DOSE
and LOCKOUT
9.
Press YES or NO to limit drug amount over time. If
yes, Press 1 or 4 to select length of limit.
10.
Set CONTAINER SIZE. Press ENTER
11.
Select AIR SENSITIVITY
12.
LOCK PUMP
13.
Press RUN/STOP to begin infusion
IF VOLUME DIFFERENT THAN PREVIOUSLY
PROGRAMED:
1.
Press REVIEW/CHANGE
2.
Press 2 for CHANGE
3.
Press 1 for CHANGE PROGRAM
4.
Follow prompts
5.
Set AIR SENSITIVITY
6.
Press RESET
7.
Press 2 for NEW CONTAINER
*ALWAYS LOCK KEYPAD WITH PATIENT
INFUSIONS.
TO VERIFY PROGRAM:
1.
Press REVIEW/CHANGE
2.
Press 1 for REVIEW
1.
2.
3.
4.
5.
6.
7.
8.
3.
Use up arrow to scroll through program
4.
Press SILENCE to return to main screen
TO OBTAIN TOTALS
1.
Press HISTORY
2.
Press 2 for VOLUME Info
3.
Press 1 for SHIFT, (Press 2 for CONTAINER).
4.
Use up arrow or HISTORY button to scroll through
5.
Press SILENCE to return to main screen.
DELIVER LOADING DOSE
1.
Press RUN/STOP and unlock keypad
2.
Press LOADING DOSE
3.
Press YES
4.
Set dose and press ENTER
5.
Press YES
6.
Press LOADING DOSE to begin delivery
7.
Press RUN/STOP and LOCK Keypad
*ALWAYS LOCK KEYPAD WITH PATIENT
INFUSIONS.
When loading dose is complete, pump will alarm if set.
CHANGE CONTAINER
1.
Press RUN/STOP and unlock keypad
2.
Press RESET
3.
Press 2 to set a NEW CONTAINER (same volume as
previously programmed)
4.
Press RUN/STOP and lock keypad
CLEAR SHIFT TOTAL
FROM STOP MODE & UNLOCK KEYPAD
1.
Press RESET
2.
Press 1 for NEW SHIFT TOTAL
Pump returns to stop mode & lock keypad.
CHANGE PROGRAM, RATE, OR VOLUME:
FROM STOP MODE & UNLOCK KEYPAD
1.
Press REVIEW/CHANGE
2.
Press 2 to CHANGE
3.
Press 1 to CHANGE PROGRAM
4.
Follow prompts to change entries & lock keypad.
ENTER NEW PROGRAM
FROM STOP MODE: & UNLOCK KEYPAD:
1.
Press REVIEW/CHANGE
2.
Press 2 to CHANGE
3.
Press 2 for NEWS PROGRAM
4.
Press NO to CLEAR HISTORY
Does not reset shift; clears current program only.
5.
Follow prompts to set new program
(See programming.)
6.
At time of NEW PROGRAM CHANGE, enter actual
container volume remaining. When CHANGING TO NEW
CONTAINER, enter new bag volume.
Always Lock keypad with Patient Infusion
To LOCK the pump
1. Press RUN/STOP
2. Press ENTER
3. Press down arrow 3 times
To UNLOCK pump
1. Press RUN/STOP
2. Press ENTER
3. Press up arrow 2 times
Medley PCA Module
1.
2.
3.
Security Lock Key Positions
a. Unlock: unlocks the security door. The
key must be in this position when
loading or changing a syringe
b. Program: allows for changes in
programming the device with out
unlocking the security door.
c. Lock: Locks the security door. The key
must be in this position to start an
infusion
Preparing Infusion
a. Press Channel Select key (Key must be
in program position)
b. Press soft key next to installed syringe
type and size (selection will be
highlighted)
c. To accept, press Confirm soft key
Priming Tubing
a. Press Options key
b. Press Prime Set with Syringe
c. Set key to Program position
d. Press and hold Prime soft key until
fluid flows and priming of tubing is
complete. Release prime key when
complete
e.
4.
To return to main screen, press Exit soft
key
Programming an Infusion
a. Perform steps in preparing syringe and
administration set
b. Power on system
c. Choose Yes or No to New Patient
d. Select profile if required (ex. ICU, West
5)
e. Enter patient identifier if required
f. Press Channel Select key
g. Unlock security door or set key to
Program position
h. Confirm time of day and change if
needed
i. Press soft key next to desired drug and
concentration
j. Confirm the drug and concentration
selection and press Yes soft key. To
change selection press No soft key and
follow prompts
k. If Yes was selected and facility has
defined a clinical advisory for that drug,
a message appears. To continue
programming, press Confirm soft key
l. Drug amount and diluent volume will
appear. Press Next soft key to confirm
5.
6.
Setting up PCA Dose Only
a. Press PCA dose only soft key from
infusion mode screen
b. Use numeric data entry keys to enter
PCA dose
c. To enter Lockout interval, press
Lockout Interval soft key and use
numeric data entry keys
d. To enter Max Limit, press Max Limit
soft key, press Yes soft key and use
numeric data entry keys
