Skilled Nursing Facility (SNF) Care and Exhaustion of SNF Benefits
Skilled Nursing Care - Intranet UnityPoint Health … · 2012-04-12 · Skilled Nursing Care...
Transcript of Skilled Nursing Care - Intranet UnityPoint Health … · 2012-04-12 · Skilled Nursing Care...
Skilled Nursing Care
Skilled Nursing Care may include, but not be limited to:
I. Administration of Medications:
A. Medications are administered by Agency licensed nurses according to Agency policies
and procedures, and within the scope of the State Nurse Practice Act. Medications are
administered only by individuals holding a current license or permit in the state as a
registered nurse or a licensed practical nurse.
B. Agency licensed nurses will administer all FDA approved medications by all
approved routes in accordance with their skills and training with the following
exceptions:
1. IV Aminophylline loading doses
2. IV Pitocin
3. IV Phenothiazine derivatives
4. IV chemotherapy agents which are not included on the Agency=s approved list
5. IV Iron-Dextran Complex
C. Licensed Practical Nurses will not administer IV medications. In addition, licensed
practical nurses may not administer parenteral anticoagulants or parenteral cardiac drugs.
D. The Agency reserves the right to refuse to administer medications if such medication
is determined to be harmful, contraindicated, expired, improperly labeled, contaminated,
or there is no physician=s order. If a medication is withheld, the physician shall be
promptly notified and the events documented in the clinical record.
E. No experimental drugs are administered unless the patient has signed a voluntary
consent form. The Agency will consider patients who are part of research, experimental
studies or clinical trials on a case-by-case basis with consideration for staffing and the
Agency=s ability to meet the needs of the patient effectively. For investigational drugs,
such as AIDS drugs specifically exempt from FDA review procedures, the Agency will:
1. Obtain a specific physician=s order in accordance with policy
2. Verify that the drug is an acceptable investigational drug for the condition
3. Obtain written literature on the drug action and side effects
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4. Obtain specific orders for treatments of reactions or side effects
5. Obtain approval of a subcommittee of the Professional Advisory Committee
physicians, nurses and a pharmacist, if possible
The Administrator is to be made aware of all potential cases in which experimental drugs
may be administered.
Participation of the patient in experimental drug therapy is strictly voluntary and must be
an informed decision by the patient. The physician is responsible for educating the
patient on the specific drug/procedure, benefits and risks, potential outcomes,
consequences, and alternative courses of intervention. Patients admitted to service who
are in the course of experimental drug therapy will be accepted on a case by case basis.
The patient=s physician will be responsible for educating agency staff in the proper care of
patient. All items listed above will be included in that education.
F. A written physician=s order must be obtained for all medication administered by
Agency personnel. Written physician orders must specify:
1. Patient name
2. Medication name, dose, route, purpose (where appropriate) and frequency
3. Medication start date
4. Medication stop date, if indicated
5. Special instructions or precautions, if indicated
6. Standing orders in case of a drug related adverse reaction, if indicated
7. Laboratory blood work to be routinely collected
G. In the case of an in-home administration of the initial dose of a new medication, the
Agency reserves the right to decide on an individual basis whether or not to administer
the initial dose. If indicated following the administration of any injectable or intravenous
medication, the employee will remain in the home to observe for possible side effects.
H. Medications, dose, route and frequency should be considered generally reasonable and
acceptable therapy for the condition for which they are prescribed. In the event the RN or
LPN has reason to question the orders of the attending physician, such as unusual route or
dosage, Agency guidelines for questioning a physician=s orders will be followed. The
physician will be contacted for specific written orders to include drug name, dose,
frequency, route, expected effects, untoward and adverse reactions. The physician will be
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requested to participate in patient education and will assist in obtaining informed and
voluntary consent by the patient. A copy of the informed consent and any applicable drug
protocol will be retained in the patient=s clinical record. MMSC pharmacy staff will also
be available for additional education as needed.
I. The nurse administering each medication is responsible for researching unfamiliar
medications for:
1. Actions
2. Indications
3. Side effects
4. Special precautions
5. Usual dose
6. Route of administration
J. The nurse shall routinely monitor all medications to determine their action,
indications, special precautions, patient=s response to therapy, side effects, allergies and
contraindications. The RN will be responsible for updating and keeping accurate the
medication profile or medication listing in the patient=s clinical file. This will be done as
soon as possible after the order is received. The medication profile will include the name
of the medication, date ordered, dose, route, frequency, duration of therapy if appropriate,
action or effect, side effects, and contraindications. This profile will include over-the-
counter drugs. The profile may also serve as a tool for the purpose of patient/caregiver
education, and/or for drug therapy review by pharmacist(s) as appropriate or required by
policy, regulation or accreditation standards.
K. The Agency may instruct the patient and/or caregiver on the administration of
injectable medications only with a written physician=s order.
L. If the patient expires, all medications become the property of the patient=s family who
shall be responsible for their disposal.
M. Injections for the prevention of flu and pneumonia may be given with an order from
the physician at the discretion of the Agency to its home care patients.
N. Controlled Substances. Only RNs and licensed practical nurses are authorized to
handle controlled substances.
