Nursing Policies and Procedures  

 

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Nursing Procedures
   
Procedure Name
Alpha Key
Key Words

Abdominal Paracentesis, Assisting with

spe 01
.

Ankle-Brachial Indices (ABIs)

spe 08
.
Aquapheresis using the Aquadex Flexflow
car 12
.
Beds:
.
.
equ 09
.

Specialty Beds and Surfaces

skc 15
.
Bladder:
.
.

Bladder Instillation of Medication

cat 13
.

Bladderscan - Adult Patient

cat 14
.
Blood Components, Administration of :
.
.

Ordering, Obtaining, Identification, and Administration of Blood Products
(RBC, Platelets, Fresh Frozen Plasma, Cryoprecipitate) - Blood Reactions -
Adults and Pediatrics

blo 03
RBC    Platelets
Plasma
Cryoprecipitate
FFP

Using a Warmer for Warming Blood

blo 05
.

Albumin

blo 08
.

Coagulation Factors - Factor VIII, Factor IX and Prothrombin Complex Concentrate

blo 09
.
Blood Specimen Collection using the Bar Coding System
poc 07
.
Collection of Diagnostic Blood Specimens by Venipuncture Method
spe 19
.
Blood Culture Collection Procedure
spe 20
.

Blood Collection Venipuncture in the NICU

nur 48
.
Bone Marrow Aspiration, Assisting with
spe 02
.
Blood Pressure, Measuring, Manual
equ 04
.
Carotid Stent Placement, Care of the patient following
car 14
.
Catheters, Urinary
.
.

Application and Removal of Male External Catheter

cat 02
.

Continuous Bladder Irrigation

cat 03
.

Suprapubic Catheter Change

cat 04
.

Catheterization - Straight and Retention / Care and Management /
Removal of Catheter - Adult

cat 05
foley
CAUTI

Urinary Catheter Irrigation

cat 06
.

Coude Catheter Insertion

cat 07
.

Intermittent Self-catheterization

cat 08
.

Urine Specimen Collection

cat 09
.

Use of Urojet/Lidocaine HC, 2% Jelly

cat 10
.

Centralized Telemetry Monitoring of Patients (CTM)

ctm 01

Troponin

Chest Tubes-Adults

tub 01
.

Chest Tubes-Discontinuation

tub 09
.

Critical Care:

.
.

Autotransfusion System for Use with Cardiac Surgical Patients

crc 06
.

Storage of Blood / Blood Components in the Cardiovascular Intensive Care Unit

crc 07
 

Care of Patient with Mediastinal Chest Tubes in the Cardiovascular Intensive Care Unit

crc 08
.

Intracranial Pressure Monitoring and Drainage of Cerebrospinal Fluid via Ventricular Catheter

crc 10

ICP
ventriculostomy

Return unused Blood / Blood Components to Suncoast Communities Blood Bank from CVICU

crc 11
.

Assisting with Emergent Open Sternotomy and Internal Defibrillation

crc 12
.

Care of Intra-Aortic Balloon Pumps (IABP)

crc 13
.

Care of Pulmonary Artery Catheters

crc 14

SWAN

Care of Radial Arterial Lines

crc 15
.

Prone Positioning of the Mechanically Ventilated Patient

crc 17
.

Measurement of Intra-Abdominal Pressure via a Urinary Catheter

crc 19
.

Therapeutically Induced Hypothermia for Cardiac Arrest or Acute Ischemic Stroke Patients

crc 20
.
Termination of Continuous Renal Replacement Therapy (CRRT)
using a Dual Lumen Catheter: (Sites: Subclavian, Femoral, Internal Jugular)
crc 21
.
Continuous Renal Replacement Utilizing the Prismaflex
crc 22
.
Peripheral Nerve Stimulator (Train-of-Four Stimulation Testing)
crc 23
.
Diabetic Procedures:
.
.

Diabetes Patient Education

dia 02
.
  1. Blood Glucose Testing-AccuChek Inform / Quality Control
poc 01
.
Insulin Administration:
.
.

7WT/ICU -DKA IV Patients Requiring Intravenous Insulin Drips - Adults

dia 11
.

Subcutaneous Single and Mixed Dose Insulin

dia 12
.

Management of Patient's Own Insulin Pump / Continuous Subcutaneous Insulin Pump Infusion

dia 13
.

Insulin Reaction / Hypoglycemia Protocol for the Adult Patient

dia 14
glucose

Diabetes Foot Care

dia 18
.
Dialysis Procedures - Hemodialysis:
.
.

Operational Guidelines for Hollow Fiber Dialyzer Preparation

dhd 01
.

AV Graft and/or Fistula Venipuncture

dhd 02
.

Fistula Points to Remember

dhd 03
.
Initiation of Dialysis Using a Temporary Catheter site
ie. Subclavian, Internal Jugular Vein or Femoral Vein
dhd 05
.

Maintenance / Care and Testing of Reverse Osmosis System / Hemodialysis Machines
and Portable R/O's

dhd 06
.

Operational Guidelines for Discarding the Prime

dhd 08
.

Blood Leak Guidelines

dhd 09
.

Operational Procedures for Recirculation

dhd 10
.

Presence of Chlorine in R/O Water

dhd 12
.

Termination of Dialysis Using a Fistula Access

dhd 15
.

Care of Dialysis Patient on the Inpatient Nursing Unit

dhd 16
.

Termination of Dialysis Using a Dual Lumen Catheter
(sites: subclavian, femoral, internal jugular)

dhd 18
.
Use of the TEGO Connector Caps on External Access of Hemodialysis Catheter
dhd 20
.