e. To enter Loading Dose, press Load
Dose soft key, press Yes soft key and
use numeric data entry keys
f. Verify parameters are correct and press
Confirm soft key
g. Close and lock security door
h. Verify parameters on second nurse
summary screen are correct and press
Start key
Setting up Continuous Infusion Only
a. Press Continuous Infusion soft key
from infusion mode screen
b. To enter continuous infusion dose, press
Cont Dose soft key and use numeric
data entry keys
c.
7.
To enter Max Limit, press Max Limit
soft key, press Yes soft key and use
numeric data entry keys
d. To enter Load Dose, press Load Dose
soft key, press Yes soft key and use
numeric data entry keys
e. Verify parameters are correct and press
Confirm soft key
f. Close and lock security door
g. Verify programming parameters are
correct and press Start key
Setting up PCA Dose and Continuous Infusion
a. Press PCA Dose + Continuous soft key
from infusion mode screen
b. To enter PCA dose, press PCA Dose
soft key and use numeric data entry
keys
c. To enter Lockout interval, press
Lockout Interval soft key and use
numeric data entry keys
d. To enter Continuous Dose, press Cont
Dose soft key, press and use numeric
data entry keys
e. To enter Max Limit, press Max Limit
soft key, press Yes soft key and use
numeric data entry keys
f.
8.
9.
To enter Loading Dose, press Load
Dose soft key, press Yes soft key and
use numeric data entry keys
g. Verify parameters are correct and press
Confirm soft key
h. Close and lock security door
i. Verify parameters on second nurse
summary screen are correct and press
Start key
Setting Loading Dose Only
a. Press Loading Dose Only soft key
from infusion mode screen
b. Use numeric data entry key to enter
dose value
c. Verify dose value is correct and then
press Confirm soft key
d. Close and lock security door
e. Verify parameters on summary screen
are correct and press Start key
f. When loading dose is complete The
Loading Dose has Completed appears
on the main display
g. Press Confirm
Setting Bolus Dose
a. Press Channel Select on PCA module
b. Press Bolus Dose soft key
c.
Set key to Program position or enter 4
digit authorization code and press
Confirm
d. Use numeric data entry keys to enter
does value
e. Press Confirm
f. If authorization code is disabled, door
must be locked prior to starting bolus
dose
g. Verify dose value is correct and then
press Start soft key
h. Once bolus complete, programmed
infusion resumes
10. Stopping a Loading, PCA or Bolus Dose
a. Press Channel Select key on PCA
Module
b. Press Stop Load, Stop PCA or Stop
Bolus soft key as applicable
c. To stop dose and resume current
program, press Yes soft key
11. Changing Program Parameters During an
Infusion
a. Press Channel Select key
b. Press Program soft key
c. Set Key to Program position or if
authorization code is enabled, enter 4
digit code
d. Press Change Modes soft key
e.
f.
Select desired infusion mode
Continue programming as outlined
above for infusion mode selected
g. Verify or change program settings and
press Confirm key
h. Close and lock door
i. Verify programming parameters on
summary screen are correct and press
Start key
12. Viewing Patient History
a. Press Channel Select key
b. From main display, press Options key
c. Press Patient History soft key
d. Press Zoom soft key to select desired
time period
e. Press Detail soft key to view detailed
patient history
f. To return to Main Patient History, press
Main History soft key
g. To return to Main Display, press Exit
soft key
13. Clearing Patient History
a. Press Clear History soft key, a
confirmation screen appears
b. To continue and clear patient history,
press Yes soft key
c. To cancel and return to patient history,
press NO soft key
d.
Once patient history is cleared, the last
24 hours of patient history data may be
retrieved and viewed.
e. Select 24h Totals soft key from patient
history screen to retrieve last 24 hours
f. Press Shift Totals soft key to return to
patient history view
14. Viewing drug Event History
a. Press Channel Select key
b. From main display, press Options key
c. Press Drug Event History soft key
d. Press Page Down soft key to scroll