1. All controlled substances are to be counted daily or at specified intervals.
2. A controlled substance may be given only with a physician=s order
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3. Each medication is to be accounted for according to Agency procedure as it is
removed from the container and before it is administered to the patient
4. If a medication is not given because the patient refused it, a partial dose is
given or the medication is contaminated, documentation is required
5. Any amount of controlled drug that is missing and can not be accounted for
requires an incident report that details particular information regarding the loss of
the drug. A nurse is required to complete the incident report. The incident report
must then be signed by the Supervising Nurse, and reviewed by the Quality
Improvement Committee or other appropriate departments such as pharmacy.
O. A medication error is anything that requires discontinuing the medication, modifying
the dose, hospitalization, treatment with a prescription medication, or an error resulting in
disability, cognitive deterioration or impairment, congenital anomalies, death or is life
threatening. All medication errors will be documented via a variance report.
P. The Agency will attempt to obtain specific orders for treatment of adverse drug
reactions on each patient where such a reaction is possible. The specific orders will be
followed should an incident occur. In the absence of specific orders, the nurse will
implement standing drug reaction/anaphylactic shock orders contained in this policy
manual and remain with the patient until the paramedics arrive. ADR/variance reports
are to be filed with the pharmacy for review by medical staff and appropriate committee.
Adverse Drug Reactions:
Adverse medication reaction is defined as any medication that elicits specific abnormal signs and
symptoms that are not normally or directly associated with the medication. These abnormal signs
and symptoms may include, but are not limited to: headache, tremors, dizziness, muscle spasms,
confusion, nausea, vomiting, diarrhea, cramps, abdominal pain, skin rash or flushing, dizziness,
hypotension, a diffuse feeling of warmth, arrhythmias, tachycardia, bradycardia, shortness of
breath, dyspnea on exertion, and/or respiratory depression.
A significant or severe adverse reaction is defined as those signs/symptoms that are so severe that
the patients requires immediate emergency medical treatment. These may include respiratory
distress, choking sensation, difficulty swallowing, tightness or pain in the chest, wheezing,
dyspnea, respiratory stridor, vascular collapse, cyanosis, imperceptible pulse, or circulatory
failure.
A mild adverse reaction may demonstrate the above signs and symptoms but with lesser severity,
and the patient is not in immediate danger. A mild reaction can progress to a significant or
severe reaction and the patient should be monitored closely for any changes.
In the event that any of the above listed signs and symptoms occur or any other adverse reaction
is observed by a clinical staff member, the staff member will:
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- Immediately discontinue the administration of the medication and call 911 or the
appropriate emergency medical support system if the reaction is significant and the
patient is in immediate danger. The staff member will then render First Aid and/or CPR
when necessary and remain with the patient until emergency assistance arrives.
- Notify the patient=s physician and the nursing supervisor of the adverse reactions and of
the emergency actions taken as soon as possible
- Document all information related to the administered medications, dosages, routes,
times and the presenting adverse signs/symptoms and file a variance report
In the event of a mild adverse reaction, the staff member will:
- Immediately discontinue the administration of the medication and call the patient=s
physician
- Follow physician=s orders received
- Stay with the patient and monitor condition (a mild reaction may progress to a
significant reaction)
- Document all information related to the administered medications, dosages, routes,
times and the presenting adverse signs/symptoms and file a variance report
A variance report will be completed for any adverse medication reaction. The data will be
collected and aggregated in order to expand epidemiological or scientific knowledge related to
the medications, the patient=s disease states, and any factors contributing to the adverse reaction.
The resulting data will be shared internally with the appropriate clinical staff and externally with
the dispensing pharmacy and the appropriate regulatory agencies.
Insulin Reactions:
Insulin reactions are defined as:
- Hypoglycemic reaction is an abnormally low level of glucose in the blood, likely to
occur when for any reason the blood sugar falls below 50 mg/100ml of blood. It may
occur at a higher level if glucose has fallen too rapidly
- Hypoglycemia occurs as a result of too much insulin, not enough food (delayed or
missed meal), and/or vigorous activity
- Reactions begin in 15-20 minutes following injection of regular insulin, but not for
several hours after NPH insulin, the majority of attacks occur in morning and early
evening
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Signs and Symptoms:
- Nervousness, weakness, sweating, trembling
- Faintness, hunger pangs
- Headache, numbness or tingling of tongue or lips
- Tachycardia, palpitations
- Confusion, aggressive or erratic behavior, mood changes
- Unsteady gait, double vision
- Chilling sensation, chilling
Some patients experience hypoglycemia so rapidly that the symptoms progress to seizures almost
without warning. Severe, prolonged hypoglycemia may cause brain damage, and sometimes
death.
Treatment:
- If the patient is conscious, give some form of glucose, candy, orange juice, corn syrup, a
lump of sugar and a source of protein (e.g., egg or milk)
- If the patient can not take anything by mouth, give glucagon. Give the patient orange
juice or ginger ale as soon as consciousness is regained
- If above measures do not reverse hypoglycemic condition, obtain emergency transport to
the Emergency Room, notify the physician and remain with the patient until the
ambulance arrives.
