Nursing Policy & Procedures Manual

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Table of Contents: Administrative Section: -1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Preface Nursing Services Organizational Chart Behavioral System Overview Change of Shift Procedure Verification of Licenses Individual/Individual and Family Teaching Code of Ethics for Nursing Services Nursing Services Records, Meeting Minutes Nursing Policy and Procedures Nursing Services Duties: Responsibilities Confidentiality of Individual Information Nursing Services Quality Improvement Program North American Nursing Diagnosis (NANDA) Taxonomy Nursing Services Mission and Organizational Structure Nursing Students Wellness & Recovery Treatment Teams (Nursing) Psychiatric Classification/Acuity Calculation and Report Psychiatric Mental Health Nursing Nursing Process Overview Spiritual Needs of Individuals Storage and Handling of Sporks Staffing Scope of Activity for Volunteers Unit Resource Reference Material for Nursing Services Staff

Section 1 - Admission and Discharge Procedures: 100 101 102 103 104 105 106 107 Admission Process Court Visit Process Death Procedure and Documentation Discharge to the Community Discharge Planning Nursing Discharge Planning/Summary Preparing Individuals for Transfer & Transfer Note Unit Process & Acceptance Note for Receiving

Section 2 - Abbreviations: 200 Unacceptable Abbreviations and Symbols

Section 3 - Nursing Care and Documentation: 300 301 302 303 304 305 Age specific nursing care Basic Bed making/Cleaning Bath tub use (medical unit) Care of the Individual with self-induced water intoxication Constipation monitoring Daily care flow sheet

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306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 334

End of life care Escorting Individuals off unit Fall prevention Feeding of individuals Legal requirements for nursing documentation Mouth care Nail care Nursing assessment: Initial, annual, and update Nursing care plans Nursing Discharge Summary Nursing progress notes Pain management Individual transfer, acceptance and/or discharge note Protective mechanical support devices Safety, security and supervision of individuals, visitors Special Incident Report Vital Signs Weight Monitoring Dysphagia

Section 4 - Treatments and Procedures: 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 425 428 429 430 431 432 433 438 Sponge bath for reducing temperature Retention catheter (foley) insertion and care Catheterization and the care of a catheterized male Individual Bed bath Dressing change Evening care of bed Individual Ear irrigation Compress for the eye hot and cold Eye irrigation Warm foot soaks Tube feeding (nasogastric) Peg Feeding/Gastrostomy Treatment of Pediculosis (lice) and scabies Cold pack treatment Oxygen Therapy Oxygen Concentrator Enemas Cast and Leg immobilizer application and care Tracheostomy care: Cleaning of inner cannula Tracheostomy suctioning Pressure soar treatment Care and use of the nebulizer Care of the Incontinent Individual Stoma Care CPAP: care, use and cleaning Central vascular access devices Giving or removing a bedpan or urinal Wounds Irrigation Bladder Irrigation Nasogastric Tube Insertion Gastric Lavage Adaptive Devices

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461

Tube Feeding

Section 5 - Medications: 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 Administration of medication and treatments: General Rules Administration of oral medication Topical Applications Suppositories Administration of Parenteral Medications Administration of Nose Drops/Nasal Spray Administration of hand-held inhalant medications Installation of eye medications Installation of ear medications Nursing protocol for Administration of Propanolol Care of the Individual receiving clozapine Care of the Individual receiving olanzapine Oxygen therapy Administration of insulin Noting physicians orders Control drugs (scheduled drugs) Medication related events Medication administration orientation / competency validation Intravenous procedures and certification Intravenous solutions and admixture I.V. solutions Inserting a male adaptor plug heparin lock saline lock Intravenous blood withdrawal by registered nurse Immunizations Self-Administration of medication 24 Hour night shift medication and treatment audit Medication Related Event Form

Section 6 - Diagnostic Procedures: 600 601 602 603 604 605 606 608 609 610 611 613 615 620 Clinic Procedures Laboratory Procedures Radiology Procedures Clean Catch (Midstream) Urine Collection Collection Of 24-Hour Urine Specimen Obtaining Stool Specimens For Laboratory Analysis DNA Specimen Procedure Blood Glucose Testing Competency Validation Blood Glucose Monitoring Collecting Specimens: Feces, Cultures And Urine Pulse Oximetry Holter Monitor Referrals Referring Individuals To Central Medical Clinic Computerized Laboratory Requisitions

Section 7 - Emergency Procedures: 700 701 702 703 Medical Emergency Management of a foreign body airway obstruction Cardiopulmonary Resuscitation (CPR) Seizures

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704 705 706 707 708 709 710 711 712 713 714 715 716 717 718

Emergency care of Burns Emergency care of wounds Heat related conditions Emergency care of shock Emergency treatment of head injury Emergency care of eye injuries Emergency care of fractures Emergency care of epistaxis Emergency care of poisoning Anaphylactic Reaction (shock) Emergency Medical Equipment Emergency care of Hemorrhage Monitor/Defibrillator Neuroleptic Malignant Syndrome Pepper Spray

Section 8 - Infection Control: 800 801 805 810 815 820 825 830 835 840 845 850 855 860 870 875 880 885 Infection control program Vernacare v2020 disposal unit/macerator Isolation and precautions for infectious/communicable disease Cleaning of electronic medical equipment used on the units Storage/handling of toothbrushes & toothpaste Dispensing individuals liquid soap/bar soap Clearing of residual instruments Safe storage and disposal of syringes and needles Safe storage and handling of shavers Use of personal protective equipment (PPE) Cleaning procedure for isolation rooms Cleaning of individuals Individual areas Hand hygiene Biohazardous waste Cleaning of water pitcher on units Disinfection of commonly shared grooming supplies Handling and storage of ice on the units Cleaning of leather restrains on the unit

Section 9 - Clothing and Linen: 900 Handling clean, infectious, or soiled linen and clothing

Section 10 - Central Supply: 1000 1001 Central Supply Medical Equipment Teaching

Section 11 - Orientation and Education: 1100 1101 1102 1103 Hospital wide orientation of nursing services staff Program Orientation HSS/NOD Orientation of new RNs to the program Orientation of staff to units not usually assigned to a unit

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Section 12 - Inside and Outside Facility Consultation: 1200 1201 1202 1203 1204 1205 1206 Staff escort of individuals to outside medical facilities Central Medical Clinic Dental Services Referring individuals to outside physician or facility EEG-ECG referrals Physical therapy services Referring special needs individuals for nursing consultation

Section 13 - Psychiatric Nursing Interventions: 1300 1301 1302 1303 1304 1305 1306 1307 1308 1309 1310 1311 1312 1313 1314 Withdrawn behavior Altered nutritional status: The Individual who is not eating Delusions Schizophrenia Bipolar disorders Continuous supervision of individuals Suicide prevention and intervention Expectorant shield Emergency use of behavioral restraint or seclusion Approaches for passive-aggressive or manipulative behavior Approaching the hostile individual Grief reaction Conversion disorder Psychosomatic disorder Hypochondriacal behavior

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Administrative Section

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative PREFACE Effective Date: August 31, 2006

PREFACE
The Nursing Policy and Procedure Manual of Coalinga State Hospital has been developed in concert with other health care professionals and clinically pertinent committees. The Committee members are representative of the Health Services Specialists, RN and PT Professional Practice Groups, Unit Supervisors, Training Center, Public Health Nurses, Nursing Performance Improvement, and staff from programs and other interested service providers. All nursing personnel shall have ready access to this manual at all times. Procedures are reviewed or updated at least every two years or as necessary to maintain quality nursing care. All clinically pertinent procedures are reviewed and approved by the appropriate committee responsible for maintaining specific protocol, e.g. Infection Control Committee, Emergency Care Committee, Pharmacy and Therapeutics Committee, Health Information Management Committee. All policies are under the direction of the Coordinator of Nursing Services. The CSH Nursing Policy and Procedure Manual can be located in CSH Intranet in PDF format. This allows for electronic access to all Nursing Policies and Procedures by staff having intranet access. Revisions of existing policies and procedures shall follow the Administrative Directives regarding Intranet access. Changes or addition of a new policy and procedure will be entered on the Intranet when the Nursing Policy and Procedure Committee make changes the week following the committees recommendations. The Manual is intended to provide nursing services personnel with guidelines, expectations, and requirements for providing quality nursing care. All individuals to whom the manuals are issued shall be responsible for maintenance and insertion of all current material provided by the CNS office.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 2 Effective Date: August 31, 2006 SUBJECT: BEHAVIORAL SYSTEM OVERVIEW 1. PURPOSE: The Behavioral Systems Model is utilized by nursing services at CSH as the framework for providing care to the forensic, psychiatric Individual in a biopsychosocial, holistic manner. The Behavioral Systems Model, which is based on Systems Theory, is evident throughout all phases of the nursing process including the CSH Individual Classification System for developing the Acuity Level specific for each Individual. There are several advantages to this model. It allows for: 1. 2. 3. 4. Allocation of staffing resources based on the degree of Individual illness; Monitoring of classification data for cost accounting purposes; Tracking changes and assisting in budget determination; Integrating classification data into utilization review and quality assessment and improvement. 5. Measuring Individual behavioral progress and intervention level. This model delineates nursing services distinct contribution to Individual care and it identifies universal patterns of behavior applicable to all individuals regardless of age, cultural differences, psychiatric, or medical diagnosis. The purpose of the Individual classification system is to determine the degree of each Individuals behavioral effectiveness and Nursings role in maintaining, supporting, and enhancing Individual behavioral effectiveness. The allocation of staffing resources is based on this dynamic relationship. The effectiveness of this classification system requires the utilization of the Behavioral Systems Model as the basis for professional nursing practice. 2. POLICY: The Behavioral Systems Model shall be used to measure Individual behavioral and intervention levels.

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3. DEFINITIONS: Behavior- The way in which one reacts to the environment. Environment - Composed of regulatory elements that impact on the behavioral system. There are both internal and external regulators in the environment. System - A whole that functions as a whole by virtue of the interdependence of its parts. Subsystem - The parts of the system that are organized around specialized tasks. Although the subsystems are mini-systems with their own particular goal and function, they are interdependent with the other subsystems that make up the larger system or whole. Systems Theory - Is an approach that considers the individual as a whole as opposed to his or her parts. The individual is considered an open system that is constantly interacting with the environment. 4. HISTORY: The behavioral systems theory springs from Florence Nightingales belief that Nursings goal is to help individuals prevent or recover from disease or injury. In addition, she maintained that the science and art of nursing should focus on theIndividual as an individual and not on the specific disease entity. Dorothy Johnson, a Nursing Theorist, using the work of behavioral scientists in psychology, sociology, and ethnology relied heavily on systems theory to develop a behavioral system approach for care of the psychiatric Individual. Later, Dr.s Jeanie Auger and Vivian Dee of the UCLA Neuropsychiatric Hospital expanded that theory to develop the Neuropsychiatric Individual Classification System to address the relationship between Individual behaviors and corresponding nursing care requirements. Today it is used at each of the California DMH State hospitals for: 1. Establishing the Individuals acuity level in order to determine levels of nursing care specific to the special care needs of the Individual. 2. A clinical measure of Individual progress. 3. To establish nursing services role in maintaining, supporting, and enhancing the Individuals behavioral effectiveness.

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5. GENERAL INFORMATION: Essential Principles of the Behavioral Systems Model: A. The Individual is viewed as an open, living system in constant interaction with the environment. B. The Individual is described as a behavioral system using 8 subsystems developed for the purpose of carrying out specific system tasks. C. The Individual, however, is viewed and functions as a whole by virtue of the interdependence of the parts. D. The Individual as a behavioral system strives for a balance. E. Balance is represented by a more or less equal distribution of energy among the 8 subsystems and is a reflection of the on-going relationship between the behavioral system and the environment. F. Environment is composed of all regulatory elements external to the behavioral system. The environment includes internal regulators such as physiological state as well as external regulators such as the family. G. Nursing Services assists the Individual to achieve system balance by creating an environment that protects, nurtures, and stimulates the behavioral subsystems. 6. THE NURSING PROCESS: When the Behavioral Systems Model is combined with the nursing process, a unique approach to Individual care emerges: Assessment - is organized around the behavioral subsystems and their interaction with regulators in the environment. Nursing Diagnoses - are labels that are formed, based on demonstration of ineffective behavior within one or more subsystems, and the relationship of these behaviors to the regulators. Outcome Identification - is based on goals for behavioral responses to more effectively achieve subsystem health and overall system balance. Planning - involves the creation of a Individual care environment of interventions.

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Nursing Interventions - are delivered, thereby enabling the Individual to initiate behavioral responses that more effectively meet the goals of the subsystems. Evaluation - is accomplished by reassessment of the subsystems and the regulators to determine if a more effective behavior is evident. 7. BEHAVIORAL SUBSYSTEMS: Ingestive - The ingestive subsystem is associated with food and fluid intake, and has to do with when, how, what, how much, and under what conditions we eat and drink. These responses are associated with social and psychological as well as biological considerations. Eliminative - The eliminative subsystem is associated with patterns of elimination, and like the ingestive subsystem, is associated with social, psychological, and biological considerations. Dependency - In the broadest sense, the dependency subsystem promotes helping behavior that calls for a nurturing response. Its consequences are approval, attention or recognition, and physical assistance. Developmentally, dependency behavior evolves from almost total dependence on others, to a greater degree of dependence on self. A certain amount of interdependence is essential for survival of social groups. Affiliative - Affiliative subsystem is probably the most critical, because it forms the basis for all social organization. On a general level, it provides survival and security. Its consequences are social inclusion, intimacy, and formation and maintenance of a strong social bond. Aggressive/Protective - The aggressive/protective subsystems function is protection and preservation from perceived or real harm. This is a basic drive, but these behaviors also derive from social learning. Society demands that limits be placed on modes of self-protection and that people and their property be respected and protected. Sexual - The sexual subsystem has the dual functions of procreation and gratification. This includes, but is not limited to, courting and mating. This response system begins with the development of gender role identity and includes the broad range of sex role behaviors. Achievement - The achievement subsystem attempts to manipulate the environment. Its function is control or mastery of an aspect of self or environment to some standard of excellence. Areas of achievement behavior include intellectual, physical, creative, mechanical, and social skills.

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Restorative - The restorative subsystem is associated with sleep, rest, recreation, and the sick role. Restoring equilibrium is a key concept in Nursings specific goal. It is defined as a stabilized but more or less transitory, resting state in which the individual is in harmony with himself or herself and with their environment. It implies that biological and psychological forces are in balance with each other and with impinging social forces. It is not synonymous with a state of health, since it may be found either in health or illness. 8. ENVIRONMENTAL REGULATORS: The concept of environment consists of external and internal factors which impact on, and are regulators of, behavior. 1. The internal regulators originate from within the individual and include: A. Developmental factors B. Bio-physical factors C. Psychological factors 2. The external regulators are comprised of the forces in the external environment which impact on the individual, including: D. Social and cultural factors E. Familial factors F. Physical environment All of these regulators have the ability to influence each of the behavioral subsystems, and the inter-relationships between subsystems. In addition, the subsystems and the behavioral system as a whole act on and influence the environment. This relationship is open, dynamic, and ongoing. The behavioral system as a whole is dependent upon the integrated performance of the eight subsystems. The integrity and balance of the system is maintained when: 1. The conditions in the environment remain orderly and predictable, 2. The functional requirements of the subsystems are met for the purpose of restoring, maintaining and attaining the highest possible level of functioning through the individuals own efforts or through an external regulatory force. 9. ASSESSMENT: The concept of behavior is basic to the model. Behavior may range from effective to ineffective. Behavioral data is gathered to determine the

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effectiveness of each subsystem. Based on the behavioral data, each subsystem is assigned a behavioral category score ranging from 1 to 5. 1 = effective 2 = inconsistently effective 3 = ineffective 4 = seriously ineffective 5 = critically ineffective In addition, data is gathered to determine the degree to which the internal and external environments protect, nurture, and/or stimulate the behavioral subsystems. Effective behaviors enable the Individual to meet the goals of the various behavioral subsystems resulting in overall system stability. Ineffective behaviors do not enable the Individual to meet the goals of the various subsystems resulting in behavioral system instability and unpredictability. 10. DIAGNOSIS: The Behavioral Systems Model defines 5 levels of effectiveness/ineffectiveness that depict behaviors on a continuum that denote a range of diagnoses from health to critical illness. The Diagnostic Process is based on the degree of effectiveness or ineffectiveness of each behavioral subsystem. Priorities are established and nursing diagnoses are formulated for those subsystems which pose the greatest threat to the overall behavioral system. The NANDA Taxonomy is used by the RN to develop the nursing diagnosis at CSH. This diagnosis provides the basis for selection of interventions for delivering Individual care to achieve outcomes for which the nurse is accountable.

ACUITY BEHAVIORAL CATEGORY: 1. Effective Behavior 2. Inconsistently Effective Behavior Deviation 3. Ineffective Behavior 4. Seriously Ineffective Behavior 5. Critically Ineffective Behavior

INDIVIDUAL HEALTH: 1. Health 2. Potential for Health 3. Illness 4. Serious Illness 5. Critical Illness

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11. PLANNING, INTERVENTION AND EVALUATION: There is a dynamic relationship between the Individual behavioral category and the levels of nursing intervention required. The numbers 1 to 5 represent these behavioral categories, and also the level of nursing intervention required. 1. Effective: The goal of nursing is to provide a nurturing and stimulating environment within the general unit milieu. Inconsistently Effective: The primary goal is the same as level 1; however, this is an alert to monitor for the potential for system imbalance and health deviation. There may be a need for a nursing care plan. Ineffective: In addition to the goal of level 1, the nurse must address the system imbalance and illness by providing frequent supervision, a nursing care plan, and special care needs. Seriously Ineffective: The Individual demonstrates serious system imbalance and illness. He is no longer able to function in the unit milieu without a restriction being placed on him. He requires a nursing care plan and intensive nursing supervision. Critically Ineffective: The Individual demonstrates critical system imbalance or illness and is no longer able to function in the unit milieu without a staff being with him at all times. Therefore, he requires a nursing care plan and constant intensive supervision with a 1:1.

2.

3.

4.

5.

Planning - is based on mutual goal setting between the Individual and the nurse in conjunction with the focus of the WARMS in order to determine the methods for increasing behavioral effectiveness. Intervention - is based on mutual goal setting, behavioral activities, and internal/external environmental changes that protect and/or stimulate the behavioral subsystems. Evaluation - involves measurement of the Individuals response to the interventions and the progress made toward the expected outcomes (short term goals) to determine if increased behavioral effectiveness was achieved.

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12. COMPETENCY/TRAINING: All nursing staff will initially receive training during New Employee Orientation, and all nursing employees will receive an overview of the Behavioral Systems Model and application.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 3 Effective Date: August 31, 2006 SUBJECT: CHANGE OF SHIFT PROCEDURE 1. PURPOSE: This Nursing Policy will provide the minimum requirements and the necessary guidelines for nursing staff to provide a meaningful change of shift report for each oncoming shift.

2. POLICY: It is the policy of Coalinga State Hospital that there will be a change of shift meeting conducted by nursing services at each shift change at 0630, 1430, and 2245. Off-going nursing staff shall remain on duty until completion of the change of shift process and until minimum staffing is present to cover the oncoming shift. As part of the change of shift procedure, the on-coming and off-going Shift Lead or designee together shall conduct environmental rounds. This shall consist of a physical walk-through of the unit including the courtyard, a counting of the individuals charts (a.k.a. medical records), sharps, tool, alarm pens and devices, shavers, individuals I.D. badges, and emergency equipment check, and a physical check of all individuals on high risk suicide observation, individuals in seclusion, and in all forms of restraint. Verification will be documented each shift in the Daybook. The Off-Going Shift Lead/designee, Registered Nurse, and Medication Room Staff, shall communicate all pertinent information about the individuals on the unit to the On-Coming Shift Lead/designee, Registered Nurse, and Medication Room Staff, which shall be documented on the unit Day Book, the unit Medication Room Log, and/or other appropriate communication tools. This information shall include but not be limited to: Containment Risks, High/Low Risk for Suicide, Assault, Seclusion, Restraint, 1:1 status, etc.

All nursing staff is responsible for providing a safe environment for individuals and reporting any and all safety hazards or safety concerns. All individuals medical records are to be accounted for at the beginning of each shift by the oncoming Shift Lead/designee and signed off in the Daybook Log with the -1N.P.P. No. 3

number of charts recorded prior to each change of shift. All charts must be accounted for and/or its location identified. 3. GENERAL INFORMATION: 1. The Unit Supervisor is responsible to ensure that each Shift Lead or designee together with the RN(s) conducts change of shift report and rounds at all shift changes. In order to assure that there is continuity of care and treatment for all individuals, there will be a formal change of shift meeting implemented and attended by: -Shift Lead or designee. -RN(s). -Employees assigned to medication/treatment room (on-coming and going) to join report after medication count/key exchange procedure. -All other employees scheduled for duty from the oncoming shift and off going not assigned to a change of shift task.

offif

Other discipline members are encouraged to attend and participate as appropriate. 2. During the change of shift procedure, the off-going Shift Lead/designee will assign one of their staff to maintain 1:1 observations and Supervise activities of the general population as required. 3. Off-going staff assigned to specific change of shift tasks is not required to attend the change of shift report. 4. Staff floated from other units will receive a report from the Shift Lead/designee advising of the individuals on specific ALERTS, 1:1s, High/Low Risk Observations, pertinent acute medical or behavior issues, individuals on containment risk, and a formal orientation to the unit physical environment including new equipment specific for that unit. 5. All staff will communicate pertinent nursing concerns to the Shift Lead and the RN(s) throughout the shift. In addition, notations on a designated form or flow sheet may be utilized and helpful.

4.