through history
e. To return to main display, press Exit
soft key
15. Restoring Infusion Following Syringe Empty
a. Unlock security door
b. Remove existing syringe and load new
syringe and administration set
c. Select syringe type and size
d. Prime tubing
e. To restart infusion using restored
parameters, press Restore soft key and
continue with next step
f. Verify parameters are valid and press
Confirm soft key
g.
To start a new infusion, select drug
form guardrails drug library and follow
steps for PCA infusion modes
h. Close and lock security door
i. Verify programming parameters on
summary screen are correct and press
Start key
16. Viewing and Clearing Volume Infused
a. To view volume infused, press Volume
Infused soft key from main display
b. To clear volume infused:
1. To clear all channels, press
Clear All soft key
2. To clear selected channels:
press soft key next to
selected channel and press
Clear Channel soft key
17. Changing Syringe During Infusion
a. To stop infusion, press Pause key on
PCA Module
b. Unlock the door
c. Open plunger grippers and syringe
barrel clamp
d. Replace syringe
e. Load new syringe
f. Select syringe type and size
g. Press Confirm soft key
h. Prime administration set
i.
j.
k.
Press Restore soft key, press Next soft
key, and confirm programming
parameters
Lock the door
To begin infusion, press Start soft key
CATEGORIES
Cry
SCORE 0
No particular
expression or smile
Content, Relaxed
Normal position
Relaxed
Lying quietly
Normal position
Moves easily
No cry
(awake or asleep)
Consol ability
Content, Relaxed
Face
Legs
Activity
SCORE 1
Occasional grimace or
frown.
Withdrawn, distressed
Uneasy, Restless
Tense
Squirming, Shuffling back
and forth
Tense
Moans or whimpers
Occasional complaint
Reassured by occasional
touching, hugging or
being talked to.
Distractible
SCORE 2
Frequent to
Constant quivering
chin, clenched jaw.
Kicking,
drawing up legs
Arched, rigid
or jerking
Crying steadily.
Screams or sobs
frequently.
Frequent complaints
Difficult to console
or comfort
The FLACC scale for noncommunicative patients
Assess each of the categories in the far left column to obtain a score of 0-2
Add the scores for all five categories to obtain a score of 0-10
Process for Obtaining Foreign Language, Hearing impaired and/or
Visually Impaired Resources
Hearing Impaired/Foreign Language Interpreters:
Monday-Friday 8am to 4:30pm
Call Patient Care Services at 341-6718
Evenings (after 4: 30pm), nights, weekends and Holidays:
Contact the Nursing Supervisor pager #220-8098
Services/Equipment Available for Hearing and Visually Impaired
Patients:
Equipment is located in the Telecommunications Department
*TTY Services
*SIGNAL PHONES
*AMPLIFIED RECEIVERS
*CLOSED CAPTIONING
*LARGE NUMBERED PHONE RECEIVER
Telephone Numbers
Admit
Pharm.
Blood
Bank
Hem
Chem
CT
Micro
Dialys In
16748
37967
18554
16810
16803
18061
16818
16502
Dietary 37951
APC
16526
ED
16880
E3 M/B 16836
E3 L&D 16875
E5
18190
E6
10166
E7
16643
ICU
16932
W4
16840
W5
18422
Infection Prevention 10654
W6
16850
W7
16855
Infusion 18113
Health
18017
Sterile Prod.
37806
Transp/Serve 17378
Ultrasound
1806
Storeroom
16341
Cardio.
16780
NucMed
18062
Dottie Haelen 18058
Credit Union 37979
DOOL
16709
Security
16899
OR
16269
PACU
38920
Medical Image 16785
SW
16718
Sally Nordquist
Diabetes Nurse
Educator 16425
Employee
Health
18017
PT
Pager Numbers
Bed Coordinator
Housekeeping
Infusion Nurse
Nurse Supervisor
Resp Therapy
SWAT Nurse
Transport
Vascular Lab
Infection Prevention
220-4434
220-8053
220-8551
220-8098
220-8019
220-8140
220-8164
220-4170
220-8160
220-0228
220-8307
Disaster
Pocket Guide
A Just-in-Time
Reference for
Highland Disaster Staff
& Volunteers
The Disaster Pocket Guide is designed as a
quick reference.
Users should refer to the current policy and
protocols of the organization to ensure the
most current and complete information.
When finished with this Pocket Guide,
please return to the Incident Command
Center.
Revised 8/07
Patients with Insulin Pump
Highland Protocol for Management of Patients
Receiving Insulin Therapy states that patients
may use their own Insulin Pumps if they meet
the criteria for safety:

