University Hospital and Clinical Programs
Professional Nursing Organization
PROCEDURES
ADDENDA

1. We do not use a sterile towel.  We leave the ETT in its sterile package until used.
2. At M.D. request, lubricate with lubrication jelly.
3. When stylet is used, retract it approximately 1 inch from end of tube.
4. Number of attempts is recorded.

Adjust suction head to the proper setting:

Adults 115-120 mm Hg

Child 90-115 mm Hg

Infant 50-95 mm Hg

Record Vt, VC, NIF as determined by respiratory therapy.

Irrigation of Chest Tube

Solutions will be instilled ONLY into chest tubes placed into post-resection chest cavities.

1. Cleanse distal portion of chest tube with Betadine soaked 4 X 4 gauze.
2. Cross-clamp chest tube with 2 chest clamps.
3. Using a Toomey syringe, draw up appropriate amount of irrigating solution per M.D. orders using sterile technique.
4. Disconnect chest tube and hold both ends of chest tube to avoid contamination.
5. Insert Toomey syringe into chest tube outlet.
6. Remove chest clamps and instill solution gently as chest clamps are released.
7. Replace clamps before removing Toomey syringe.
8. Reconnect chest tube and retape lengthwise and spiral tape.

If control test is ordered: Using the same procedure as for the TB test, place control on the opposite forearm. Preferred sites are the right forearm for the test, and the left forearm for the control, 2 to 4 inches below the antecubital fossa.

Do not prep arm with alcohol.

Controls are prepared by pharmacy and available on call.

Place the control antigens 1-inch apart and parallel to each other.

Read controls with PPD.

Chart test and control sites.

Equipment: 

·        Add medication label

Preparation of Equipment:

·        Wash your hands

For single dose ampules: 

·        Before discarding the ampule, check the medication label against the patient’s medical record and verify name and date of birth.  Discard the filter needle and the ampule.  Attach IM needle to the syringe.  Label the syringe with name of medication, dose, date and your initials.

·        Do not use an air bubble in the syringe. Change needles.  Label the syringe with name of medication, dose, date and your initials.

Implementation:

·        Delete the statement...”If your facility uses bar code ……”

Documentation:

·        If the medication is a first time dose of a new medication, follow UAMS policy:   http://www.uams.edu/nursingmanual/Policy/policy-24.htm   

1.  Abbreviations:  We do not use OD, OS, O, U.

2.  (R) Eye - Right Eye

3.  (L) Eye - Left Eye

4.  (B) Eye - Both Eyes

1. Performance Phase

2. Reference - Millne, C. and Corbitt, L. (2003). Wound Ostomy Continence Nursing Secrets.

Equipment

• Only use an irrigating bag with a stoma cone. Do not ever use a soft rubber catheter. They may rupture the bowel.
• Irrigate with 750-1000 ml.
• Performance Phase - Do not follow instructions using a catheter.

When performing site care of a gastrostomy/jejunostomy device, rotate gastrostomy/jejunostomy device tube one quarter turn daily (90 degrees).

Change tubing every 24 hours.

For administration of IV fat emulsion in adults, place fat emulsion tubing below the filter of hyperalimentation.

Equipment to send specimens to lab

1.  Urine Collection Kit containing towelettes and 2 vacutainer tubes one grey one yellow.

2. Peel back yellow label on container lid and fill tubes for the lab. The yellow tube is for  U.A and the grey for C and S. The tubes should be filled prior to performing any Point of Care Testing.

3. Label each tube with patient stickers.

1. Lateral thigh may also be used as an injection site
2. Rationale: Most individuals are able to lightly grasp a fold of skin and inject 90 degrees. Thin people or children may need to pinch the skin and inject at a 45 degree angle to avoid IM injection. Taut skin for injection is not a standard.
3. Injections given in the abdomen should not be within a 2 inch radius of the naval

TO LOAD THE SYRINGE

1. To reduce local irritation at the injection site and to mix, advise patients to roll the bottle between the palms, bring the bottle of insulin to room temperature before withdrawing the dose, or store the insulin at room temperature.
2. Patient is taught to clean the vial with alcohol using friction rub.

TO FILL A SYRINGE WITH LONG AND SHORT ACTING INSULIN MIXTURE

1. Rapid acting or regular insulin (clear) is usually drawn up followed by the intermediate acting insulin (cloudy). This practice limits the potential for contamination that may result in a dose variance.