PROCEDURES: At 0630, 1430, and 2245 hours, each shift will conduct a formal change of shift t assure pertinent information is reported to the on-coming shift. The off-going Shift Lead/designee shall be responsible for the change of shift report with appropriate clinical input from the RN(s), medication room staff, and other relevant treatment staff. Off-going and on-coming Medication/Treatment Room staff will conduct a separate change of shift review including an accounting of controlled medications; syringe -2N.P.P. No. 3

count, key exchange, oxygen tank, emergency drug box, etc. then join report after this procedure to recount the shift events at the change of shift report. Individual care need and acuity will be reviewed and updated as clinically indicated. The Shift Lead will consult with the RN(s), and make assignments based on RN assessed clinical needs to address nursing concerns of each individual, giving special attention to the following areas as applicable. Change of Shift Report: The number of charts present on the unit and an accountability of the location of each chart. All individuals with an acuity level of 4 or 5 requiring an individual care assignment, or individuals with an acuity level of 3 needing a special care assignment or nursing intervention(s) Alerts (suicide behavior, assaultive behavior, fire setting, blood and body fluids precautions, medical-physical precautions related to behavioral intervention {e.g. containment risks}, etc.) Seclusion, restraints, special incidents. Individual Care assignments. Psychosocial Factors, subjective and objective observations (self-abusive behavior, delusional depression, manic behavior, impulsiveness, psychomotor agitation or retardation, social withdrawal, etc.) Significant information regarding PRN medication, treatments, physical and psychological profiles, conferences (including Staffing), and behavior unusual to specific individuals. Vital signs, special Diagnostic procedures and Consults. Behavior during the previous shift, sleep patterns and activity level (sleeping, wandering about dorm, smoking habits, incontinence, frequent trips to the rest room, etc.) Personal hygiene and general ADL care needs (appraisal of individuals ability for self-care including ability to shower, shampoo, care for dental, nail, skin, and foot care needs) Eating habits (compliance and non-compliance with restricted diets, diet intake, water intake) New physician orders and monthly medication reviews. Preps for lab work, x-ray, EEG/EKG, etc. Individuals scheduled for court visit, discharge, off grounds or on grounds clinic appointments. Specific documentation and/or follow-up needed. Other pertinent information related to individuals care. The off-going shift is responsible to leave the unit in an acceptable condition. If the condition of the unit is unsatisfactory to the on-coming Shift Lead or an individuals medical record cannot be accounted for, the Unit Supervisor or Program Management shall be notified of the appropriate action. -3N.P.P. No. 3

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 4 Effective Date: August 31, 2006 SUBJECT: VERIFICATION OF LICENSES 1. PURPOSE: To outline the requirements of the Central Nursing Services office to ensure each nursing services employee maintains a current and valid license (RN, PT, LVN) or CNA certificate (for PTA) as a condition of employment at Coalinga State Hospital. 2. POLICY: 1. Verification of Licensure or certification will be done prior to employment and annually thereafter during the Annual Performance appraisal process to assure compliance with current licensure and certification requirements. 2. It is the direct responsibility of the individual nursing employee to: 3. Maintain a current valid license or certificate as a condition of employment at Coalinga State Hospital. 4. Have the license or certificate in your possession at all times while on duty. 5. Present your new license or certificate on or before the expiration date shown on the license or certificate to the Central Nursing Services office or to authorized management personnel for verification. Authorized management personnel are defined as Program Management or your Unit Supervisor. The verification process by authorized management personnel consists of the following: A. Verify the license or certificate renewal by confirming the expiration date and confirming the licensees signature is present on the new license. B. Make a photocopy of the renewed license or certificate and compare the copy with the actual license or certificate. C. Authorized management personnel will then write on the photocopy, Verified By: and provide their full signature, title, and date indicating confirmed verification

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D. Document the Program, Unit, Shift, and Cycle of the employee on the photocopy E. This photocopy may then be hand carried to the CNS office or routed through the Coalinga State Hospital mailing system. During the renewal process, if you have not yet received your current license from the Board, "Acceptable Evidence of renewal may be accepted until the actual license is received. Acceptable Evidence shall include the following: Money Order receipt and return receipt from Certified Delivery indicating license renewal; or, copy of canceled personal check; or, current/valid license, registration, or certificate and confirmation of renewal from the respective Boards by the CNS Office. The photocopy of the license or certificate will remain on file in the Central Nursing Services office for term of the license. A condition of employment is that you possess a valid current license or certificate. It is your responsibility to maintain your license. If you have not renewed your license or certificate by the expiration date you will not be able to work. Employees without a current license or certificate do not meet minimum qualifications for employment, therefore the employee. 3. GENERAL INFORMATION: The CNS Office maintains two systems for license or certification verification: -Binders with hardcopies of the actual license with employee names listed I in alphabetical order. -A computer database with all nursing staff information regarding licensure that is continually updated. Renewal of licenses should be done immediately upon notification by the Licensing Board. You must have a current license or certificate in order to work. It may take 6 to 8 weeks for the Board of Registered Nurses, Board of Vocational Nurse and Psychiatric Technicians, or the Department of Health Services (CNA certification for PTA) to process your license or certificate for renewal. To avoid disruptions in your employment, renew your license or certificate early. It is strongly recommended that you renew as soon as you get notice that your license is due. If you do not get this notice you must contact the Board and pay your renewal fee. Make sure you include a list of your Continuing Education Units (CEU) with their designated Nursing Provider

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Number and sign the form in each location requesting a signature (this may be both the front and back of the form). If the renewal form is unsigned, the CEUs not listed, or any other discrepancy is on the form, your license renewal process may be delayed. The Board expects the licensee to retain their course completion certificates for a period of 4 years. 4. DEFINITIONS: Active license - A license is considered active when payment of the renewal fee and submission of proof of 30 hours of CE are submitted prior to the expiration of the license. Inactive license - A license is considered inactive when payment of the renewal fee is made but proof of completion of 30 hours of CE is not submitted. Delinquent license - A license is considered delinquent when payment of the renewal fee and/or proof of completion of 30 hours of CE have not been received by the Board within 30 days following the expiration date printed on the license. To make inquiries about your license:

Board of Registered Nurses: Tele # 916-322-3350 Email address: www.rn.ca.gov

Tele # 800-838-6828

Board of Vocational Nurse and Psychiatric Technicians: Tele # 916-263-7800 FAX # 916-263-7855 Email address: www.bvnpt.ca.gov Department Of Health Services: Tele # 916-327-2445

FAX # 916-327-4320

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 5 Effective Date: August 31, 2006 SUBJECT: INDIVIDUAL AND FAMILY TEACHING 1. PURPOSE: Health education is an essential component of nursing care and is directed toward promotion, maintenance, and restoration of health and toward adaptation to the residual effects of illness. The objective of this policy is to assist the Individual to strive toward achieving their maximum health potential by development of an Wellness and Recovery approach to Individual/family teaching and through effective health teaching practices. 2. POLICY: 1. The teaching-learning process is an integral part of the nursing process. With a focus on learning and with regard for the principles, variables, techniques, and strategies of teaching and learning the steps of the nursing process. Assessing, planning, implementing, and evaluating are used for the purpose of meeting the teaching and learning needs of the Individual and his or her family. Individual and family teaching shall be an essential part of nursing care for each Individual. This teaching shall begin at the Individual's admission and continue through discharge. The family shall be included when available and appropriate. On admission, the RN/Case coordinator will begin to identify the physical and mental health learning needs of the Individual and incorporate those needs into the Individual care plan. By applying the nursing process to a learning/teaching situation, the RN will utilize a systematic approach to include the following steps: A. Identify the Individuals learning capabilities (assessment); B. Identify the Individuals learning needs (nursing diagnoses); C. Develop learning goals and behavioral objectives designed to meet those goals (planning); D. Select the appropriate teaching strategy (intervention); E. Evaluating the Individuals progress and the effectiveness of the overall teaching plan (evaluation).

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5.

Utilizing the Wellness and Recovery Individual/Family Health Education Record, each Individual will be assessed to determine their learning needs, abilities, learning preferences and readiness to learn. This assessment will consider cultural and religious practices, emotional barriers, desire and motivation to learn, physical and cognitive limitations, language barriers, and the financial implications of care choices. The Wellness and Recovery Individual/Family Health Education Record will be initiated on all Individuals. The RN/Case coordinator shall be responsible for insuring this record is present for each Individual they case manage. The Wellness and Recovery Individual/Family Health Education Record will be included in the Admission packet and shall be filed in the Education section of the Individuals chart. The Wellness and Recovery Individual/Family Health Education Record shall be completed as follows: A. Part I (Readiness to Learn and Specific Barriers to Learning) this assessment section shall be completed by the Registered Nurse on the Admission Unit prior to the Individual 7 Day Master Treatment Plan Conference. It shall be reviewed and updated by the RN as needed when the Individual is transferred or returns from a discharge of more than seven days. If changes are made, the RN shall initial and date the changes. B. Part II (Referrals section) shall be completed when referrals related to education needs or identified barriers are sent out (e.g. ADEP, Easy Street, inability to read or write). C. Part III is a complete list of codes to be used in the recording of the teaching/education provided identified in Part IV. D. Part IV is the ongoing flow of Individual teaching done by all disciplines. This section documents what, who, and how the Individual was taught and their response to the education. After completion, the providers signature is entered.

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The Education Record is meant to consolidate Individual information regarding teaching being provided by the Individuals Wellness and Recovery Team members. Education recorded on the Wellness and Recovery Individual/Family Health Education Record does not need to be

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recorded in the Wellness and Recovery Notes. Pertinent information not addressed on the Record shall be addressed in the IDN. 11. The Wellness and Recovery Individual/Family Health Education Record shall not be thinned from the chart. Individual teaching shall include but not be limited to the following: A. All Individuals shall be taught basic hygiene for infection control purposes (e.g. Hand hygiene; personal grooming; discouragement of the sharing of utensils, cups, toothbrushes cigarettes, hats, clothes, avoid sleeping in socks); B. Measures to avoid blood borne pathogens (e.g. process for obtaining and the effective use of condoms; discouraging the sharing of razors, ear piercing, tattooing; safe sex); C. All Individuals shall be taught the importance of their medication, purposes of use, expected beneficial effects, and food-drug interactions. Teaching shall include potential side effects on individual medications and self monitoring for recognition of adverse response; D. All Individuals will be provided counseling on nutrition and modified diets; E. All Individuals shall be taught in the areas of communication, interpersonal relations, social skills, behavioral self-control, and coping skills; F. The rationale for the treatment program; G. The Unit Milieu (e.g. Orientation to the unit and Treatment Team members, rules of the unit, PST activities, How to make a request from the team, How to tell staff when feeling sick or in need of medical attention); H. The underlying pathology causing the disease symptoms; I. The nature of diagnostic tests and studies, the preparation for those tests, and the meaning of the test results. 3. GENERAL INFORMATION: The Wellness and Recovery Individual/Family Health Education Record designed to be utilized by all disciplines to provide an on-going record of the progress of the Individual and family education, their response to the

12.

was

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education provided, and areas for teaching still needed for the Individual and/or family. It serves to provide information about the Individuals individual teaching needs and their potential barriers to the education process. When assessing the Individuals Readiness to Learn the Individual is given a rating of (P= Poor, A = Average, G = Good) for their ability to understand verbal instructions, ability to understand written instructions, and their knowledge of their educational needs and Treatment Plan. When assessing the Specific Barriers to Learning and Special Considerations determine the presence or absence of barriers associated with physical, sensory (visual or auditory impairment), cultural, religious, reading, language, motivation, cognitive, age related issues, emotional, or financial concerns. Family, Other is defined as the Individuals family, spouse, significant other, conservator, legal guardian, or accepting facility that will oversee the Individuals care and treatment.

Principles of teaching and learning:

The teaching-learning process requires the active involvement of both the nursing staff member and the Individual. The desired outcome of the teaching-learning process is a change in the Individuals behavior. The nursing staff member serves as a facilitator of learning. Learning facilitated by progressing from the simple to the complex and from the known to the unknown. Learning is facilitated when the Individual is aware of his/her progress toward the learning goals.

Variables that affect learning readiness:

1. Physical readiness: A. Physical distress that absorbs the Individuals attention prevents effective learning. B. Readiness to learn can be promoted by alleviating or at least minimizing as much as possible the Individuals physical or emotional distress. 2. Emotional readiness: Motivation learning depends upon: A. Acceptance of the illness or acceptance of the fact that

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illness is a threat. B. Recognition of the need to learn. C. A therapeutic regimen compatible with the Individuals life style or altered lifestyle. 3. Motivation to learn can be promoted by: A. Creating a warm, accepting, positive atmosphere B. Encouraging the Individual to participate in the establishment of acceptable, realistic, attainable learning goals. C. Providing feedback about progress, that is, positive reinforcement, when the Individual is successful and constructive criticism when he or she is unsuccessful. 4. Teaching Strategies: Selecting teaching techniques and methods that are most appropriate to meet the Individuals needs facilitates learning. A. Lecture - is the most useful in teaching groups of Individuals who share the same learning needs. The Lecture format should always be accompanied by discussion, which allows the Individual to express their feelings, and concerns, ask questions, and clarify information. B. Group discussion - is most useful for Individuals who relate well in groups. It allows Individuals to experience security through being a member of a group of Individuals with similar problems or learning needs. It also provides Individuals with the opportunity to gain support, assistance, and encouragement from group members. be C. Demonstration and practice - is most useful when skills are to learned. Ample opportunity must be provided for practice sessions. Equipment should be the same as that which the Individual will use after leaving the hospital. D. Teaching Aids - are useful to supplement the resources of the nurse in helping the Individual to learn. It includes books, pamphlets, pictures, films, slides, tapes, and models. The teaching aids must be reviewed prior to presentation to ensure that they are appropriate for meeting the Individuals individual learning needs.

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E. Reinforcement and follow-up - allow ample time for the Individual to learn and to have his/her learning reinforced. Follow-up sessions promote the Individuals confidence in their ability to retain their newly learned behaviors. Evaluate the Individuals progress, which is imperative and plan additional teaching sessions as necessary.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 6 Effective Date: August 31, 2006 SUBJECT: CODE OF ETHICS FOR NURSING SERVICES 1. PURPOSE: The code (adapted from the American Nurses Association Code of Ethics for Nurses) provides guidelines with respect to the care of individuals and for accountability to individuals, to the profession, and to society. The objectives and expectations for nursing staff at Coalinga State Hospital follow this code. 2. POLICY: Nursing Services staff shall interact in professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. Nursing Services staff safeguards the individual's right to privacy by judiciously protecting information of a confidential nature. Nursing Services staff promotes, advocates for, and strives to protect the health, safety, and rights of the individual. Nursing Services staffs are responsible and accountable for individual nursing practice and determine the appropriate delegation of tasks consistent with the nurses obligation to provide optimum individual care. Nursing Services staff assumes responsibility and accountability for individual nursing judgments and actions. Nursing Services staffs have a responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. Nursing Services staff exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibilities, and delegating activities to others.

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Nursing Services staff participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. Nursing Services staff participates in the professions efforts to establish and maintain conditions conducive to high quality care. Nursing Services staff collaborates with other health professionals and the public in promoting community, national, and international efforts to meet heath needs. The profession of the Nursing Services staff, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

3. OBJECTIVES: 1. To provide care and treatment with respect and dignity with the desired outcome of improving the quality of life for the individuals committed to our facility. 2. To administer nursing care in accordance with the Hospitals Mission and Vision statement delineates the philosophy, goals, and policies of Coalinga State Hospital. 3. To review existing policies and procedures on an annual basis and verify that they include current theory and reflect national standards. 4. To formulate new policies and procedures that reflects changes created by advances in the health field. 5. To provide an environment in which Nursing personnel work effectively with others. 6. To provide a climate for the encouragement of individual and group participation in professional Nursing organizations. 7. To establish and maintain a relationship of mutual respect and collaboration with other disciplines throughout the hospital. 8. To develop clinical management skills by promoting staff development programs.

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9. To maintain a systematic approach in monitoring and improving Nursing Care. 10. To recruit and select qualified Nursing personnel who meet the specific job criteria.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 7 Effective Date: August 31, 2006 SUBJECT: NURSING SERVICES RECORDS, MEETING MINUTES, QUALITY IMPROVEMENT DATA AND REPORTS 1. PURPOSE: To identify timeframes for retention of Nursing Service records, meeting minutes, Quality Assessment/Improvement data collection, and reports according to State and Federal requirements. 2. POLICY: Central Nursing Services shall retain the following records as identified below: -CNS Department Quality Improvement, Meeting Unit (QIMU) Minutes/Projects for 3 Years. -HSS Staff Meeting Minutes for 3 Years. -Nursing Quality Improvement Committee Meeting Minutes for 3 Years. -Nursing Quality Improvement Committee and HSS Quality Assessment/Improvement Indicators and Monitors for 3 Years. -Nursing Policy and Procedures for 1 Year/after update. -HSS 24 Hour Reports for 3 Years. -Nursing 0800 Report for 3 Years. -Nursing Staffing Compliance Worksheets for 3 Years. -Search and Seizure Records for 2 Years. -Professional Practice Groups Meeting Minutes for 1 Year. -License Verifications for; Registered Nurse, Psychiatric Technician, Licensed Vocation Nurse and Psychiatric Technician Assistant (CNA) for 2 Years.

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Program Nursing Coordinator Office shall retain the following records as identified below: -Drug Regimen and Medication Reviews for 1 Year -NPPM New/Revised Nursing Policy Sign Sheet (Indicating each unit employee from each shift has read the updated policy) for 1 Year -Unit QIMU Meeting Minutes and Projects for 3 Years -Program Auditor data collection and reports for nursing personnel for 3 Years -Staff Competency Training, employee orientation to program/unit, update continuously.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 8 Effective Date: August 31, 2006 SUBJECT: NURSING POLICY AND PROCEDURES 1. PURPOSE: 1. To provide a guide for nursing care that reflects optimal standard nursing practice. 2. Define and describe the scope and conduct of individual client care provided by staff. 2. POLICY: 1. The Coordinator of Nursing Services ensures that nursing standards of individuals care and standards of nursing practice are consistent with current nursing research findings and nationally recognized professional standards. 2. The Coordinator of Nursing Services implements the findings of current research from nursing and other literature into the policies and procedures governing the provision of nursing care. 3. Nursing policies and procedures, nursing standards of individual client care, and standards of nursing practice are approved by the nurse executive (Coordinator of Nursing Services) or a designee(s). 4. Development of nursing policy and/or procedures shall be the responsibility of the Chair of the Nursing Policy and Procedure Committee working in collaboration with the Nursing Policy and Procedure Committee and appropriate staff and pertinent departments associated with the subject matter of the policy. 5. Program Management shall be responsible to ensure nursing staff reviews all new and/or revised Nursing Policies. 6. Program management shall be responsible to assign and supervise participation of their program representative to the Nursing Policy and Procedure Committee.

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3. GENERAL INFORMATION: The nurse executive (Coordinator of Nursing Services) is responsible for ensuring that policies, procedures, and standards describe and guide how the nursing staff provides the nursing care required for all individuals and client populations served by the hospital and as defined in the hospitals plan(s) for providing nursing care. All nursing policies, procedures, and standards are defined, documented, and accessible to the nursing staff in written or electronic format. Regardless of how it is documented, the nurse executive (CNS), or designee(s) approves each element, before it is implemented. 4. DEFINITIONS: Policies and Procedures - The formal, approved description of how a governance, management, or clinical care process is defined, organized, and carried out. Practice Guidelines - Descriptive tools or standardized specification for care of the typical individual in the typical situation, developed through a formal process that incorporates the best scientific evidence of effectiveness with expert opinion. Synonyms include clinical criteria, parameter (or practice parameter), protocol, algorithm, review criteria, preferred practice pattern, and guideline. 5. ONGOING POLICY REVIEW SCHEDULE: The Nursing Policy & Procedure Manual will be reviewed on an ongoing basis, utilizing the following schedule: MONTH January February February March April May June July August September October November December SECTION Administrative Section Section I Admission & Discharge, Section II Abbreviations & Terms Section III Basic Nursing Care Section IV Treatment Procedures Section V - Medication Section VI Diagnostic Procedures Section VII Emergency Procedures Section VIII Psychiatric Nursing Section IX Clothing & Linen, Section X Central Supply Section XI Orientation & Education Section XII Infection Control Holiday Month / Make-up Month (Appendix)

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6. PROCEDURE: 1. Chairperson:

The Chairperson of the NPPM Committee is an ACNS (Assistant to the Coordinator of Nursing Services) 2. Committee: A. The committee meets one times monthly or on call of chairperson B. The committee membership is composed of interested staff and: -H.S.S. representative(s) -Training Center representative(s) -Public Health Nurse -Representative from the Unit Supervisor Group -Representative from each Program (RN or Psychiatric Technician) -Standards Compliance Coordinator Representative -Chairpersons of the RN and PT Professional Practice Groups. - (After activated and these positions are in operations) 3. Committee Process: A. Always and makes recommendations on nursing procedures and policies every two years or more frequently as necessary. B. Develops drafts of Nursing Policy and Procedures. C. Assures Nursing Policy and Procedures reflect current levels of clinical practices D. Distributes drafts of the policy for review and input from appropriate staff and pertinent departments associated with the subject matter of the policy. 4. Review Process Guidelines: Effort will be made to review sections of the policies according to the Ongoing Policy Review Schedule (see page xii.1). Section 2 is reviewed and approved by the medical staff via the (MHDS) Medical Records Committee (February). Section 5 is reviewed the 5th month (May) with selected policies reviewed by the Pharmacy and Therapeutics Committee and the Med Room Group.

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The Emergency Care Committee reviews section 7 policies. The Infection Control Committee reviews section 12 policies. Recommendations for changes may be made by any employee via: A. Formal process: The program representative will bring the recommendations and input they obtain from the program to committee. B. Informal process: Written memos or telephone calls can be made to the Chairperson who will bring to committee for discussion as the policy comes up for review. The Chairperson will send drafts on new policies to appropriate staff for input. Policy and Procedures related to infection control are reviewed and approved by the Infection Control Committee. Policies and Procedures related to emergency care are reviewed and approved by the Emergency Care Committee. The Pharmacy and Therapeutics Committee reviews medication related policies. Dependants on the policy, pertinent staff or departments associated with specific policies are consulted for input and review of the policy. Final drafts are then prepared and submitted to the Coordinator of Nursing Services and the Chief of Medical Staff for review, approval, and signature. 5. Distribution: Policy and Procedures are sent by the Chair of the Nursing Policy and Procedure Manual Committee to all Department holders of the manual via the hospital LEGEND "E" distribution list. Policies for manuals on nursing units are sent as packets to the Nursing Coordinators of each Program. The packets consist of the following: 1. A cover letter addressed to the Nursing Coordinator (NC) of the identified Program describing the policies(s) being distributed and any additional instructions that may be needed. The NC packet also includes a copy of the policy for the Program Management Manual. 2. Within the NC packets are individual packets addressed to each Unit Supervisor of the Program. Each Unit Supervisors packet consists of two copies of each procedure including a NPPM Signature Sheet. The Signature Sheet is to be used as a management and

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supervision tool for the Unit Supervisor. Unit staffs are to read the policy and show evidence of this requirement by signing the NPPM Signature Sheet. 3. One copy of the procedure shall be placed in the Nursing Policy and Procedure Manual by the unit supervisor. One copy shall be posted with the Signature Sheet for the unit staff to read. 4. The Unit Supervisor/designee shall date and post the NPPM Signature Sheet (see ATTACHMENT A). Unit Staff of all three shifts are expected to review the posted new and/or revised policies. The Unit Supervisor and/or the Shift Leads of all three shifts are to ensure that their staff review and sign the Signature Sheet. When completed, and after review by the Unit Supervisor, the Signature Sheet will be forwarded to the Nursing Coordinator to be retained in the Program Office for 1 year. 5. The Unit Supervisor/Shift Leads of all three shifts are encouraged to assist staff with methods to alert staff of the new changes (e.g. provide an in-service at the Change of Shift, request training assistance from the Staff Development Center, etc.).