Diabetic Health Source is contacted
(341-6425)

The patient is alert and oriented

Independent in ADLs

Agrees to sign the “Insulin Pump
Therapy Patient Contract”
When Criteria is met:

MD completes preprinted order form
#10894

Pt. signs contract, keeps yellow
page

Patient uses own pump and tubing
set

Hospital Insulin must be used

Patient will provide basal & bolus
insulin rates.
Pt. assessed EVERY hour for mental status, site
status and correct infusion rate.
Patients with Insulin Pump (cont)
Patient must continuously meet criteria.
If condition changes, pump is discontinued and
Pt is switched to either Lantus SQ@ HS
with Novolog SQ AC meals OR
Regular Insulin IV continuous infusion.
BGs must be monitored (by staff or pt with RN
supervision) with hospital meter (FBS, AC
meals, 2hr after each insulin bolus, HS & 0300
& prn s/s hypoglycemia)
Hypoglycemic treatments:
BG<70 If PO:
 Give oral glucose gel; if refused
 4 oz. juice (15gm Carb)
 Recheck in 15 minutes

Repeat until BG> 70.
If NPO:
 Give 50 ml (1amp) dextrose 50% IVP
 Notify MD/PA/NP



Recheck BG 15 min after treatment
If BG<70 repeat above
Recheck bg every 15 minutes; if at 1
hour bg remains <70 start IV D10% at
150 ml/hr
Refer to SOC: Diabetes Management in the
Hospitalized Patient.
Organ and Tissue Donation
All anticipated (withdrawal of life support) and actual
deaths must be referred to the donor hotline at
1-800-774-2729 whether or not they are suitable for
potential donation.
The Organ Procurement Office (OPO), Finger Lakes
Donor Recovery Network (FLDRN) and the
Rochester Eye and Tissue Bank (RETB) coordinate
the donation of all organs and tissue.
Any health care provider involved with the patient’s
care can make referrals to the Donor Hotline; the
unit secretary usually makes the call at Highland.
Document referral in chart.
ONLY FLDRN coordinators conduct the consent
process and offer the option of donation to the
families.
.
Elevate head, place NS drops into the eyes and ice
packs over the eyes in anticipation of eye donations.
(over)
Organ and Tissue Donation (cont)
There is no cost to family.
No disfigurement will result.
Eyes will be retrieved in the morgue. If time is of the
essence, eyes may be removed in the Emergency
Department from patients who have died there.
RETB will arrange transportation for the recovery of
other tissues with the family and hospital staff.
Tissue removal documentation will be provided by
the recovery agency for the medical record.
Highland Staff will give condolence Card to the
family if tissue/organs are determined suitable for
donation.
Alaris Pump Points

Refer to the Alaris Medley Medication Safety
System Operator’s Quick Reference Guide
for Priming, Loading, Programming and
Troubleshooting instructions. These are
laminated and should be attached to pumps.

Be sure correct priming and loading
sequence is followed. Misloading can lead to
unregulated flow of medication to the
patient.

Remember to open roller clamp for IV
piggybacks to infuse.

If receiving a patient transferred from
another unit with a pump, ensure proper unit
specific guardrails are selected.

Keep pump units plugged in when not in use
to recharge battery.

Return unused pumps to SPD for cleaning
between patients.
Highland Adult Normal & Therapeutic Lab Values
Acetone
Negative
Albumin
3.2-4.8 gm/dl
Alk. Phos
45-129 U/L
Ammonia
10-47 umol/L
Amylase
30-118 U/L
Bilirubin-Total
0.3-1.5 mg/dl
Bilirubin-Direct
0.0-0.5 mg/dl
BUN
9-23 mg/dl
Chloride
99-109 meq/l
CO2
20-32 meq/l
CPK-Male
38-174 U/L
CPK-Female
26-140 U/L
Creatinine-Male
0.7-1.4 mg/dl
Creatinine-Female
0.6-1.1 mg/dl
Glucose
74-106 mg/dl
Iron-Female
38-138 ug/ml
Iron-Male
40-159 ug/ml
TIBC
250-450 ug/ml
Potassium
3.5-5.5 meq/l
Sodium
132-146 meq/l
TSH
0.35-5.50 uU/ml
Tegretol
8.0-12.0 ug/ml
Digoxin
0.9-2.0 ng/ml
Phenytoin (Dilantin)
10-20 mcg/ml
Salicylate
20-25 mg/dl
Theophylline
10-20 ug/ml
0
1
0
--
0.45
0.91
1.36
1.81
2.27
2.72
3.18
3.63
4.08
20
9.07
9.53
9.98
10.43
10.89
11.34
11.79
12.25
12.70
13.15
40
18.14
18.60
19.05
19.50
19.96
20.41
20.87
21.32
21.77
22.23
60
27.22
27.67
28.12
28.58
29.03
29.48
29.94
30.39
30.84
31.30
80
36.29
36.74
37.19
37.65
38.10
38.56
39.01
39.46
39.92
40.37
100
45.36
45.81
46.27
46.72
47.17
47.63
48.08
48.53
48.99
49.44
120
54.43
54.88
55.34
55.79
56.25
56.70
57.15
57.61
58.06
58.51
140
63.50
63.96
64.41
64.86
65.32
65.77
66.22
66.68
67.13
67.59
160
72.57
73.03
73.48
73.94
74.39
74.84
75.30
75.75
76.20
76.66
180
81.65
82.10
82.55
83.01
83.46
83.91
84.37
84.82
85.28
85.73
200
90.72
91.17
91.63
92.08
92.53
92.99
93.44
93.89
94.35
94.80
220
99.79
100.24
100.70
101.15
101.61
102.06
102.51
102.97
103.42
103.87
240
108.86
109.32
109.77
110.22
110.68
111.13
111.58
112.04
112.49
112.95
260
117.93
118.39
118.84
119.30
119.75
120.20
120.66
121.11
121.56
122.02
280
127.01
127.46
127.91
128.37
128.82
129.27
129.73
130.18
130.64
131.09
300
136.08
136.53
136.99
137.44
137.89
138.35
138.80
139.25
139.71
140.16
320
145.15
145.60
146.06
146.51
146.96
147.42
147.87
148.33
148.78
149.23
340
154.22
154.48
155.13
155.58
156.04
156.49
156.94
157.40
157.85
158.30
360
163.29
163.75
164.20
164.65
165.11
165.56
166.02
166.47
166.92
167.38
380
172.37
172.82
173.27
173.73
174.18
174.63
175.09
175.54
175.99
176.45
400
181.44
181.89
183.34
182.80
183.25
183.71
184.16
184.61
185.07
185.52
#
2
3
4
5
6
7
8
Weight Conversion Chart: Pounds and Kilograms
9
Code 15(Stroke) Process














