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Published by darlene.mention, 2017-07-28 15:18:41

2017 Annual Education Book

2017 Annual Education Book

 Too much insulin (Insulin Given without Food, Incorrect dose)
 Time of Fingerstick
 Vomiting & diarrhea
 Inadequate food intake (poor appetite, late tray)
 Changes in eating status (NPO, reduced enteral or parenteral feedings)
 Tapering off steroids
 Previous history of hypoglycemia

What can I do to prevent hypoglycemia?

 Fingerstick must be done up to 30 minutes before administration of insulin
 2nd verification from Registered Nurse while preparing insulin
 Exceptions:
 Gastroparesis, Slow Eating, Geriatric, Pediatric
 Consider administration of insulin after the meal is consumed
 Look at trends – How did patient tolerate insulin the shift or day before?
 Offer patients a bedtime snack if glucose less than 100 mg/dl (1 carb & 1 protein)
 Discuss insulin concerns or adjustments with Provider
 Never withhold insulin without order


Florida Hospital Tampa encourages any staff member who observes an employee or
Licensed Independent Practitioner (LIP) who is attempting to work while impaired,
to take certain actions.

What does being impaired mean?

A person is impaired if any physical, psychiatric, or emotional condition, adversely
effects the practitioner’s ability to safely do his or her job, or is disruptive to
hospital operations. Chemical substances may also impact a practitioner’s ability to
do their job.

What should an employee do when a care provider is suspected of being impaired?

When an observed behavior suggests that an employee or LIP is impaired, the
observer should report the behavior to their immediate supervisor. The report
should include a description as to what was observed and should be factual in

What if an observed impairment seems to create an emergency situation?

Clinical Annual Education- August 2017

 If the observer believes that an emergent situation exists or is about to be created, the observer should
immediately contact their immediate supervisor, or the Administrative Nursing Supervisor. The
Administrative Nursing Supervisor is available through the operator twenty-four hours a day.

 The manager or supervisor, to whom the report was submitted, will take the appropriate actions.
Maintaining high standards of patient care and safety will be a priority, when responding to real or
potential conditions of impairment.


Important Points

 Nursing can mix IVs only under emergency situations where the delay would be harmful to the patient

 CDC One and Only Campaign : Practice one needle, one syringe, only one time to eliminate infections
resulting from unsafe injection practices

 Check diluent and volume size needed.
o Some drugs that can only be mixed in NS: ampicillin, erythromycin,
ampicillin/sulbactam(Unasyn), phenytoin
o Some D5W only drugs: Bactrim, amphotericin

 Check diluent and volume size needed.
o Some drugs that can only be mixed in NS: ampicillin, erythromycin,
ampicillin/sulbactam(Unasyn), phenytoin
o Some D5W only drugs: Bactrim, amphotericin

 No manipulations can be made to admixtures prepared by Pharmacy or premixed products from
o Do not add medication to a prefilled saline flush syringe
o Only Pharmacy can mix chemo, epidurals, intrathecal, and IVs with concentrated electrolytes


Clinical Annual Education- August 2017

What is Malignant Hyperthermia

 Malignant Hyperthermia is an inherited disease that causes a rapid rise in body temperature (fever)
and severe muscle contractions when the affected person undergoes general anesthesia and their
body reacts to specific anesthetic drugs.

 Since malignant hyperthermia (MH) was first identified in 1960, each year has brought a greater
understanding of this syndrome.

 All patients undergoing general anesthesia should be screened for a family history of MH.

Signs and Symptoms

 Tachycardia/Tachypnea
 Increasing ETC02
 Trunk or total rigidity
 Masseter spasm or trismus
 Mixed Respiratory and Metabolic Acidosis
 Increased Temperature (may be a late sign)
 Myoglobinuria

Acute Phase Treatment

 Get Help. Get Dantrolene – Notify Surgeon.
o Discontinue volatile agents and succinylcholine.
o Hyperventilate with 100% oxygen at flows of 10L/min. or more.

 Dantrolene 2.5 mg/kg rapidly IV through large-bore IV, if possible.
o Dissolve the 20mg in each vial with at least 60 ml sterile, preservative-free water for injection.
o Repeat until signs of MH are reversed.

 Bicarbonate for Metabolic Acidosis
o 1-2 mEq/kg if blood gas values are not yet available.

 Cool the patient with core temperature >39 degree Celsius.
o Lavage open cavities, stomach, bladder, or rectum. Apply ice to surface.

 Infuse cold saline intravenously.
 Dysrhythmias usually responds to treatment of acidosis and hyperkalemia.

o Use standard drug therapy except calcium channel blockers, which may cause hyperkalemia or
cardiac arrest in the presence of dantrolene.

 Hyperkalemia - Treat with hyperventilation, bicarbonate, glucose/insulin, calcium.
 Follow ETCO2, Electrolytes, blood gases, CK, core temperature, urine output and color, coagulation

 Venous blood gas (e.g. femoral vein) values may document hyper-metabolism better than arterial

 Central venous or PA monitoring as needed and record minute ventilation.
 Place Foley catheter and monitor urine output.

Clinical Annual Education- August 2017

Post Acute Phase of Treatment

 Observe the patient in an ICU for at least 24 hours, due to the risk of recrudescence.
 Dantrolene 1mg/kg every 4-6 hours or 0.25mg/kg/hr by infusion for at least 24 hours.
 Continue with vitals and labs. Frequent ABG’s as per clinical signs.
 Counsel the patient and family regarding MH and further precautions; refer them to MHAUS.
 (MHAUS – This protocol may not apply to all patients; alter for specific needs.)


Problem Prone Areas:

 Medication Storage
 Medication Security
 Medication Orders
 Medication Reconciliation

Medication Storage and Security

 Warmed Solutions- Must be labeled with expiration date (14 days if 90-104 degrees and 3 days if >
104 degrees ). Do not reheat.