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 9 Effective Date: August 31, 2006 SUBJECT: NURSING SERVICE: DUTIES AND RESPONSIBILITIES

1. GENERAL: The Nursing Services is an important member of the Wellness and Recovery Model System who is frequently in closest contact with the Individual and can observe and impact the day-to-day adjustment and behavior of the Individual. The relationship between the Individual and his staffs is a fundamental aspect of his care and treatment. All Individuals will be assigned to licensed nursing service staffs, which may include one staffs each from the a.m. and p.m. shifts. I. INTRAHOSPITAL TRANSFER - ORIENTATION (Admission to the hospital Receiving Unit Protocols.) A. Interview the Individual as soon as possible after admission to the unit in order to supply the Individual with needed support and guidance, to assess the Individual's adjustment to the hospital and unit environments, and to identify immediate problem areas. B. Explain unit rules and expectations, e.g. attendance at groups, therapeutic community meetings, Individual Access System (PAS) rules, unit visiting rules, etc. C. Introduce the Individual to other Individuals, particularly unit government officers. They will be helpful in explaining unit routines and in further orienting the new Individual. D. Direct the Individual to the Individuals Rights bulletin board. Review his rights with him and point out the phone numbers of Individuals Rights officers posted. Chart his response in the I.D. Notes per - Individuals Rights Advocacy Program. II. ESTABLISHING NURSING GOALS AND OBJECTIVES A. Upon receiving the Individual on the unit, a Registered Nurse will update that Individual's Nursing Assessment

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B. Nursing Staff members will meet with the Individual to develop a Nursing Care Plan to present to the Wellness and Recovery Model System. The nursing goals and objectives for each Individual are the result of collaboration between the Psychiatric Technician and the Registered Nurse assigned to his care. C. The staffs will provide input to other members of the Wellness and Recovery Model System to assist in establishing and/or revising priorities in treating identified problems at each scheduled Team meeting. It is the staffs responsibility to act as the Individuals advocate in issues brought before the ID Team. III. OBSERVING AND COMMUNICATING A. Staff has the responsibility of frequent observation of the Individuals assigned to them and for relaying pertinent information about their behavior to other members of the treatment staff. Staffs shall have at least weekly contact with their assigned Individuals to evaluate and to assist their progress toward attaining their individual goals. B. All pertinent observations are to be entered in the Intergraded Assessment Notes C. Special problems of the Individual (mental and physical) will be verbally reported during the change of shift report and referred to the unit physician if needed. D. Any Individual observation that requires the special attention of staff shall be entered into the unit communication log. For example: "See IDN (5/25 at 1300) on J. Smith, assaultive, depressed, etc." E. Staffs are responsible for routinely reviewing and updating Rand Card information on each of their assigned Individuals. IV. DAY-TO-DAY NEEDS OF THE INDIVIDUAL Individuals rely on their staffs for many of their day-to-day needs. A. The staffs initiates requests for and receives the Individual's property from storage (CDS) and the Trust Office. B. The staffs advocates for referrals to treatment-oriented work assignment, occupational therapy shop, clubs, therapy groups, etc. C. The staffs, as a member of the Wellness and Recovery Model System, has a responsibility to assist the Individual on a daily basis to implement his Nursing Care Plan. D. The staffs will conduct nursing group activities as assigned by the Unit Supervisor. E. The Staffs will work 1:1 with his or her assigned Individuals to assist them to meet their nursing care objectives. -2N.P.P. No. 9

V. STAFFS GROUPS A. All Individuals will be assigned to a staffs group. B. The staffs group will create an accepting atmosphere for the Individual. C. The staffs offers encouragement and support as needed in order to develop trust toward his therapeutic milieu. D. The staffs evaluates each Individual's ability to participate in group. The staffs will meet on a 1:1 basis with Individuals that require individual remedial attention before they are able to function in a group setting. E. The purpose of the staffs group is to: 1. Assist the Individual to resolve personal issues that arise from living in an in-Individual setting; 2. Assist the Individual to increase his problem-solving abilities; 3. Provide information; 4. Assist the Individual to improve interpersonal interaction skills; 5. Provide support; 6. Assist Individual in meeting treatment goals related to his dispositional setting. VI. MEETING WITH OTHER MEMBERS OF THE WELLNESS AND RECOVERY MODEL SYSTEM Staffs will meet regularly with the primary clinician, other members of the unit staff, and the Wellness and Recovery Model System to evaluate the Individual's progress, to evaluate the effectiveness of the Individual's treatment plan, and to make recommendations regarding the Individual's needs. Nursing Care Plans are reviewed as needed in the I.D. Team. The Registered Nurse and / Psychiatric Technician will be responsible for bringing dietary information, nutritional assessment updates to the Wellness and Recovery Model System Conferences. VII. CHARTING The staffs is responsible for documenting in the Integrated Assessment Notes the Individual's progress or lack of progress in meeting the Nursing Care Plan objectives. Weekly staffs summaries must address any pertinent Individual care issues, changes in the overall acuity rating, temporary conditions, and the Individuals progress toward meeting the specific objectives identified in psychiatric nursing care plans and acute physical problems. The Staffs will also ensure that pertinent behavior, participation in activities, response to treatment, PAS status, and overall progress toward release from the hospital is recorded. When there is a nutritional problem open on the Individual's Physical Profile, the staffs will review the nutritional assessment and will incorporate the plans the dietitian has recommended that requires nursing service staff -3N.P.P. No. 9

interventions into the Individuals treatment. The staffs will also monitor and document compliance in weekly Integrated Assessment Notes and Document all teaching on the Individual Family Education Record.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 10 Effective Date: August 31, 2006 SUBJECT: CONFIDENTIALITY OF INDIVIDUAL INFORMATION 1. PURPOSE: Confidentiality applies to any and all information obtained in the course of providing nursing services to the Individual. The following expectations are provided to ensure that all Individual information is maintained in a confidential manner according to clinical and legal requirements. 2. POLICY: Nursing personnel shall keep all Individual information confidential in accordance with relevant CA, W&I Code Section 5328. All phone calls to the units requesting information shall be referred to the unit Physician, unit Social Worker, or Program Director. When in public areas, either on CSH grounds or off, nursing personnel is expected to comply with confidentiality statutes and not refer to Individuals by name or discuss confidential information outside of the workplace. Confidentiality does not apply within the treatment team. Pertinent information shall be shared with all members of the treatment team and the Individual should be so advised prior to giving confidential information to one member of the team. All nursing personnel are responsible for maintaining confidentiality of any and all portions of the Individuals medical record and for safeguarding its informational content against loss, defacement, tampering and from use by unauthorized individuals. Disposition of all materials containing Individual information shall be done in such a manner as to ensure confidentiality. All employees are required to observe for and report breaches in the maintaining of confidentiality to supervisors. Nursing personnel shall immediately report to the physician or Program Director any threat to person or property made by a Individual.

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3. DEFINITION: Confidential Individual information is defined as any and all information obtained in the course of providing services to Individuals. This information includes, but is not limited to: Individual records, reports, photographs, fingerprints, correspondence, Addressograph plates, documents generated and discarded during a Individuals hospitalization, draft reports, and notes designed for disposal rather than filing in Individual records, etc. FAX COVER SHEET: The following is a recommended phrasing on the FAX Cover Sheet when faxing Individual information to other agencies or facilities:

This message is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this message is not the intended Recipient or the Employee or Agent responsible to deliver it to the intended Recipient, you are hereby notified that any use, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received the facsimile in error, please immediately notify us by telephone and return the original message to us at the address on this cover sheet via the U.S. Postal Service. Thank You.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 11 Effective Date: August 31, 2006 SUBJECT: NURSING SERVICES QUALITY IMPROVEMENT PROGRAM 1. PURPOSE: 1. To monitor and evaluate the quality and appropriateness of care provided to Individuals. 2. Maintain high quality Individual care where it already exists. 3. Improvement of Individual care in identified areas of concern. 4. Compliance with Standards of Nursing Care adopted by Coalinga State Hospital. 5. Compliance with JCAHO, DHS, and Title 22 requirements.

2. POLICY: 1. The Coordinator of Nursing Services ensures that nursing standards of Individual care and standards of nursing practice are maintained. 2. To assess, monitor, and evaluate the effectiveness of Individual care and nursing practice, Central Nursing Services maintains a Quality Improvement Program consistent with the Quality Improvement goals of the hospital. 3. Under the guidance, direction, and approval of the CNS, development of Quality Improvement (QI) indicators shall be the responsibility of the Nursing Quality Improvement Coordinator in collaboration with the Nursing QI Committee and appropriate staff and pertinent departments associated with the subject matter being monitored. 4. Indicators are developed and designed based on the important aspects of Individual care utilizing the principles of high risk, risk management, high volume, and problem prone issues. 5. Data results, with recommendations for corrective actions, are reported on a monthly/quarterly basis or more frequently, if indicated, to CQIT or EQIT. -1N.P.P. No. 11

6. Program specific data compilations shall be submitted to the Program Directors or designees by the Health Services Specialist for corrective actions and follow up. Recommended corrective actions will be included when clinically appropriate. 7. Program Quality Improvement items involving clinical nursing issues will be referred to the CNS in writing. 3. COMMITTEE STRUCTURE AND FUNCTION: 1. Chairperson: The Chairperson of the Nursing Quality Improvement Committee is an RN/HSS (Health Service Specialist). 2. Committee: The Committee meets the second Wednesday of each month. The committee membership is composed of interested staff and: - 1 Health Services Specialist representative from each compound - Staff Development Center representative(s) - Chairpersons of the RN and PT Professional Practice Groups - Unit Supervisor(s) and/or representative from the Unit Supervisor Committee - Nursing staff representative from each Program (Program Auditor, RN, PT, or LVN Level of Care Nursing staff) 3. Committee Responsibility: -Determine important aspects of Individual care to be monitored and the frequency of evaluation. -Identify problems, criteria, data sources, and sample size for areas of Individual care being monitored. -Determine if care is appropriate according to Standards of Practice and policy. -Approval of methodologies to investigate problem causes. -Recommendation of appropriate problem solutions to CNS and Program Management for implementation. -Referral of Individual care concerns, not related to Nursing Services, to the appropriate discipline, department, or hospital Quality Improvement Program. 4. Committee Reporting -Annually, the Nursing Quality Improvement Coordinator will submit a

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summary of the important aspects of Individual care, review quality improvement plan and activities on ongoing basis, and the proposed activity schedule to the Coordinator of Nursing Services (CNS) and the Medical Director for final review an approval. 5. Committee Accountability: - The CNS is accountable for the monitoring and evaluation of Individual care to the Medical Director, the Executive Director, and ultimately to the Governing Body. The CNS is responsible for the integration of the activities through the CQIT and other pertinent hospital QI Programs. - The Health Service Specialists (HSS) are responsible to the CNS for the conducting of monitoring activities during their shift within their respective building and are responsible to the CNS for the proper and timely completion of its activities. 6. Communication: - The CNS provides the communication link between the NSQIC for CQIT & EQIT. - In the absence of the CNS, the Nursing Quality Improvement Coordinator assumes this duty of communicating the QI data, findings, and recommendations to the CQIT and/or other pertinent QI Programs or committees. - The HSSs assigned to each building will attend each Program Quality Improvement Committee meeting to review data findings and recommend corrective action to the Program for their implementation. - The HSSs may receive referrals from the Program Quality Improvement Committee that are appropriate for review by the Nursing Services Quality Improvement Committee. 7. Report Distribution: -Nursing QI Reports are sent to: Hospital-wide Performance Improvement Manager. CQIT for distribution to: -Chairperson of Physician Quality Improvement -Chief of Psychiatric Services -Chief of Medical Surgical Services -PNED for distribution to the Nursing Instructors. -Clinical Administrator for distribution to each Program Director

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-Nurse Executive Council members -Medical Records Committee -Pharmacy Director who will in turn prepare a report for the Pharmacy and -Therapeutics Committee -HSS staff -Med Room Group (Medication Error Audit findings) -Standard Compliance Coordinator

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 12 Effective Date: August 31, 2006 SUBJECT: NORTH AMERICAN NURSING DIAGNOSIS (NANDA TAXONOMY FOR DEVELOPING THE NURSING DIAGNOSIS) 1. PURPOSE: In 1982 the professional association, North American Nursing Diagnosis Association (NANDA), was established to develop, define, and promote taxonomy of nursing diagnostic terminology of general use for professional nurses. NANDAs intent is to provide a common language for the health problems nurses deal with. The nursing diagnosis serves as the vehicle to inform nurses about the nature of and care activities required for the specific health problem. The ANA has officially sanctioned NANDA as the organization to govern the development of a classification system of nursing diagnosis. 2. POLICY: The NANDA taxonomy is used by the RN to develop the nursing diagnosis. Nursing diagnoses provide the basis for selection of interventions for delivering Individual care to achieve outcomes for which the nurse is accountable. 3. GENERAL INFORMATION: Developing the diagnosis: The assessment component of the nursing process serves as the basis for identifying nursing diagnoses and collaborative problems. After completing the nursing assessment, the nurse organizes, analyzes, synthesizes, and summarizes the data collected and determines the Individuals need for nursing care. The nurse then proceeds to develop the nursing diagnosis, which is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. A nursing diagnosis is a statement that describes the Individuals actual or potential response health problem that the nurse is licensed and competent to treat.

to a

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When choosing the nursing diagnoses for a particular Individual, the nurse must first identify the commonalties among the assessment data collected. These common features lead to the categorization of related data that reveal the existence of a problem and the need for nursing intervention. The Individuals identified problems are then defined in the nursing diagnosis. It is important to remember that nursing diagnoses are not medical diagnoses; they are not medical treatments prescribed by the physician; they are not diagnostic studies; they are not the equipment used to supplement medical therapy; and they are not the problems that the nurse experiences while caring for the Individual. They are the Individuals actual or potential health problems that are amenable to solution by independent nursing actions. Nursing diagnoses that are succinctly stated in terms of the specific problems of the Individual will guide the nurse in the development of the nursing care plan. To give additional meaning to the diagnosis, the characteristics and the etiology of the problem must be defined and included as part of the diagnoses. The nursing diagnosis consists of three components: 1. The human response or problem 2. The related factor 3. The signs and symptoms Each of the three parts of the nursing diagnosis is written differently. The first part of an actual diagnosis, the human response or problem, comes from the NANDA list whenever possible. The NANDA taxonomy list contains qualifiers or adjectives that clarify the nursing diagnoses and precede the human response. The vast majority of human responses identified by the North American Nursing Diagnosis Association (NANDA) define problems that nurses are licensed to treat by virtue of their education. After gathering and analyzing assessment data, the nurse formulates the nursing diagnosis by selecting the human response from the list of accepted nursing diagnoses. If the nurse is unable to locate a human response on the NANDA list, he or she develops a statement that defines the Individuals problem. The second part of the nursing diagnosis is the related factor. It is linked to the human response with the words related to, abbreviated in the text as R/T. The words related to demonstrate that there is a relationship between the first two parts of the diagnosis; this implies that if one part changes, the other will also.

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The third part of the statement consists of the pertinent defining characteristics, the signs and symptoms. They are linked to the second part with the words as evidenced by, abbreviated AEB in this text. The three-part actual nursing diagnosis has been referred to as the PES format: Problem (or human response), Etiology (related factors), and Signs and Symptoms (or defining characteristics). 4. NANDA TAXONOMY: Pattern 1: Exchanging
Altered Nutrition: More Than Body Requirements Altered Nutrition: Less than Body Requirements Altered Nutrition: Risk for More Than Body Requirements Risk of Infection Risk for Altered Body Temperature Hypothermia Hyperthermia Ineffective Thermoregulation Dysreflexia Risk for Autonomic Dysreflexia Constipation Perceived Constipation Diarrhea Bowel Incontinence Risk for Constipation Altered Urinary Elimination Stress Incontinence Reflex Urinary Elimination Urge Incontinence Functional Urinary Incontinence Total Incontinence Risk for Urinary Urge Incontinence Urinary Retention Altered Tissue Perfusion (Specify Type: Renal, Cerebral, Cardiopulmonary, Gastrointestinal, Peripheral) Risk for Fluid Volume Imbalance Fluid Volume Excess Fluid Volume Deficit Risk for Fluid Volume Deficit Decreased Cardiac Output Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Inability to Sustain Spontaneous Ventilation Dysfunctional Ventilatory Weaning Response Risk for Injury Risk for Suffocation Risk for Poisoning Risk for Trauma Risk for Aspiration Risk for Disuse Syndrome Latex Allergy Response Risk for Latex Allergy Response Altered Protection Impaired Tissue Integrity Altered Oral Mucous Membrane Impaired Skin Integrity Risk for Impaired Skin Integrity Altered Dentition Decreased Adaptive Capacity: Intracranial Energy Field Disturbance

Pattern 2: Communicating
Impaired Verbal Communication

Pattern 3: Relating
Impaired Social Interaction Social Isolation Risk for Loneliness Altered Role Performance Altered Parenting Risk for Altered Parenting Risk for Altered Parent/Infant/ Child Attachment Sexual Dysfunction Altered Family Processes Caregiver Role Strain Risk for Caregiver Role Strain Altered Family Processes: Alcoholism Parental Role Conflict Altered Sexual Patterns

Pattern 4: Valuing
Spiritual Distress (Distress of the Human Spirit)

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Risk for Spiritual Distress Potential for Enhanced Well-Being

Pattern 5: Choosing
Ineffective Individual Coping Impaired Adjustment Defensive Coping Ineffective Denial Ineffective Family Coping: Disabling Ineffective Family Coping: Compromised Family Coping: Potential for Growth Potential for Enhanced Community Coping Ineffective Community Coping Ineffective Management of Therapeutic Regimen: Individuals Noncompliance (specify) Ineffective Management of Therapeutic Regimen: Families Ineffective Management of Therapeutic Regimen: Community Effective Management of Therapeutic Regimen: Individual Decisional Conflict (specify) Health Seeking Behaviors (specify)

Pattern 6: Moving
Impaired Physical Mobility Risk for Peripheral Ne4urovascular Dysfunction Risk for Perioperative Positioning Injury Impaired Walking Impaired Wheelchair Mobility Impaired Transfer Ability Impaired Bed Mobility Activity Intolerance Fatigue Risk For Activity Intolerance Sleep Pattern Disturbance Sleep Deprivation Diversional Activity Deficit Impaired Home Maintenance Management Risk for Altered Growth Relocation Stress Syndrome Risk for Disorganized Infant Behavior Altered Health Maintenance Delayed Surgical Recovery Adult Failure to Thrive Feeding Self-Care Deficit Impaired Swallowing Ineffective Breastfeeding Interrupted Breastfeeding Effective Breastfeeding Ineffective Infant Feeding Pattern Bathing/Hygiene Self-Care Deficit Dressing/Grooming Self-Care Deficit Toileting Self-Care Deficit Altered Growth and Development Risk for Altered Development Disorganized Infant Behavior Potential for Enhanced Organized Infant Behavior

Pattern 7: Perceiving
Body Image Disturbance Self-Esteem Disturbance Chronic Low Self-Esteem Situational Low Self-Esteem Personal Identity Disturbance Sensory/Perceptual Alterations (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory Unilateral Neglect Hopelessness Powerlessness

Pattern 8: Knowing
Knowledge Deficit (Specify) Impaired Environmental Interpretation Syndrome Acute Confusion Chronic Confusion Altered Thought Processes Impaired Memory

Pattern 9: Feeling
Pain Chronic Pain Nausea Dysfunctional Grieving Anticipatory Grieving Chronic Sorrow Risk fore Violence: Directed at Others Post-Trauma Syndrome Rape-Trauma Syndrome Rape-Trauma Syndrome: Compound Reaction Rape-Trauma Syndrome: Silent Reaction Risk for Post-Trauma Syndrome Anxiety Death Anxiety

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Risk for Self-Mutilation Risk for Violence Self-Directed

Fear

5. DEFINITIONS: Pattern 1: Exchanging Risk for injury - The state in which an individual is at increased risk for being invaded by pathogenic organisms. Pattern 2: Communicating Impaired verbal communication - A state in which an individual experiences a decreased or absent ability to use or understand language in human interaction. Pattern 3: Relating Altered family processes - The state in which a family that normally functions effectively experiences dysfunction. Altered parenting - The state in which the ability of nurturing figure(s) to create an environment that promotes the optimum growth and development of another human being is altered or at risk. Altered role performance - Disruption in the way one perceives one's performance. Social Isolation - Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatened state. Sexual Dysfunction - The state in which an individual experiences a change in sexual function that is viewed as unsatisfying, unrewarding, or inadequate. Altered patterns sexuality - The state in which an individual expresses concern regarding his or her sexuality. Pattern 4: Valuing Spiritual distress (distress of the human spirit) - Disruption in the life principle that pervades a person's entire being and that integrates and transcends the individual's biologic and psychosocial nature. Pattern 5: Choosing

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Impaired adjustment - The state in which the individual is unable to modify his or her lifestyle or behavior in a manner consistent with a change in health status. Family coping: potential for growth - Effective managing of adaptive tasks by family member involved with the client's health challenge who now exhibits desire and readiness for enhanced health and growth in regard to self and in relation to the client. Ineffective Family Coping: Compromised - Insufficient, ineffective, or compromised support, comfort, assistance, or encouragement usually by a supportive primary person (family member or close friend); client may need it to manage or master adaptive tasks related to his for her health challenge. Ineffective family coping: disabling - Behavior of significant person (family member or other primary person) that disables his or her own capacities and the client's capacities to effectively address tasks essential to either persons adaptation to the health challenge. Ineffective individual coping - Impairment of adaptive behaviors and problem-solving abilities of a person in meeting life's demands and roles. Noncompliance - A person's informed decision not to adhere to a therapeutic recommendation. Pattern 6: Moving Altered health maintenance - Inability to identify, manage, or seek out help to maintain health. Diversional activity deficit - The state in which an individual does not experience stimulation from or interest or engagement in recreational or leisure activities. Altered growth and development - The state in which an individual demonstrates deviations in norms from his or her age group. Impaired home maintenance management - Inability to independently maintain a safe, growth promoting immediate environment. Self-care deficit - A state in which the individual experiences an impaired ability to perform or complete bathing and hygiene, dressing and grooming, feeding, or toileting activities by self.