Evaluate patient for acute stroke symptoms.
Call for Rapid response team
RRT will assess for need to call Code 15.
If Code 15: Call 1-6666 for operator to page.
Bring patient chart, Crash Cart and defibrillator to
patient room.
Obtain “Stroke Kit” from Crash Cart notebook –
Code 15 log has all necessary documentation
Obtain “Acute Stroke Triage Orders” from the
Stroke Packet folder
Record last time the patient was seen without
stroke symptoms
Anticipate need for emergent head CT and blood
draws
Labs: obtain reqs in HBOC under “Stroke Panel”
Page CT tech and lab to alert of potential tPA
candidate; process has changed – only 1 page
now alerts CT, lab and neurology in addition to the
Code 15 team
Prepare for potential patient transfer to CT
Complete progress note about events
Prepare for possible transfer to ICU or the Stroke
Unit (W7).
Goal: Stroke Team evaluation within 15 minutes
BLS ADULT/PEDIATRIC CPR
UNRESPONSIVE Person - Phone 16666 or call for Help
■
Send someone to get AED
■
Pediatric - Do 2 min. CPR then AED
AIRWAY - Open airway; head tilt-chin lift
BREATHING - Look, Listen, Feel 10 sec.
■
Not breathing give 2 breaths- 1 sec per breath
CIRCULATION- Check pulse < 10 seconds:
■
Adult/child – carotid pulse
■
Infant – brachial
Pulse Present/No Breathing: Rescue Breaths
■
■
■
Adult 1 breath every 5-6 sec
Infant/Child 1 breath every 3-5 sec.
Recheck Pulse every 2 min
Pulse Absent; Begin compressions
■
■
30 compressions/2 breaths
Infant/child 2 person: 15 compressions/2 breaths
DEFIBRILLATION: Goal is Less Than 3 minutes to SHOCK
AED/Defibrillator Arrives
1. AED ON - Turn ON Power
2. Apply Pads per package
■ Use Pediatric Pads if needed
3. Connect Pads Cable & Plug in connector
4. Analyzes Heart Rhythms; Do Not Touch Patient
NOTE: use manual mode for pediatric patients < 55 lbs
Procedure for Assisting Patients with a Bedpan
Patient has requested a bedpan:
1. Gather needed supplies: clean gloves, bedpan, toilet tissue
2. Close door and pull privacy curtains
3. Instruct patient to bend his/her knees and press down with feet
and slip the bedpan beneath the patient’s buttocks.
OR if patient is unable to lift themselves:
Lower head of bed, roll patient to their side and
position
the bedpan.
4. Raise the head of the bed, ensure toilet tissue and call light are
within reach.
5. Instruct patient to call for assistance when they are done.
6. Return and, with gloved hands, remove bedpan having patient
repeat same process as above.
7. Assist with removing residue of urine, feces from the skin.
8. Help position patient for comfort.
9. Provide handwashing supplies.
10. Dispose of bedpan contents in patient’s toilet. Measure and
record volume of urine if patient’s intake and output are being
monitored.
Procedure for Assisting Patients with their Hygiene Needs
Partial Bedbath: when an alert patient needs to bathe in bed or sitting
in a chair at their bathroom sink:
1. Gather needed supplies: towels, wash cloth, soap, tooth brush,
toothpaste, comb, deodorant, clean gown, wash basin, kidneyshaped basin, clean cup.
2.
3.
4.
5.
6.
Sit patient up in bed, at bedside or assist them to bathroom.
Assisting Patient with Oral Care
a. For patient in bed, obtain fresh cool water and kidney
shaped basin.
b. Assist/allow patient to brush teeth, rinse and spit into
kidney basin.
c. If patient has denture/partials and needs assistance:
Apply clean gloves, gently brush dentures/partial
using toothbrush and toothpaste. Rinse. Assist patient to
put dentures in place if needed.
d. Dispose of water and contents of basin when patient is
done.
Obtain basin full of warm water.
Close door, pull privacy curtains and leave call bell in reach.
Instruct patient to wash all areas of body they are able to
comfortably and safely reach. Advise patient to use call bell to
ask for help when they are done.
Return, obtain fresh warm water, apply gloves and assist
patient to wash legs, back, and provide perineal area.
Administering Perineal Care:
a. Assist patient to lie on their back.
b. For the female patient: Bend the patient’s knees and
spread the legs. Separate skin folds. Using clean area
of the cloth for each stroke, wash from pubic area
toward anus (top to bottom). Never go back over an
area that has already been cleansed. Pat area dry
gently with towel.
c. For the male patient: Grasp the penis and retract the
foreskin if the patient is uncircumcised. Clean the tip
of the penis using circular motions. Never go back
over an area that has already been cleansed. Replace
the foreskin. Wash the shaft of the penis in downward
motion. Spread the legs and wash the scrotum. Pat
skin dry with a towel.
d. Turn patient to the side and wash from the perineum
to anus (“clean” area to “dirty” area). Pat dry
7. Assist patient into clean gown and cover them with a
blanket/sheets.
8. Empty and rinse bedpan, put dirty linen in hamper.
9. Remove gloves and wash hands.
10. Position patient comfortably with call bell in reach.