 Never carry medications in your pockets
 NO FOOD! NO BATTERIES! in medication refrigerators- meds only!
 Refrigerator temperatures are monitored by Pharmacy and Engineering remotely via Aero scout

o Remember to close door completely to prevent out of range temperature
o Unit to keep the refrigerator clean and frost free
 All drugs and biologicals must be secure
o Secure - defined as locked container in a locked room or under constant surveillance
o Carts are not secured since they are mobile
 Remember to lock your WOWs- do not leave medications in or on WOWs
o No medications are left at bedside
 Controlled substances: must always be secured, waste documented, discrepancies reconciled. IT IS
See PCS 2-2-020 Refrigerator Monitoring PCS 6-029 Intentional Warming of Sterile Solutions

Medication Orders (PCS 6-009)

 Medications need to be clear and applicable to patient’s needs
 Incomplete, illegible, or unclear medication order requires clarification prior to implementing
 PRNS need indication – e.g. DiphenhydrAMINE: Itching? Rash? Sleep?

Clinical Annual Education- August 2017

 PAIN orders – need to indicate MILD, MODERATE, or SEVERE pain

 Unless otherwise specified by prescriber, the pain score is: Mild 1-4, Moderate 5-7, Severe is 8-10

o Repeat back and verify orders. Many sound alike e.g. Celexa, Celebrex
o READ labels THREE times – many drugs look alike
o Tall man lettering helps differentiate e.g. HYDROmorphine and morphine

Medication Administration

Medications will be taken to the patient, scanned and opened in front of the

 Verify correct patient utilizing two patient identifiers
 Verify the 6 patient rights: right patient, right drug, right dose, right time, right route, and

 Verify there are no allergies or contraindications to administering medications
 Visually inspect the medication integrity (no particulates, etc)

READ the order comments – may have information such as prescriber specific
orders such as hold parameters, administration information (DO NOT CRUSH, IV

push rate, etc)

 Self-Medication Administration
o Patient self-administration may be allowed if patient is documented to be competent
(competency must be documented)
o PCA administration is by the patient only
o Reinforce to family members

High Alert Medications PCS 6-005

 High alert medications have additional safety strategies such as only restricted access, required lab
before initial dose (warfarin), double checks, etc.

 Doses requiring INDEPENDENT double check verification by a second healthcare professional prior to
administration include:

 Heparin  Antineoplastics
 Magnesium sulfate in the OB  All medications on neonatal units
 Epidural and PCA infusions pump programming also
 Insulin must be double checked (PCS 6-005)
 IV narcotics on pediatric units

Clinical Annual Education- August 2017

Do not bypass their safeguards!

 Independent double checks play an important role in error detection
o The independent nurse verification promotes the second nurse to identify the medication,
dose, and patient without assistance from the first nurse to ensure accuracy immediately prior
to administration of the high alert medication

Use IV pump drug library

Medication Reconciliation NPSG

 Upon admission, current medications are recorded in Document Medication by Hx
o Enter medications accurately – Careful with ER & regular products
o Include last dose information in compliance section – avoids duplicate administration.
o Do not send medications home with family member until a pharmacist has determined if
medication is on the formulary

 Reconciling on Transfer/Discharge
o Transfers orders
 Required for change in level of service
 Review for medications held due to procedure/surgery like aspirin, warfarin, etc.
o Prior to discharge
 Validate discharge reconciliation is complete and reflects accurately onto medication
depart list.
 Clarify any discrepancies with the prescriber


Patient Assessment

 How Large is the Patient?
 Larger patients require more caregiver support and specific types of assistive devices
 Can the Patient Bear Weight?
 If patient is fully weight-bearing, caregivers may only need to stand by to help if needed
 If patient is partially weight-bearing, the patient may be able to assist with the transfer
 Non-weight-bearing patients will need assistive devices capable of supporting their full weight and/or a

number of caregivers who can safely handle their full weight
 Is the Patient Cooperative and Able to Understand Instructions?

o Non-cooperative patients require more caregivers

Clinical Annual Education- August 2017

 Does the Patient Have Arm Strength?
o Patient’s with arm strength can help with transfers using devices such as a trapeze

 Does the Patient Have any special conditions?
o Patients with wounds, lines, contractures, etc. may need special handling procedures

Safe Patient Handling Algorithms

 How large is the patient Based on the answers to these
questions, the algorithm indicated:
 Can the patient bear weight
o Fully?  Best transfer method
o Partially?  Number of caregivers needed
 Type of equipment needed
 Is the patient cooperative and able to
understand instructions?

 Does the patient have arm strength?

Body Mechanics

 Keep the Body in Alignment

Clinical Annual Education- August 2017

o Maintain the 3 Natural Curves in the Back
 In at the neck
 Out at the ribcage
 In at the low back

 Maintain Balance
 Use the Largest and Strongest Muscles of the Body to Do the Work

o Never use muscles of the back to lift
o “Lift with your legs”

Mobilization Best Practice

 Involve the Patient When Possible
 Explain the Lift or Transfer
 Use Devices That Allow Patient to Help When Possible

o Trapeze
o Footboard
 Use Appropriate Size “Vehicle” for Transport
o Wheelchair, Stretcher, Bed, etc.
o Push transfer vehicle – Don’t Pull!!

Assistive Devices

 OSHA Recommends:
o Minimize (or eliminate) strict patient handling
 Refers to patient handling that uses only the muscles of the caregiver to lift or transfer
 Use appropriate assistive devices to avoid strict manual handling
o Eliminate Manual patient Handling When Possible

 Mechanical Lateral Transfer Aids
o Height adjustable stretchers transfer patients mechanically
 Hand cranked or motorized
o Independent devices are available for use with most beds and stretchers to mechanize transfers

 Mechanical Lifting Devices
o Portable total lifts
o Sit to stand lifts

Friction-Reducing Lateral Slide Aids

 Transfer Boards
o For supine lateral transfers
o Provides smooth, low-friction surface to facilitate transfer of patient from bed to stretcher, etc.