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Sleep pattern disturbance: - Disruption of sleep time causes discomfort or interferes with desired lifestyle. Pattern 7: Perceiving Hopelessness - A subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf. Powerlessness - Perception that one's own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening. Body image disturbance - Disruption in the way one perceives one's body image. Personal identity disturbance - Inability to distinguish between self and non-self. Self-esteem disturbance - Disruption in the way one perceives one's selfesteem. Pattern 8: Knowing Knowledge deficit - A state in which specific information is lacking. Altered thought processes - A state in which an individual experiences a disruption in cognitive operations and activities. Pattern 9: Feeling Chronic pain - A state in which the individual experiences pain that continues for more than 6 months in duration. Anxiety - A vague, uneasy feeling, the source of which is often nonspecific or unknown to the individual. Fear - Feeling of dread related to an identifiable source that the person validates. Anticipatory grieving - A state in which an individual grieves before an actual loss. Dysfunctional grieving - A state in which actual or perceived object loss (object loss is used in the broadest sense) exists. Objects include people,

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possessions, a job, home, status, ideal, parts, and process of the body, etc.
Higher Priority Diagnoses Airway Function: -Potential for Aspiration -Potential for suffocation Impaired swallowing Altered Respiratory Function: -Impaired Gas Exchange -Impaired Gas Exchange R/T excessive mucous production -Ineffective Airway Clearance -Ineffective Breathing Pattern Decreased Cardiac Output: -Decreased Cardiac Output R/T altered electrical conduction Altered Tissue Perfusion: -Renal -Cerebral -Cardiopulmonary -Gastrointestinal -Peripheral Altered Fluid Volume: -Fluid Volume Excess -Fluid Volume Deficit -Potential Fluid Volume Deficit Moderately High Altered Nutrition: -More than body requirements -Less than body requirements -Potential for more than body requirements Altered Body Temperature: -Hyperthermia -Hypothermia -Ineffective Thermoregulation Dysreflexia Altered Skin Integrity: -Impaired Tissue Integrity -Impaired Skin Integrity -Potential Impaired Skin Integrity -Altered Oral Mucosa Membranes Altered Comfort: -Pain -Chest Pain -Chronic Pain Potential for: -Infection -Injury -Poisoning -Trauma -Violence: Self-Directed or Directed at Others -Feeding -Bathing/Hygiene -Dressing/Grooming -Toileting Sensory/Perceptual Alterations: -Visual -Auditory -Kinesthetic -Gustatory -Tactile -Olfactory -Spiritual Distress Moving: -Diversional Activity Deficit -Impaired Home Maintenance Management -Altered Heath Maintenance -Altered Growth and Development Perceiving: -Body Image Disturbance -Self-Esteem Disturbance -Chronic Low Self-Esteem -Situational Low Self-Esteem -Personal Identity Disturbance Knowing: -Altered Thought Processes -Knowledge Deficit (Specify) Feeling: -Dysfunctional Grieving -Anticipatory Grieving -Post-Trauma Response -Rape-Trauma Syndrome -Anxiety -Fear Moderate Priority Altered Urinary Elimination: -Stress Incontinence -Reflex Incontinence -Urge Incontinence -Functional Incontinence -Total Incontinence -Urinary Retention Altered Bowel Function: -Constipation -Perceived Constipation -Colonic Constipation -Diarrhea -Bowel Incontinence Altered Activity/Rest: -Impaired Physical -Mobility -Activity Intolerance -Fatigue -Sleep Pattern Disturbance -Potential for Disuse Syndrome -Unilateral Neglect Self-Care Deficit: Lower Priority Diagnoses Relating: -Impaired Social Interaction -Social Isolation -Altered Role Performance -Altered Parenting -Potential Altered Parenting -Altered Family Processes -Parental Role Conflict -Altered Sexuality Patterns -Sexual Dysfunction Communicating: -Impaired Verbal Communication Choosing: -Noncompliance (Specify) -Ineffective Individual Coping -Impaired Adjustment -Defensive Coping -Ineffective Denial -Ineffective Family Coping -Decisional Conflict -Health Seeking Behaviors Valuing:

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Risk for violence directed at others - A state in which an individual experiences behaviors that can be physically harmful to others. Risk for violence self-directed - A state in which an individual experiences behaviors that can be physically harmful to self. Rape-trauma syndrome - Forced, violent sexual penetration against the victim's will and consent; the trauma syndrome that develops from this attack or attempted attack includes an acute phase or disorganization of the victim's lifestyle and a long-term process of reorganization of lifestyle. Prioritization of Diagnosis is highly dependent on your Individuals condition. (In general, remember your ABCs. Anything, which can lead to Individual injury or death, has higher priority for your care plans). 6. KEY POINT WHEN DEVELOPING THE NURSING DIAGNOSIS: When an appropriate nursing diagnosis is not available from the NANDA taxonomy list, the RN may develop the diagnosis succinctly stating the diagnosis in terms of the specific problem of the Individual. Psychiatric nursing diagnoses are available in the 800 Section of the NPPM Manual for Psychiatric issues.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 13 Effective Date: August 31, 2006 SUBJECT: NURSING SERVICES MISSION AND ORGANIZATIONAL STRUCTURE 1. PURPOSE: Nursing Services at Coalinga State Hospital reflects the Mission and Vision of the hospital. This policy serves to outline that mission, vision, and define the organization of nursing services. 2. POLICY: 1. There shall be an organized Nursing Services at Coalinga State Hospital 2. A nurse executive (Coordinator of Nursing Services) who is a Registered Nurse qualified by advanced education and management experience directs nursing services. 3. The nurse executive (CNS) has the authority and responsibility for establishing standards of nursing practice. 4. The nurse executive or a designee approves standards of nursing practice, nursing policies and procedures, and nursing standards of care for the individuals we serve. 5. The nurse executive and other nursing leaders participate with leaders from the governing body, management, medical staff, and clinical areas in planning, promoting, and conducting organization wide performanceimprovement activities. 3. NURSING SERVICES MISSION: Nursing Services reflects the Mission of the hospital. Nursing Services Mission is to provide state of the art mental health care and treatment to forensic and civilly committed individuals in need of a structured, secure environment. The major components of the Nursing Services mission are evaluation, treatment, protection, and disposition.

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Evaluation - To provide professional evaluations based on the Nursing Process including recommendations to the Wellness and Recovery Team and individual members as relevant to the Nursing Diagnosis Treatment - To design and provide individualized quality nursing care and treatment utilizing a biopsychosocial rehabilitation model Protection - To maintain a secure, safe, therapeutic, and supportive environment for the benefit of the individuals we serve, staff, ID Team, and community Disposition - To prepare the individuals we serve for transfer or discharge to the next level of care 4. NURSING SERVICES VISION: Nursing Services reflects the vision of the hospital. Nursing Services staff will continue to play a significant role in the provision of effective culturally competent mental health services to forensically committed individuals in the State of California. We will continue to improve upon our work processes, which will lead to improved outcomes of care. We will assist with creating, maintaining, and enhancing collaborative efforts toward helping our clients achieve recovery. Nursing Services staff will understand and measure whether the individuals are getting better faster (e.g. use of the NOSIE, Performance Improvement projects conducted by the Program Auditors or the Nursing P.I. Coordinator). Within the framework of the Mission and incorporating the philosophies and values of the hospital, we will continue to demonstrate excellence in the field of forensic mental health nursing. 5. NURSING SERVICES PHILOSOPHY: Nursing Services reflects the Philosophy of the hospital: We believe that by providing a secure and therapeutic environment, within the context of a biopsychosocial rehabilitation model, we will maximize our individuals potential to live as independently as possible and minimize the disruption of their lives and the lives of others impacted by their illness. We believe that the use of the nursing process to provide expert clinical assessment and treatment for mentally ill individuals takes place most effectively in an environment which fosters innovation, creative problemsolving, mutual respect, and a dynamic therapeutic milieu characterized by collaboration between nursing services staff, the individuals we serve, the ID

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Team, and the community. We foster this collaboration through communication based upon understanding of customer-supplier relationships resulting in responsive work processes. As a forensic psychiatric facility whose mission is vitally linked to public policy and community concerns, we believe that our clients are best served in an environment which balances each individuals treatment needs with security. All Nursing Services staff are personally responsible for the safety and security of the hospital environment including identification of environmental security risks. To maintain security, we provide the structure, support, validation and interactions, which promote self-responsibility, well being, and health. 6. NURSING SERVICES VALUES: Nursing Services reflects the values of the hospital. Nursing Services is committed to clinical, forensic, and organizational excellence, and a strong spirit of community while providing individual care with respect and dignity. Nursing Services staff and the individuals we serve are empowered and held accountable to identify problems, propose recommendations, and implement solutions. Our key values are: -Excellence -Security -Safety -Spirit of Community -Dignity and Respect -Innovation -Individual Responsibility -Diversity 7. ANNUAL STRATEGIC PLAN: Nursing Services supports the hospitals Strategic Plans and the roles of the key function teams: -Assessment of the Individuals we serve -Continuum of Care -Care of the Clients -Client Education -Improving Organizational Performance -Infection Control -Leadership -3N.P.P. No. 13

-Management of the Environment -Management of Human Resources -Management of Information -Clients Rights and Organization Ethics 8. NURSING SERVICES ORGANIZATIONAL STRUCTURE: Nursing Services is under the overall responsibility of the Coordinator of Nursing Services (CNS) who reports directly to the Executive Director. The CNS collaborates with the Medical Director on matters of Medical/Nursing Care. The CNS has 24-hour responsibilities for all Nursing Services and has clinical authority over all nursing care matters. The CNS, in coordination with the Clinical Administrator, assigns staff in adequate numbers to provide nursing care. I. COORDINATOR OF NURSING SERVICES (Nurse Executive): The Coordinator of Nursing Services has overall responsibility for defining, directing, providing, and evaluating nursing care at Coalinga State Hospital. The CNS has organizational and clinical responsibility for the Standards of Nursing Practice, including staffing and clinical training for all Nursing Services employees. The CNS develops guidelines, policies, and procedures in accordance with existing Hospital, State, and Federal laws, and Joint Commission Accreditation Standards. II. ASSISTANT COORDINATORS OF NURSING SERVICES: There are five Assistant Coordinators of Nursing Services (ACNS). The ACNS provides supervision of Health Services Specialists (and other level of care nursing staff when appropriate). The ACNS provides an extension of the CNS authority to assure twenty-four hour nursing care and to fulfill delegated responsibilities. The ACNS provides consultation on Nursing Services issues and is involved in the administration of nursing care. III. HEALTH SERVICES SPECIALIST: (HSS) are assigned to provide Clinical Nursing supervision of nursing services staff as an extension of the CNS. HSSs evaluate the clinical performance of Registered Nurses and Shift Leads and collaborate with the Unit Supervisor in evaluating employees. They are responsible for addressing and reporting nursing concerns regarding individual care and treatment. An HSS is also Chairperson of the Nursing Services Quality Assessment and Improvement Committee.

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VI. REGISTERED NURSES: Registered Nurses (Case coordinators) are assigned through the CNS based on established clinical needs of the individuals. RNs assigned to the units, are under the administrative direction of the Unit Supervisor and the clinical supervision of the HSS. Registered Nurses will complete criteria based clinical performance evaluations for Psychiatric Technicians. In order to assure that there is quality and appropriate care for both the physical and psychiatric components of nursing care, Registered Nurses will be assigned the responsibilities of Case Management. The Case coordinators role is considered an essential point in which nursing and the overall team care of an individual is focused. The activities of the Case coordinator include the following priority items: -The initial Nursing Assessment at the time of admission -Participation in the 72-hour planning and Master Team Conferences -The development, in collaboration with the Psychiatric Technician counselor, of the Psychiatric and Physical Nursing Care Plan -The daily review of the individuals overall condition and the coordination of clinical Nursing Services for that individual -Review of medication with the Unit Physician, medication reactions, and referrals to the Physician -The evaluation of the clients responses to the individual care plan objectives -Assist the Shift Lead in the preparation of daily individual care assignments and change of shift reports -Review and modification of the Nursing Treatment Plan V. PSYCHIATRIC TECHNICIANS: Psychiatric Technicians are allocated through Nursing Services consistent with the established Nursing needs of the individual to provide basic physical and psychiatric Nursing care as a part of the Wellness and Recovery Model System. VI. NON-LICENSED NURSING SERVICES STAFF: Psychiatric Technician Assistant (PTA), Pre-Licensed Psychiatric Technician (PLPT), Psychiatric Technician Trainee (PTT) are allocated and assigned to the Programs through the CNS and Central Staffing Office and serve as supportive personnel to the RN and PT for providing client care and safety. VII. STUDENTS: Students (Nursing and Psychiatric Technician) may be assigned to units and are under the direct supervision of the Unit Supervisor or Shift Lead. Clinical supervision is provided by the Registered Nurse.

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VIII. NURSING TREATMENT TEAMS: Nursing Treatment Teams - On each unit at CSH, Nursing Service is delivered by means of psychiatric Nursing Care Teams. Each individual is assigned a counselor and co-counselor from the Psychiatric Technician nursing services staff. Each individual is also under the care of a Registered Nurse Case coordinator. The Registered Nurse plans, supervises, and evaluates the Nursing care for each individual. The RN makes an individual assessment before delegating appropriate aspects of Nursing Care to other Nursing Personnel. 9. ADMINISTRATIVE LINE OF AUTHORITY: Administrative line authority runs from the Medical Director and Clinical Administrator to Program Management (Program Director, Program Assistant, and Nursing Coordinator) to Unit Supervisor to Shift Lead ending with unit Nursing Staff. This administrative line is accountable for assuring compliance with and execution of all Hospital and Nursing Services policies and procedures.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 14 Effective Date: March 29, 2007 SUBJECT: NURSING STUDENTS 1. PURPOSE: This policy will provide guidelines for the relationship between CSH and the nursing students (including Registered Nurse candidates, Psychiatric Technician students, and Licensed Vocational Nursing students) assigned to the hospital for psychiatric clinical experience on the units. 2. AUTHORITY: Nursing Administrator 3. POLICY: Coalinga State Hospital provides a learning environment for RN, PT, LVN students and other related nursing programs. 4. METHOD: A. The nursing students and their faculty, who are present during clinical sessions, will follow the philosophy, objectives, standards, policies, and procedures of the hospital and the nursing services. B. The Training Officer, in coordination with the Psychiatric Nursing Education Director (PNED), is responsible for establishing contracts with the schools of nursing. C. Coalinga State Hospital shall provide a nursing liaison who shall coordinate the arrangements for clinical facilities, classrooms, and use of visual aids or resource persons as requested by the school of nursing. D. The school shall supervise all instruction and clinical experience given at the Hospital. The school shall assume full responsibility for the content of the educational program. E. A maximum student-teacher ratio of one instructor to fifteen students will be maintained for clinical experiences in the hospital. F. The Hospital and the school will jointly agree upon hospital Clinical areas

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and time schedules used for student assignments. The best available experiences to meet the objectives of the course shall determine clinical areas used. G. The school shall supply the Hospital with a list of clinical objectives one month prior to the beginning of each clinical rotation. H. Depending on the institution and length of clinical rotation, the Hospital shall provide orientation taught by Hospital Staff and aided by the instructors of the school. This orientation shall include, but not limited to, Prevention and Management of Assaultive Behavior (PMAB) evasive techniques, the role of the student in a forensic psychiatric hospital, and the signing of oaths of confidentiality. I. Signed oaths will be provided by the identified school instructors.

J. The Hospital, upon request, will permit its clinical facilities to be inspected by the appropriate Licensing Boards for purposes of approval and accreditation. K. Coalinga State Hospital reserves the right to terminate at any time, the clinical experience of any student when the behavior of the student is inappropriate and threatens the safety of Individuals, personnel, the student, or inappropriate behavior of the student interferes with the treatment regimen of the Individuals. L. Coalinga State Hospital retains all responsibility for nursing care when students are providing care on a unit. M. Students under the direct supervision of their designated Nursing Instructor may prepare and administer medication(s) and/or treatment(s). The licensed CSH nursing staff assigned to the med room for that med pass shall observe the preparation and administration of medication(s) and treatment(s) and be available to assure medications are administered in accordance with CSH policies and procedures.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 15 Effective Date: August 31, 2006 SUBJECT: WELLNESS AND RECOVERY MODEL TREATMENT TEAMS (Nursing Input) 1. PURPOSE: 1. To assure that the care given to the Individual is consistent with the nursing care plan, Integrated Treatment Plan, acuity level, and nursing policy and procedures. 2. To assure the nursing staff member assigned to perform Individual care needs has the knowledge and experience necessary to competently perform these duties. 3. To insure continuity of Individual care between shifts. 2. POLICY: 1. The Unit Supervisor/designee will insure that each Individual will be assigned to a nursing treatment team consisting of the RN/Case coordinator, and PT/LVN Primary Counselor. 2. The Unit Supervisor/Shift Lead, in collaboration with other Wellness and Recovery Model System members, will assign Individuals to a nursing treatment team caseload of Individuals based on the Individuals care needs, the experience and expertise of the nursing staff consistent with an equitable distribution of the workload between the nursing teams. 3. The nursing treatment teams of each unit consists of a Registered Nurse and 3 to 4 Psychiatric Technicians/Licensed Vocational Nurses, and Psychiatric Technician Assistants (this classification will not be used until after activation of the facility can accommodate students). 4. To insure continuity of Individual care between shifts, each Individual will be assigned to a primary nursing treatment team and an alternate nursing treatment team on the opposite shift.

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5. The primary nursing treatment team has the responsibility to work together on an ongoing basis to establish and implement appropriate nursing care plans and interventions specific to the Individual needs and consistent with the therapeutic approach recommended by the I.D. team. 6. The alternate nursing treatment team on the opposite shift has the responsibility to follow through with all Individual treatment in a manner consistent with the primary teams recommendations. In the absence of a primary team member an alternate nursing treatment team member shall function as a primary team member. 7. If the primary RN/Case coordinator and/or PT/LVN Counselor is away, an alternate will be assigned to take over the duties and responsibilities for insuring Individual continuity of care. 8. The nursing plan of care is meant to be a collaborative effort between the RN, PT/LVN Primary Counselor, ID Team, and the Individual. Using the shortterm Individual care goal developed by the ID Team, the RN in collaboration with nursing services staff, develops and implements nursing interventions that meet that goal. 9. Daily Care assignments will be established by the Shift Lead of each unit, in collaboration with the RN/Case coordinator based on the Individual care needs for that day. These nursing staff assignments will be based upon the needs of the Individual(s), the level of skill required to provide the appropriate care to the Individual, and according to the experience and expertise of the nursing staff. 3. PROCEDURE: -All staff will communicate pertinent nursing concerns during the change of shift report giving special attention to the following areas as applicable: -All Individuals with an acuity level of 4 or 5 requiring an individual care assignment, or Individuals with an acuity level of 3 needing a special care assignment or nursing intervention(s); -Alerts (e.g. suicide behavior, assaultive behavior, fire setting, blood and body fluid precautions, and Individuals receiving antibiotics); -Seclusion, restraints; special incidents; -Individual Care assignments;

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-Psychosocial factors, subjective and objective observations (self-abusive behavior, delusional depression, manic behavior, impulsiveness, psychomotor agitation or retardation, social withdrawal, etc.); -Significant information regarding PRN medication, treatments, infection control issues, physical, psychological, and educational needs; -Physical and psychological profiles, conferences, staffings, and behavior unusual to specific Individuals; -Vital signs, pain rating assessments, diagnostic procedures and consults; -Behavior during the previous shift, sleep patterns and activity level (sleeping, wandering about dorm, smoking habits, incontinence, frequent trips to the rest room etc.); -Personal hygiene and general ADL care needs (appraisal of Individuals ability for self care including ability to shower, shampoo, care for dental, nail, skin, and foot care needs); -Eating habits (compliance and non-compliance with restricted diets, diet intake, water intake); -New physician orders and monthly medication reviews; -Preps for lab work, x-ray, EEG, etc.; -Individuals scheduled for court visits, discharge, off campus or on grounds clinic visits; -Specific charting and follow-up needed; -Acuity level of each Individual; -Other pertinent information related to Individual care e.g. social, familial, spiritual, and cultural. -The Shift Lead of each unit, in collaboration with the RN/Case coordinator and other team members, will then make written assignments based on the Individual care needs for that day. -To assist with staffing based on Individual care needs, on units where there is no RN coverage available, the HSS will do a clinical assessment of the needs of that unit and the needs of any adjacent unit or program which has two RN's available and make recommendations to the RN and/or Shift Lead

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who will be responsible for facilitating the appropriate action. Specific areas the HSS will evaluate, but not be limited to, are the following items: -Number of Individuals with an acuity level > 3 -Number of Individuals with special care assignments -Number of Individuals in some form of restraint or seclusion -Number of Individuals receiving special treatments -Number of Individuals admitted or expected to be admitted -Number of RNs scheduled -Number of Case Conferences scheduled -Number of Individuals scheduled for sick call/Med Review -Number of Nursing Discharge Summaries

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 16 Effective Date: August 31, 2006

SUBJECT: PSYCHIATRIC INDIVIDUAL CLASSIFICATION/ ACUITY CALCULATION AND REPORT 1. PURPOSE: Individual Client Classification System refers to the identification and classification of individuals into behavioral and intervention categories and to the quantification of these categories as a measure of nursing effort required. By quantifying the nursing interventions needed for each individual, a numerical system of acuity points is established to reflect individual care complexity. The overall individual behavioral and intervention category ratings represent the acuity for the individual and the intensity of individual care provided for that client and identifies the regulator that has the greatest impact on nursing care. Individual client acuity ratings are used to compute the overall unit acuity. In addition, the Individual Client Classification System serves to assure: 1. Staffing ratios and appropriate staff mix on the units reflect current level-ofillness factors and are adequate to provide a safe environment for individuals and staff. 2. The prompt recognition of any untoward change in a Individuals condition and to facilitate appropriate interaction. 3. That the care given to the individual is consistent with the nursing care plan, wellness recovery plan, acuity level, and nursing policy and procedures. 2. POLICY: 1. There shall be a method for determining staffing requirements based on assessment of individual needs. This assessment shall take into consideration at least the following: -The ability of the individual to care for himself -His degree of illness. -1N.P.P. No. 16