Drug Abuse Reaction:
1. Narcotic and Opiod, Analgesics (e.g., Morphine, Demerol, Codeine, Dilaudid, Tylox,
Numorphan)
Signs and Symptoms:
- Coma
- Pinpoint pupils
- Cool, damp skin with cyanotic hue
- Severe respiratory depression
- Ataxia
Emergency Management- MAINTAIN RESPIRATION
- Employ resuscitative measures as needed
- Call 911 for emergency transport to emergency room
- Notify the physician
- Remain with the patient until emergency squad arrives
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2. Sedatives and Hypnotics (e.g., Dalamane, Seconal, Restoril, Halcion)
Signs and Symptoms
- Drowsiness
- Dizziness
- Lethargy
- Disturbed coordination
- Daytime sedation
- Confusion
Emergency Management- MAINTAIN RESPIRATION
- Employ resuscitative measures as needed
- Call 911 for emergency transport to emergency room
- Notify the physician
- Remain with the patient until emergency squad arrives-
3. Antianxiety Agents (e.g., Valium, Xanax, Tranxene, Serax, Centrax)
Signs and Symptoms
- Drowsiness
- Lethargy
- Ataxia
- Hypotension
- Vertigo
- Pulmonary edema
- Coma
- Possible death
Emergency Management:
- Employ resuscitative measures as needed
- Call 911 for emergency transport to emergency room
- Notify the physician
- Remain with the patient until emergency squad arrives
4. Other Drug Adverse Reactions:
Oral medications may cause adverse reactions of toxicity and/or side effects. The nurse will
review all medications on admission, each time a medication change is made, and at least every
60 days to determine the presence of side effects or adverse reactions and/or contraindications.
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The nurse will teach the patient/caregiver signs and symptoms of side effects and adverse
reactions throughout the course of care. If any adverse reaction is noted, or suspected, the patient
will be instructed to hold the next dose, watch for worsening symptoms, or to call the physician
for further instructions as deemed appropriate by the nurse. The nurse may choose to notify the
physician immediately if appropriate.
5. Food/Drug Interactions:
Some foods negatively interact or interfere with absorption/actions of certain medications. The
nurse will include these interactions/precautions in the teaching of these medications. As
appropriate, the nurse will contact the pharmacist and/or dietician for further information and
instruction.
Cross Reference: _St. Anthony Publishing___________________________________________
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II. Administration of Injections:
A. Orders for intercutaneous, subcutaneous or intramuscular injections will be accepted.
B. In considering the administration of any injectable drug which needs to be given over a long
period of time on a routine basis, the nurse will attempt to teach the patient, family members,
friends, neighbors, etc.
C. If a patient is ordered a medication carrying a potential risk, the following shall apply:
1. The nurse shall stay in the home thirty (30) minutes after the administration of the drug
is complete to monitor the patient for adverse effects
2. In conjunction with signed physician=s orders, arrangements should be made to have
two (2) doses of adrenalin available to the nurse in the home, in addition to the prescribed
medication, when appropriate.
3. The dose of adrenalin must be specified as well as the method of administration on the
physician order
4. The patient has been informed of the possible side effects of the medication carrying
potential risk
5. If an anaphylactic reaction occurs, the patient will be treated for shock, and
transportation to the nearest emergency room should be obtained. A note in regard to any
medications or nursing actions taken should accompany the patient to the Emergency
Room along with a listing of vital signs and observations.
6. The physician and Agency supervisory should be notified of an adverse reaction
D. The Agency retains the right to refuse to give injections, or to teach anyone to give such
injections which:
1. By history are known to have caused an unusual reaction in a patient
2. Require more supervision for administration and observation than is possible to be
provided by the Agency
3. It is believed to be in the patient=s best interest to initiate the medication regime within
a setting in which emergency medical assistance is readily available
E. Types of injections include:
1. Immunizations. Immunizations may be given as a component of public health in the
home care program.
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a. Flu and pneumococcal vaccines may be given to the home care patients with a
physician=s order.
b. The order should include an indication by the physician that the patient has been
informed about the vaccine and is in satisfactory health to receive the vaccine
2. Narcotics. Orders for the administration and teaching the injection of narcotics will be
accepted. The teaching of families will be done by the registered nurse.
3. Gold. Gold may be given under the close supervision of a physician.
4. Iron-Dextran Complex. Iron-Dextran Complex may be given I.M. Z- Track under the
close supervision of the physician. Registered nurses only may administer. No teaching of
family members is to be permitted because of the dangers inherent with the use of this
medication. Monitoring the CBC of the patient is recommended.
5. Antibiotics. The nurse must inquire about sensitivity and any other untoward reaction
to previous injection on each visit. The nurse should observe the patient for any reaction to
an injection, the general policy for administration of Epinephrine will be followed. The
nurse is to remain with the patient for at least thirty (30) minutes after the dose is given.
Antibiotics may not be given to a child under the age of eighteen (18) without a legally
responsible adult being present.
6. Vitamin B12. Orders for Vitamin B12 will be accepted on an individual basis.
7. Anti-Allergic Drugs. Orders for anti-allergic injections used in asthma or hay fever may
be accepted provided the patient is on a maintenance level dose
Cross Reference: _____________________________________________________
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III. Intravenous (IV) Therapy:
A. The following criteria must be met for a patient admission to the IV program:
1. The patient must meet the general criteria for admission:
a. Physician=s order
b. Source of payment
c. Residence in geographical service area of the Agency
2. The patient shall be capable of self care or a responsible caregiver must be available and
willing to participate in the patient=s care.
3. The patient has adequate venous access for IV therapy
4. The patient has telephone service available
5. The patient=s home is safe and adequate for the provision of IV therapy
B. Only RNs who have been certified in IV therapy or who have had recent IV therapy experience
may perform IV therapy. Exceptions may be made when past nursing experience and appropriate
training have been provided.