Dialysis Temporary Catheter (Insertion, Dressing Change, Removal, etc)

dhd 21
.

Guidelines for the Care of the Patient in the Hemodialysis unit

dhd 22
.

Measurement of Recirculation in the Vascular Access

dhd 37
.

Alarm System for Reverse Osmosis (R/O) Water System for Hemodialysis

dhd 41
.

Operational Procedure for Using the Crit Line

dhd 42
.
Checking for Residual Chlorine Post Bleaching Fresenius Machine
dhd 45
.

Pericidin Disinfectant Procedure  

dhd 46
.

Presence of Chlorine in Portable R/O Machine

dhd 47
.

Use of the Dialysis Catheter on Day Treatment Center (Dressing and Connector Change; Removal; Medication and Blood Draws; TEGO Cap Use)

dhd 48
.
Dialysis Procedures - Peritoneal Dialysis
.
CAPD

Peritoneal Dialysis, General Information for Nursing

dpd 01
.

CAPD Exchange Procedure

dpd 02
.

De-Clotting Tenckhoff CAPD Catheter using Alteplase (t-PA)

dpd 07
.

CAPD Transfer Set Change

dpd 12
.

Titanium Adapter Insertion-CAPD

dpd 13
.

Collecting and Preparing Peritoneal Effluent for Laboratory Testing

dpd 16
.
Use of Cyclers for Continuous Peritoneal Dialysis
dpd 17
.
Documentation
.
.

Admission Database – Adults (Downtime Procedures)

doc 02
.

24 Hr. Integrated Record/Integrated Narrative Notes (Downtime Procedures)

doc 03
.

Patient Discharge (Home Care) Instruction Form (Downtime Procedures)

doc 06
.

Nursing / Patient Collaborative Care Plan and Interdisciplinary Patient Plan of Care

doc 07
care plan

Interdisciplinary Patient Plan of Care- Downtime

doc 08
care plan

Pediatric Admission History

doc 12
.

Computerized Pediatric Nursing Assessment / Reassessment Flowsheet

doc 13
.
Ear Irrigation      
spe 11
.
Electric Hot Water Bottle (K-Pad), Application of
equ 05
K-pad  kpad
Endoscopy
.
.

Endoscopic Procedures - Colonoscopy

end 01
.

Endoscopic Retrograde Cholangiopancreatography (ERCP)

end 02
.

Gastroscopy (Panendoscopy, Upper Endoscopy )

end 03
.
Enemas - Irrigating and Retention       
spe 17
.
Enterostomal Therapy Procedures
.
.

Colostomy/Ileostomy, Changing and Care of the 1-piece Ostomy Pouch

ent 01
.

Colostomy Irrigation

ent 03
.

Loop Ostomy, Care and Pouching

ent 04
.

Urostomy and Ileal Conduit: Care and Management

ent 08
.

Obtaining Urine Specimen from Ileal Conduit/Urostomy (Culture & Sensitivity)

ent 09
.

Ileostomy Lavage

ent 10
.
Epicardial Pacing Wires
.
.

Epicardial Pacing Wires -Grounding

pac 01
.

Epicardial Pacing Wires - Dressing Change

pac 02
.

Epicardial Pacing Wires-Discontinuation

pac 06
.
Eye, Care of the Prosthesis
spe 13
.
Fecal Impaction, Removal of
spe 09
.
Femoral Sheaths
.
.

Care of Femoral Arterial Sheaths

car 04
.

Discontinuation of a Femoral Venous / Arterial Sheath and Groin Management

car 11
.

Gastrostomy Tubes (G-Tubes, PEG Tubes, Jejunostomy Tubes), Care and Maintenance

tub 02
.
Hemoccult Slide / Fecal Occult Blood Screening
poc 05
.

Hickman and Groshong Tunneled Central Venous Catheter Care and Maintenance

hic 01
.
Hyper / Hypothermia Blanket      
equ 06
cooling
warming
Incentive Spirometry
equ 02
.
Injections
.

Preparation and Administration of Subcutaneous and Intramuscular

inj 01
.

Injections: Z-Track Intramuscular

inj 02
.
Intermittent Pneumatic Compression Devices (IPCD) and TED Stockings
equ 08
.

                                                 Intravenous (IV) Procedures:

.
.

Summarized Protocol for the Management of Intravenous Therapy for Adult Patient

inv 01
.

Peripheral IV Therapy: Initiation and Care for the Adult Patient

inv 02
.
Intraosseous Needle Care and Removal
inv 08
.

Venous Central Line Catheters: Insertion, Dressing and Tubing Changes,
Blood Specimens, and Removal

cen 01
.
Management of Vascular Access Devices
cen 05
declotting, infiltration phlebitis, TPA extravasation, Regitine

Parenteral Nutrition and Intravenous Fat Emulsion (Adult and Pediatrics)

inv 11
TPN
Hyperal
Kidney Biopsy, Assisting with
spe 03
.
Lifevest, Care of the Patient Wearing
car 15
.
Liver Biopsy, Assisting with
spe 04
.
Lumbar Puncure, Assisting with
spe 05
.
Medications, Administration of
.
.