-Requirements for special nursing activities -Amount of Nursing Care Hours (NCH) required 2. The RN/Case coordinator, in collaboration with the ID Team, will determine the individuals acuity level and the regulator that has the greatest influence on nursing care. The RN/Case coordinator is responsible for completing, revising, and updating the individuals acuity on the (CSH #7025 see ATTACHMENT A) and on the Nursing Acuity Outcome Log (CSH #7152 see ATTACHMENT B). 3. Individual client acuity levels are established by the RN at the time of the initial nursing assessment and are re-evaluated on a weekly basis and PRN. Changes will be made as clinically indicated. These will help to: A. Recognize and communicate changes in condition. B. Facilitate appropriate interventions. C. Identify appropriate staffing mix. 4. The RN Case coordinator will maintain the individuals current acuity and intervention ratings and the regulator that has the greatest impact on nursing care on the RAND. The acuity and intervention level of each individual is to be evaluated on a daily basis by the RN in collaboration with the Shift Lead. The RAND will be modified to reflect any change from the previous acuity level. 5. The NOC shift will use this information to project the total unit acuity and intervention level. 6. The NOC shift will complete form (CSH xxxx) unit overall projected Intervention rating on a daily basis using the data from the cardex and fax to the Staffing Office nightly. These acuity projections are intended to be a guide for the staffing needs, including the mix of staff, for the next 24 hours. 7. The units daily compliance and acuity numbers shall be faxed to the CNS Central Staffing Office (CSO) each shift using form CSH xxxx. 8. There are minimums below which staffing levels will not fall. They are specified according to the type of unit and the shift. TYPE OF UNIT ACUTE UNITS ICF UNITS RRU UNITS AM SHIFT 1:6 1:8 1:50 PM SHIFT 1:6 1:8 1:50 NOC SHIFT 1:12 1:16 1:50

9. In addition to meeting minimum standards for the number of staff assigned, every attempt will be made to maintain a minimum of one RN on each unit each shift and the appropriate skill mix as identified by acuity. 10. The Unit Supervisor or Shift Lead, in collaboration with other Wellness and -2N.P.P. No. 16

Recovery Model System members, will assign individuals to a nursing treatment teams caseload of clients. This will be based on the individual clients care needs and the experience and expertise of the nursing staff. This will also be consistent with an equitable distribution of the workload between the nursing teams. 3. GENERAL INFORMATION: The assignment of the acuity rating to the individual is based on the Behavioral Systems Model and the Nursing Assessment/Update. It reflects the regulator and levels of behavioral effectiveness and the related levels of required nursing intervention. The acuity system measures nursing staff involvement. It validates the quality and quantity of nursing care, and is used to help determine the appropriate staffing mix. Unit acuity levels may be used to determine if additional staff are required for that unit and for that shift.
4. PROCEDURE:

The Nursing Assessment/Update: At the time an individual is admitted, each time an individual is transferred, annually, and whenever it is clinically indicated, a nursing assessment is completed. At CSH, the nursing assessment is based on the Behavioral Systems Model and the data gathered is the basis for defining the individuals behavioral functioning in eight subsystems, the requirements for nursing intervention, and staffing resources. Formal nursing assessments are completed using the Nursing Assessment/Update (MH #5700). Establishing the acuity begins with completing the sections of the Nursing Assessment/Update form (refer to NPPM # Nursing Assessment/Updates). Start with PART A of the Nursing Assessment/Update form: This part is for identifying and rating the impact of the regulators that influence the subsystem functioning. Impact Ratings: Once this information has been gathered and documented on the nursing assessment form, the next step is to gather data about the individuals functioning within the eight behavioral subsystems in PART B. After the individuals functioning within the eight behavioral subsystems is determined, go back to the environmental internal and external regulators in Part A and make an assessment on their impact on the subsystems that will be a focus of treatment.

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After this is completed, the regulators are given a numerical impact rating in each sphere in PART A. At the top of the first page is the rating scale: 1 = minimal impact 2 = moderate impact 3 = major impact At the bottom right-handed side of each area is a square where the impact rating is entered. Complete the sections of PART B which addresses each of the eight behavioral subsystems. Once these sections are completed, the next step is to give a numerical rating to each of the eight subsystem behavioral categories. This is placed in the box to the far right. The rating scale is as follows: 1 = effective 2 = inconsistently effective 3 = ineffective 4 = seriously ineffective 5 = critically ineffective Now you can fill in the overall behavioral category rating number. To do this, pick the highest number from the ratings given to the eight subsystems. That will be the overall number. The numbers from each of the behavioral subsystems and the overall behavioral rating are the numbers that are entered on the cardex in pencil, and used to compute unit acuity levels. Nursing intervention/nursing care hours (nch): The RN, in collaboration with the PT/LVN, will determine the number of nursing care hours (NCH) projected to be delivered the following day. Using the table below, determine the level of intervention related to projected NCH being delivered and indicate the appropriate intervention level on the RAND. LEVEL AM SHIFT PM SHIFT NOC SHIFT I 0.5 1 0.5 1 0.5 0.75 II 1.5 2 1.5 2 1 1.75 III 2.5 4 2.5 4 2 2.75 IV 4.5 - 7 4.5 - 7 37

The intervention level and regulator from each individuals RAND are entered on the units projected intervention rating form and faxed to the CNS Central Staffing Office nightly.

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When the units overall BIOPHYSICAL regulator intervention level is greater than 200 the unit staffing mix shall include one RN and an additional RN or LVN on the AM and PM shifts. When the units overall psychosocial regulator intervention level is greater than 300 the unit staffing mix shall not include more than one unlicensed staff on the AM and PM shifts. No unit with a minimum of 8 or less staff shall exceed more than two unlicensed staff in the mix on the AM and PM shifts. 5. HOW TO DETERMINE A SPECIFIC INDIVIDUALS OVERALL ACUITY: Refer to the Behavioral Systems Model and the eight behavioral subsystems. Each subsystem is divided into five levels of individual behavioral effectiveness, and the level of nursing intervention associated with each. Each level is assigned a number, ranging from 1 to 5. These numbers will be recorded by the RN on the RAND for each individual in his/her caseload. These numbers may remain STABLE over time or may CHANGE frequently. The RN is responsible for keeping the RAND current. These numbers will be used to determine the individuals overall acuity on a daily basis. 1. The highest level for the Behavioral Category in any one of the 8 subsystems will determine the Overall Behavioral Rating for that individual. 2. The task for NOC shift is to tally up the projected Overall Intervention rating numbers from each individuals RAND in order to arrive at the overall number for the units acuity for the next 24 hours and fax the form to the CNS Office (ext. 7723) by 2400. Each individual clients intervention level will be tabulated separately and entered on units overall projected intervention rating form (CSH xxxx). After determining each individuals regulator and intervention level an x is placed in the appropriate column related to the regulator (biophysical or psychosocial) as identified on the RAND. Those numbers are totaled and will be multiplied by predetermined nursing care hour factors, as indicated on the form. The resulting numbers are then added together to determine the overall unit acuity. Level 5 is not included in this compilation. Level 5 always denotes a 1:1, which generates additional staff. Next, the overall intervention number is used to determine the number of staff required for each shift for that unit. These numbers vary according to the level of care and the shift.

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The total of each of the regulators will determine the appropriate staffing mix for required nursing care. Current 1:1's will require additional staff. The extra 1:1 staff is provided as soon as the level five 1:1 is identified and ordered by the physician. This is in ADDITION to the projected staffing needs based on level 1. The second page of the DAYBOOK has a section titled, Individual Care Assignments. Individuals who have an acuity rating of level 4 or 5 require an individual care assignment. His or her name would be listed here along with a specific written care assignment. Individuals who have an acuity rating of level 3 may, or may not, be listed in the daybook for a special care assignment depending on the nursing intervention required. All level 3 ratings and higher will have Nursing Care Plans. 6. INDIVIDUAL CARE ASSIGNMENT: Individuals Name ______________________________Acuity ______________ Care Needed_____________________________________________________ ________________________________________________________________ ________________________________________________________________ Staff Shift: AM _________________ PM _________________NOC __________ 7. NURSING ACUITY OUTCOME LOG: This form records the rating numbers, or acuity number, of each of the eight subsystems on a weekly and PRN basis. There are two sides to this form, and a total of 52 vertical columns, one for each week, 52 for a year. The NOC Shift is responsible for filling it out every Sunday night. The information is obtained from the RAND, which is kept current by the RN/Case coordinator. The Nursing Acuity Outcome Log allows for graphing of: 1. The effectiveness of individual behavior in each subsystem. 2. Progress or lack of progress over time. 3. Trends and cycles. 4. It quickly provides a visual reference over time. 5. It allows staff to see exacerbation of problems and identify the time period for a quick reference to IDNs and other charting information.

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6. This is particularly useful with suicidal individuals, aggressive/assaultive individuals, self-inflicted behaviors, manic/depressive cycles, and increases in psychotic symptoms. Whenever there is a significant change in individual behavior, this should be indicated on the Acuity Outcome Log. Staff is not restricted to weekly entries. Entries must be entered no less often than weekly. Be sure to put in the appropriate date at the top of the column.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 17 Effective Date: August 31, 2006

SUBJECT: PSYCHIATRIC MENTAL HEALTH STANDARDS OF NURSING PRACTICE 1. PURPOSE: The Psychiatric Mental Health Standards of Nursing Practice consist of Standards of Care and Standards of Professional Performance. The Standards of Care are built around the steps of the nursing process and define a competent level of nursing care. The Standards of Professional Performance delineate a competent level of professional role behavior in terms of quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource utilization. Each standard has accompanying measurement criteria that are considered indicators of competent practice. Thus, the Standards of Practice address the nursing professions responsibility to the public and provide a means to measure the outcome of care. It is through these Standards of Practice that nursing maintains professional autonomy and public confidence in its service. 2. POLICY: 1. Regardless of level of preparation or certification, all practicing nurses are accountable for meeting the Standards of Clinical Nursing Practice developed by the American Nurses Association (ANA). These Standards of Clinical Nursing Practice delineate the professional responsibilities of all registered nurses engaged in clinical practice regardless of setting. 2. All nurses must have a firm foundation in the use of the nursing process in order to provide effective nursing care for individuals. 3. DEFINITIONS: Standards of care pertain to professional nursing activities that are demonstrated by the nurse through the nursing process. These involve assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The nursing process is the foundation of clinical decision making and encompasses all significant action taken by nurses in providing psychiatric mental-health care to all individuals that is developmentally appropriate and

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culturally relevant. Standards of nursing practice are authoritative statements that describe a level of care or performance common to the profession of nursing by which the quality of nursing practice can be judged and guidelines describing a process of Individual management which has the potential of improving the quality of clinical and consumer decision making and are based on available scientific evidence and expert opinion. The psychiatric mental health nurses at CSH are registered nurses (RNs) who are educationally prepared in nursing and licensed to practice in California. At CSH the psychiatric-mental health nurse is qualified for specialty practice at the Basic Level. 4. BASIC LEVEL: Psychiatric Mental Health Registered Nurse - Registered nurses at the basic level have completed a nursing program and passed the state licensure examination, Registered nurses, who practice psychiatric-mental health nursing, care for mental health individuals in various settings. Basic level nurses work as staff nurse, case coordinators, nurse managers and other nursing roles in the psychiatric mental health field. Nurses who work at the basic level are responsible for adhering to the scope and standards of psychiatric - mental health clinical nursing practice. Psychiatric Mental Health Registered Nurse, Certified (RN, C) - After acquiring experience and ongoing continuing education in the specialty, the basic level nurse may become certified as a psychiatric mental health nurse. Certification is a formal process that validates the clinical competence of the basic level nurse. This certification demonstrates that the basic level nurse has met the professions standards of knowledge and experience in the specialty, exceeding those of a beginning RN or a novice in the specialty. The letter C, placed after the RN (i.e., RN, C), is the initial that designates basic - level certification status. (Certification is through the American Nurses Credentialing Center ANCC)

5. STANDARDS OF CARE: Standard 1 Assessment - The psychiatric mental health nurse collects individual health data. Standard 2 Diagnosis - The psychiatric mental health nurse analyzes the assessment data in determining diagnosis.

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Standard 3 Outcome Identification - The psychiatric mental health nurse identifies expected outcomes individualized to the Individual. Standard 4 Planning - The psychiatric mental health nurse develops a plan of care that prescribes interventions to attain expected outcomes. Standard 5 Implementation - The psychiatric mental health nurse implements the interventions identified in the plan of care. Standard 6 Counseling - The psychiatric mental health nurse uses counseling interventions to assist individuals in improving or regaining their previous coping abilities, fostering mental health, and preventing mental illness and disability. Standard 7 Milieu Therapy - The psychiatric mental health nurse provides, structures, and maintains a therapeutic environment in collaboration with the individual and other healthcare providers. Standard 8 Self-Care Activities - The psychiatric mental health nurse structures interventions around the individuals activities of daily living to foster self-care and mental and physical well being. Standard 9 Psychobiological Interventions - The psychiatric mental health nurse uses knowledge of psychobiological interventions and applies clinical skills to restore the individuals health and prevent further disability. Standard 10 Health Teaching - The psychiatric mental health nurse, through health teaching, assists individuals in achieving satisfying, productive, and healthy patterns of living. Standard 11 Case Management - The psychiatric mental health nurse provides case management to coordinate comprehensive health services and ensure continuity of care. Standard 12 Health Promotion And Health Maintenance - The psychiatric mental health nurse employs strategies and interventions to promote and maintain mental health and prevent mental illness. Standard 13 Evaluation - The psychiatric mental health nurse evaluates the individuals progress toward attainment of outcomes.

6. STANDARDS OF PERFORMANCE: Standard 1 Quality Of Care - The psychiatric mental health nurse systematically evaluates the quality of care and effectiveness of psychiatric mental health nursing practice.

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Standard 2 Performance Appraisal - The psychiatric mental health nurse evaluates his/her own psychiatric mental health nursing practice in relation to professional practice standards and relevant statutes and regulations. Standard 3 Education - The psychiatric mental health nurse acquires and maintains current knowledge in nursing practice. Standard 4 Collegiality - The psychiatric mental health nurse contributes to the professional development of peers, colleagues, and others. Standard 5 Ethics - The psychiatric mental health nurses decisions and actions on behalf of individuals are determined in an ethical manner. Standards 6 Collaboration - The psychiatric mental health nurse collaborates with the individual, significant others, and health care providers in providing Individual care. Standard 7 Research - The psychiatric mental health nurse contributes to nursing and mental health through the use of research. Standard 8 Resource Utilization - The psychiatric mental health nurse considers factors related to safety, effectiveness, and cost in planning and delivering individual care.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 18 Effective Date: August 31, 2006 SUBJECT: NURSING PROCESS OVERVIEW 1. PURPOSE: The nursing process is a deliberate, problem-solving approach to meeting the health care and nursing needs of Individuals. It involves assessment (data collection), nursing diagnosis, planning, implementation, and evaluation with subsequent modifications used as feedback mechanisms that promote the resolution of the nursing diagnoses. The process as a whole is cyclical, the steps being interrelated, interdependent, and recurrent. 2. POLICY: Nursing Services shall provide individualized, goal directed nursing care to all Individuals through the use of the nursing process (assessment, nursing diagnosis, planning, implementation, and evaluation). 3. GENERAL INFORMATION: Nursing Process is adapted from the scientific method involving the recognition and statement of a problem, the collection of data about the problem through observation and experiment, and the creation and testing of a hypothesis to solve the problem. Nursing Process is central to nursing actions in any setting. It is a method of organizing thought processes for clinical decision making and problem solving. It is a series of activities in which the nurse collects the information needed for intelligent action, uses that information to identify Individual needs, makes a plan, implements the plan and evaluates the effectiveness of these actions. The process of assessment consists of three separate activities; Data collection, data organization, and formulation of nursing diagnosis. Problem solving requires the following skills: Assessment - systematic collection of data relating to Individuals and their problems followed by identification of actual or Potential biopsychosocial problem that is amenable

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to resolution by means of nursing actions. Planning - choice of solutions. Implementation - putting the plan into action. Evaluation - assessing the effectiveness of the plan, and changing the plan as indicated by the current needs. All of these phases of the Nursing Process are interrelated and form a continuous, ongoing circle of thought and action. These four phases overlap and recur as a Individual's needs and appropriate nursing responses change. As decision making is crucial to each step of the process, some assumptions important for the nurse to consider are: 1. The Individual is a human being who has worth and dignity. 2. There are basic human needs that must be met and when they are not, problems arise requiring interventions by another person until the individual can resume responsibility for self. 3. Individuals have a right to quality health and nursing care delivered with interest, compassion, and competence and with a focus on wellness and prevention. 4. The therapeutic nurse-Individual relationship is important in this process. 4. NURSING ASSESSMENT: The Nursing Assessment is the beginning phase of the nurse-Individual relationship. Assessment involves the nurse's inquiry into various aspects of the Individual's life: bio-psychosocial, spiritual, physical and cultural. At Admission, the nurse, Individual, family, or significant others together plan the course of treatment and discharge disposition. Questioning and knowledge seeking by both the Individual and the nurse characterize this beginning phase. The nurse assesses the Individual's present state of well being or illness and the potential for growth. An accurate physical and psychosocial history must be gathered to provide baseline data regarding the Individual's pre-morbid functioning pre-hospitalization (e.g. at home, in school, in the workplace). Such data is crucial to a later evaluation of the effectiveness of nursing interventions (expected outcomes). Expectations of the Individual must be gleaned from historical data and Individual interview. In examination of the Individual during the

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assessment, such questions as "How did you hope this hospitalization could help you?" Or How did you hope we could help you?" can help clarify the Individual's perceptions as well as the expectations of the caregiver. The data gathered from this questioning could be put to good use in deciphering realistic and unrealistic expectations of the Individual. During this beginning phase the logistics of the relationship are determined - for example where, when, and how often nursing service staff and Individual will meet. Treatment goals are established after considering the proposed length of stay, court issues, family issues, community resources, and future aftercare issues and outIndividual followup. 5. DATA COLLECTION: Data collection involves observation, interviewing, and examination. The Individual is the primary source to collect this data but other sources include the Individual's family, other people giving care to the Individual, and clinical specialists. Observation is continuous throughout the nurse-Individual relationship. Every time nursing service staff is with the Individual, the nurse should be gathering data through the skills of observation. Interview has two facets. The formal Interview involves history taking, and exploring the Individual's perception of his or her illness, and his/her response to the illness. The purpose of the interview is to help the nurse obtain information that will help in planning the nursing care of the Individual. The informal interview is the conversation between the nursing service staff and the Individual during the course of giving nursing physical or psychological care frequently enabling the Individual to express feelings and problems. Examination can include the taking of Vital Signs, chest, heart sounds, or the observing for skin problems while paying particular attention to any physical complaints of the Individual. In obtaining data, the nurse may use the cephalo-caudal approach (head to toe) or a body systems approach to the exam (e.g. respiratory; digestive...) In completing the Assessment, the following aspects should be addressed: 1. 2. The Individual's perception of his current health status e.g. how he feels, what symptoms he is experiencing. Health related or personal stressors in his life and his strategies for coping with them.

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3. 4. 5.

6. 7. 8. 9. 10.

Lifestyle (his daily routines and his ability to perform daily living. Developmental level. Basic physiological needs (his ability to carry out basic body functions related to breathing, and circulation, elimination, nutrition, rest and sleep, hygiene and grooming, sexuality, mobility, and exercise), safety and sensory status(his vision, hearing, taste, ability to speak, ability to experience pressure, heat, and cold). Other basic needs as described by Maslow. (See below) Resources (his abilities, strengths, assets, and sources of support such as friends and family). Deficits (his limitations, weaknesses, liabilities, financial problems, loneliness, fears, court/legal issues, etc.). Goals (what the Individual expects to gain and how he expects to benefit from medical, psychological, and nursing interventions). Help needed to achieve goals (what assistance the Individual needs and is willing to accept.

Data organization and preparing data for use: Information collected from many sources and at different times must be examined and organized before it can be used. Data must be sorted, categorized, and prioritized. There are many ways of organizing data, but each nursing service staff should be guided by pragmatism, that is, use what works best for you! One way of viewing data is based on the work of psychologist Abraham Maslow. He postulated that all human beings have common basic needs that can be arranged in the following hierarchical order. 1. 2. 3. 4. 5. Physiological Needs - needs which must be met for survival. Safety and Security Needs - things that make the person feel safe and comfortable. Love and Belonging Needs - the need to give and receive love and affection. Esteem Needs - things that make a person feel good about himself; pride in one's ability and accomplishments. Self-actualization Needs - the need to continue to grow and change; working toward future goals.

Maslow further theorized that basic physical needs must be met to some degree before higher level needs can be met. By collecting data in each of these need categories, the nursing service staff develop a format for systematically considering the total Individual rather than viewing an illness or a symptom. Comprehensive nursing care

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results from a consideration of the total Individual. It is important to share data with other people working with the Individual, either orally or in writing, to facilitate continuity of care and ensure a consistent approach to the Individual's problems. 6. NURSING DIAGNOSIS The final step in the Assessment phase is the formulation of the Nursing Diagnosis. The assessment of the data collected leads to the identification of problems or areas of concern and/or needs. These problems or needs are expressed as a nursing diagnosis. Nursing Diagnosis is a statement of a present or potential Individual problem that requires nursing intervention and management in order to be resolved or lessened. It may be related to the medical or psychiatric diagnosis but it is separate and distinct. Nursing diagnosis is a clinical judgment about an individual, family, or community, which is derived through a deliberate, systematic process of data collection and analysis. It provides the basis of prescriptions for definitive therapy for which the nurse is accountable. It is a uniform way of identifying, focusing on, and dealing with specific problems. The nursing diagnostic statement has three parts: 1. Statement of the Individual's response 2. Factors contributing to or probable causes to the response 3. Symptoms The three parts are joined by the words "related to" or "associated with" and "as evidenced by". It implies a relationship and, if one part of the diagnostic statement changes, so may the other part. Examples of nursing diagnosis demonstrating these three parts are: 1. Ineffective breathing pattern (response) related to pain (contributing f actor) as evidenced by hyperventilation (symptom). 2. Disturbance in self-concept (response) related to loss of arm (contributing factor) as evidenced by withdrawal (symptom). 3. Grieving (response) related to anticipated loss (contributing factor) secondary to husband's illness as evidenced by continual crying (symptom).