 Air-Assisted Sliding Aids (i.e. HoverMatt®)
o Flexible mattress placed under patient
o Air flow through mattress allows patient to be transferred on an “air-cushion”

Clinical Annual Education- August 2017

o Significantly reduces manual effort required to accomplish the transfer

Important to Remember

Proper Body Mechanics Alone Can Not Prevent Injury!



 Federally designated Organ Procurement Organization (OPO) that works with your hospital to facilitate
organ donation

 Works collaboratively with Lions Eye Institute for the recovery of eyes and corneas
 Designated service provider for 63 hospitals in the West Central Florida area
 Certified by Centers for Medicare and Medicaid Services (CMS), Agency for Healthcare Administration

(AHCA), and Association of Organ Procurement Organization (AOPO)

Hospital Requirements: CMS & The Joint Commission

 Hospital provides timely notification to OPO for every imminent or cardio-respiratory death
 OPO determines medical suitability
 OPO, as the trained requestor, discusses donation with the family
 OPO operates in accordance with HIPAA regulations

Tissue Donation

 Heart Valves
o Replace diseased, damaged, or deformed heart valves

 Tendons and Ligaments
o Repair shoulder, knee, and joint injuries

 Bone grafts
o Prevent amputation
o Reconstruct skeletal defects due to trauma, degenerative disease, and fractures

 Skin
o Temporary graft to reduce infection and healing time of burn patients

 Corneas
o Restore sight

 Whole eye tissue

Clinical Annual Education- August 2017

Organ Referral Process

Call 1-800-64-DONOR (36667)
Intubated, brain injured patients, which meet ANY of the following criteria:

 GCS ≤ 5
 No pupillary, corneal reflex
 No cough/gag
 No spontaneous respirations


 Hospital staff to call LifeLinkat:1-800-64-DONOR (36667)
 Call within 1 hour of death
 Referral triaged to appropriate screener/coordinator
 Have chart available when calling in a referral
 Coordinator returns call
 Screening for contraindications is crucial to protect tissue/organ transplant recipients

Every Referral Counts
Saving Lives Begins with You!



An Unpleasant Sensory and Emotional Experience Associated with Actual or
Potential Tissue Damage, or Described in Terms of Such Damage.

Clinical Annual Education- August 2017

Treatment of Pain: A Multimodal Approach

Pharmacologic interventions

 Cornerstone of treatment for the management of pain
 Right agent – based on type (somatic, visceral, neuropathic) and severity of pain and patient

 Right dose – controls pain with fewest side effects
 Right route – oral when possible. If has IV pain med ordered, may administer 30min after oral dose

after reassessment if needed.
 Right time – PRN versus around the clock. Document your reassessments.

Non-pharmacologic interventions

 Physical modalities
 Psychosocial/cognitive-behavioral interventions
 Spiritual care

Regional interventions (nerve blocks, epidurals)

Treatment of Common Adverse Drug Effects

 Constipation
o Patients do not develop tolerance to constipation; it requires scheduled stimulant laxative +/-
stool softener e.g. Sennosides + Docusate (Senna-S)

 Nausea / Vomiting

Clinical Annual Education- August 2017

o Tolerance usually develops in 3-5 days to nausea/vomiting
 Pruritus

o Not an immune mediated allergy (unless rash/bronchospasm/anaphylaxis)
 Secondary to histamine release
 Push IV opioid slower (5 minutes)



 Requires MD order to initiate.
o In an emergency, RN may initiate restraints but the physician must be notified ASAP and the
order obtained.
o Initiation of restraints may be obtained by verbal/telephone order if necessary.

 NO PRN restraint orders

Restraints should be the last resort.

Types of Restraints

 Behavioral
o An eminent violent threat to self
o An eminent violent threat to others

 Medical
o Patient is unable to follow a plan of care.
o Attempting to pull medical equipment, dressings,
o Unable to ambulate independently but is actively attempting to get
out of bed
See Policy 120.86 Restraints

Behavioral Restraints

 Adult Patients
o MD order every 4 hours

 Children and adolescents (under age 18)
o MD order every 2 hours

 Children (under 9)
o MD order every 1 hour

 Clinical staff sitter is required

Clinical Annual Education- August 2017

o Close observation is needed because patient cannot eat, drink or toilet independently.

Medical Restraints

 MD order is required within 12 hours of initiation
 MD must evaluate the patient daily.
 New orders for restraint shall be obtained only if the restraint is discontinued and needs to be


Physician Assessment

 Behavioral restraint assessment should be done within 1 hour of initiation.
 Medical restraint assessment should be done face to face within 24 hours


 Medical restraint patients assessments are documented every 2 hours
 Behavioral restraint patients in restraints require documentation every 15 minutes

Documentation Highlights

 Ensure physician’s order is obtained ASAP
 All preventative strategies, innovative alternatives attempted prior to restraint application are noted
 Reason/actions that required the patient to be restrained.
 Complete restraint section on EMR.

EMR Charting

Clinical Annual Education- August 2017


Why is it important?

 It is the law!
o Resource Conservation and Recovery Act (RCRA)
o Protect our environment

 For employee safety
o Items identified as cytotoxic or chemotherapy require special handling and/or disposal

 Cost containment
o We pay by the pound for hazardous waste
o Non – compliance FINES expensive- up to $50,000/day per hazardous waste violation

Hazardous Medications

Non Chemotherapy

 Includes antiviral, hormones, immunosuppressants, etc
 Labeled “Cytotoxic”
 Use proper precautions, including but not limited to wearing gloves

Clinical Annual Education- August 2017

 Use gloves when handling transdermal hormonal patches
 Identified in EMR e.g.,
 “DO NOT CRUSH. Note active ingredients are surrounded by wax matrix to prevent healthcare

exposure; women who are pregnant , or may become pregnant should not handle crushed or broken

Chemotherapy Agents

 Labeled “Caution Chemotherapy”
 Proper PPE required
 Use proper precautions, including but not limited to wearing gloves (e.g., oral administration)
 See PCS 6-010 Cancer Chemotherapy Administration policy

BLACK containers: when there is medication left in a vial, syringe, ampoule, IV bag,
pills, medicated creams and capsules.