Administering Medications - Adults and Pediatrics

med 01
EMAR
Administration of Amphotericin B - Adult Patient
med 05
.
Administration of Cytovene-IV (Gancyclovir Sodium)
med 06
.
Administration of Intravenous Gamma Globulin (lgG)
(Adults/Pediatrics/ Adolescents / Neonatal)
med 07
IVIG
Care of the Adult Patient Receiving Intravenous Phenytoin (Dilantin) and Fosphenytoin (Cerebyx)
med 09
.
Administration of Transdermal Medication Patch
med 14
fentanyl
Sincalide (Kinevac) Injection: 3-minute IVP and 60 minute infusion for Cholescintigraphy
med 15
CCK
Tuberculin Skin Test
med 16
.
Medtronic Synchromed Infusion Sustem
med 08
.
Nasal Specimen Collection Protocol for MRSA DNA Testing
spe 18
.
Nasogastric Tubes
.
.
Nasogastric Tube Insertion, Feeding, Medications and Removal - Adult
nas 01
ng
Nasogastric Tube: Irrigation
nas 02
.
Insertion, Feeding, Medications and Removal of a Small Lumen Feeding Tube
nas 04
keofeed
Small Bowel Feeding Tube 10-10-10 Protocol
nas 05
.

Nephrostomy Tube Irrigation and Dressing Change

tub 03
.
Neurological Procedures
.
.
Lumbar Intrathecal Subarachnoid Cerebrospinal Fluid Catheter (Set-up and Maintenance) - Adults
neu 02
.
Intracranial Pressure Monitoring Using Camino Fiberoptic Monitoring Bolt and ICP Monitoring using Camino Fiberoptic Monitor and Drainage of Cerebral Spinal Fluid
neu 03
.
National Institute of Health Stroke Scale
neu 04
NIH
Nursery Procedures
.
.
Care of the Infant Born via Cesarean Section
nur 01
.
Admission of Infant to MBU
nur 02
.
Breast Milk Feeding Guidelines for Normal Newborn Infants
nur 03
.
Care of Fetal, Neonatal and Infant Deaths
nur 06
.
Gavage Feeding Procedure
nur 11
.
Exchange Transfusion of the Infant
nur 12
.
Circumcision
nur 13
.
Phototherapy for the Treatment of Hyperbilirubinemia
nur 14
.
Chest Tube Insertion in the Infant
nur 15
.
Insertion, Monitoring and Discontinuation of an Umbilical Catheter
nur 16
.
Interfacility Transfer of Patients To  / From the Neonatal Intensive Care Unit
nur 17
.
Administration of Red Blood Cells and Whole Blood to a Neonatal Patient
nur 18
.
Use of IV PRN Adapters: (Initiation, Maintenance, and Discontinuation) - NICU
nur 19
.
Care of Neonate on a High-Frequency Oscillating Ventilator
nur 20
.
Surfactant Administration to the Neonate
nur 21
.

Safety in the Use of Cutting or Sharp Instruments in the NICU

nur 23
.
Collection, Storage and Handling of Expressed Breast Milk; Use of Pumps and Pump Rooms
nur 24
.
Skin Care Protocol for the Very Low Birth Weight Infant
nur 26
.
Sucrose Administration in the NICU, Pediatrics and MBU
nur 27
.
Guidelines for Neonatal Abstinence Syndrome: Assessment  and Management
nur 28
NAS
Neonatal Pain Management Protocol-NICU
nur 29
.
Vital Signs for the Micropreemie Patient
nur 30
.
Lighting, Positioning and Bedding Guidelines for Infants in the NICU
nur 31
.
Developmentally Supportive Care of the Premature Infant’s Sensory System in the NICU
nur 32
.
Kangaroo Care
nur 34
.
Isolette Covers
nur 35
.
Procedure for Insertion, Dressing Changes, Blood Culture Obtaining, and Exchanges
of PICC Catheters and Midline Catheters in the NICU
nur 36
.
Breast Milk ID Scanner Procedure
nur 40
.
Alternative Feeding Methods
nur 41
spoon cup

Administering Medications - Neonatal ICU patients, Newborn Nursery Infants

nur 42
.
Parenteral Nutrition-Neonatal
nur 43
.
Procedure for Reconstituting Ampicillin in the NICU
nur 44
.

Glucose Monitoring-Neonatal

nur 45
.

Apnea of Prematurity & Bradycardia (Cardiorespiratory Events)
Management, Monitoring and Documentation

nur 47
.