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An accepted nursing diagnosis is a health or psychological problem amenable to nursing intervention and sufficiently defined for clinical testing. The group that generates these lists is called the North American Nursing Diagnosis Association (NANDA). In formulating the nursing diagnosis, consider the three components of the nursing diagnostic categories. They are referred to as the PES format (Problem, Etiology and Symptoms). P - The terms describing the problem: This component, referred to as the diagnostic label or title is a description of the Individual's health or psychological problem (actual or potential) for which nursing therapy is given. To be clinically useful, category labels need to be specific. e.g. a knowledge deficit may be in the area of medication prescription, dietary adjustments, or disease process and therapy. E - The etiology of the problem: These are the contributing factors. This component identifies one or more probable causes of the problem and gives direction to the required nursing therapy. Etiology may include behaviors of the Individual, environmental factors, or interactions of the two. e.g. The probable causes of alteration in health maintenance could include cognitive impairment, lack of gross or fine motor skills, lack of material resources or ineffective individual coping. S - The defining characteristics or cluster of signs and symptoms: This aspect provides information necessary to arrive at the diagnostic category. e.g. Defining Characteristics: History of lack of health-seeking behavior; demonstrated lack of adaptive behaviors to internal or external environmental changes; reported or observed lack of equipment, financial, and/or other resources.

7. PLANNING: Planning is the time to develop a plan of care and determine what approach you are going to use to help save, lessen, or minimize the effect of your Individual's problem. The nurse applies the skills of problem solving and decision making to a particular Individual's identified problems. There are three steps in the Planning phase: setting priorities, writing goals, and planning nursing actions. Setting priorities The nurse and Individual determine the order in which the Individual's problems should

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be approached and which nursing diagnosis poses the greatest threat to the Individual's well being. The nursing diagnosis given the highest priority should be treated first. Subsequent problems are ordered in priority. Priority setting does not mean that one problem must be totally resolved before another problem is considered. Problems can frequently be approached simultaneously.

8. NURSING GOAL: Nursing goal is the desired outcome of nursing care that you hope to achieve with your Individual. It is designed to remedy or lessen the problem identified in the nursing diagnosis. The goal statement is needed to let you know specifically what it is you hope to accomplish. Without a clear, concise goal statement the nurse does not know what to do or if the desired end has been achieved. A nursing goal may actually be a learning objective if the nursing diagnosis relates to a lack of Individual knowledge or skill. Each progressive short-term goal requires a series of nursing actions for its accomplishment. The following suggestions may be helpful as you begin to write goal statements: 1. The goal statement should be phrased to demonstrate the reduction or alleviation of the Individual's problem behavior. This problem would have been identified in the nursing diagnosis. 2. Goal should be realistic for the Individual's resources and capabilities in the time span you designate in your goal. 3. Goal should be realistic for the nursing staff's level of skill and experience. 4. Goal should be congruent with and supportive of other therapies. It is important that multidisciplinary goals do not conflict. 5. Whenever possible, the goal should be important and valued by the Individual, the nursing staff, physician, and Treatment Team. It should be mutually acceptable so that all members of the team agree that the goal is important, reasonable, and worth working for.

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6. When you start to write goals, start with short-term goals. The terminology must be stated in words the Individual can understand.

Formula for writing a goal: Subject + verb + criteria of performance + Conditions (if needed) = goal statement. Subject= the Individual Verb= action that the Individual will perform Criteria of acceptable performance= the level at which the Individual will perform a certain behavior. E.g. How well? How long? How far? How much? The criterion of acceptable performance contains a designated time or date for achievement of the behavior. e.g. - by the time of discharge - at the end of this shift - by 6/4 Condition- the circumstances under which the behavior will be performed. e.g. - with the use of medications - with the help of the counselor Example: The Individual will perform self-injection of insulin using sterile technique by 10/12. A goal (objective) is specific when the desired action, behavior, or response is clear-cut and not open to interpretation. A goal (objective) is measurable indicating that the expected outcome can be seen, heard, or felt and is compared with the initial (or subsequent) assessments. When developing the goal (objective) it is more helpful to think in terms of the Individual's behavior. Precisely what behavior needs to be changed? What behavior do you want the Individual to increase or decrease (what a Individual does or does not do)? Behavior is an action that is observable and can be easily measured. To change behavior you must be able to count it. You need to know what the

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behavior is and how often it occurs. You must be able to state how much or how little of the behavior that you want to change is presently occurring. Do not look at motivation or attitude, as these can't be measured. Focus on behavior or actions and not on indirect matters such as feelings, motivations, or attitudes. 9. Planning: 1. A depressed Individual refuses to get out of bed to practice an important exercise, walking. What is the behavior to be changed? A. Depression? No, that is a feeling or mood state, not a behavior. B. Motivation? No, that is a feeling or mood state, not a behavior. C. Resistance? No, that is not specific enough. D. Walking? Yes, that is what needs to be increased. Measurable goal: The Individual will walk for 5 minutes twice a day within 48 hours. 2. An angry, sullen Individual harasses the nursing staff by pounding on the nursing station door every few minutes. What is the behavior to be changed? A. Anger? No, that is not a behavior. B. Negativism? No, that is not a behavior. C. Pounding on the nursing station door? Yes, that is the behavior that needs to be reduced in frequency. Measurable goal: The Individual will reduce frequency of pounding on the Nursing Station door to x1/hour within one week. 3. An elderly, moderately senile Individual with occasional memory lapses forgets to zip his trousers and walks about the unit exposing himself. What is the behavior to be changed? A. Memory loss? No, that is not a specific behavior. B. Regression? No, that is not a specific behavior. C. Trouser zipping? Yes, that is what should be increased. Measurable goal: Individual will show evidence of increasing trouser zipping behavior 2x/shift on AM and PM shift by next Team Conference 12/5.

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4. A Individual resists taking medications. He always argues with the nurse before swallowing his medications. What is the behavior to be changed? A. Negativism? No, that is not a behavior. B. Lack of motivation to get better? No, that is not a behavior. C. Taking medications? No, he is already doing that. D. Arguing with his nurse? Yes, that is what should be decreased. Measurable goal: Individual will decrease arguing behavior to x1/shift within one month. 5. A young woman, diagnosed as "Anorexia nervosa", comes with no pattern of vomiting but a consistent pattern of 800 to 1000 calories a day of dietary intake and a body weight of 72 pounds. What is the behavior to be changed? A. Weight? No, that is not a behavior. B. Calories taken? No, calories are not behaviors. C. Eating? Yes, that is a behavior. (It might be counted as mouthfuls). Measurable goal: Individual will increase eating behavior by taking 5 mouthfuls of food per meal within 24 hours. As you go about analyzing Individual problems, you should try to identify as precisely as possible what behavior needs to be changed. This must be done precisely not vaguely. For example, to set your goal or target as that of helping the Individual to be able to take care of himself is too vague and general. Precisely what is it that the Individual needs to do more or less of? Precisely what behavior is to change. This is the viewpoint to utilize when formulating goals. 10. PLANNING NURSING ACTIONS: Planning Nursing Actions is the third facet of the planning phase. Nursing actions or interventions are those things the nurse plans to do in order to help the Individual achieve a goal. Nursing actions may be thought of as instructions for all nurses caring for the Individual. The nurse leaves a set of instructions for other nurses on how they might best care for a particular Individual. A knowledge base is vital to this process because the rationale for the interventions needs to be sound and feasible with the intention of providing individualized care. The actions may be independent, collaborative, or dependent and encompass orders from nursing, medicine, and other disciplines.

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Planned actions should be written on the care plan and numbered sequentially. This helps the nursing service staffs organize Individual care and ensures continuity in the Individual's care from one shift to another. Nursing orders are a form of nursing actions identifying specific care and treatments which nursing personnel have the authority to initiate for a particular Individual and what a Individual should do by him-self if able. The care and treatments are designed to help the Individual meet one or more nursing goals and thus lessen or remedy a diagnosed Individual need or problem. They are often written in the form of an order on a Individual's care plan with frequency of treatment and the date clearly indicated. It is expected that other nursing personnel will follow these orders just as carefully as they would follow a physician's orders. Respect for a colleague's professional judgment is communicated by implementing the nurse's plan for Individual care as outlined in the care plan. Nursing personnel are accountable for implementation and documentation of nursing orders. 1. Nursing actions must be safe for the Individual. 2. Nursing actions must be congruent with other therapies and consistent with the Medical Plan of Care. 3. Nursing actions should be based on principles and knowledge integrated from previous nursing education and experience and from the behavioral and physical sciences. 4. Write one set of nursing actions to accomplish each goal. 5. Choose a set of nursing actions most likely to develop the behavior described in the goal statement. There may be many different nursing actions that would accomplish the same goal. 6. Nursing actions should be realistic: For the Individual consider: age, disease, willingness to change behavior, resources. For staff: Experience and ability of available staff needs to be considered. If most of the staff is unfamiliar with the nursing actions you are suggesting, there is a high probability they will not be carried out. Nursing actions should be realistic: For the Individual consider: age, disease, willingness to change behavior, resources. For staff: Experience and ability of available staff needs to be considered. If most of the staff are unfamiliar with the nursing actions you are suggesting, there is a high probability they will not be carried out.

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Whenever possible, nursing actions should be important to the Individual and compatible with the Individual's personal goals and values. The Individual should understand how the nursing actions would result in achievement of the goal. Use the Individual as a source for choosing nursing actions. The Individual may have many good suggestions for activities he can use to achieve a certain goal based on his past experience. Together the nurse, Individual, and counselor collaborate on the nursing actions that will become the Individual's care plan. The more involved the Individual is and the more he values the goal, the more he will cooperate with his care. List the nursing actions sequentially. Develop a teaching plan. Identify the Individual's knowledge deficit. e.g. specific area in which the Individual needs information in order to understand or perform a particular activity. Assess Individual's readiness to learn. Assess Individuals previous knowledge and skills. Begin at the level of Individual understanding using language clear to the Individual. Develop the Discharge Plan. The written interventions that guide Individual care need to be dated and signed. At the Individual conference, the nurse summarizes Individual data, problems, goals, and planned actions. The nurse spends most of the time focusing on presenting the care plan to the Team. At such time, the nurse may also gain new information from team members to add to the care plan. This conference may also be used as a problem-solving session during which a nurse may request assistance from colleagues to further develop a care plan. The care plan contains more than actions initiated by medical orders. It also contains a combination of nursing orders and is the written coordination of care given by all disciplines. The nurse becomes the person responsible for seeing that these different activities are pulled together in a functional whole. The nurse collaborates with all disciplines. This relationship is necessary to provide holistic relationship with the Individual.

11. IMPLEMENTATION Implementation is putting the nursing care plan into action. During the implementation phase, the nursing service staff continues to collect data and validates the nursing care plan. Continued data collection is essential

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not only to keep track of changes in the Individual's condition but also to obtain evidence for the evaluation of goal achievement in the next phase. To validate the care plan, the nurse determines: A. Whether planned nursing actions are realistic and help the Individual achieve the desired outcome or goal. B. Whether the Individual's priorities are being considered. C. Whether the plan is individualized to meet the particular needs of the Individual. Key Points: The Individual is always the primary participant in implementing the nursing care plan. Reassessing and validating the nursing care plan occur continuously during the implementation phase. Cognitive, interpersonal, and technical skills are used to implement nursing strategies. Cognitive skills include problem solving, decision making, critical thinking, and creativity. Creative thinking helps nursing service staff and the Individual to establish innovative nursing actions. Implementing activities are communicating, caring, teaching, counseling, managing, and using technical skills. Communication is essential for all nursing activities and for establishing relationships. The implementing phase of the nursing process is terminated with the documentation of nursing activities. All nursing activities, all assessment data, and all Individual responses to nursing activities require documentation. Teaching plays an increasing role in most nursing activities. Counseling is a helping process designed to promote personal growth and to help the Individual cope with stress. It requires therapeutic communication and leadership skills on the nurse's part. 12. EVALUATION: Evaluation is the final step of the nursing process. The purpose of evaluation is to decide if the goal in the care plan has been achieved. The

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progress in meeting the goal is evaluated at the time specified in the goal statement. While giving Individual care, the nurse is continuously collecting new data about the Individual. Some of this data will be used for evaluation of goal achievement. 13. IMPLEMENTATION: When evaluating goal achievement, the nurse returns to the goal statement in the care plan. What was the specific Individual behavior stated in the goal? Was the Individual able to perform the behavior by the time allowed in the goal statement? The answers to these two questions are the basis for an evaluation of goal achievement. Evaluative statement will identify if the was goal met, partially met, or not met? Include the Individual's behavior as evidence. Use these steps in your evaluations: Examine the results of your intervention, including whether or not you met the criteria established during the planning phase. Assess your Individual for possible side effects and/or adverse effects of the nursing intervention. Analyze the results: Is your Individual better? Why? Is your Individual worse? Why? Then, make a nursing judgment based on the data. This statement of your Individual's current problem(s) (if any remain) is a new nursing diagnosis. If the data shows that the Individual's condition is unchanged or has deteriorated, begin your investigative work again with a new Individual assessment. Your new nursing diagnosis indicates how you will set new Individual goals and what nursing actions you will take to achieve them. If the problem has been resolved, the nurse indicates on the care plan that the goal has been achieved. (Target Met and date). If the problem still exists, reassessment must always be done. This process involves the changing or eliminating the previous nursing diagnosis, goals, and actions based on new Individual data.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 19 Effective Date: August 31, 2006 SUBJECT: SPRITUAL NEEDS OF INDIVIDUALS 1. PURPOSE: To assure Individuals constitutionally guaranteed right to the free exercise of religion. 2. POLICY: 1. Nursing services shall make every effort to provide for the spiritual needs of all Individuals. 2. Individuals religious preference shall be entered on the Identification/Admission Note and Nursing Assessment 3. The Chaplain of Individuals preference will be notified when a Individual makes a request. 4. Nursing personnel will provide as much privacy as possible for Chaplain visits. 5. The Unit Supervisor or Shift Lead shall immediately notify the Chaplain when a Individual becomes seriously/critically ill and threatens or attempts suicide. Notify Chaplain immediately when a death occurs. 6. When a Code Blue is called, the telephone operator is to notify the Chaplain in accordance with Administrative Directives 7. Chaplains are available to nursing staff who request spiritual guidance and/or counseling. 3. GENERAL INFORMATION: Staff escort duties for Individuals attending religious services: When it is time for services, the Unit Supervisor or Shift Lead shall ensure that this is announced and that Individuals who have signed up are reminded that it is time for services.

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Plan departure from the unit for services shall be timed so that Individuals arrive 15 minutes before the services begin; late comers disturb services that have begun and deprive Individuals of integral parts of the services. In the event the Individual needs to use the restroom and the restroom is outside the chapel area, the Individual is to be escorted by a staff person. After services, Individuals shall be allowed a brief time (5 - 10 minutes) to contact the chaplain for bible, rosaries, appointments, etc. Escorts will bring unit sign-up sheets to services. These documents are necessary for chaplaincy record keeping. Blank sign-up sheets are to be returned to the respective chaplain by mail.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 20 Effective Date: August 31, 2006

SUBJECT: STORAGE AND HANDLING OF SPORKS 1. PURPOSE: To provide Nursing staff with appropriate guidelines and procedures to ensure plastic ware control and to provide a safe and secure environment for individuals and staff in the dining rooms. 2. POLICY: 1. Clean plastic-ware shall be stored in a designated area with identified unit and secured at all times when not in use. 2. The number of plastic-ware sets given to each unit shall equal 50. An equal number of knives, spoons, and forks shall be maintained. 3. Mealtime shall be properly supervised by all available nursing personnel with a minimum of 3 without counting the 1:1 staff. 4. Nursing personnel shall be knowledgeable in the practice of handling of plastic-ware and Standard Precautions of Infection Control. 5. Nursing staff assigned to plastic-ware duties shall be responsible for ensuring an accurate count of plastic-ware is maintained during mealtime. 6. Plastic-ware is not to be shared between Individuals. 7. The nursing employee assigned to plastic-ware duties is responsible for giving each Individual a complete set of plastic-ware consisting of one spork and one knife. 3. PROCEDURE: NURSING ACTION A. Wash hands prior to handling plasticware. -1KEY POINTS A. Prevent cross-contamination.

N.P.P. No. 20

B. Using plastic disposable gloves, count each set of knives, forks, and spoons. Each set shall contain an equal number. C. Distribute a complete set of plasticware consisting of one knife, one fork, and one spoon to every individual in attendance after the individual goes through the tray line. D. Count and return excess plastic-ware to the Nutrition Services staff. E. Maintain proper supervision of all individuals. F. Collect used plastic-ware from individuals at each table and place them in a bag for recycling after each meal is completed. Write the unit number on the bag and deposit it into a recycle bin. G. If an individual needs to leave the dining room prior to the clearance of plastic-ware, ensure the plastic utensils are collected and accounted for.

B. To insure accountability.

C. Exceptions shall be individuals who have a current Denial of Rights.

D. Insures accurate count.

E. To insure control of plastic-ware.

F. Observe for complete set of plasticware being returned by each individual.

G. Insures accurate count and accountability of all plastic-ware.

Procedure for missing plastic ware: NURSING ACTION A. Report missing items to immediate supervisor and Program Management. KEY POINTS A. Give a clear, accurate description of incident. Remain in dining room until authorized by Program Management to return to unit. B. Observe for unusual behavior and individuals whom may be suspect.

B. Start search of all individuals in the dining room and search the dining room. Wait for further instructions from Program Management. No one is allowed to leave the dining room during the search.

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Plastic ware for unit activities: Plastic ware for unit activities (e.g. unit barbecue) can be obtained from the kitchen. Proper handling of plastic-ware must be observed during unit activities as well.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 21 Effective Date: August 31, 2006 SUBJECT: STAFFING 1. PURPOSE: This policy and procedure outlines the responsibilities for meeting staffing and clinical coverage requirements. 2. POLICY: 1. Staffing levels on each unit shall not fall below the minimum licensing standards. 2. The Staffing Coordinator or designee has the responsibility and authority to assure that each unit is appropriately staffed. This authority includes, but is not limited to, the ability to reassign any level of care nursing staff within the facility in order to meet staffing and clinical requirements. The Staffing Coordinators responsibilities do not relieve the Program Directors from the responsibility of staffing their respective programs. Nursing Coordinators will continue to be responsible to Program Directors for all program duties and responsibilities. They will be responsible to the Staffing Coordinators Office for duties related to hospital-wide staffing. 3. The Nursing Coordinator and Unit Supervisors will review program staffing on a daily basis. Unit staffing will be determined for the next 24 hours and will be reported to the CSO (Central Staffing Office) immediately; if prior to holiday and/or weekends, staffing will be projected through that period. The contact unit will utilize this projected staffing sheet to adjust staff, if necessary, to meet required minimums for each unit and shift. 4. Each program shall have a designated Staffing Unit. The Shift Lead/designee on that unit is the designated contact person. The Program Director is accountable for overall compliance with staffing rules and procedures. 5. Each program shall provide the Staffing Office and HSS Office with 24-hour projections of scheduled program staffing by 1000 each morning during the week and 7 day projections each Thursday. -1N.P.P. No. 21

6. The Program Daily Staffing Record shall be completed and E-mailed to the Central Staffing Office by the Nursing Coordinator or designee. 7. Each shift will notify the Program Nursing Coordinator or designated Base Staffing Unit of the actual staff on duty within the first 10 minutes of the shift. The shift lead/designee is responsible for reporting accurate staffing information to the Base Unit. The Base Unit will contact the Central Staffing Office (CSO) within 30 minutes of the start of each shift and report the actual staff on duty for each of the four units within the Program. 8. Staff are required to remain on duty until the end of their shift and until the minimum staffing ratio is obtained. If there are no volunteers for covering until the court ordered minimum is obtained then the next employee on the mandatory overtime list will remain until the units staffing minimum is obtained. Mandated staff remaining > 7 minutes will be placed on the bottom of the mandated list. 9. The hospital will maintain a minimum of one Registered Nurse on duty on each unit whenever possible. Shift Leads, medication room staff and the last RN on duty will be exempt from floating. 10. The Health Services Specialist (HSS) shall assess and make recommendations as to the clinical needs of all units that predict no RN on duty. 11. AM and PM shift shall not have more than 2 non-licensed staff. NOC shift may have 1 non-licensed staff member if there is 3 licensed staff on duty. 12. Staff working to work overtime may call the desired program overtime list telephone line after the following times: -AM call after 2215 -PM call after 0615 -NOC call after 1415 4. SPECIFIC DUTIES OF THE BASE STAFFING UNIT: At the beginning of shift: 1. Receive staffing report from previous shift. 2. Call units to verify physically present staff; late employees. 3. Call compliance numbers of staffing to the Central Staffing Office at ext. 7310 within 20 minutes after the beginning of the shift. Areas to consider: -Privacy for clients

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-One to one coverage -Licensing minimums -RN coverage -Escort to outside facilities -Acuity Obtain the compliance numbers from each unit before the off-going shift leaves duty. This will help determine any last minute overtime needs or adjustments. The off-going staff will not leave until the oncoming shift is covered. The offgoing shift lead or designee is responsible to assure coverage. 5. ESTABLISHING STAFFING PROJECTIONS: One hour prior to the beginning of the next shift, the Base Staffing Contact Unit of the program will call each of their units to verify their staffing projections. If the program is below minimums, call the CSO for projected pluses in other programs. Call the program with a plus and arrange for coverage. If there are no pluses within the hospital, contact the CSO as to utilization of the registry staff or the need to hire overtime staff. If overtime staff is needed, the Base Staffing Unit will follow hospital procedure for obtaining voluntary overtime before using mandatory overtime. Float procedure: 1. The first level of redirection of staff will be for the program Nursing Coordinator (NC), or Staffing Unit, to float staff within his/her own program. 2. If no staff is available within their own program, the NC/designee will seek assistance of the Central Staffing Coordinator/designee for information regarding units/ programs that are staffed over court ordered minimums. The order of consideration will be to obtain relief within their sister program, same compound, then the other compounds. 3. If sufficient staff is not available hospital-wide, the Central Staffing Coordinator/designee will utilize the hospital staffing pool. 4. If no help is available from within the other compounds, or the staffing pool, the Staffing Coordinator/designee is then responsible for authorizing the use of overtime. The NC/designee is responsible for hiring overtime after authorization has been obtained. (See overtime procedure). 5. Program management has the responsibility and will endeavor to have both male and female employees on duty so the privacy needs of the individuals can be maintained during the delivery of nursing care. If female/male standards cannot be met within the program, the Staffing Office should be notified so

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appropriate float arrangements can be made to have at least one male/female available in order to provide privacy. 6. Staff will be floated immediately and will be in place on the receiving unit within 15-20 minutes of the start of the shift. If the floating unit has a late employee, they will deal with that situation and the receiving unit will receive the float on time. 7. In cases where staff fail to report on time to the unit/program which is scheduled to float, that unit/program must send a float as arranged if the oncoming shift has started. Responsibility for finding coverage rests on the unit/program that was sending the float. 8. Lunch periods are not to be granted during the first or last hour of the shift. Floating RNs to meet assessed clinical needs procedure: 1. The first level of redirection of RN staff will be for the program Nursing Coordinator or designee to float within his/her own program. The NC or Base Staffing Unit shall confer with the Health Services Specialist (HSS) for determination of the programs clinical needs. 2. If no RN is available within their own program or prior to floating a RN outside their program, the program will notify the HSS who will evaluate the clinical need and make a recommendation to the Program. (See HSS procedure). 3. The NC/Base Staffing Unit will notify the CSO if a unit will be without RN coverage so that efforts can be made to staff the unit with a RN. 4. If no RN is available from the Registry, the NC/Base Unit will hire from the overtime list. 5. If there is no RN available from the Program overtime list, the Base Unit will confer with the CSO to determine other resources. HSS procedure: 1. A minimum of two hours prior to the oncoming shift the HSS shall review the programs 24-hour projection sheet and contact the Base Staffing Unit of each program for changes in projections. For all units that do not have an RN scheduled for the oncoming shift, the HSS will discuss with the RN and Shift Lead on duty any clinical need requirements and complete a Guidelines for Assessing Clinical Needs of Units form. The HSS will do a clinical assessment of that unit and the needs of the sister units that have two or more RNs available. Specific areas the HSS will evaluate, but not be limited to, are the number of individuals for the following categories as follows:

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-Acuity level > 3 -Special care assignments -In some form of restraint/seclusion -Those individuals receiving special treatments -Individuals admitted or expected to be admitted. -RNs scheduled -Case Conferences scheduled -Individuals scheduled for sick call or Med Review -Nursing Discharges Summaries needed. 2. The HSS will immediately notify the CSO/designee of units that do not have RN coverage and provide an assessment of the clinical needs of the unit and their recommendations for RN coverage. 3. The HSS will then make recommendations to the Shift Lead of the base staffing unit. The base unit shift lead will indicate if he/she does or does not concur. If the Shift Lead does not concur they shall document reason and the HSS shall notify the ACNS on duty. In case of disagreement or uncertainty, the CSO/ACNS will contact the appropriate program management/program officer of the day (POD) for resolution. If disagreement continues between the NC/POD and CSO/ACNS, the CNS and Clinical Administrator/Executive Officer of the Day (EOD) will be contacted for resolution. The completed form shall be taken to the CNS office at the end of shift. The clinical needs assessment form is kept on file in the CNS office. Overtime procedure: The Central Staffing Office must authorize overtime. Prior to hiring overtime, all other sources of extra staff shall be utilized. The following sequence will be followed for hiring overtime: A. First level to be hired will be staff from the Central Staffing Office. B. Staff on duty from the unit, which is in need of the overtime. C. Voluntary overtime staff from the Program. D. Voluntary overtime from the overtime list. E. If no voluntary staff is available, request the Central Staffing Office to have the telephone operator page for voluntary overtime. F. For mandatory overtime the next staff in line from the mandatory overtime list is to be used. 2. After receiving authorization from the Central Staffing Office, the Base Unit will complete the Daily Overtime Report (CSH 7066). The Shift Lead on the unit hiring the overtime will verify the number of hours worked and forward copies as indicated.