Reference: Diabetes Management Therapies, 2001 p. 99-101

Community and Home Considerations Addendums 

1. Patients are instructed not to reuse their insulin syringes at UAMS Hospital due to the increased risk of infection. Patients are advised if the make the decision to reuse their syringes that the markings on the syringe may rub off and that the needle will become dull with repeated use.

2. Patients are instructed to clean the top of the insulin vial with alcohol and to clean the skin prior to the injection.

Ref: Diabetes Management Therapies, Marion J. Franz, MS, RD, LD, CDE, 2001, p100

 Addendum by Debbie Hauk, BSN, RN, CDE

 Self-injection of Insulin Addendums    

6. Alternate equipment to the traditional syringe-needle unit is available. The variety of injection devices includes automatic needle injectors, automatic needle and insulin injectors, pen injectors, and needle-free injectors. The needle-free jet injectors propel insulin through the skin by air pressure.

 Ref: Diabetes Management Therapies, Marion J. Franz, MS, RD, Ld, CDE, 2001  p100

 Insulin Regimens: 

NPH/Regular or NPH/Lispro  or NPH/Aspart Addendums to content and title 

1. Short-acting regular insulin, lispro insulin, or aspart, can be added to NPH to promote postprandial glucose control.

4. Mixed insulin does given before breakfast and before supper is termed a “split-mix” regime and can provide 24 hour insulin coverage for type 1 or type 2 patients.
5. If you mix aspart or lispro with NPH you must give the injection immediately to prevent bunting the rapid effect of the lispro or aspart.   Ref  Diabetes Management Therapies, Marion J. Franz, MS, RD, LD.  CDE, 2001, p. 102

 Intensive Insulin therapy (Itt) Addendums

 3.  NPH, Ultralente, Lente, or Lantus (glargine) is used for basal insulin control.

4.  Regular insulin acts as a pre-meal bolus given 30 minutes before each meal. Lispro or aspart insulin may be used instead of regular and is taken with meals no more than 15 minutes before the meal. Ref: Management Therapies, Franz, 2001, p. 97

Continuous Subcutaneous Insulin infusion(CSII) and Insulin Pump Therapy Addendums 

1. & 2.  Lispro and aspart are used in insulin pumps today. Buffer Regular (Velosolin) is no longer being used in insulin pumps at the time of this addendum.

4. b. Boluses if lispro or aspart given with the meal or no more than 15 minutes prior to the meal allow for flexibility in meal content and timing.

c. Supplements or lispro or aspart  boluses can rapidly correct blood glucoses.

 Combination Oral Agent and Insulin Therapy 

1. Appropriate in Type II Diabetes Mellitus.
2. Intermediate-acting insulin (NPH) or Lantus (Glargine) is given in the evening and an oral sulfonylurea agent in the morning-called BIDS therapy (bedtime insulin, daytime sulfonylurea).
   1. No oral anti-diabetic agent is given at bedtime
   2. Controlling hepatic glucose production overnight with evening insulin helps to start the day with a lower FBS.
   3. Daytime anti-diabetic agent (usually sulfonylurea), along with diet and exercise, controls daytime blood glucose levels.
   4. Some patients may require regular or Lispro or Aspart- NPH insulin injected before supper to assist with elevated post-prandial evening glucoses.
3. Combination therapy may also include the use of a thiazolidinedione (pioglitazone [Actos], rosiglitazone [Avandia], metformin [glucophage], or other agents.

Ref: Management Therapies, Franz, 2001, P. 210

.

1. Cleanse the skin with alcohol only.
2. Blood cannot be drawn from the feet by unlicensed personnel.
3. Do not remove the needle from the syringe before disposing in sharps container.
4. Identify patient by asking them their name and matching the name and birth date on the patient label, specimen pick up sheet, and the patient identification band.
5. Label and initial tube at bedside, after the blood has been drawn.
6. Match labeled blood tube to transmittal and patient, have coworker verify and both sign the transmittal form.

American Heart Association standards are followed

Adult CPR, 1 and 2 rescuer, compression to breathing ratio is 15:2.

Compressions are 100 times a minute

Reference: American Heart Association "Fundamentals of BLS for Healthcare Providers" 2001

Flush IV infusion will be prepared with normal saline unless indicated in physician's order for heparin flush. MD order for Heparin flush shall be written to include the fluid type and dosage of Heparin to be added.

Do not use antibacterial ointment at site. 
Continue the saline flush unless otherwise indicated per M.D. orders.