Medications left in a sharp
• Syringe (with meds)
• Ampoules (with meds)

Medications left in a non-sharp format
• Partial IV bags, partial vials
• Pills/capsules
• Medicated creams

No empty IVs, trash, gloves, etc.

*No controlled substances
* Remove patient identifiers and disposed appropriately before disposing medication

REQUIRES SPECIAL DISPOSAL: Aerosols, Flammables, Oxidizers

These labels indicate return these products to Pharmacy for proper disposal

Aerosols Flammable Oxidizers (Silver nitrate-unused)

Clinical Annual Education- August 2017

Incompatible Rx wastes include: aerosols/flammables (SP) oxidizers (SPO): unused silver nitrate



 Quality control (QC) is used to ensure the bedside test will be of good quality.
 The operator checks the quality of instruments and reagents; including strips, cards, cassettes,

verifying they are ready for use.

Clinical Annual Education- August 2017

The patient is properly identified using 2 identifiers.

 Whole Blood Glucose QC solutions and glucose strips bottles must have the corresponding 90 and 180
days expiration date visible on them.

 Check the orange label containing the received, opened and expiration dates prior to run patient’s

 Contact the POC department to obtain more supplies if the label is missing or the supplies are expired.

Quality Control


 Required within 24 hours prior to patient testing.
 Consists of 2 levels of control solution
 QC testing is also required when opening a new bottle of strips
 Glucose quality control solutions expire 90 days from opening date.


 Internal Quality Control – happens at the same time the patient specimen develops.
 This internal control must be valid or acceptable before accepting the patient result.
 When controls are found to be unacceptable, patient testing is not reported. The testing is redone

(repeated) on a new card or strip cartridge.

Quality Control – If QC Fails

 The operator must repeat the testing.
 Reasons for failure; the quality control solution may be out of date, the lid or cap left off the strip vial,

or the QC solutions vials were switched when tested?
 Retest and if results still fail, retest with new control solutions or a new vial of strips.
 Quality control must be within acceptable range.
 Patient testing must be sent to the Laboratory until a solution has been found.
 Document what you have done by using comments from the dropdown box.

 Anytime an issue is not resolved, Call POC @ 57209, a POC Laboratory staff member will help you
resolve this situation.

 Send patient specimen to the Laboratory.

Specimen Collection

 Proper Identification of patient.
 Wearing gloves to collect the specimens.
 Specimens must be collected properly, refer to Mosby’s
 All specimens must be labeled bedside. If collected in some form of a container, cup, test tube, vial or

card, it must be labeled with the patient’s name, MRN or FIN, date, time and OPID. Use red ink pen.

Clinical Annual Education- August 2017

 Specimens not collected properly will be rejected because the results from that specimen may be
compromised, not reflecting the true results for the patient.

Whole Blood Glucose

 NOVA Bedside glucose meters are used for glucose testing.
 The glucose strips for use with the NOVA glucose stat strip meter are only
the strips labeled NOVA stat strip. Do not use any other glucose strips.
 The glucose meter allows scanning of both operator’s and patient’s
identification bar codes.
 Manually entering an account number may introduce an error in
identification, so scan the patient’s bar coded identification armband.

Testing the patient

 Clean the side of the finger you intend to use. Let dry.
 Stick the side of the finger.
 Wipe away the first drop of blood.
 When dosing the glucose strip, the strip is filled from the end of the strip.

Whole Blood Glucose – Testing

 A beep will be heard if filled properly.
 Do not touch the strip to the finger a second time
 Discard the test strip and repeat the test using a new strip
 Any initial critical glucose result must be immediately rechecked or verified by laboratory testing.

Interfering Substances

 There is a potential for incorrect glucose results from patients with decreased peripheral blood flow.
Examples: severe dehydration, hypotension shock, peripheral arterial occlusive disease.

 A venous specimen must be used for glucose monitoring if these conditions apply.
 For possible interfering products refer to Policies/ Procedures found in ARC under Patient Care Services

Whole Blood Glucose Maintenance

 Turn the instrument off after testing.
 Wipe down the instrument in-between each patient using the hospital’s approved disinfectant.
 Squeeze out excess moisture from the wipes before cleaning the instrument (Moist , not Wet)
 Let dry
 The glucose meter must be completely dry before placement back into the downloader – recharger.
 The instrument must be placed in the downloader to recharge the batteries

Clinical Annual Education- August 2017

Occult Blood – HemaPrompt FG

Fecal and Gastric

 Open the Card
 Apply thin smears of fecal, gastric aspirate or

vomitus material to the two separate windows.
 Do Not cover the entire area of the specimen

 Immediately develop the card by.
 Turning the card over.
 Grip the card
 Lift up the silver tab and VERY slowly pull it

completely out
 Wait 60 seconds, then read results
 Any Blue color present in the patient areas indicate a positive result.

Urine Dipstick Testing

 Areas doing POC Urine Dipstick testing
 If the order includes a urine culture (C Urine) along with a urine dipstick
 Send the specimen to Lab for testing
 Do not do POC urine dipstick testing
 For immediate urine dipstick testing, separate the specimens into two separate sterile cups so the

urine dipstick does not contaminate the specimen needing a culture (C Urine).
 For immediate urine dipstick testing
 Separate the specimens into two separate sterile cups so the urine dipstick does not contaminate the

specimen needing a culture (C Urine).

2 Levels of Quality Control (QC) are tested:

 Once every 24 hours (every day) prior to patient testing or
 After opening a new bottle of strips.