Complete Bedbath: when a non-alert patient needs to be given a
bed bath:
1. Gather needed supplies: Bath blanket, towels, wash cloths,
soap, wash basin, clean gown, deodorant, comb.
2. Close door, pull privacy curtain and raise bed to an appropriate
height.
3. Position patient on his/her back.
4. Cover patient with bath blanket and remove patient’s gown.
5. Obtain warm basin full of water and place on overbed table.
6. Apply clean gloves, wet wash cloth and fold it to fashion a
mitt.
7. Lather wet washcloth with soap and wash the patient’s face.
8. Rinse washcloth, remove soapy residue, they gently dry well.
9. Bathe each of patient’s arms separately; chest, then axillae
(underarm).
Rinse and dry well.
10. Apply deodorant or antiperspirant if wanted/available.
11. Place each hand in the basin of water as it is washed. Cleanse
under fingernails if needed, but never cut patient’s
fingernails or toenails.
12. Discard and replace the water in the wash basin; rinse the
washcloth well or replace it with a clean one.
13. Wash the abdomen, each leg, and the feet, following the steps
described for the upper body.
14. Help the patient roll onto his/her side.
15. Change the water and bathe the patient’s back
16. Wash buttocks and perineal area last (see Administering
Perineal Care)
17. Assist patient to apply clean gown.
18. Change sheets of bed (see Making Occupied Bed)
18. Discard water, put dirty laundry into appropriate hamper.
19. Return bed to lowest position
References: Timby, B.K. (1996). Fundamental Skills and Concepts in
Patient Care (6th ed.).
Philadelphia, PA: Lippincott-Raven
Publishers.
Procedure for Making an Occupied Bed
Plan to change the linen after the patient’s hygiene needs have been
met.
1. Obtain assistance if the patient is too weak or unable to
cooperate.
2. Gather needed supplies: fitted sheet, sheet, pink pad, pillow
case, blanket.
3. Close door and pull privacy curtain
4. Apply gloves and raise the bed to an appropriate working
height.
5. Cover patient with a bath blanket or leave top sheet loosened,
but in place.
6. Check for personal items that may be in bed. Move them to a
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
secure location.
Loosen bed linen from where it has been tucked under the
mattress.
Lower the side rail on the side of the bed where you are
standing and roll the patient toward the side rail on the far side
of the bed.
Roll the soiled bottom sheets as close to the patient as possible.
Apply fitted sheet to top and bottom of side of bed closest to
you and spread toward the middle of the bed.
Position and apply pink sheet on top of fitted sheet on side
closest to you.
Roll excess fitted sheet and pink sheet tightly and tuck under
soiled bottom sheets as close to patient as possible. Use a towel
as a barrier between clean and dirty linens if necessary to keep
clean linen dry.
Raise side rail and assist patient to turn onto their other side
over the roll of linens.
Go to other side of bed, or if working with another person, help
patient maintain side-lying position.
Roll of linens may now be pulled through under patient.
Soiled linens may be put aside for later placement in appropriate
hamper.
Clean fitted sheet should be applied to top and bottom, and pink
pad pulled through and smoothed under patient.
Patient may be assisted onto back.
Place clean sheet and blanket (if patient desires) over patient,
and remove dirty sheet. They may be tucked under mattress if
patient wishes, but be sure to leave room for patient’s toes to
move freely under blankets.
20. Return bed to lowest position.
21. Assist patient into comfortable position.
22. Ensure call bell is within patient’s reach.
Principles of Positioning Patients
1. Patient’s are encouraged and assisted to change positions at
least every 2 hours.
2. Bed is raised to an appropriate height.
3. All pillows and positioning devices are removed before
repositioning.
4. Drainage tubes are unfastened from the bed linen.
5. The patient is turned as a complete unit (log rolled) to avoid
twisting the spine.
6. The body is placed in good alignment with joints slightly
flexed/bent.
7. Pillows and positioning devices are replaced after
repositioning.
8. Elevate/raise on pillows those areas that are swollen/enlarged.
9. Notice any areas where skin has become red. Do not rub if
red. Position patient to relieve/remove pressure on red areas –
notify nurse.
10. Once repositioned, ask patient or look at them and ask yourself
if they seem comfortable the way that you have positioned
them. Are all parts of the body supported and in
alignment/straight? If no, reposition.
Patient Feeding
Serving Trays
Match tray to patients name on ticket.
Verify correct diet
Open lids and identify foods
Call bell within reach
Amount of assistance will vary, cutting food, preparing coffee,
butter bread
Patient Feeding
Offer hand towelett for hand hygiene
Patience is important
Test temperature of food, steam, stir, feel outside of bowl
Fill spoon ½ way only