Venipuncture Blood Collection for Neonatal Labs and Blood cultures in the NICU

nur 48
.
Neonatal Herpes Simplex Virus (HSV) Culture Collection
nur 49
.
Enteral Feedings for Infants less that or equal to 1500 grams
nur 51
.
Obtaining Admission Labwork from Placenta in the NICU
nur 52
.
Use of Donor Breast Milk
nur 53
.
Obstetrics Procedures
.
.
Care of the Patient Requiring Cesarean Delivery
obs 01
.
Magnesium Sulfate Administration for Antepartum, Intrapartum and Postpartum Patients with Pre-Eclampsia
obs 03
.
Magnesium Sulfate for Neuroprophylaxis
obs 04
.
Non-Stress Testing (NST) Vibroacoustic Stimulation (VAS)
obs 05
.
Oxytocin Induction / Augmentation of Labor
obs 08
.
Protocol for Cervidil/Misoprostol (Cytotec)
obs 09
.
Delivering a Twin Gestation by Means of a Double Set-up in the Labor and Delivery Setting
obs 11
.
Obtaining Blood Gas from the Umbilical Cord
obs 13
.
Amnioinfusion (Al)
obs 19
.
Termination of Pregnancy
obs 23
.
Care of the Intrapartum Patient Receiving Continuous Intravenous Insulin Administration
obs 25
.
Blood Type/Rh Testing Obstetrical Patients
obs 27
.
Cordocentesis
obs 28
.
Nitroglycerin Administration in the Intrapartum Setting
obs 29
.
Care of the Patient Requiring an External Version
obs 31
.
Fetal Fibronectin Specimen Collection
obs 32
.
Extraamniotic Foley Catheter Balloon Placement-Cervical Ripening
obs 33
.
Intrauterine Catheter Replacement / IUPC
obs 34
.
Fetal Spiral Electrode Placement
obs 35
.
Release of Placenta to Patient after Childbirth  
obs 37
.
Post-partum Perineal Care
gyn 01
.
Oncology Procedures
.
.
Administration of Chemotherapeutic Agents and Biotherapies
(Including Monoclonal Antibodies) - Adult
onc 01
.
Use of Drug Information Sheets when Administering Chemotherapy
onc 02
.
Administering (Non-Vesicant) Chemotherapeutic Agents by Intravenous (IV) Push
onc 05
.
Handling Excreta from Patients Receiving Chemotherapy
onc 07
.
Disposing of Chemotherapy Tubings, Solution Bags and Syringes
onc 08
.
Handling Liquid Chemotherapy Spills
onc 09
.
Chemotherapy Extravasation Management Guidelines
onc 10
.
Care of the Patient Receiving High Dose Cytarabine (ARA-C) Chemotherapy
onc 16
.
Radiation Therapy
onc 18
.
Calculating Doses per Meter Squared and Area under the curve (AUC)
onc 19
.
Mucositis - Mouth Care
onc 20
.
Thrombocytopenia Precautions
onc 21
.
Neutropenia Precautions
onc 23
.
Intraperitoneal (IP) Port Use for IP Chemotherapy Administration
onc 24
.
Administration of Peripheral Vesicant Chemotherapy (PVC)
onc 26
.
Use of the CADD-Legacy Plus Model 6500 Ambulatory Infusion Pumps
for Continuous Infusion Chemotherapy
onc 27
.
Orthopedic Procedures
.
.
Casts, Application and Care
ort 02
.
Cast Cutting
ort 03
.
Traction: Overhead Frame
ort 05
.
Traction: Unilateral or Bilateral Leg Traction (Buck's Traction)
ort 06
.
Traction: Cervical Traction
ort 07
.
Immobilization: Cervical Collar: (Soft Collar, Phillie Collar)
ort 11
.
Pin Care
ort 12
.
Orthopedic Spreader - Abduction Pillow
ort 13
.
Log Rolling
ort 14
.
Harris Splint with Pearson Attachment and Overhead Frame (Balanced Traction)
ort 17
.
Intracompartmental Pressure Monitor System
ort 20
.
Orthopedic Drainage/Reinfusion System
ort 23
constavac
Cold Therapy Unit / Ice Machines (for Orthopedic Patients)
ort 24
.
Continuous Passive Motion Machine (for Orthopedic Patients)
ort 25
CPM
Pacemaker
.
.
Care of Patients with Temporary Pacemakers and Determining Pacemaker Threshold
pac 03
.
Care of Patients Requiring Temporary Epicardial Pacemakers Including Grounding, Dressing Change and Discontinuation
pac 07
.
Patient Transfer (Unit to Unit)
trn 02
.
Transferring a Patient to In-House Hospice Care and Discharge
trn 05
.
Pediatrics Procedures
.
.
Use of the Apnea Bradycardia Monitor, (Pediatric)
ped 01
.
Gastrostomy Tubes (G-tube) Care and Re-insertion (PEG, G-Tube, Button) - Pediatric
ped 05
.
Insertion and Placement of the Nasogastric (NG) or Orogastric (OG) Tubes
ped 06
.
Pediatric Enteral Tube Feedings or Medications
ped 07
.
Accessing/Deaccessing of an Implanted Vascular Device for Continuous Intravenous Infusion or Adapter (Pediatric)
ped 08
port,  VAD
Toy Cleaning in the Pediatric Unit
ped 09
.
Gastric Suction, Gravity Drainage and Irrigation (Pediatric)
ped 15
.
Peripheral IV Therapy: Initiation for the Pediatric Patient
ped 16
.
Music Room (Instrument) Cleaning on the Pediatric Unit
ped 17
.

PICC and Midline IV Catheters: Insertion, Removal, Care, and Mainenance

pic 00
.
Pleurodesis (Instillation of Medicine), Assisting with
spe 06
.
PleurX Catheter and Drainage System     tub10
.
Preoperative Care -- Preparation of the Patient for Surgical Operation
pso 01
surgery
pre-op
Pulse Oximetry Utilization
equ 03
.
RAD - Care of the patient following Diagnostic or Interventional Catheterization via the Radial Arterial approach with RadStat Compression System or TRB compression device
car 13
.
Rectal Tube (Flatus)
tub 04
.
Rectal Tube (Flexiseal)
tub 08
.
Restraints
.
.
Applying Hard Restraints
res 01
.

Applying Soft Restraints

res 02
.

Posey Bed Enclosure (Ordering and Use)

res 05
.
Roller Board / Slider Board
trn 03
.
Seizure Precautions - Adults
neu 05
.
SCM (CareVISION) flags; Hold and conditional orders
scm 01
.
Skin Care
.
.
Protective Barrier Wipes – Skin Sealants (Kendall Preppies)
skc 01
.
Hydrocolloid Dressing (Duoderm)
skc 02
.
Polymem Wound Dressing
skc 03
.
Skin Care for the Incontinent Patient
skc 04
.
Film Dressing (Thin Transparent Dressing)
skc 05
.
Treatment Protocol for the Care of Skin Tears
skc 06
.
Hydrocolloid Wafer Skin Barrier
skc 08
.
Wound Care - Wet to Moist Dressings
skc 09
.
Preventive Skin Care
skc 10
.
Gel Wound Dressing (Amorphous Gel)
skc 11
.
Calcium Alginate Fiber/Aquacel or Aquacel AG Hydrofiber Dressing
skc 13
.
Specialty Beds and Surfaces - SEE: Beds (above) skc 15 .
Skin Care upon Admission
skc 16
.
Speculum Exam - Preparing Patient for Papanicolaou Test (Pap Smear)
gyn 03
.