Urine Pregnancy Testing

 The first morning urine specimen is the best specimen for a pregnancy screen because the
concentration of hCG is much higher

 The specific gravity of the patient’s urine should be more than 1.010
 Send urine specimens to Laboratory for testing if they are cloudy, bloody, or brown in color due to

possible interfering substances.
 For testing, use the pipette provided in the cartridge packaging.
 Add 3 drops of urine to the circular specimen well, wait 3 minutes do not read past 4 minutes.
 All valid tests must have a line present at C for control. C is the internal control of urine pregnancy

 Results are entered into the glucose monitor using it as a recording device

Clinical Annual Education- August 2017

Specific Gravity - Refractometer

 The TS meter must be cleaned using a soft cloth or lint free tissue, soap and water.
 Clean in between each specimen with water.
 Label your specimen cup or diaper prior to testing using two identifiers
 External Quality Control is done daily
 Quality control consists of Calibrator 1 which should read 1.000
 Calibrator 2 reading at a higher range, followed by controls Level 1 and Level 2
 See the acceptable range on the log-sheet.

pH paper or Nitrazine paper

 Quality control testing uses Quantrimetrix control solutions Level 1 and Level 2
 Do the QC by applying a drop of control to separate strips of pH paper for each control to ensure the

pH paper is ready for use.
 Results are recorded on the Quality Control (QC) log sheet
 Results must be within the expected ranges.
 Remember to initial the log sheet.

Post Analytical

 All Results must be reviewed by the operator and reported to the appropriate care giver
 If testing indicates a initial critical result, or a result is not believable for the patient, a specimen should

be sent to Main Laboratory to confirm the result.
 Critical results communicated to the appropriate care giver must be documented with date and time of

report and full name of the care-giver the report is given to.
 If equipment is used, it must be cleaned in-between each patient
 Care must be used to squeeze out any excess moisture so the equipment is damaged.

Where to Get More Information

 POC can be reached at x57209 as needed Monday-Friday 06:30 am – 08:00 pm
 Laboratory at x52105, 24 hours, 7 days a week
 Downtime Manuals are available from POC as needed
 Instrument can be supplied upon demand if your testing area is unable to locate theirs.

Clinical Annual Education- August 2017

Procedures can be found in ARC, Policies and Procedures, select Department
policies, policies are under either Patient Care Services or Laboratory, Point of Care

Alternate Site Testing.



IONIZING Radiation is used commonly in the healthcare setting, for both diagnostic and therapeutic purposes.
Both IONIZING radiation and other modern-day imaging techniques, such as magnetic resonance imaging (mri)
(Non-ionizing radiation), have greatly improved the quality of healthcare and increased the options available
to patients.

Because both radiation and MRI procedures involve powerful forms of energy, precautions must be taken to
prevent associated injury.

Radiation: Risks to Patients & Healthcare Workers

The primary health risk associated with exposure to ionizing radiation is an increased incidence of cancer.

Diagnostic ionizing radiation procedures expose patients to relatively small doses
of ionizing radiation, equivalent to the amount of background radiation a person
would naturally receive over the course of a few weeks, months, or years.

Thus, single diagnostic ionizing radiation procedures do not generally pose a risk
for patients or healthcare personnel.

Remember, however, that certain healthcare personnel are involved in
performing procedures involving radiation day after day, year after year. These
individuals are known as occupational radiation workers

If these personnel do not take appropriate precautions, their long-term occupational exposure to radiation
may reach levels which can pose significant health risks. We will take a closer look at situations in which
healthcare workers may be exposed to radiation, and how they can protect themselves.

Clinical Annual Education- August 2017

Radiation Sources

 Radiation used diagnostically and/or therapeutically may be broadly divided into four categories:
o Radioactive materials in nuclear medicine:
 Unsealed sources for therapeutic purposes
 Unsealed sources for diagnostic purposes
o Brachytherapy (sealed source implants
o External radiation beams
o Unsealed Source Therapeutic Radiation

Contamination from unsealed sources may be eliminated from patients that have this type of treatment. The
routes of elimination may be:

 Feces

 Urine

 Perspiration

Nuclear Medicine/Pet Scan: Radiation Dose and Elimination

Nuclear medicine uses relatively low doses of radiation.

As we have seen, however, this radiation is powerful (gamma-emitting).

Moreover, as with unsealed source therapeutic procedures, the radiation is not contained, and may be
eliminated from the patient's body by way of:

- Feces - Urine - Blood
- Vomit - Perspiration - Breath (moisture)

Until you know otherwise, treat all of the patient’s body fluids as potentially radioactive.

External Radiation Beams: Risks

Diagnostic x-ray procedures: the highest level of radiation comes from the primary beam aimed at the
patient. Secondary radiation scatters off the patient's body while the radiation is “on”.

Thus, as a caregiver, you are exposed to some scattered radiation while you are in the room during a
procedure. While in a room while the x-ray unit is energized (fluoroscopic or radiographic), you must wear a
leaded apron at all times. While operating a portable radiographic unit, you must wear a leaded apron.

Time, Distance, and Shielding

 The three key factors for limiting your exposure to radiation are time, distance, and shielding:
o Minimize the amount of time that you are exposed to the Radiation.
o Maximize the distance between yourself and the source.
o Use appropriate shielding to absorb the radiation, and prevent them from hitting YOU.

Clinical Annual Education- August 2017

 If you use time, distance, and shielding effectively, you will achieve the goal of ALARA: you will keep
your radiation exposure As Low As Reasonably Achievable.

General Precautions

Keep in mind the overarching concepts of time, distance, and shielding as you review the following list of
general precautions for working with radioactivity and/or radioactive patients:

Always work toward reducing the amount of time you or any portion of your body is exposed to a source of

Wear gloves and a protective impermeable gown at all times when handling sealed sources, radioactive
materials or potentially contaminated materials (e.g., patient excretions). Wash hands after removing gloves.

Always work at the greatest distance possible from a source of radiation, without compromising patient care.

Use shielding whenever possible. This may include lead or other shields set up in a radioactive patient's room,
or a lead apron when working around x-ray equipment.

Personnel Dosimetry

When issued personnel dosimetry (formerly referred to as film badges) , always wear them when working
around radiation producing equipment or radioactive materials.