C. Administration of IV medications will be performed under the following conditions:
1. Orders for IV medications and solutions, and PRN orders for anaphylaxis and allergic
reactions have been given to an RN by a physician or pharmacist (per individual physician
order)
2. Orders for IV medications and solutions must include the name of medication and
solution, dosage, dilution, route, frequency and rate of infusion
3. Whenever possible the patient should receive the first dose of the medication in a
controlled setting. AFirst dose@ shall be defined as any drug to be given initially in a home
setting which the patient has not previously received.
4. If the Agency receives a request to administer a AFirst dose@ IV medication in the home,
the following procedure should be followed:
a. If the patient is still hospitalized, the physician should be called to request the
first dose to be given prior to discharge with at least one hour of post-dose
observation by hospital personnel
b. If the patient is at home, Agency personnel should contact the physician and
patient and arrange, if possible, for the first dose to be given by an
Agency RN in the physician=s office
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c. If administering the first dose in the physician=s office is not possible, the
nurseshall request an order from the physician for the Agency=s AAllergic Reaction
Protocol@ and the Agency personnel must observe the patient for a minimum of one
(1) hour after the start of the drug infusion. If the physician will not approve the
allergic reaction protocol or provide a reasonable alternative, the Agency will not
accept the patient and the physician shall be informed. Only RNs who have met the
Agency criteria may administer AFirst dose@ antibiotics in the home.
d. Interventions for an allergic reaction must be administered by an RN. The RN
must monitor the patient for one (1) hour after the first dose is completed or the
allergic reaction protocol is initiated.
e. The Agency will not administer AFirst dose@ of the following intravenous
medications: Bleomycin, Aquamephyton, Amphotericin B or Aminophylline.
f. IV medications and solutions shall only be administered through an established
peripheral or central venous line.
g. Venipuncture for the establishment of a peripheral IV infusion site may be
performed only by an RN who is certified in IV therapy or has had recent IV
experience and/or passed the NLN IV therapy examination (76%score).
h. No more than three (3) attempts will be made to initiate a venipuncture to start
an IV infusion by the nurse. Any additional venipuncture attempts will be initiated
following consultation with another nurse.
I. All venipuncture sites for infusion of IV therapy will be in the upper extremities
unless otherwise ordered by the physician.
j. Laboratory work as indicated for each medication will be drawn by the RN per
physician orders.
5. Maintenance of the peripheral IV line (unless protocols of the infusion company
supplying the medication and supplies specifies otherwise):
a. Particulate matter filters of one (1), 1.2 or five (5) microns shall be utilized.
Filter change shall coincide with the tubing changes. Use of the filter should be in
keeping with the manufacturer=s guidelines to prevent damage of the filter
membrane.
b. Tubing on continuous IVS will be changed every seventy-two (72) hours.
c. IV administration tubing for piggy backs will be changed every twenty-four (24)
hours
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d. Gauze dressings over IV sites are changed every 24 to 48 hours. All other
dressings over peripheral IV sites will be changed by a responsible party every
forty-eight (48) to seventy-two (72) hours or sooner if they become wet, unless it is
a transparent bio occlusive dressing. At this time the site is to be closely examined
for complications.
e. Peripheral IV sites will be changed if infiltration, thrombophlebitis or
extravasation occurs. Otherwise the site will be changed as ordered by the
physician. Pediatric cases must have specific orders to change sites.
f. Catheters and needles of patient=s IV infusions may be flushed or irrigated to
insure and maintain cannula patency and to prevent the mixing of
medications/solutions which are incompatible with one another.
g. IV locs will be flushed with normal saline every eight (8) to twelve (12) hours
by an RN or responsible party. If time periods between flushes exceeds twelve (12)
hours, the loc will be flushed with Heparin 10 units/ml.
h. Thrombolytic agents specific for dissolving clots which have been proven safe
and effective, may be administered according to specific physician orders and
manufacturer=s guidelines.
I. No IV container shall be allowed to hang for longer than twenty-four (24) hours,
unless approved in writing by the physician.
j. IVs , if infiltrated, may be discontinued by an RN or LPN or primary caretaker
(after proper instruction).
6. The physician is to be notified when:
a. Abnormal lab results are present
b. Untoward patient symptoms (including allergies or toxic symptoms) are present
c. A serious question regarding the placement of a central line exists
d. The nurse is not able to establish a continuous patent peripheral line.
e. When patient/caregiver cannot or will not comply with safe administration
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7. The Agency staff should refer to the following resources for specific procedures relating to IV
therapy, IV antibiotics, TPN, central venous catheters, IV pain management, and IV chemotherapy:
a. Clinical Procedure Manual for Home Healthcare, 1992, Hollingsworth and
Doggett, National Health Publishing
b. Nursing Procedures, Fourth Edition, 2004, Lippincott, Williams, Wilkins
c. MMSC Nursing Patient Care Policies, Marshalltown Medical and Surgical
Center
d. MMSC pharmacists and references will be available
e. Manual of Home Health Nursing Procedures, 1995, Rice, Mosby Publishing
f. High Tech Home Care Manual, 1996. Goeski, Aspen Publishers
g. Marshalltown Medical and Surgical Center Laboratory and Speciman
Collection, 1995.
h. Infusion Therapy: Techniques & Medications, 1996. Booker and Ignatavicius.