Stool Specimen Collection and Transport, Procedure for

poc 06
.
Suction
.
.
Pharyngeal Suctioning
suc 01
.
Nasotracheal Suctioning
suc 02
.
Endotracheal Suctioning of the Adult Patient
suc 03
.
Gastric Suction - Gomco
suc 04
.
Suture Removal
spe 14
.
Suture - Skin Staple or Clip Removal
spe 15
.
Thoracentesis, Assisting with
spe 07
.
Tracheostomy Care
tub 07
.
Transfer Belt / Gait Belts
trn 01
.
T-Tubes
tub 06
.
Tube Feedings
.
.
Administration of a Feeding or (Continuous or Intermittent) or Medication via a Gastrostomy Tube - Adult
tuf 04
.
Administration of a Feeding or Medication via a Jejunostomy Tube - Adult
tuf 05
.
Implanted VAD (Implanted Port) Care and Maintenance
vad 01
.
Wound Care
.
.
Wound Suction (closed) - Hemovacs and Davols (Jackson-Pratts)
wou 02
JP, J-P
Application of Steri-Strip Skin Closures
wou 03
.
Sterile Dressings
wou 04
.
Discontinuing Hemovac / Davol / Jackson-Pratts Drains
wou 05
JP, J-P
Penrose Drain: Withdrawal /Discontinuation
wou 06
.
Wound Debridement
wou 07
.
Vacuum-Assisted Closure (VAC) Therapy (Wound VAC)
wou 08
VAC
Medical Maggot Debridement Therapy
wou 09
.
MedX Phototherapy
wou 10
.

Wound and Ostomy Care (WON / ET)

wou 11
.
Medicinal Leech Therapy
wou 12
.
 
.
.
NURSING POLICIES
.
Administrative Department Policies
.
.

Clinical Practice/Standards of Care References

126.001

.

Accountability for Nursing Care at SMH

126.003

.

Professional Peer Review for Nurses

126.004

.

Nurse Residency Program

126.007

.

Clinical Coach Program / Clinical Preceptors

126.008

.

Assignment and Performance of Nursing Students

126.021

.

Nursing Competency Validation Program

126.033

.

Nursing Education and Travel

126.041

.

Privately Hired Caregivers (Nurses / Sitters)

126.044

.

Private Duty Sitters

126.046

.

Nurse Staffing

126.048

.

Ultimate Schedule for Nursing

126.050

.

Patient Care Delivery Model/Assignment of Nursing Care

126.054

.
Continuing Nursing Education Activity Process
126.067
.

Education Programs for Nursing Personnel

126.068

.

Performance Based Development System (PBDS)

126.070

.

Orientation for Nursing Personnel

126.074

.

Vacation Guidelines for Patient Care Services

126.075

.

Nursing Department Policies and Procedures: Initiation, Review and Distribution

126.080

.

Maintenance of Required Records and Reports

126.082

.

Standards of Nursing Care

126.225

.
Patient Care Department Policies
.
.

Medication Administration Times

126.151

Pharm 129.002

Controlled Substances: Not Dispensed from Pyxis Medstations

126.152

Pharm 129.721

Administration and Nursing Care of Adult Patients on Specific Intravenous Medications (including Cardiovascular, Vasoactive, Thrombolytics, Neuromuscular Blockade and Electrolytes)

126.155

vasopressor
cardiac

Titrations of Selected Pharmaceuticals for Critical Care Areas, Hemodialysis, PACU, Emergency Care Center, Cardiac Care Areas, Neuro Progressive Care, and the Meckler
126.156
Pharm 129.061

Dilutions of Selected Pharmaceuticals (Standard and Maximum Concentration)

126.157

Pharm 129.167

Nursing Guidelines for the Initiation and Administration of Dofetilide (Tikosyn) 126.158  

Discharge of a Patient from SMH to Bayside Center for Behavioral Health

126.164
.

Oxygen Administration (Including Emergency)

126.167

RT 135.012

DVT/VTE Nursing Protocol Prevention

126.168
.

Acute and Post-Operative Epidural / Intrathecal Pain Control

126.169
.

Criteria for the Performance of Cardiovascular Diagnostics at the Bedside

126.171

CVD 103.012

Care of the Outpatient / Procedural Outpatient on Home Ventilation Support
126.175
.
Breast - Related Lymphedema
126.176
 

Admission of Post-Partum Mother and Baby Following Initial Discharge From Hospital

126.179

.

Radiation Monitoring and Care of Permanent Implant Patients

126.182

CVD 125.508

Non-invasive Positive Pressure (NPPV) Ventilation (CPAP / BIPAP
126.184
RT 135.118

Maintenance of Emergency Equipment

126.185

RT 135.029

Protocol for Passy-Muir Tracheostomy Speaking Valve

126.186

RT 135.008

Intravenous Patient Controlled Analgesia (PCA) and Narcotic Infusions

126.187

IV PCA
Pharm 129.199
Hazardous Drug Handling
126.201
Pharm 129.197

Self Administration of Medications by Patients

126.202

Pharm 129.062

Medication Storage and Compliance Monitoring

126.203

Pharm 129.007
home
home meds
home medications

Medication Order Processing and Distribution

126.204

Pharm 129.105

Management of Patient's Own Medication

126.205

Pharm 129.063

Medication-Limited Prescription Dispensing

126.206

Pharm 129.065

Nursing and Pharmacy Guidelines for the Administration of IV Epoprostenol (Flolan and Veletri)

126.207

Pharm 129.060

Pyxis Medstation Operational Procedures

126.209

Pharm 129.110

Pyxis Medstation System-Override of Medications

126.212

Pharm 129.113

Intake and Outputs/Patient Weights - Adult

126.213

.