If you must handle radioactive materials, always wear your ring badge with the detector facing the palm of
your hand to better assess extremity radiation dose.

When wearing a leaded apron, always wear your dosimeter on the collar (often hanging from a thyroid shield)
to properly assess dose to the unshielded head and eyes.

Specific magnetic resonance imaging (MRI) Safeguards

 Specific safeguards to ensure that ferromagnetic objects (such as iron objects) and electronic devices
remain outside the MRI field include:
o Controlling access to the strong-magnetic-field area of the MRI room itself (zone 4)
o Obeying warning signs outside the strong-magnetic field area
o Removal of metallic objects from clothing and pockets prior to entering the MRI room (wallet,
credit cards, hearing aid, watch, jewelry, pens, paper clips, safety pins, keys, coins, hair pins)
o Thorough screening of patients prior to MRI
o Using MRI-safe non-ferrous patient care items (only use MRI Safe oxygen tanks, IV poles, etc.)

Remember, MRI uses powerful magnetic and radiofrequency fields to visualize internal structures of the

MRI Safety: Removal of Metallic Objects:

Also be sure to remove:

Clinical Annual Education- August 2017

 Any article of clothing with metal:  Threads
 Zippers  Shoes
 Buttons  Belt buckles
 Snaps  Underwear containing silver or other metals
 Hooks
 Underwire bras (e.g. copper)

Visitors and untrained staff members must be screened before entering the MRI room itself. Any
metallic objects identified should be left outside the MRI room. Ferromagnetic objects are not
permitted in the MRI room.

Ferromagnetic objects can become dangerous projectiles, as they are attracted to the core of the MRI
magnet (the "projectile effect").

MRI Safety: Thorough Patient Screening:

Patients MUST be screened thoroughly prior to an MRI exam.

A thorough patient screening/questionnaire should establish:
 The nature of any previous surgeries
 The presence of any implants
 The presence of any foreign metallic bodies or prosthesis
 Any special medical conditions that may be relevant to the appropriateness of MRI

Any potential occupational exposure to metal fragments (if occupational exposure to metal fragments is
established, x-rays or CT scans should be obtained to rule out the presence of metal fragments in the eyes)

MRI Safety: Patient Screening - Contraindications to MRI

If patient screening reveals any of the following, MRI should not be performed.

Presence of an active electronic device in the body:

 Cochlear implant
 Nerve or bone stimulator
 Cerebral aneurysm clip
 Intraocular metal fragments
 Ferromagnetic foreign bodies
 Any unfamiliar device
 Cardiac pacemaker (except certain new models)

The items in this list should be considered absolute contraindications to MRI, unless and until absolute evidence to the
contrary is obtained.

MRI Safety: Patient Screening – Safe Metallic Implants

Patient screening may reveal metallic implants that are not absolute
contraindications to MRI.

These include:
 Orthopedic hardware
 Extracranial surgical clips
 Staples and wires
 All dental devices
 Intravascular stents, coils, and filters (if firmly embedded in the vessel wall)

Before MRI is performed, obtain medical documentation from the appropriate device vendor to verify the
safety of ANY metallic implant



 Sepsis kills 258,000 Americans each year.
 40% of patients diagnosed with severe sepsis do not survive
 It is a medical emergency that requires early

detection and treatment for survival
 A 2006 study showed that the risk of death from

sepsis increases by 7.6% with every hour that passes
before treatment begins


 Check every patient, every shift for sepsis using the Sepsis Screening Tool, not just when suspecting

 If the Severe Sepsis or Septic Shock Screening is positive:
 Obtain the following labs per policy:

o Lactic Acid,
o CBC with diff,
 “Time Zero” is the time when criteria has been met for Severe Sepsis or Septic Shock.
 Call for the Rapid Response Team(RRT) when the sepsis screen is positive.
 SBAR with the MD to get fluid resuscitation orders and come in for an evaluation of patient

Clinical Annual Education- August 2017


 Similar to trauma, AMI, or stroke, the speed and appropriateness of therapy administered in the initial

hours after severe sepsis develops are likely to influence outcomes
 To screen effectively, it must be part of the nurses’ daily routines (i.e. part of admission and shift



 The Sepsis Screening Tool provides a better understanding for the nursing staff to more readily identify
or suspect severe sepsis and septic shock

 The tool provides a step by step checklist to guide nurses in the assessment of sepsis
 When to contact the Rapid Response Team
 How to call the physician with SBAR
 What the treatment is for Severe Sepsis and Septic Shock


Clinical Annual Education- August 2017



 Verify physician’s order-make sure it’s not a duplicate
 Review the lab order label and collect all supplies needed

(appropriate color blood tubes to match tests)
 Identify the patient by name and FIN # using their ID band
 Explain the procedure to the patient
 Wash hands and put on gloves
 Scan the patient’s armband and print the labels for the blood

 Locate site for venipuncture by palpation of the vein
 Apply the tourniquet approximately 4 inches from the collection

 Cleanse the site with alcohol in a circular motion
 Insert needle with the bevel side up and place tube onto the needle
 If multiple tubes are needed, begin with the red top tube
 Collect necessary specimens
 Remove tourniquet after blood is flowing freely, remove needle when complete
 Apply pressure to the site with a gauze sponge until bleeding has stopped.
 Apply adhesive bandage to site
 Discard needle in sharps container, discard gloves
 Label tubes before leaving the bedside. Scan the labels and click sign on the computer.
 Place tubes in specimen transport bag - do not combine specimens from different patients
 You may attempt the procedure only twice before notifying another competency validated staff