W.B. Saunders Company
I. Handbook of Home Care IV Therapy: 1994. LaRocca. Mosby Publishing
8. The Agency reserves the right to refuse to administer IV fluids, blood or medications.
9. Agency staff will assist the patient in arranging and obtaining necessary equipment,
supplies and medication.
C. Types of Infusion Therapy include:
1. Total Parenteral Nutrition and Intralipids
a. Patient must meet criteria for admission to IV Therapy program
b. All care and instruction is performed in accordance with specific orders from the
physician regarding solution, dilution, amount, rate and frequency
c. TPN and lipid infusions require central line access or PICC line
d. TPN and lipid infusions are to be delivered via a volumetric pump
e. The solution is never to hang longer than twenty-four (24) hours
f. The tubing is to be changed every twenty-four (24) hours
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g. TPN solutions should be removed from refrigerator two (2) to four (4) hours
before infusing
h. Only RNs may administer TPN and lipids
I. Dressings around central lines are to be changed two (2) to three (3) times a
week or when they become wet, unless otherwise specified by the physician
1. Sterile technique is to be used for dressing change
2. A mask should be worn if the central line has been placed within
fourteen (14) days or less
j. Laboratory testing will be done as ordered by the physician
k. The nurse is responsible for educating the patient/caregiver regarding:
1. Purpose of the infusion
2. Handwashing technique
3. Sterile technique
4. Storage of TPN, including recognition of deteriorated or unstable
mixtures
5. Dressing changes
6. Trouble shooting
7. Symptoms to report
8. Life style modifications
l. All patient/caregiver teaching and competency demonstrations will be
documented in the clinical record
2. Chemotherapy
a. Criteria for admission to IV chemotherapy program:
1. Physician=s orders are required
2. Source of payment is needed
3. Previous treatment with the drug is required
4. Caregiver in the home who is available and willing to participate in the
patient=s care is needed
5. Patient must have a telephone in the home
6. Transportation to emergency room is established
7. Informed consent is signed
8. Lab values are available to the nurse prior to drug
administration
9. Pre and post treatment plans are ordered
10. Emergency protocol is ordered for extravasation and anaphylaxis
11. Venous access is adequate for drug administration
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b. The physician=s order for antineoplastic drugs for home administration must
include:
1. Dose, dilution, route of administration, absolute dosage, frequency,
number of doses, length of infusion, and total lifetime dose when
appropriate
2. Orders for PRN antiemetic drugs when appropriate
3. Orders for treatment of extravasation PRN if drug is vesicant
4. Orders for anaphylaxis PRN
5. Orders for heparin PRN when appropriate
6. Appropriate laboratory work within forty-eight (48) hour prior to
administration
c. Only RNs that are certified in chemotherapy administration may administer
chemotherapeutic agents.
d. CBC with differential and platelet count and other appropriate lab work should
be performed one (1) or two (2) days prior to the initiation of therapy
e. The physician will be notified prior to administration of the drug if:
1. Clinical findings are abnormal
2. Laboratory values are abnormal
3. Placement of the central vein line is questioned
f. Chemotherapy may be withheld if:
1. Platelet count is below 100,000 (normal range being 150,000 -
300,000).
2. WBC is below 4,000 (normal range being 5,000 - 10,000)
3. It is the professional prerogative of the RN to elect not to administer
chemotherapy should the patient develop any untoward clinical signs and
symptoms related to their treatment, diagnosis, or any other pre-existing
conditions. Should this occur, the RN will notify the physician so that other
arrangements can be made.
g. All chemotherapeutic agents are to be prepared in the pharmacy and received in
the patient=s home ready for administration
h. All syringes and tubings used for administration must be Luer-lock
I. IV chemotherapeutic drugs shall be administered through an established
peripheral cannula or central venous line according to individual drug protocols.
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j. Medications may be administered by IV bolus, short term infusion or
continuous infusion
1. Volumetric pumps are used for all infusions
2. IV bolus injections should be administered through the side arm of a
running IV
k. Spill kits are to be provided to all patients with antineoplastic drug deliveries
l. The following chemotherapeutic drugs can be administered in the home. Any
other prescribed chemotherapeutic medications will be evaluated on an individual
basis by the medical advisor
1. Aldesleukin
2. Blenoxane (Bleomycin)
3. Cyclophosphamide (Cytoxan)
4. Cytarabine (Cytosar-U)
5. Dacarbazine
6. Doxorubicin hydrochloride (Adriamycin)
7. 5-Fluorouracil (5-FU)
8. Metoclopramide
9. Methotrexate
10. Mithramycin
11. Mitomycin C
12. Ondansetron hydrochloride
13. Thiotepa
14. Vinblastine sulfate (Velban)
15. Vincristine sulfate (Oncovin)
16. Dexamethasone (Decadron)
m. The RN performing the administration of the chemotherapy will remain with
the patient until the procedure is completed or until the infusion has been safely
started, in the case of a twenty-four (24) hour infusion. In both cases, a family
member will be instructed to observe for possible adverse reactions of the particular
agent and how they can reach the nurse or the physician should they occur.
n. If the chemotherapy drugs are given IV push or by infusion, the needle should be
flushed with 5-10cc NS (or other compatible solution) immediately before and after
administration of the chemotherapy agent.
o. The RN will wear gloves and a gown while handling all chemotherapeutic
agents.
p. All basic IV policies apply
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q. IV equipment and unused drugs are defined by law as bio-hazardous waste and
must be disposed of according to state laws and regulations.