Pyxis Connect System or Equipment Failure Procedures (Scanning of Pharmacy Orders)

126.215

Pharm 129.120

Pyxis Medstation System or Equipment Failure Procedures (Troubleshooting)

126.216

.

Care of the Suicidal Patient in the Acute Care Setting

126.219

suicide

Pyxis Medstation User Authorization and Verification

126.221

.
Potassium Chloride Replacement - ADULT 126.222 Pharm 129.059

Nursing and Pharmacy Guidelines for the Administration of IV Remodulin (Treprostinil)

126.226

 

Cancer Care Services - Research Department
.
.
Satellite Site Management Plan
256.000
.
Standard Operating Procedure for Investigational Drug Accountability, Storage, Transport, Dispensing and Return
256.001
.
Standard Operating Procedure for Responsibilities of the Research Team
256.002
.
Standard Operating Procedure for Monitor/Auditor Visits
256.003
.
Standard Operating Procedure for Data Collection / Submission
256.004
.
Standard Operating Procedure for Collection and Storage of Tissue Obtained from TCC Subjects in Surgery
256.005
.
Standard Operating Procedure for Collection and Storage of Biopsied Tissue from TCC Subjects in Surgery
256.006
.
Standard Operating Procedure for Collection and Storage of Biopsied Tissue from TCC Subjects in Radiology
256.007
.
Standard Operating Procedure for Collection and Storage of Biopsied Tissue from TCC Subjects in Endoscopy
256.008
.
Standard Operating Procedure for Collection and Storage of FNA Tissue in Endoscopy
256.009
.
Standard Operating Procedure for Collection and Storage of FNA Tissue from TCC Subjects in Radiology 256.010  
MNC Collection, Identity Verification and Shipping - Specific Procedures for CAN-004 Ovarian Cancer Vaccine Study 256.011  
Standard Operating Procedure for Screening and Enrolling Subjects 256.012  
Transporting Specimen
256.013
.

Cardiac Policies

.
.

Standards of Care/Standards of Practice: Cardiac Acute and Cardiac Progressive Units

126.235

.

Admission/Discharge Criteria: Cardiac Acute (CAC)

126.325

.

Admission/Transfer Criteria: Cardiac Progressive Units

126.327

.

Admission/Discharge Criteria: Cardiovascular Thoracic Step-down Unit .

126.329

.
Non-elective (Urgent) Cardioversions
126.330
.
Center for Wound Healing
.
.

Center for Wound Healing (CWH) Outpatients

200.000
.
Standards of Care: Center for Wound Healing (CWH)
126.288
 

Day Treatment Center Policies

.
.

Standards of Care - Day Treatment Center

126.256

.
Day Treatment Center Admission Criteria
126.926
.

Day Treatment Center Discharge Criteria

126.927

.

Day Treatment Center Scheduling System

126.929

.

Day Treatment Center - Medical Record and Documentation

126.945

.

Discharge Services Policy

.
.

Patient Criteria for Discharge Services

126.285

.

General Medical Surgical Unit

.
.
Standards of Care: Medical Surgical Division
126.276
.
Admission/Transfer Criteria: General Medical/Surgical Unit
126.286
.

General Surgical Policies

.
.

Standards of Care: Medical Surgical Division

126.276

.

Admission/Transfer Criteria: General Surgical Unit

126.281

.

Hemodialysis Policies

.
.

Standards of Care: Hemodialysis

126.231

.

Guidelines for Hemodialysis Treatments

126.503

.

SMD Dialysis and Outpatient Chronic Center Continuity of Care

126.531

.
Maternal Services Policies
.
.

Standards of Care: Mother-Baby Unit

126.239

.

Standards of Care: Maternity Care Services

126.240

.

Admission / Discharge / Transfer Criteria: Women's Services

126.700

.

Neonatal/Maternal Transport Team: Accident Procedure

126.702

RT 135.023

Electronic Fetal Monitoring (EFM) Doppler Device Use during AnteAntepartum/Intrapartum for Fetal Assessment

126.703

.

Oxytocin Induction or Augmentation of Labor

126.706

.

Mode of Response for Maternal and Neonatal Transport Vehicles

126.707

.

Maternal/Neonatal Transport Teams: Disaster or Breach in Homeland Security

126.708

.

Maternal/Neonatal Transport Team: Mobilization Time

126.709

.

Rapid HIV Testing and STD Testing of Mothers in the Labor, Delivery and Post-partum Settings

126.710

.

Cesarean Section Classification

126.712

.

Labor and Delivery Scheduling Process

126.714

.

Placement and Care of Neonates of Questionable And/or Non-Viability

126.715

.

Guidelines for the Newborn Delivery Team

126.718

RT 135.024

Assignment for Medical Care for Obstetrical Walk-in Patients

126.720

.

Video Camera and Still Photography Use in LDR and Satellite OB/OR

126.721

.

Management of the Pregnant Patient with Epidural Anesthesia

126.722

.
Vaginal Birth after Cesarean Section (VBAC)
126.724
.