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3. The Base Staffing Unit of each program shall maintain a voluntary overtime log. Staff wishing to work voluntary overtime should notify the base unit(s) prior to the beginning of the shift they desire to work and have their name placed on the overtime log. Each program has an overtime telephone line where messages to request to work may be left on the voice mail. RN coverage for units without a RN will take priority when hiring from the overtime list. 5. Mandatory overtime will be per bargaining units contract. Nursing Staff not counted in minimums: 1. Staff in training on grounds greater than 4 hours. 2. Staff off grounds with individuals for appointments, etc: A. Off grounds appointments before 12:00 Hours: Use AM staff when possible to cover appointments. Staff is not to be counted in the units minimums. B. Off grounds appointments after 123:00 Hours: Use PM staff when possible to cover appointments. Schedule the employee to come in 1 hour prior to the appointment time. If expected to return prior to 1630 hours the employee will count in the minimums. C. Off grounds appointments after 16:00 hours: Use PM staff when possible to cover appointments. Staffs are not counted in the units minimums. 3. Employees new to the hospital worksite orientation period: A. RNs: two weeks (14 days) upon arrival to unit B. PTs: one week (7 days) upon arrival to unit 4. Employee transfer from other Programs within the hospital worksite orientation: A. RNs: 1st day in the program B. PTs: 1st day in the program 5. Employees assigned limited duty (no Individual/individual care) 6. Shift Leads working as acting Unit Supervisors for more than (5) consecutive calendar days. 6. OFF GROUNDS NURSING COVERAGE PROCEDURE:

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Individuals being transferred to the outside medical facilities do not require an escort unless: A. Requested by Corrections staff B. There is a physicians order for a 1:1 C. Program Management pre-approval D. Clinical need is determined If the individual will require a 1:1 at the outside facility, the program Nursing Coordinator, or designee, is responsible to insure individuals admitted to offsite hospitals have a nursing staff assigned. The first level of providing this offsite coverage will come from the hospital Registry staff. If Registry staff is unavailable, the program will be required to provide this coverage. Employee escorting individual to off-grounds activities, and where lunchtime is not permitted, will be provided an escort meal by nutrition services. 7. HOW TO DETERMINE STAFFING RATIOS: 1. There are minimums below which staffing levels will not fall. They are specified according to the type of unit and the shift. Staffing levels on each unit will not fall below the current licensing and hospital standards of: SHIFT INFIRMARY UNITS ICF UNITS AM SHIFT 1:6 1:8 PM SHIFT 1:6 1:8 NOC SHIFT 1:12 1:16

2. In addition to meeting standards for the number of staff assigned every attempt will be made to maintain a minimum of 3 licensed nursing personnel on duty on each unit on the AM & PM shifts to assure supervision of unlicensed staff, to properly dispense Medication, and to provide quality Individual care. 3. It is the intent that the hospital will maintain a minimum of one registered nurse on each unit on the AM & PM shifts whenever possible. The last RN on duty will be exempt from floating. If two (2) or more RN's are on one unit, one may be floated to meet assessed clinical needs. (Refer to AD 4.21 Staffing Coordinators Office). 4. Under the guidance and direction of the Program Nursing Coordinator, each program has a designated Base Staffing Contact Unit. The Shift Lead/designee on that unit is the designated contact person. The Program Base Staffing Person/designee will call the CSO within the first hour from the beginning of each shift identifying the following information for each unit: -Unit Census

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-# of 1:1's, 2:1s -Minimum staff required -Staff on duty -Acuity number -Overtime hired -RN's & if Shift Lead is an RN -Licensed staff (PT'S) -Non-licensed staff (PLPTs, PTAs) -Privacy issues/Gender needs -Off ground appointments -Floats (floating activity to meet requirements internal & external) -Identify if there are late staff and staff holding over to maintain minimums.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 22 Effective Date: August 31, 2006 SUBJECT: SCOPE OF ACTIVITY FOR VOLUNTEERS 1. PURPOSE: To provide a means by which interested, non-paid individuals can assist hospital programs in providing services otherwise not available. 2. POLICY: All use of volunteers shall comply with Administrative Directives Volunteers shall be under the direct supervision of the service or unit utilizing their services, and shall receive general direction and guidance from the volunteer coordinator. 3. PROCEDURE: All requests for services shall be made in writing to the Coordinator of Volunteer Services, utilizing the Volunteer Services Request Form, MH 5476.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Administrative POLICY NUMBER: 23 Effective Date: August 31, 2006 SUBJECT: UNIT RESOURCE REFERENCE MATERIAL FOR NURSING SERVICES STAFF 1. PURPOSE: Nursing works within an Integrated and Wellness and Recovery role and depends upon the literature of the biomedical and social sciences as well as its own. The list of resource material available on each unit is to assist nursing personnel with the care and treatment for each Individual offering contemporary concepts, theories, and trends in nursing. 2. POLICY: Central Nursing Services authorizes the following publications, in addition to the Nursing Policy and Procedure Manual, to serve as a resource references on the unit. -Merck Manual of Diagnosis & Therapy -Nurses Manual of Laboratory and Diagnostic Tests -Nursing Drug Reference Book -Tabors Cyclopedia Medical Dictionary -Communication Skills Reference Text The current editions of the identified list of books have been placed on each unit and clinical area to serve as resource reference material for nursing staff. They are updated as needed every 2 - 4 years. In addition to the unit resource material, the CSH Staff Library offers the following: 1. Online services with MEDLINE, services 2. Interlibrary loan services available for staff needing additional information on treatment of Individuals 3. Books, journals, and audio tapes associated with the following major categories are also available at the CSH library or through the interlibrary loan services.

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N.P.P. No. 23

Specific categories available through the CSH Staff Library are: Administration and Management AIDS/HIV Nursing Anatomy and Physiology Cancer Nursing Cardiovascular Nursing Communicable Disease Nursing Communication Community Health Nursing Coronary Care Nursing Critical Care Nursing Dictionaries Diet and Nutrition Education Emergency Nursing Ethics Family Nursing Fluid-Electrolyte Balance Fundamentals of Nursing Geriatric Nursing Gynecologic Nursing Health Promotion Home Health Nursing Infection Control Intravenous Nursing Laboratory Diagnosis Legal Aspects of Nursing Long-Term Care Maternal-Child Nursing Medical and Surgical Nursing Microbiology and Pathology Neurologic Nursing Nurse Anesthetists Nursing as a Profession Nursing Diagnosis Nursing Informatics Nursing Research Nursing Theory Nutrition Obstetric and Gynecologic Nursing Occupational Health Nursing Oncologic Nursing Operating Room Nursing Orthopedic Nursing Otolaryngologic Nursing Pathology Individual Education Pediatric Nursing Perioperative Nursing Pharmacology Physiology Practical Nursing Psychiatric Nursing Quality Assessment and Improvement Rehabilitation Nursing Research Respiratory Care Nursing Review of Nursing Standards Statistics Surgical Nursing Terminal Care Total Quality Management Transcultural Nursing Transplantation Nursing Trauma Nursing Urologic Nursing Water-Electrolyte Balance

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Section 2 Abbreviations and Terms

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Abbreviations POLICY NUMBER: 200 Effective Date: August 31, 2006 SUBJECT: UNACCEPTABLE ABBREVIATIONS AND SYMBOLS 1. PURPOSE: This policy will provide Nursing Staff with a listing of unacceptable abbreviations and symbols, which may lead to confusion, misinterpretation, and possible medication error(s) if used. 2. AUTHORITY: 3. POLICY: Prescribers shall not use the listed abbreviations and/or symbols in their orders/prescriptions. Orders using any of these unacceptable abbreviations and/or symbols shall not be noted/transcribed by Nursing staff and shall be returned to the prescriber for correction. Orders using these unacceptable abbreviations and/or symbols received by the Pharmacy shall be returned to the prescriber for correction prior to being filled. Staff shall not use the listed unacceptable abbreviations and/or symbols when documenting in the medical record. (Please see chart on next page)

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N.P.P. No. 200

Unacceptable Abbreviation/ Symbol/ Expression u (u), mu or iu

Intended Meaning

Misinterpretation (Potential Problem)

Use Instead (Preferred)

units, million units or read as a zero (0) or international units a four (4), causing a 10-fold overdose or greater (4u seen as 40 or 4u seen as 44). iu misread as iv microgram mistaken for mg when handwritten. mistaken as q.i.d. especially if the period after the q or the tail of the q is misunderstood as an i. misinterpreted as 77

unit has no acceptable abbreviation use unit.

ug

mcg

q.d., q.d., q.i.d., or q.o.d.

in latin for once daily, four times a day, or every other day

daily or every day or four times a day or every other day

(ditto marks)

repeat what is above

do not use, rewrite what is above instead write greater than

>

greater than

misunderstood/ mistaken for the opposite meaning misunderstood/ mistaken for the opposite meaning decimal point is missed and misread as 20 mg

< less than

write less than

trailing zero (2.0 mg)

2 mg

do not use trailing/ terminal zeros for doses expressed in whole numbers (2 mg) always use a zero before a decimal when the dose is less than a whole unit (0.5 mg)

lack of a leading zero (e.g. .5 mg)

.5 mg

decimal point is missed and misread as 5 mg

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/ (slash mark)

separates two doses or indicates per

misunderstood as the do not use slash number 1 (25 mark to separate units/10 units read doses. use per. as 110 units) misinterpretation (potential problem) can easily be confused for one another use instead (preferred) write morphine sulfate or magnesium sulfate write out halfstrength or at bedtime

unacceptable abbreviation/ symbol/ expression ms mso4 mgso4

intended meaning

morphine sulfate (ms, mso4) magnesium sulfate

h.s.

half-strength or latin for hour of sleep (at bedtime)

mistaken for halfstrength or hour of sleep q.h.s. mistaken for every hour all can result in dosing error mistaken for three times a day or twice weekly, resulting in an overdose mistaken as sl for sublingual or 5 every interpreted as discontinue whatever medications follow (typically discharge meds.) mistaken for u (units) when poorly written

t.i.w.

three times a week

write 3 times weekly or three times weekly

s.c. or s.q.

subcutaneous

write sub-q, sub q, or subcutaneously write discharge

d/c

discharge

c.c.

cubic centimeter

write ml for milliliters

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SECTION 3 NURSING CARE AND DOCUMENTATION

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 300 Effective Date: August 31, 2006

SUBJECT: AGE SPECIFIC NURSING CARE 1. PURPOSE: To provide guidelines for appropriate, age specific, evidenced-based nursing care for the Individual population of Coalinga State Hospital. 2. POLICY: Nursing staff shall provide the highest possible standard of care utilizing the nursing process and the most currently available evidence-based nursing practice guidelines. Nursing care shall also be based on the Age Specific stages of development for each Individual. 3. GENERAL INFORMATION: The following Age Specific stages of development may be useful in planning care for Individuals. The nurse should keep in mind that all individuals may vary in progressing through the stages of growth and development; therefore the identified ages should not be considered absolute categories. This facility does not accept Individuals under the age of 18, therefore the following age specific stages of development begin with Early Adulthood, at age 18. 4. STAGES OF DEVELOPMENT: Early Adulthood Characteristics (18-29 Years of Age): The period of early adulthood, also referred to as the settling down period, is influenced more by social and cultural expectations than by physical development. As a person makes the transition from adolescent to adult, he is expected to achieve independence from the parents home and care. During this time, the individual chooses a vocation, receives appropriate education, establishes a residence, and formulates ideas about selection of a mate or someone with whom to have a close relationship. These accomplishments provide personal satisfaction, economic security, and a feeling of contributing to the welfare of society. The early adult also establishes a personal set of

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values, attitudes, and interests, and formulates his own meaningful philosophy of life. Needless to say, this can be a time of emotional stress and conflict. Physical characteristics: 1. Brain cell development peaks during the early stages of adulthood, which increases understanding and problem solving abilities of the early adult. 2. Very few physical changes occur during this stage of development 3. Women see the most significant physical changes during pregnancy and lactation 4. The average adult maintains an active lifestyle and is generally in good physical health. Common health problems: 1. The four major causes of death in this age group are related to violent death: motor vehicle accidents, other traumatic accidents, suicides, and homicides. 2. The early adult may experience stress and depression related to pressure of independence, college, competition in the workplace, marriage, childbearing, social expectations, or acceptance of peers. 3. Stress and/or their new found freedom may lead to experimentation with various lifestyles and may contribute to destructive behavior such as suicidal tendencies, substance abuse, eating disorders, or spousal abuse. 4. Sexually transmitted diseases including syphilis, genital herpes, gonorrhea, and acquired immune deficiency syndrome (AIDS) are areas of concern for the early adult. 5. Other physical health problems may include pregnancy complications, cervical or breast cancer, and orthopedic injuries. Nursing Measures: 1. Perform at least on thorough health assessment, including screening for sexually transmitted diseases, hypertension, and cholesterol levels, during this period 2. Provide health education to help develop healthy lifestyle habits with an emphasis on weight control, exercise, problems related to human sexuality, effects of drugs and alcohol, family planning, child care, and home management. 3. Provide counseling for smoking cessation programs. 4. Promote recreational and personal safety habits. 5. Encourage good personal hygiene.

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Education:

Adult learning is influenced by the individuals environment, educational level, personal values and perceptions, previous experiences, and attitudes. Thinking and learning patterns are centered around problem solving. Adults tend to be more cooperative in the learning process if they are aware of the benefits. They are focused on time constraints and only want to learn what is practical for them. Repetition is beneficial. Young Adulthood Characteristics (30-44 Years of Age): The goals of this age group are an extension of the early adult, particularly managing a household, rearing children, and developing a career. Common health problems: Major causes of death reflect the stresses of this period and the impact of unhealthy lifestyles adopted earlier in life. Causes of death differ in relation to sex and race. Factors contributing to illness and death include external environmental conditions such as job stress and other occupational hazards, marital problems, and adjusting to parenting. Nursing measures and health care needs: Health habits are firmly entrenched by this stage of development. It is important to promote habits for good health and the prevention of chronic diseases. Specific interventions include: -Stress management -Utilization of resources and instructional courses in household management and parenting -Dietary management: reduction in intake of sodium and sugar and maintenance of normal body weight -Education on the dangers of substance abuse -Developmental of healthy habits for smokers and overweight individuals -Emphasize the importance of exercise Education: Education techniques are similar to the early adult.

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Middle Adulthood Characteristics (45-65 Years of Age): An increasing number of Americans are considered middle-aged. This period is a time of relatively good physical and mental health and new personal freedom. They help growing or grown children become responsible adults and free themselves from the emotional independence of their children. The middle-age adult has the ability to make decisions in the workplace, hold high status jobs, and earn a maximum income. The begin accepting a role reversal with aging parents and preparing emotionally for the declining health of living parents. During this time, a person begins to prepare for retirement and must deal with the physical changes that occur as part of the natural aging process. Common health problems: Cardiovascular diseases such as heart attacks and stroke become the major cause of death in both male and female as they reach their middle years. Among the top five causes of mortality are lung and breast cancer, and cirrhosis of the liver. Chronic respiratory disease and hypertension are also major health problems that require continuous and cooperative management on the part of the Individual and health care providers. Additional health care needs may be related to sexual dysfunction, and for women, adjustments to menopause. External and internal factors that contribute to deterioration of health status in the middle-aged are similar to those of young adult. Nursing measures and health care needs: Care practices should be related to preserving and prolonging the period of maximum energy and optimal mental social activity. Physical exams should be performed annually at 50 years of age to rule out hypertension, diabetes, respiratory diseases, and cancer. Provide an assessment of nutrition, exercise, occupational hazards, sexual dysfunction, and adjustment to menopause, use of over-the-counter medications, alcohol, and tobacco use. Education: Educational techniques are similar to the early adult.

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Geriatric Characteristics (65 Years of Age and Over): The geriatric person is adapting to the physical changes of aging related to the loss of some body cells and a reduction of metabolism. These changes cause a decrease in physical strength and increase susceptibility to fatigue and disease. They are adjusting to changes in living arrangements relating to changed in income associated with retirement, relationships with children, or even the death of a child, spouse, and/or friends. They are learning to accept oneself as an aging person and their life with its joys and limitations. They may be developing a personal view of death, which prepares for the final stage of life. Physical changes: -Loss of fat layers on limbs and face and a general decrease in skin turgor -Perspiration decrease and skin becomes drier -Changes in skin pigmentation -Development of gray hair -Bones become prominent and joints become stiff, as do areas such as the rib cage causing difficulty in breathing -Shrinkage in intervetebral disc -Slower voluntary movement -Sense of smell and taste is less acute -Slower decision making and startle response -Increased susceptibility to infection -Increased susceptibility to high blood pressure -Visual and hearing acuity decreases and a loss of teeth is likely -Kidneys are less efficient causing genitourinary problems -Renal function and bladder capacity decreases -Decrease in gastrointestinal absorption rate, cardiac output, and airway clearance Health problems: The normal aging process places this population at a higher risk for illness and injury, for example: -Increased risk of strokes, related to decrease in cerebral blood flow -Increased risk of injury and falls, related to changes in the spine, brittle bones, and osteoporosis (in women) -Increased risk for heart conditions -Increased risk of respiratory disease related to the weakening of chest muscles and the inability to clear secretions -Urinary retention in men related to prostatic hypertrophy -Increased risk of infection related to the weakening of the immune system

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Nursing measures to promote optimization of Individuals abilities: 1. Re-orient the geriatric Individual to environmental, time, and day, ect. as frequently as necessary. 2. If a deficiency exist on one side of the body, approach and address the Individual form the unaffected side. 3. Use assistive devices such as walkers, canes, wheelchairs, magnifying glasses, ect. 4. Encourage the Individual to participate in as many self-care activities as possible. Provide direct or supportive care as necessary. 5. Institute measures to promote intact skin integrity. 6. Allow ample time for decision making, verbal expression, and activities requiring movement. 7. Encourage visiting from family and/or significant others. 8. Institute measures to prevent physical injuries that may be caused by an unfamiliar environment. 9. Aging individuals often take longer to learn but have not lost the ability to learn. When education a geriatric Individual, keep instructions simple and direct, while using continued reinforcement of instructions. Education: Although there are significant changes related to the aging process, there are many myths as well. Remember that the following are myths, will help when working with older adults. -Most older people are senile (Actually fewer than 20% have measurable memory impairment). -Most older people feel miserable most of the time (Studies have shown that older people are just happy as they were when they were younger) -Most older people cannot work as effectively as younger people (Studies show that older workers are more consistent in their work, have fewer accidents, less absenteeism, and less job turnovers than younger workers) -Most older adults are unhealthy and need to help with activities of daily living. (Actually, 80% of older adults are healthy enough to maintain a normal lifestyle) -Older people are set in their ways (People do tend to become more stable as they grow older, but they remain able to adapt to changes. Actually an older adult may have to adjust to more lifestyle changes than a younger person does)

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 301 Effective Date: August 31, 2006 SUBJECT: BASIC BEDMAKING/CLEANING 1. PURPOSE: 1. To provide a clean, comfortable bed to suit Individual need 2. Promote physical comfort of Individual 3. Prevent cross-contamination and complications associated with soiled or wrinkled linen. 2. POLICY: 1. Basic hygiene and a clean, comfortable environment shall be a concern of all nursing staff 2. Service shall be provided for all Individuals who are ill or otherwise unable to care for their own needs 3. Bed linen shall be changed at least weekly and as needed 4. Linen shall be handled in accordance with nursing policy 900 5. Beds and bed frames shall be cleaned weekly with linen change and between Individuals 6. Handling infections (contaminated) linen is the responsibility of nursing staff. Under no circumstances will Individuals be involved in the handling of infectious (contaminated) linen. 7. Hand washing procedures shall be followed prior to bed making and after to prevent cross infection. Gloves are encouraged especially when handling dirty or soiled linen. 3. EQUIPMENT: 1. 2. 3. 4. 5. 6. 2 sheets Blanket Pillow and pillow slip Bed spread Clean bucket of water, detergent, and sponges Laundry bad and Hamper host. 32-bushel plastic lined cart for clean laundry 7. Disposable gloves

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4. IMPLEMENTATION AND INTERVENTION: Nursing Action A. Adjust the bed to a comfortable height, put on gloves and remove dirty linen into hamper host bags, or soiled linen bag B. Clean mattress, bed and bed frame as appropriate with soap, water and detergent, using sponges C. Place bottom sheet on bed. Tuck under at head of bed D. pick up edge of sheet so it hangs straight up and down E. Make a diagonal or mitered corners Key Points A. Handling procedure for infectious or soiled linen. NPPM# 900

E. Has a neat appearance and keeps sheet securely under the mattress

F. Tuck sheet under mattress G. Place top sheet on bed, wide hem at head of bed, about six inches above top of mattress H. Repeat steps 3, 4, 5 and tuck under foot of bed I. If blanket is used place sic inches from top of mattress and center on bed. Put a clean pillow case on the pillow and place it on the top of the bed J. If Individual is in seclusion only, J. To prevent Individual/staff injury explain procedure and get enough help before making bed K. If Individual is restrained, get K. For the safety of Individual and staff enough help and release one wrist and ask Individual to turn toward the staff on opposite side while the linen is rolled to same side of the mattress is cleaned. L. Apply clean linen to half of bed length wise with center folded in middle of bed. M. Have the Individual roll back onto clean side of bed, reapply wrist restraint and have your partner repeat step 11 & 12 above. Remove dirty/soiled linen and place in soiled linen bag, reapply restraint properly and tuck sheet under mattress. N. Discard linen per policy, remove N. Standard precaution gloves and wash hands. -2N.P.P. No. 301

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 302 Effective Date: August 31, 2006 SUBJECT: USE OF BATH TUB (MEDICAL UNIT) 1. PURPOSE: This policy will provide appropriate guidelines for bathing of individuals using bath tub. Bathing is one method to improve self-image by promoting relaxation and feeling of being refreshed and comfortable. It is also a method to stimulate circulation and reduce body odor by removing secretions, perspiration and bacteria from the skin. 2. POLICY: 1. Individuals have access to bath tub as ordered by physician (physician order is necessary prior to any individual using bathtub) 2. Nursing staff shall provide adequate supervision and assistance to individuals during bathing 3. Fall risk assessment needs to be done by RN prior to the individual using the bathtub 4. The individual shall be provided as much privacy as possible 5. Individuals safety is of primary concerns and shall be maintained by encouraging/reminding the individual to use safety bar when getting in and out of the tub and using seat when necessary 6. Bathtub is to be cleaned before and after each treatment with hospital approved disinfectant (refer to Infection Control Policy 4.4.6) 3. EQUIPMENT: -Towel and washcloth -Clean clothing -Soap and shampoo -Medication (if ordered) -Approved disinfectant (to clean the tub before and after each use, refer to Infection Control Manual) 4. PROCEDURE: (Be alert to Individuals with self-injurious, suicidal or fall risk) The unit staff will stay with the Individual until the procedure is competed and cleans the bath tub after completion.