1. In areas where there are no specific state laws regarding disposal, all
material used in the administration of chemotherapeutic agents will be
placed in a ziploc bag and sealed. The bag then is placed in a puncture
proof container with lid and disposed of in patient=s trash. The unused
medication is to be returned to the pharmacy.
2. Some pharmaceutical vendors who supply the chemotherapeutic agents
will assume the responsibility for disposal of contaminated waste and
unused medication. The administrator should make arrangements with the
pharmaceutical companies if possible.
3. All spills or splashes will be cleaned with absorbent material found in
the chemo spill kit and disposed of according to above procedure. (III C 2
q)
r. Extravasation Protocol
1. The RN shall observe for signs and symptoms of infiltration during
administration of peripheral IV vesicant chemotherapeutic drugs.
Symptoms include:
a. Edema
b. Blanching
c. Pain
d. Redness
e. Stinging and burning near the injection site and upward along the
vein
2. If infiltration occurs, the RN is to complete the following steps:
a. Discontinue infusion of chemotherapeutic medication
immediately
b. Aspirate 3-5 ml of blood from IV, if possible
c. Remove the IV needle from the patient
d. Using a 25 gauge needle, inject a total of 1 ml of Decadron
(4mg/ml) intradermally at five (5) to six (6) sites around
extravasation
e. Immediately apply icebag
f. Instruct patient to continue using icebag for twenty-four (24)
hours
g. Instruct patient to call the physician if there is pain, signs of
infection, or ulceration and to see the physician
h. Complete a Variance Report. Notify the Administrator or
Supervising Nurse.
I. Document the complete event on the progress note, including all
nursing actions, observations, and patient=s response
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3. IV and Continuous Subcutaneous Administration of Analgesics and Narcan
a. Intravenous and continuous subcutaneous opiates and Narcan may be
administered only by an RN certified in IV therapy or who has had recent IV
therapy experience and has a score of 76% or higher on the NLN IV therapy
examination.
b. Criteria for admission to IV management program are:
1. The patient must meet the general Agency admission policies
2. The patient must have a terminal condition with limited life expectancy
or acute pain in which other methods of pain control have proven
ineffective
3. The patient and family have specified their wishes concerning
resuscitation and the information has been documented in the record
4. A ADo Not Resuscitate@ order has been signed by the physician if
appropriate
5. There is a full-time caregiver available in the home who is willing to
assist in the patient=s care and can be taught the therapy
6. Intravenous and continuous subcutaneous opiate therapy shall be
initiated when possible in the hospital setting and the patient should be on a
controlled dosage for twenty-four (24) hours prior to discharge, subject to
the exceptions listed below:
a. An Agency approved RN is available in the home during the
administration of intravenous or continuous subcutaneous opiates
for the first twenty-four (24) hours
b. The patient has been managed previously with Class II narcotics
without evidence of adverse reactions
7. Administration of intravenous and continuous subcutaneous opiates shall
be limited to morphine sulfate (preferred) and hydromorphone (Dilaudid, on
individual consideration)
8. The patient is to be seen daily by an RN to assess patient status and
instruct caregiver until the caregiver is deemed competent. Visits will then
be decreased accordingly.
9. Orders for Narcan administration which include dosage parameters shall
be requested from the physician
10. The physician must be notified under the following conditions:
a. If the caregiver is determined to be incapable of monitoring safe
administration of the medication
b. Pain control is not effective
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c. When the patient or caregiver titrates pain medication beyond
physician=s orders
d. When an adverse reaction is suspected
e. When opiate toxicity is suspected
f. When Narcan is administered
4. Blood and Blood Products
a. Patients accepted for home transfusion therapy shall meet specific patient
selection criteria
1. The patient must have a history of receiving an uncomplicated blood
transfusion including absence of hemolytic or severe allergic reactions
2. The patient must have a chronic disease for which transfusion therapy is
appropriate with no medical history of acute congestive heart failure,
respiratory insufficiency, chronic renal failure, unstable angina, or other
evidence of clinical instability
3. The patient must be alert, oriented and able to communicate bodily
responses and symptoms and be able to give an informed consent
4. The patient must have physical limitations or existing hardships which
would make transportation to, or transfusion in, a hospital or ambulatory
setting difficult
5. The patient must have sufficient venous access (peripheral or central) to
administer components
6. The attending physician must be readily available by telephone during
and up to thirty (30) minutes after the transfusion
7. There must be one competent adult present, other than the nurse and the
recipient, to participate in patient identification/product verification and
remain in the home during the transfusion and one hour post-transfusion in
the event that emergency assistance is needed
b. Home transfusion therapy shall only be performed by an RN under the direction
of a physician and in accordance with local, state and federal regulations. The RN
shall be adequately trained in emergency procedures and have prior experience in
administering transfusions. All RNs administering blood or blood components in
the home shall have successfully passed the Home Blood Transfusion Skills
Review.
c. Blood components appropriate for home administration include:
1. Packed red blood cells
2. Washed packed red blood cells (plasma poor)
3. Leukocyte poor red cells by filtration
4. Frozen, thawed deglycerized red cells
5. Platelets (leukocyte poor, single, or random donor)
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6. Fresh frozen plasma
7. Gamma globulin, after the physician has calculated the dose
8. Cryoprecipitate
d. Use of whole blood or granulocytes is prohibited in the home
e. The patient must not require, within a twenty-four (24) hour period, more than:
1. Ten units random-donor platelet concentrates
2. Two units packed red blood cells, and
3. Two units fresh frozen plasma
4. Ten units cryoprecipitate
f. Storage and transportation shall be at the direction of the blood bank
g. The physician ordering the transfusion must inform the patient of the nature and
purpose of the transfusion, the risks and benefits involved and alternative
treatments available. The RN should reinforce or re-educate the patient on the
physician=s information. Written patient education materials or brochures should be
left in the patient=s home.
h. An informed consent must be signed by the patient and witnessed.