Anesthesia Care and Intraoperative Monitoring

126.726

Surg 139.0501

Unintended Intraoperative Awareness During General Anesthesia

126.732

Surg 139.0502

Safety Basic Standards for Perioperative Services and Women's Services Satellite OR

126.733

Surg 139.0307

Proper Identification and Warming of IV Fluids and Irrigation Solutions - surgery, PACU, & OB

126.734

Surg 139.0105

Chain of Command for Resolution of Interpretative Differences in Obstetrics

126.735

.

Cord Blood Collection and Labeling for Labor & Delivery

126.737

.

Quantification of Amniotic Fluid Index (AFI) by RN Staff

126.741

.

Collaborative Care of the High Risk Obstetrical Patient

126.742

RT 135.022

Prostin / Misoprostol Utilization for Cervical Ripening / Dilation in IUFD and Medically Indicated TOP

126.745

.

Concentrated Oxytocin Infusion for Labor Induction (for up to 27 completed weeks of gestation)

126.746

.

Standards of Care: Maternal Transport Team

126.748

RT 135.035

Transportation of Maternal Patients Off Campus (Outside of Hospital)

126.749

RT 135.034

Collaborative Care of the Surgical Pregnant Patient
(24 Weeks or Greater)

126.750

RT 135.036
Surg 139.0230

Care of the Pregnant Patient Cared for by a Community Licensed Midwife

126.755

.

Parental Refusal to Comply with Florida Statutes Regarding Routine Treatment and Screening of Newborns

126.761

.
Infection Control Policy for Perioperative Services and Women's Services - Satellite OR
126.762
.
Traffic Patterns for Perioperative Services and Women's Services - Satellite OR
126.763
.

Adoptions

126.774

.

Discharge Criteria, Mother/Baby Unit

126.776

MBU

Visitation within OB ECC, LDR, and the High Risk Antepartum

126.777

.

Visitation on the Mother Baby Unit

126.778

.
Admission of Post-Partum Mother and Baby Following Initial Discharge from Hospital
126.779
.

Admission Criteria: Mother/Baby Unit

126.781

MBU
Tetanus, Diphtheria, Pertussis (TDAP) Vaccination Post-partum
126.783
.

Temporary Release and Return of Infant's Body From the Morgue

126.785

.

Admission/Discharge Criteria: Post Anesthesia Care Units

126.802

Surg 139.1603

Malignant Hyperthermia

126.805

Surg 139.0225

Meckler Admission Center

.
.

Admission Center: Patient Placement Criteria

126.950

.
Medical 1 Department Policies
.
.

Standards of Care: Medical Surgical Division

126.276

.

Admission/Transfer Criteria: Medical One/Medical Services/Respiratory/NurseResidencyUnit

126.275

.
Medical Short Stay
.
.
Medical Short Stay Patient Placement Criteria
126.287
.

Medical/Wound Care/Renal/Diabetic Policies

.
.

Standards of Care: Medical Surgical Division

126.276

.

Admission/Transfer Criteria: Medical/Wound Care/Renal/Diabetic

126.283

.

Neonatal Services Policies

.
.

Standards of Care: NICU

126.242

.

Standards of Care: Neonatal Transport Team

126.245

.

Admission of Infants Born Outside of SMH

126.602

.

Placement and Care of Neonates of Questionable and/or Non-Viability

126.603

.

Admission Criteria: Mother/Baby Unit

126.604

MBU

Discharge Criteria: Mother/Baby Unit

126.605

MBU

Family Care Time and Visitors in the NICU

126.609

.

Neonatal ICU Intravenous (IV) Therapy

126.610

.

Neonatal Outpatient Eye Clinic-Medical Record and Documentation

126.611

.
Infection Control Department Policy for NICU
126.612
.

Visiting on the Obstetrical, Neonatal, and MBU Units

126.631

MBU

Adoptions

126.632

.

Neonatal Intensive Care Unit: Discharge Criteria and Planning

126.651

.
Guidelines for Newborn Assignment to Appropriate Level of Care
126.652
.

Guidelines for the Newborn Delivery Team

126.655

.

NICU: Admission, Care and Transfer Procedure
and Acuity Criteria

126.660

.

Parental Refusal to Comply with Florida Statutes Regarding Routine Treatment and Screening of Newborns

126.661

.

Neonatal/Maternal Transport Team Accident Procedure

126.662

.

Mode of Response for Maternal and Neonatal Transport Vehicles

126.663

.

Maternal/Neonatal Transport Teams: Disaster or Breach in Homeland Security

126.664

.

Car Seat Protocol Essentials for NICU Patients

126.665

.

Maternal/Neonatal Transport Team: Mobilization Time

126.666

.

Car Seat Protocol Essentials for MBU Term and Late Pre-Term Infants

126.667

.

Vaccine/Immunization Administration in the NICU and Nursery

126.682

.

High Patient Volume: NICU

126.683

.

Oxygen Saturation Guide Premature Infants <33 Weeks on Supplemental Oxygen

126.684

.

Neuro Progressive Unit

   
Admission / Transfer Criteria: Neuro Progressive Care Unit 126.490 .
Standards of Care: Neuro Progressive Unit 126.491 .

Neuro/Uro Comprehensive (S2) Unit Policies

.
.

Standards of Care: Neuro-Uro

126.236

.

Admission/Transfer/Discharge Criteria: Neuro-Uro

126.279

.

Oncology Department Policies

.
.

Standards of Care - Oncology Unit

126.227

.

Admission/Transfer Criteria: Oncology Unit

126.821

.

Orthopedics Unit Policy

.
.

Standards of Care: Medical Surgical Division

126.276

.