Clinical Annual Education- August 2017

Blood Cultures

 Verify physician’s order, scan the patients armband and print the labels at

bedside. Explain procedure to patient

 If blood specimens are being collected at the same time as blood
cultures, the blood culture bottles should be filled first.
 No more than 3 sets of blood cultures are to be collected in a 24
hour period
 If multiple blood culture collections are ordered, collect from
different venipuncture sites 15 minutes apart
 Each blood collection should include one aerobic (blue top) and
one anaerobic (purple top) bottle
Wash hands and put on gloves
Remove the plastic cap from the blood culture bottles and wipe the top
of the bottle vigorously with a sterile alcohol pad
 Using a back and forth friction scrub, apply the chlorhexidine swab to the
venipuncture site for 1 minute then turn the swab to the other side and repeat for 1 minute. Allow to
dry on the skin
 Apply tourniquet, perform venipuncture and inoculate the bottle-always inoculate the aerobic bottle
(blue or grey top) first and then the anaerobic (purple top). Avoid injecting air into the anaerobic
 Once complete, apply pressure to the puncture site and apply adhesive bandage
 Dispose of needle in sharps container.
 Place the lab barcode label vertically on each specimen, scan the label and click sign on the computer,
prior to leaving the patient’s bedside, mark the time, source on the bottles. Do not cover the barcode
on the bottle
 Transport to laboratory promptly.


 For all specimens, verify physician’s order, identify the patient
using patient name and FIN number from patient ID band, collect all
supplies, wash hands and put on gloves.

Foley Cath Specimen Collection

 Clean port on drainage tubing with alcohol swab
 Insert syringe and needle and withdraw 10-20 ml urine
 Place urine into sterile specimen container, scan the patient’s
armband and print the labels that are needed scan the labels after they
are placed on the container and click sign in the computer then write the
source prior to leaving the patient’s bedside and send to lab.

Clean Catch Specimen Collection

 Give detailed instructions to the patient for specimen collection. Assist as


Clinical Annual Education- August 2017

 Place urine into sterile specimen container, scan the patient’s armband and print the labels that are
needed scan the labels after they are placed on the container and click sign in the computer then write
the source prior to leaving the patient’s bedside and send to lab.

 Label specimen with patient label and the date, time, source, and your OPID prior to leaving the
patient’s bedside and send to lab

Straight Cath Specimen Collection

 Follow Indwelling/Straight Cath Procedure
 Obtain sterile specimen
 Place urine into sterile specimen container, scan the patient’s armband and print the labels that are

needed scan the labels after they are placed on the container and click sign in the computer then write
the source prior to leaving the patient’s bedside and send to lab.


 Verify physician’s order
 Identify the patient using the patient name and FIN number from the patient ID band, collect all

supplies, wash hands and put on gloves
 Explain procedure to the patient
 Wait 1-2 hours after patient’s last meal
 Have patient rinse mouth or brush teeth with sterile water or saline
 Place patient in semi-Fowler’s or sitting position. If suctioning specimen, place patient in high Fowler’s.
 Provide patient with specimen container
 Instruct patient to take 3-4 slow deep breaths and have patient cough fully and expectorate sputum

directly into specimen container. Have patient repeat until adequate specimen has been collected.
 Scan the patient’s armband, print the lab labels, label specimen with the lab label, scan the label, click

sign and write on the label the source, prior to leaving the patient’s bedside and send to lab.

If suctioning the patient for specimen:

 Connect suction tube to adapter on sputum trap
 Apply sterile gloves
 Connect sterile suction catheter to rubber tubing on sputum trap
 Thumb should be on trap prepared to provide suction and trap should be covered
 Gently insert tip of suction catheter through nasopharynx, endotracheal tube or trach tube without

applying suction
 Advance catheter into trachea
 As patient coughs, apply suction for 5-10 seconds, collection 2-10 ml of sputum
 Remove catheter without applying suction, then turn off suction
 Detach catheter from specimen trap, and dispose of catheter
 Scan the patient’s armband, print the lab labels, label specimen with the lab label, scan the label, click

sign and write on the label the source, prior to leaving the patient’s bedside and send to lab.

Clinical Annual Education- August 2017


 Verify physician orders
 Scan the patient’s armband, print the lab labels, collect all supplies, wash hands and put on gloves
 Connect the mucus trap (Luken’s tube) to a suction pump and catheter, turn on suction and adjust to

suggested suction pressure.
 Insert the end of the catheter through the external nares to the posterior pharynx
 Apply suction while slowly withdrawing the catheter, allowing the catheter to remain in the

nasopharynx no longer than 10 seconds.
 After aspiration, flush material out of catheter with 1-1.5 ml of sterile saline

o Label specimen with the lab label, scan the label, click sign and write on the label the source,
prior to leaving the patient’s bedside.

 Send to lab.
For nasal wash syringe method, nasal wash bulb method and nasopharyngeal swab collection, consult Mosby’s





Suicide Precautions

 Patients at risk:
o Previous suicide attempt(s)
o Expressing suicidal thoughts
o Family history of suicide or psychiatric illness
o Substance abuse, or alcohol abuse
o Traumatic stress disorder
o Chronic pain
o Poor prognosis
o Social stressors (divorce, money problems)

Typical Suicidal Behavior Warning Signs

 Irritability  Crying spells
 Anxiety/panic  Declining medications
 Agitation/impulsivity  Requesting early discharge
 Decreased emotional reactivity  Sense of hopelessness
 Refusing visitors  Refusing to eat

Clinical Annual Education- August 2017

 Verbalizations of self harm  Decreased interest in treatment or

Hospital Environmental Safety Risks

 Anchor points for hanging (coat hooks on doors and door handles)
 Plastic trash-liners
 Shower heads
 Towel bars
 Cords and lines of all kinds (i.e. blind cords)
 Sheets and blankets, curtains, shower curtains
 Mirrors
 Unsecured windows
 Unsecured toxic cleaning products
 Sharp objects

Assessment and Interim Safety Precautions

Suicide Risk Assessment indicates risk for suicide:

 Ask the patient if he or she has thought about suicide.
 If the answer is “yes,” ask the patient about previous attempts and family history.
 Inform the patient’s admitting physician immediately
 Institute suicide safety precautions
 Enter patient care order for “Suicide Precautions” in Cerner (signals Nutrition Services to provide an

isolation tray with plastic tableware only).
 Referral to Social Worker or Case Management.