5. Diuretics
a. Orders should indicate that the parenteral route is needed because the patient can
not be maintained on oral diuretics.
6. Antibiotics
7. IV fluid replacement
8. IV Cardiovascular Medications
Cross Reference: ________________________________________________
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IV. PICC Lines
A. Only RN s who are certified or competency tested in PICC line insertion may perform this
procedure
B. PICC line certification will include at least four (4) hours of classroom instruction followed by
supervised clinical practice with a qualified clinical preceptor
C. Only PICC lines without guidewires are to be used for pediatric patients
D. PICC lines that are advanced in the axillary vein beyond the mid-axillary area must have
verification of tip placement by chest x-ray or other means prior to initiation of therapy. Note:
these catheters shall be considered central only when the tip is located in the superior vena cava or
the subclavian veins.
E. PICC lines will not be inserted if the patient has bleeding disorders or a PT/PTT lab value of
two (2) times the control, or the patient has undergone recent heart surgery.
F. Removal of the catheter will be determined by, but not limited to:
1. Condition and diagnosis
2. Type and duration of therapy administered
3. Determination of infectious or inflammatory process
4. Determination of malposition made
G. A physician=s order to remove the PICC line shall be obtained immediately upon suspected
complication or contamination. If infection is suspected, it is recommended that a physician=s
order be obtained to culture the catheter tip
H. PICC lines are not to be repaired or ruptured. The catheter should be immediately removed if
there is any breakage in the catheter.
V. Enemas
A. No more than 1000cc of tap water or six (6) to eight (8) ounces hypertonic-type enema (i.e.,
Fleets enema) will be given in response to an enema order, unless other amounts or solutions are
specifically ordered, or unless Aenemas until clear@ are ordered prior to diagnostic tests.
B. Pediatric patients must have physician=s orders specifying the type of solution and amounts
C. The nurse should report to the physician any difficulty in removal of fecal impaction or poor
results with a regular enema and request further orders
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VI. Catheter Care
A. An order for catheter insertion does not automatically include an order for irrigation or
instillation. This must be ordered specifically
B. Unless specific solution is requested, catheters will be irrigated with sterile normal saline
C. Orders for insertion of catheters will be accepted providing assurance is given by prescribing
physician that there is no abnormal encroachment on the urethra
D. Catheter Size:
1. The RN/LPN may use his/her own judgment in increasing the size of the catheter or
bulb when necessary, if the physician has granted prior permission on the signed written
orders or given verbal orders via telephone
2. When, or if, the nurse does change the size of the catheter or bulb, the physician should
be notified in writing when a request is made for the next signed orders
3. RNs may change suprapubic catheters using a regular Foley or nonmushroom type bulb
VII. Range of Motion
A. Nurses will do ARange of Motion@ exercises, but not Astretching@ exercises
B. Stretching exercises must be specifically ordered by the attending physician for the physical
therapist to perform
VIII. Vital Signs and Blood Pressure Checks
When orders are received to check vital signs and to check blood pressure until stable, specific
ranges of the patient=s vital signs an blood pressure readings should be requested. If the vital signs
and/or blood pressure are unstable, the nurse will request additional orders with specific guidelines
from the physician
IX. Sutures/Staples
RNs may remove sutures/staples from simple routine non-infected wounds when ordered by the
physician
X. Tracheostomy Care and Suctioning
Tracheostomy care and suctioning using sterile techniques may be done as needed to remove
secretions. RNs may change the outer cannula with physician=s orders after the tract is well
established.
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XI. Gastrostomy Tubes
RNs may change gastrostomy tubes using nonmushroom type catheters or Foley catheters as
directed by the physician=s orders after the tract is well established.
XII. Nasogastric Tubes
A. RNs may change N/G tubes (Levin) as directed by physician=s orders
B. RN s must remain in the home for thirty (30) minutes after feeding is initiated through a newly
inserted tube
XIII. Ostomy Care
Ostomy appliances may be changed as needed by the RN or LPN
XIV. Colostomy Irrigations
Colostomy irrigations may be done as ordered by the physician
XV. Cardiopulmonary Resuscitation
A. Staff will begin CPR when indicated unless a definite plan has been made to the contrary
B. Staff will continue CPR until relieved by ambulance personnel
XVI. Personal Care
A. Personal Care is defined as bathing, shampooing, dressing, feeding, and other activities of daily
living
B. Personal Care my be instructed by RNs, LPNs, HHAs at will
C. Personal Care does not require a physician=s order
D. If the nurse assesses need for medical intervention, he/she may request it or have the family
secure the same
XVII. Heating Pads
A. Heating pads require a physician=s order
B. Heating pads shall never be turned above low.
C. A cover of some sort is necessary for the pad.
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D. The length of time the heating pad may be used shall be determined by the physician.