Do not give more food until read
Alternate solids and liquids
Dysphagia
Difficulty chewing and/or swallowing
Increased risk of choking
Thin liquids are highest risk of causing choking
Care:
Thickened liquids, soups etc. No thin liquids
No straws
Never position flat on back
Keep head of bed up at least 30 degrees
Observation & Reporting
Information collecting
Constant ongoing process
Important job function
What to Observe
Color of skin, temperature of skin Patient level of
alertness, mental status changes Breathing sounds, work of
breathing, cough Movements, ability to move,
ability to transfer, walk, etc
Patient reports of pain other discomforts
Report
Report accurately and promptly
Report patient name and location
Falls and Restraints
What is the patient’s status for Falls Risk:
History of falls
Mobility problems
Certain medications
Age >65
Confusion, agitation
Incontinence
Physical conditions
Falls prevention
Use side rails if needed
Assist with walking
Use lights/night lights
Frequent visual checks
Clean up spills immediately
Falls and Restraints cont.
Keep assistive devices in reach such as canes
Keep personal items such as glasses in reach
Safe footwear or slipper socks on patient
Locks on bed/wheelchair at all times
Frequent toileting
Keep patients surroundings free of obstacles
Restraints
Last resort only
Restraints are not a means to prevent falls
May be used if patient is a danger to themselves or others
Used when we are unable to provide care safely
Must have order
Patient Care when restrained:
Visual checks every 15-30 min
Release restraint every 2 hours
Never restrain patient flat on back
Position patient comfortably
Meet patient’s needs such as hygiene, nutrition/feeding,
elimination, positioning and emotional support.
Safe Mobilization of Patients
When ambulating patients assure that the patient is safe while
they are up and moving around. You are also responsible for
protecting yourself (ie. your back/body) while assisting that
patient. It is important, not only to think about safety for the
patient, but also anybody who is taking care of that patient.
Make sure there is an out of bed activity order before getting
a patient out of bed. You can do this by checking with the
nurse
Be aware of any weight bearing limitation orders.
Utilize pink pads/bedrails to minimize lifting/pulling.
Always have slipper socks or shoes on the patient.
Indications for 2 assist – Very agitated, very weak, a lot of
equipment/attachments. A mechanical
Safe Mobilization of Patients cont.
lift is indicated for patients that are too weak to stand.
Use an assistive device if it is recommended or in the room
for the patient to use (including gait belts, walkers, canes, etc.).
Avoid or be aware of unnecessary clutter or tubing that the
patient can become caught in or trip over, such as: IV poles,
oxygen tubing, and Foley catheters.
If getting a patient out of bed and into a chair:
Choose an appropriate chair.
Determine if you need a second assist.
Set the chair up (with a sheet and pink pad) close to the
bed.
Make sure the chair and bed brakes are on.
Allow the patient to do as much as she can to help.
Safe Mobilization of Patients cont
Allow the patient to sit at the edge of the bed for a few
minutes before
standing in case of dizziness/light
headedness.
Place assistive device directly in front of the patient.
Place gait belt on patient if using one
Make sure any oxygen or IV tubing is in place.
Encourage the patient to stand, pushing from the bed
with her hands to prevent the walker from falling on her.
Assist the patient to standing, if needed, with one hand
under the patient’s shoulder and the other hand around her
waist (or holding gait belt).
Give the patient time to do as much of the transfer as
she can on her own. Encourage the patient to take
small steps until she feels the chair against the back of
her leg.
Safe Mobilization of Patients cont
Have the patient reach both hands back and hold onto the
chair.
Assist the patient slowly into the chair.
Encourage the patient to scoot all of the way back into
the chair. If they need assistance, you can use the pink pad to
boost the patient back into the chair, or you can place an
upright pillow behind their back to boost them forward.
If walking a patient: Follow above steps
If the patient is using a walker, make sure they do not
walk too close to the front of the walker or too far behind it. It
is recommended that patients try to keep their feet in line with
the back of the walker.
Within reason, allow the patient to dictate direction. This
will give them some control.
Defer to the nurse for specifics regarding how long a
patient should stay out of bed or how far she should walk.
INFECTION PREVENTION
HAND HYGIENE
Use 15-20seconds of rubbing when
sanitizing hands. Proper hand hygiene using
waterless hand rubor soap and water (always
choose soap and water if hands are visibly
soiled, after using restroom, before eating).
Always clean hands:

before and after direct contact with a
patient

before surgical procedures

after removing gloves

before giving meds

after moving from a contaminated
body site to a clean body site during
patient care after contact with
inanimate objects in the
INFECTION PREVENTIONcont
immediate vicinity of patient

after coughing or sneezing

before and after meals and food
breaks

after using toilet facilities

after contact with blood or body
fluids
PROPER USE OF PERSONAL PROTECTIVE
EQUIPMENT (PPE)
The following items are worn for PPE:
 gowns
 gloves
 masks
 goggles/face shield/side slip-on
shield
GOWNS - should be water resistant
- should be worn if clothing might
l be splashed/soiled
INFECTION PREVENTIONcont
- put on before entering patient’s
room and removed before leaving room
- should be worn once unless severe
shortage exists.- when removed, gown
should be rolled “outside in” to prevent
re-contamination from the outside of the
gown
GLOVES - must be changed between patients
- must be worn to enter room
- hand hygiene must be performed
after removing
- should be changed when going from
a “dirty site” to a “clean site”
INFECTION PREVENTIONcont
(i.e. urinary catheter to an IV site)
MASKS- should be worn within 6 feet of any
person coughing
 are either on or off – never
allowed to hang around neck
 must be changed if they become moist
particulate respirator masks(N95) are required for
aerosol generating procedures.
PROPER SEQUENCE FOR PUTTING ON PPE:
(graphics go with this one)
PROPER SEQUENCE FOR REMOVING PPE:
(see graphics)
COUGH ETIQUETTE
Follow the steps of cough etiquette at all
times:
use tissues to cover mouth/nose when
coughing or sneezing - if tissues
are not available, use sleeve

dispose of tissues in the nearest waste
receptacle immediately after use

avoid touching eyes, nose or mouth

perform hand hygiene with either a
waterless hand sanitizer or soap and
water ASAP

wear a mask if coughing frequently
DO NOT EAT OR DRINK in patient care or
clinical areas.
DO NOT COME TO WORK if you have the
following symptoms:

fever > 37.8◦C or 100.4o F

sore throat

diarrhea

flu-like symptoms

VENTILATOR BASICS
Some things to remember:
1. All ventilated patients must have a manual resuscitation bag
with them at all times.
Resuscitation bags for patients requiring PEEP ≥ 10 cm. H2O
must be equipped with a PEEP valve.
3. Never silence ventilator alarms and leave patient alone.
4. The safest action for a ventilated patient experiencing
respiratory distress with an unknown cause is:
1. Disconnect patient from ventilator
2. Manually ventilate patient using resuscitation bag.
3. Call Respiratory Care immediately.
Suctioning:
• Suctioning is done as needed, NOT a scheduled activity.
• Use Normal Saline ampules for lavage if needed.
• Suction if patient is coughing frequently with mucus in E-T or
Tracheostomy tube, ventilator is high pressure limiting or
oxygen saturation is dropping.
• Notify Respiratory Therapist if patient’s secretions are getting
thicker, oxygen saturation is dropping or you get thick mucus
plugs when you suction. Call Respiratory Care for any
situation if you are unsure of the needed action.
• IMPORTANT: If patient has a tracheostomy tube and you
think that the tube may be plugged, first try to suction. If you
can’t pass the suction catheter, remove the inner cannula,
ventilate the patient manually using resuscitation bag and call
Respiratory Care
2.