Admission/Transfer Criteria: Orthopedics Unit

126.840

.
PACU Nursing Policies
.
.
Medical Supervision of the PACU
139.1601
.
Admission / Discharge Criteria for Post Anesthesia Care Units
139.1603
.
Documentation of Nursing Care - PACU
139.1606
.
Emergency Pediatric Orders - PACU
139.1611
.
Emergency Adult Orders - PACU
139.1612
.
Initiating PCA on Patients in the PACU
139.1615
.
Admission / Discharge Criteria for PACU-Phase II
139.1630
.
PACU Nursing Procedures for Electroconvulsive Therapy
139.1632
ECT

Pediatrics Nursing Policies

.
.

Standards of Care: Pediatric Unit

126.244

.

Admission Criteria for Pediatrics

126.850

.

Pediatric Fall Prevention Program

126.853

.

Pediatric Pain Management for Needle Sticks

126.855

ped pain

Visitors on the Pediatric Unit

126.858

.
Continuity of Educational Services for the Hospital/Homebound Patient
126.865
.

Pediatric Intravenous (IV) Therapy

126.868

.

Special Care Policies

.
.

Standard of Care: Critical Care Units (ICU & CVICU)

126.248

.

Admission/Discharge Criteria: Medical/Surgical and Cardiovascular Intensive Care Units

126.401

.

Collaborative Care of the High Risk Obstetrical Patient

126.437

.

Guidelines for Intra-Hospital Transporting of Adult Special Care Patients

126.442

.

Propofol Sedation Policy

126.443

.

Mechanical Ventilation Weaning and Extubation of the Post Open Heart Surgical Patient

126.480

.

Oral Care Procedure for Critically Ill Adult Comatose Patients or Patients Requiring Mechanical Ventilation

126.483

.
 
.
.
SMH Patient Care Policies
.
.
Chain of Command
01 adm 00
chain command
Visitors
01 pat 01
.
People with Special Needs (PSN) Operations During a Disaster
01 pat 02
.
Code Blue Management and Responsibilities
01 pat 03
.
Breast Milk Exposure
01 pat 04
.
Antiplatelet Medication Management for Cardiac Stent Patients Undergoing Invasive Procedures
01 pat 05
.
Release of Patient Condition / Status
01 pat 07
.
Transfer of Patients to and from Sarasota Memorial Hospital
01 pat 08
.
Patient Identification - Inpatient / Outpatient
01 pat 09
.
Organ and Tissue Donation
01 pat 14
.
Patient Expiration Including Fetal Death, Pronouncing of Patient, Autopsy Requests, Post-Mortem Care & Medical Examiner Cases
01 pat 16
morgue
Food Stored on Nursing Units
01 pat 17
.
Correct Patient, Procedure and Site Verification
01 pat 18
.
Prevention of Retained Surgical Items: Soft Goods, Sharps and Instrument Counts
01 pat 19
.

Safe Patient "Smart Assist, Smart Lift"

01 pat 21
maxi slides
maxi move
lifts
Transportation and Monitoring of Patients
01 pat 23
.
Specimen Preperation and Handling for Operative and Other Invasive Procedures
01 pat 24
.
Handoff Communication Guidelines
01 pat 25
.
Discharge Planning
01 pat 27
.
Photographing / Videotaping / Audio Recording of Patients
01 pat 28
pictures photos
Termination of Pregnancy, First and Second Trimester
01 pat 30
.
Influenza Vaccinations Adults and Pediatrics
01 pat 31
.
Code Blue Cart Management and Replacement
01 pat 46
.
Admission, Discharge and Transfer Process
01 pat 52
.
Sarasota Memorial Hospital (SMH) Patient Flow and Over Capacity Alert Plan
01 pat 53
.
Fall Safety Program
01 pat 60
falls
Restraint and Seclusion
01 pat 64
.
Using Abbreviations, Acronyms and Symbols in Health Record Documentation
01 pat 66
.
Blood Bank Identification Bands
01 pat 67
.
Infant Screening Program
01 pat 78
.
Pneumococcal Vaccination (PPV23) Adults and Pediatrics
01 pat 80
pneumonia vaccine
Medication Reconcilliation
01 pat 81
.
Disruptive Patient Behavior
01 pat 82
.
Rapid Response Team
01 pat 83
.
Corporate Financial Policy
   
Patient Valuables and Belongings
00 FIN 02
.
Corporate Infection Control Policy
.
.
Infection Control for Intravascular Lines
00 ifc 54
IV lines
Corporate Patient Care Policies
.
.
Administration of Blood and Blood Components
00 pat 00
.
Code Blue Classification and Do Not Resusicitate (DNR) Orders
00 pat 02
.
Therapeutic Clowning
00 pat 04
clown
Education for Patients, Families, and Support Persons
00 pat 05
.
Care of the Prisoner
00 pat 08
forensic
Reporting of Critical Results
00 pat 12
.
Safe Haven for Newborns
00 pat 16
.
Identification, Treatment and Reporting of Suspected Abuse (Children, Elderly and Disabled)
00 pat 21
.

Telephone / Verbal Orders - Receiving and Documenting

00 pat 32
.
Interpreter Services - Hearing Impaired / Foreign Language
00 pat 34
.
Moderate Sedation
00 pat 38
.
Pain Management
00 pat 44
.
Exclusion from Patient Care
00 pat 54
.
Patient Assessment / Reassessment
00 pat 66
post op
vital signs
VS
Latex Allergy
00 pat 68
.
Ambulatory Summary List
00 pat 76
.
Computerized Order Management
00 pat 82
.
Patient Identification Label Management
00 pat 84
.