E. HHAs may not apply heating pads.
XVIII. Obstructed Airways
A. If an obstruction is in the oropharynx, the nurse can attempt to remove it manually
B. If an obstruction is below the level of the oropharynx, the nurse should perform the Heimlich
Maneuver
C. If an obstruction is still present, or if it appears that the airway obstruction is secondary to head
or neck trauma, contact emergency medical service
XIX. Unable to Obtain Pulse
A. Check for the presence of pulse and spontaneous respirations; if absent, artificial respiration
should be instituted immediately (unless a Do Not Resuscitate Order has been received by the
physician prior to this event). Contact emergency medical services to transport patient.
B. If patient is unconscious and does not have spontaneous respiration or pulse, chest
compressions should be performed and maintained until arrival at the hospital. Level of
consciousness and respiratory activity should be monitored at all times.
XX. Loss of Consciousness
A. Check for presence of pulse and spontaneous respirations; if absent, institute cardiopulmonary
resuscitation and contact emergency medical services to transport. (Unless a Do Not Resuscitate
Order has been received from the physician)
XXI. Ventilator Patients
A. Criteria for Admission:
1. Patient=s condition must be stabilized
2. Ventilator must be supplied by durable medical equipment supplier that has a
respiratory therapist available twenty-four (24) hours a day and who is available to make
home visits
3. All staff caring for the patient must receive training on the ventilator prior to
assignment.
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4. Care must be ordered by a physician and must be detailed on a signed plan of treatment.
Orders must include:
a. Type of ventilator to be used
b. Whether ventilator is controlled or assisted
c. Whether the patient is to receive O2 or compressed air
d. Respiratory rate
e. Inspiratory volume
f. Tidal volume
g. Oxygen percentage
5. Cases will be accepted only if twenty-four (24) hour a day skilled care is ordered, or
there is a competent caregiver in the home. The physician must verify in writing that there
is a competent caregiver in the home and that the patient can safely be maintained with less
than twenty-four (24) hour skilled care. (Competent caregiver is defined as someone who
has been instructed and demonstrates understanding of the care of the patient, operation of
the ventilator, and what to do in case of emergency).
6. General guidelines for ventilator care:
a. The ventilator equipment is to be set up initially by a respiratory therapist
b. The ventilator dealer is responsible for the instruction in maintenance of the
equipment
c. The ventilator will be cleaned according to manufacturer specifications. Upon
admission, the nurse will identify the parties who will assume this responsibility
based on level of competence and document information in the patient record
d. Ventilator settings and connections are to be checked every two (2) hours to
verify ventilator is functioning properly and as prescribed by the physician
e. Alarms are never to be turned off. Alarms are to be checked for functioning at
the beginning of each shift. Nurses are to document the check in their visit notes.
f. Delivery tubing is to be checked every hour for water condensation. Any water
collected in tubing is to be drained and discarded.
g. Only humidified gas is to be administered to the patient
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7. Suctioning Procedure
a. Patient is to be oxygenated for one (1) to two (2) minutes pre and post suctioning
with hand held resuscitator or ventilator sigh
b. Patient should be suctioned PRN or as ordered by physician, using sterile
technique
c. Suctioning procedure is never to exceed more than fifteen (15) seconds, unless
otherwise specified by physician
d. Suctioning procedure is to be recorded on nurse=s notes
8. Tracheostomy Care
a. Tracheostomy care is to be done at least twice a day and PRN
b. If the patient has a cuffed tracheostomy, the cuff is to be deflated in accordance
with physician=s orders
9. Ventilator Failure
a. A hand held resuscitator, oxygen supply, flow meter and tubing is to be available
in the home in case of power failure or problems with ventilator functioning. A
back-up ventilator should be available if possible. Ventilator (back-up) shall be
checked daily to ascertain it=s functioning.
b. In case of ventilator failure, patient is to be manually ventilated at a rate of
sixteen (16) to eighteen (18) breaths/minute. The respiratory therapist is to be
called immediately. If the patient is in immediate danger, the paramedics are to be
called.
c. The local fire station and ambulance service are to be notified of the patient with
a ventilator upon admission to the Agency, as an alert to emergency response teams
in the event of a local occurrence that in some way would put the ventilator patient
in jeopardy
XX. Obtaining and Transporting Specimens
A. Gloves shall be worn when obtaining any and all specimens. If there is the potential for
splashes or splatter of blood or fluids, face shields or protective eyewear and surgical masks
should be worn
B. If there are splashes or splatters, the outside of the specimen container should be cleansed with
disinfectant. The container shall be labeled with the patient=s name, the physician=s name, and the
date and time of collection.
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C. For transportation, the specimen shall be placed in a separate, protective container capable of
maintaining the desired temperature. If specimens are transported to the office for pickup by lab
personnel, they shall be placed in a refrigerator that contains no food or drugs. The Administrator
may contact the lab for specific information regarding temperature and time interval for transport.
The lab may provide containers for transport of specimens. Containers used for transport and
refrigerators used for storage shall be labeled as a biohazard. Laboratory specimans in tubes shall
be placed in a sealed bag with a biohazard label, then placed in a hard container that is sealed.
Cross Reference: ____________________________________________________________
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