Ask Any of the Following Questions

 Do you have a plan for how to kill yourself?
 Do you have what you need for your plan?
 Have you practiced your plan?
 Do you tend to be impulsive?
 How strong is your suicidal intent?
 Can you resist the impulse to hurt yourself?
 Have you heard voices telling you to hurt or kill yourself?

Precaution Strategies

 Removal of Harmful Patient Possessions by RN and Security officer team
 Sharp objects-nail files, razors, scissors
 Glass items-picture frames, mirrors, aftershave in glass bottles
 Belts, ties, straps, shoelaces, suspenders, scarves
 Lighters, matches

Clinical Annual Education- August 2017

 Tape, plastic bags
 Aerosol cans, aluminum soda cans
 Hair dryer, curling iron, other appliances with cords


 All patients in Baker Act status will be on suicide precautions.
 Psychiatric consultation is required on all admitted patients
 Maintained on suicide precautions.
 The Baker Act will be considered for all suicidal patients by medical staff.
 Suicidal Patients who try to leave A.M.A, and are not yet placed on Baker-Act status, will be verbally

detained until their physician can be reached. Security will be called to the scene.
 Engage the patient and family in the care and discharge plans.
 Effective hand off communication to all members of the Care Team is essential to ensure continuity of

care and a safe environment.
 Staff must accompany the patient off the unit for tests and procedures.
 No Lobby privileges will be granted to patients on Suicide Precaution status.
 Daily Physician assessment required; Physician order is required to discontinue Suicide Precautions.
 RNs, LPNs, NTs, CNAs can all monitor patients on suicide precautions
 RN assessment is required at least once per shift for continuing risk.
 Physician order for the nicotine patch or alcohol/drug withdrawal medication should be considered.
 Place patient in pewter gown for safety.


Spot A Stroke

Clinical Annual Education- August 2017

The National Patient Safety Goals (NPSGs) were established in 2002 to help
accredited organizations address specific areas of concern in regards to patient


The first set of NPSGs was effective January 1, 2003


 Difficulty swallowing
 Changes in mental status
 Numbness or tingling on one side of the body
 Difficulty speaking
 Vision changes: decreased, double or loss of vision
 Loss of coordination or balance

Clinical Annual Education- August 2017

Suspect Stroke? What to do?

If you suspect that your patient may be having a stroke:
Notify rapid response nurse (RRT) X66210

RRT will assess pt. and call stroke alert as needed

Obtain point of care blood glucose
Determine when patient last appeared “normal”?

 Be ready to provide a brief health history of patient (including medication i.e. anticoagulants, HX of AF,
recent lab work.)

 Prepare patient for rapid transport to emergency room CT
o Obtain portable cardiac monitor and O2 tank
o Take patient belongings as pt. will be going to 3M or ICU


Who is responsible?

All clinical staff who are involved in surgical and invasive procedures taking place both
inside and outside Surgical Services are required to review and know the “Universal
Protocol” Operative Invasive Safety Management Process and documentation.
Why bother?

To Keep OUR Patients SAFE

What is it?

 Guidelines intended to prevent surgery/procedure errors
o Wrong Site
o Wrong Procedure
o Wrong Person

 Required by Joint Commission, CMS & ACHA

Clinical Annual Education- August 2017

 Applicable to ALL Operative/Invasive procedures
o Not just surgery in an Operating Room

 Includes three major steps

The Universal Protocol consist of several steps:

 A pre-procedure verification process.
 Marking the operative/procedure site.
 A “Time Out” (final verification) which is performed immediately before starting the surgery /

 Ensuring Antibiotic Stewardship
 And the Fire Risk Assessment with guideline implementation

Prior to transport to Pre-Procedure area:

 Complete the Pre-procedural Checklist (iView)
 Obtain Operative/Invasive Procedure Consent
 Obtain Anesthesia Consent if applicable (page 2 of Operative/Invasive Consent)

If applicable, Practitioner/LIP performing procedure marks “initials” at procedure
site/spinal region or applies an alternative laterality identifier (i.e. Green Bracelet

and/or Tegaderm.)

Surgery / Procedure Area:

 Final Time-Out: Immediately prior to procedure start all procedure team members present must pause
and be actively involved and in agreement for the Final Verification Checklist process.

 The “Time Out” …
o Purpose: To conduct a final verification that the team is in agreement with all information.
o Process: Active communication among all members of the surgical/procedure team,
consistently initiated by a designated member of the team, conducted in a “fail-safe” mode,
that is, the procedure is not started until any questions or concerns are resolved.

The “Time Out” …

 MUST be done in the location where the procedure will be done, just prior to starting the procedure.
 MUST involve the entire Procedural Team
 MUST use active communication
 MUST be documented

Clinical Annual Education- August 2017

Patient Safety

“The achievements of an organization are the results of the combined effort of each individual.”
Vince Lombardi


Ventilator Checks

 Ventilator checks should be performed at scheduled times, on a regular basis, for all ventilator
patients, and should be done Q3 to Q4 hours & PRN

 Items to be checked are:
 Patient information
 Ventilator operation
 Physician orders
 Ventilator settings
 Patient response to mechanical ventilation
 Primary Responsibility of Respiratory Care Practitioner (RCP)

Unexpected Events

 Unexpected endotracheal tube self-extubations should be reported via Riskmaster report prior to the
end of the shift the incident occurred

 In the event of observed facial skin breakdown from ET tube securement device, and suspicion of a
stage one ulcer is noted, a wound care consult should be placed immediately or as soon as possible to
avoid further progression

Ventilator Alarms

 Life sustaining intervention
 Extremely critical/complex interaction between machine and patient
 Arguably most vital piece of equipment
 Complex variability between various designs/manufacturers

You have successfully completed annual mandatory education.
See you next year!

Clinical Annual Education- August 2017

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