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KEY POINTS A. Physicians orders are required for tub bath (sitz) if also indicated can be used. B. Explain procedure to the individual. B. To reassure him and to ensure his cooperation and more successful treatment. C. Individual is to be escorted by a staff C. Document any pertinent behavioral to the tub and observed during observations in the IDNs. procedure. Staff shall remain with the individual until procedure is complete. D. Bath tub is to be cleaned before and D. To ensure bathtub is disinfected. after each treatment with hospital approved disinfectant. E. Assist Individual to undress, sit in E. Prevent injuries, observation of the tub, and drape if required by Individual, prevent chilling from draft. Individuals ability. F. Treatment is 20 minutes, unless F. Ensures maximum benefit from otherwise specified by physician. treatment. G. After treatment Individual may be G. Protects Individual as much from assisted in drying and dressing in accidental injury. Allows Individual as necessary. Allow the Individual to do as much privacy as possible. much as he can for himself. H. When Individual is done bathing, H. Prevent cross contamination. (refer clean the tub with hospital approved to CSH Infection Control Manual 4.4.6 disinfectant solution and return for proper disinfection method). disinfectant to non-Individual access storage area.

NURSING ACTION A. Obtain physicians order.

5. RECORDING: Record treatment and medication on Individuals MAR, and or Treatment Record and on Wellness and Recovery note (IDN). Record the Individuals response to treatment and outcomes of treatment including the effectiveness of the treatment and Individuals understanding for the need of treatment. Document Individuals education on IDN.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 303 Effective Date: August 31, 2006 SUBJECT: CARE OF THE INDIVIDUAL WITH SELF-INDUCED WATER INTOXICATION/FLUD MONITORING 1. PURPOSE: To provide guidelines for the most current evidenced-based nursing care of Individuals with compulsive (psychogenic) water drinking. 2. POLICY: 1. Individuals with an open MHDS (CRDS) problem for fluid intoxication and/or hyponatremia or a known history of fluid intoxication and who are not currently noted with signs and symptoms of excess fluid intake shall have their weight taken weekly unless ordered otherwise. 2. Individuals on a 1:1 for fluid restriction shall have their weight taken daily (before breakfast and at 2000 hours unless other times are ordered by a physician), and intake measured each shift. 3. Individuals with a history of water intoxication shall be referred to the unit physician or medical-surgical physician promptly for possible placement on fluid restriction and other precautions/treatment when staff note the Individuals body weight is over 5% of his or her baseline weight from the same days morning weight. 4. A Individual shall also be assessed and referred promptly to a physician when any lab work is returned with abnormal results (e.g. low sodium level, low urine specific gravity, low serum osmolality, low urine sodium and/or urine osmolality levels) 3. GENERAL INFORMATION: 1. Caring for the Individual with compulsive (psychogenic) water drinking poses a major challenge to the ID Team. Continued ingestion of large volumes of water can lead to life threatening hyponatremia. This policy outlines recommended care for the Individual with self-induced water intoxication. 2. Self-induced water intoxication (SIWI) is the term used to describe a condition in which individuals engage in excessive fluid intake to the extent that physical and mental symptoms occur, including seizures and generalized weakness. This condition is not to be taken lightly as death can result in some cases. SIWI is a common condition in chronic psychotic

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Individuals. SIWI is associated with a serum sodium level below 135 mEq/L, and/or serial weight increase of 5% from morning to evening. Marked fluid intoxication is associated with sodium levels below 120 mEq/L and a morning to evening serial weight increase greater than 7.5%. This level of fluid intoxication is life threatening. 4. ASSESSMENT: 1. Assess the Individuals closely for signs of polydipsia; frequent trips to the water fountain; drinking out of toilets and showers; keeping cups hidden or hoarding any type container that could be used to hold fluids. 2. Assess for signs or symptoms of distended abdomen and other GI symptoms such as nausea, vomiting, and diarrhea. Observe for enuresis, rapid changes in mental status including irritability and aggression. A possibility of fluid intoxication needs to be considered when any Individual is noted to have seizures. 3. Assess and establish baseline weight on all Individuals with a history of fluid intoxication. This can be established by obtaining more than one serum Sodium level in normal range with the Individual having his or her weight taken within 15 minutes of the blood draw for this 4. Data collection should also be done at high-risk time such as 2:00 PM (1400) to 9:00 PM (2100). (PM shit blood draws and urine specific gravity gives a better picture of how the Individual is truly doing in controlling his fluid excess) 5. PARTIAL LISTING OF POTENTIAL NURSING DIAGNOSIS: Fluid volume excess (actual) related to exorbitant water intake. Fluid volume excess (potential) related to surplus fluid intake. Alteration in health maintenance related to excessive fluid intake. Acute reversible confusion related to fluid imbalance (excessive). Altered level of consciousness related to imbalance in body fluids (excessive). 6. PLAN/INDIVIDUAL OUTCOME: 1. Maintain fluid balance within normal limits, as evidence by weight gain from baseline and/or AM weight not over 3% to PMs. 2. Maintain normal urine specific gravity. 3. Individual will remain free of complications of SIWI such as seizures. 4. Teach fluid intake control. 5. Individual show willingness to sign a contract or make a verbal contract not to drink excessive fluids as evidence by at least twice daily weights that show (once baseline weight is established) no more than a 3% gain as noted above in #1 of plan/Individual outcome. 7. IMPLEMENTATION AND INTERVENTION:

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NURSING ACTION A. Use the least restrictive method to control drinking fluid(s) B. Teach Individual about the nature of their SIWI and to learn how to monitor and control their fluid balance

KEY POINTS

C. Determine a target weight as an indicator of excessive water intake.

D. Establish written contract with Individual to limit fluids

B. Explore with the Individual the reasons he/she may be having excessive fluid intake (e.g. command hallucinations or delusions). Obtain verbal contract not to carry cups with him/her. C. When drawing any fluid intoxication related lab work also take the Individuals weight promptly (within 15 minutes) and document both blood draw and weight of Individual at the time in the IDN to assist in establishment of baseline weight. D. Because cognitive functioning is decreased during symptoms of both moderate and severe SIWI, these Individuals must be dried out before beginning an educational program.

E. Present Individual with option of drinking or refusing water at specified times throughout day F. Maintain fluid balance within normal limits by monitoring diurnal weight variation. G. Divide the Individuals day into 60 minute intervals. At the end of each interval present them with the option to consume or refuse a specified amount of water as allowed by Rx. H. If the Individual is on any level of ordered observation, weigh Individual at least twice a day, unless otherwise ordered.

G. If Individual requests additional water beyond the specified time, they should wait an additional 60 minutes to obtain another drinking of water. H. Weight to be taken within 15 minutes of drawing any fluid intox. related lab work (e.g. serum electrolytes). Both weight and lab drawn shall be documented in the IDN to give meaning to the weight parameters given by the physician. I. These Individuals need to be protected from water intoxication; therefore, fluid intake needs to be controlled by staff. J. Symptoms of hyponatremia that indicate impending water intox. include

I. SEVER SIWI: Control Individual access to fluids and monitor weight, urine specific gravity, and serum sodium levels as ordered. J. Assess at least daily to determine the presence of symptoms impending

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water intoxication

restlessness, excitability, confusion, aggression, slurred speech, pressured speech, and tremors. Observe for edematous eyelids or face, distended abdomen, and hypothermia.

8. PRECAUTION: Use of ice chips, hard candies (e.g.sour lemon drops) to stimulate saliva and decrease thirst or use of isotonic beverages (e.g. Gatorade) as alternative interventions to restrict fluids may not help. Recent studies show electrolyte containing beverages to be of limited assistance in raising serum sodium levels. 9. DOCUMENTATION: Develop a nursing care plan and review with the Wellness and Recovery team during treatment planning conference. Accurately record intake for each shift on Individuals with moderate and sever SIWI. When drawing lab work for electrolytes or any other fluid intoxication related lab, document both the weight and the drawing of lab in the IDN to give meaning to the weight parameters given by the Physician.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 304 Effective Date: August 31, 2006

SUBJECT: CONSTIPATION MONITORING 1. PURPOSE: This policy will provide nursing staff with appropriate guidelines to identify individuals who are at risk for constipation and to promote measures to prevent constipation. 2. POLICY: Individuals receiving Clozaril, anticholinergics, and other drugs that may lead to constipation, shall be monitored at least weekly for possible constipation. 3. GENERAL INFORMATION: Constipation is a decrease in frequency of bowel movements, accompanied by prolonged or difficult passage of hard, dry stools. Straining during defecation is an associated sign. When intestinal motility slows, the fecal mass becomes exposed over time to the intestinal walls and most of the fecal water is absorbed. Little water is left to soften and lubricate stool. Passage of dry, hard stool may cause rectal pain. Each person has an individual defecation pattern that nursing staff must assess. It is important to remember that not every adult has a daily bowel movement. A bowel movement only every 4 or more days is considered abnormal. A usual bowel movement patter of even 2 to 3 days without any difficulty, pain, or bleeding may be normal for an elderly person. If daily records start to suggest a decrease in the frequency of defecation there is cause for concern. Constipation is a significant hazard to health. Individuals with histories of cardiovascular disease, diseases causing elevated intraocular pressure (glaucoma), and increased intracranial pressure should prevent and avoid the Valsalva maneuver. Exhaling through the mouth during straining can avoid use the Valsalva maneuver.

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4. COMMON CAUSES OF CONSTIPATION: Irregular bowel habits and ignoring the urge to defecate can cause constipation Individuals who have a low-fiber diet high in animal fats (e.g. meats, dairy products, eggs) and refines sugars (rich desserts) often have constipation problems. Also, low fluid intake slows peristalsis Lengthy bed rest or lack of regular exercise cause constipation Heavy laxative use causes loss of normal defecation reflex. In addition, the lower colon is completely emptied, requiring time to refill with bulk. Tranquilizers, opiates, anticholinergics, iron, diuretics, antacids with calcium or aluminum, and antiparkison drugs can cause constipation Older adults experience slowed peristalsis, loss of abdominal muscle elasticity, and reduced intestinal mucus secretion. Older adults often eat lowfiber foods. Constipation is also caused by GI abnormalities such as bowel obstruction, paralytic ileus, and diverticultis Neurological conditions that block nerve impulses to the colon (e.g. spinal cord injury, tumor) can cause constipation Organic illness such as hypothyroidism, hypocalcemia, or hypokalemia can cause constipation. Individuals may have constipation from certain medications. Drugs that may lead to constipation include:

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Antihistamine Drugs: -All Anticholinergic Drugs: -Cogentin -Akineton -Donnatal Food and Vitamins/Minerals: -Iron -B Vitamins -Cheese -Chocolate Antiemetics: -All Neuroleptic: -All Narcotic Analgesics: -All Aluminum Containing Drugs: -Sucralfate -Amphogel -Maalox -Clozaril

Antidepressants: -All TCA -Wellbutrin Other Drugs: -Propranolol -Carbamazepine -Phenobarbital -Verapamil -Methyldopa -Clonidine -Phenytoin -Prozac -All Benzodiazepine -H2-Blockers -Amytal Sodium -Metamucil (without enough water) -And Codeine containing -Antidiarrheals -All Opioid containing such as Lomotil

5. PRECAUTIONS: Fecal impaction results from unrelieved constipation. It is a collection of hardened feces, wedged in the rectum, which cannot be expelled. In cases of severe impaction, the mass can be extended up into the sigmoid colon. Individuals who are debilitated or confused are most at risk for impaction. They are weak or unaware of the need to defecate. 6. NURSING DIAGNOSIS: Bowel Elimination, Altered: Constipation [Potential] related to: -Inadequate diet/fluid intake -Medication -Immobility 7. PLAN: 1. Establish and/or maintain an elimination pattern suitable to physical needs and lifestyle. 2. Provide 15-30 minutes or exercise (walking), daily if individual is capable. 3. Allow adequate uninterrupted time for individual to defecate at a fixed time daily.

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8. IMPLEMENTATION AND INTERVENTION: NURSING ACTION A. Ascertain individuals previous bowel habits and lifestyle. B. Investigate delayed or absence of bowel movement pattern weekly C. Monitor diet and fluid intake KEY POINTS A. To establish a baseline B. Refer to NPPM # Daily Care Flow Sheet C. Work closely with the dietician to establish a dietary treatment plan to prevent constipation D. Work closely with the rehabilitation therapist to establish a treatment plan to include an exercise program. E. Educate individual to importance of maintaining adequate fluids and exercise for bowel regularity. Record on Wellness and Recovery Individual/Family Heath Education Record.

D. Exercise (particularly walking), daily 15-30 minutes per day E. Encourage adequate water intake of approximately 8oz. every 4 hours

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 305 Effective Date: August 31, 2006

SUBJECT: DAILY CARE FLOW SHEET 1. PURPOSE: This policy will provide the guidelines for the appropriate use of the Daily Care Flow Sheet (MH 5504), which is a tracking form that serves to record the individuals Activities of Daily Living (ADLs). It is also meant to serve as a tool for staff to customize nursing care observation specific to the Individual on a daily basis. 2. POLICY: Daily Care Flow Sheets and Continuation Sheets will be used for nursing care given on a daily basis (see ATTACHEMENT A and B) Wellness and Recovery Notes will be used to supplement the Daily Care Flow Sheet whenever additional information is needed to describe why some portion of the care was not carried out or to explain some particular incident or situation. If there is an open MHDS problem requiring monitoring (e.g. constipation/BM, weight, individual who is not eating, fluid intoxication individual), the related problem for observation shall be placed on the Daily Care Flow Sheet. The RN/Case Manager will insure a Nursing Care Plan is initiated and maintained. For items of car not listed on the Flow Sheet, use spaces marked Specify or Daily Care Continuation Sheet MH 5504A ( e.g. behavior observation). 1. Review items listed on form for relevancy for the individual. if not applicable, enter NA. If the item of care is to be provided, enter a (). 2. Use the Legend (at the top of the Flow Sheet) and/or Legend I and II (at the top of the Daily Care Continuation Sheet) for recording care not completed as planned, or care completed as planned, and the amount of staff assistance required. 3. Completing the eating section on the Daily Flow Sheet is required on all individuals. Space is provided to make two entries at each meal, one goes above the diagonal line and one goes below the diagonal line.

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4. The space above the diagonal line is for recording the percentage (%) of food eaten at the meal. 5. The space below the diagonal line is for entering the amount of assistance required by the individual. EXCEPTIONS to use the Legend and/or Legends I and II are: Sleep, bowel care, and menses. Codes are provided on the form for recording of these items. Where further explanation is necessary, place and I in the space provided for that day and shift to indicated an IDN has been made. 1. When entering items of care in the Specify spaces of the Continuation Sheet, be sure these items are appropriate for flow sheet recording. Items should be compatible with the appropriate Legends I and II recording Legend. 2. Opening and Closing Entries are used if a non-applicable care category becomes applicable sometime after the form has been initiated. Enter an I on the date it becomes applicable and explain in IDN. Draw a horizontal arrow from date form was started to the date applicable. If an entry again becomes non-applicable, enter N/A on that date. If the individual leaves the unit temporarily (e.g. court visit), enter this information in the date column. Draw a horizontal line from the date individual leaves to the date individual returns. 3. Staff will monitor daily the bowel movement activity of all individuals, especially those on Clozaril, and will record this information on the Daily Care Flow Sheet. 4. When the physician orders a special diet, the Med Person will transcribe the Special Diet order on the Treatment MAR. Med Person will then write See Daily Care Flow Sheet adjacent to the transcription. If the diet comes pre-printed on the Treatment MAR from Pharmacy, the Med Person will write See Daily Care Flow Sheet on this MAR. The Special Diet order will then be written on the Daily Care Flow Sheet. 5. The Daily Care Flow Sheets shall be taken to the Dining Room at each mealtime. At the conclusion of the individuals meal, the staff member shall document the individuals mean intake on the Daily Care Flow Sheet. During meals, all available staff is to monitor, circulate, and observe the individuals in the dining room. 6. Pertinent observations and information shall be shared at the Change of Shift Report so that continuity of care and observation can be consistent on all three shifts.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 306 Effective Date: August 31, 2006 SUBJECT: END OF LIFE CARE 1. PURPOSE: This policy will provide the guidelines for the essential care of the terminally ill individual. 2. POLICY: 1. Each individual shall be allowed to die with dignity, respect and humanity. 2. Each individual shall be allowed to die with minimal pain. 3. The hygienic and physiologic needs of the dying are great importance and shall not be neglected. 4. Each individual should have the opportunity to recall the love and benefits of a lifetime of sharing, the individuals family and friends should be allowed to visit together, if they so wish. 5. Each dying individual should be able to clarify relationships, to express wishes, and to share sentiments. 6. The individual and his/her relatives should plan for the changes which death imposes on the living, if possible. 7. The individual should die in familiar surroundings, if possible. If not possible, then death should take place in surroundings made as nearly homelike as possible. Consideration should be given to placing the individual in a Hospice Program or unit. 3. GENERAL INFORMATION: Dying is a natural and inevitable part of living. Helping an individual and family members find comfort and meaning in the experience of dying is often more important than correcting physiologic abnormalities. All staff should preserve and enhance the dignity of the dying individual by allowing the individual and his/her family members to participate in and maintain control of the end-of-life care whenever possible. The members of the health car team must also prevent and relieve distress (whether physical, emotional, or spiritual) as effectively as possible. Some dying individuals benefit from curative, rehabilitative, or preventative care. For other, however, supportive care is the only realistic choice. Good care of the dying involves more than discontinuing unwarranted treatment; it

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includes developing a care plan that accounts for the clients own goals and the limits imposed by illness. The Five Stages of Death and Dying (Elisabeth Kubler-Ross): 1. First stage: Denial and isolation The refusal to believe that one is dying is used as a defense mechanism against anxiety. It acts as a cushion to protect the individual from unexpected bad news and allows time to come to terms with the situation, and to mobilize other less radical defenses. The extent to which this is used and the length of time may vary with each individual. Usually, the initial reaction is shock followed by denial. Occasionally, an individual may use denial right up to his/her death, but most eventually come to at least partial acceptance. Depending on the circumstances, an individual may resort to at least partial denying the seriousness of the illness; the individual is feeling that he/she is alone. This feeling may be intensified by the family members who are frightened by the situation, as well as by those who are responsible for providing care (e.g. nursing staff). For al individuals, movement from denial to less drastic defenses depends upon the establishment of an maintenance of a caring relationship. In this type of climate the individual will talk about whatever comes to mind, whether its thoughts of better times, of the present, or of when he/she will cease to be. 2. Second stage: Anger Sooner or later most individuals feel anger, rage, and envy. This is a difficult stage as the individual displaces his/her anger on staff and family. Rejection is seen where kindness was meant. He/she may criticize everyone and everything, (e.g. the food is cold, the nurse is unfeeling, dull needles are selected to cause pain, sheets are rough, the physician does not know what he is doing, the hospital is inferior). As in other situations, the extent and manner in which individuals express their anger differs with each individual. Those who have been tyrants when healthy generally continue to be tyrants when they are ill. When nursing staff strive to act on the principle that hostility breeds hostility and that they are the object of displaced anger, they will then be more likely to be able to cope with the individual (and the displaced anger). When an individual feels that an effort is being made to understand his/her feelings, and that those who are providing the care for him or her care about him or her, and that he/she is not being abandoned, a satisfactory relationship can usually be established.

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3. Third stage: Bargaining In this stage the individual promises God, or someone else, that he/she will make certain changes in their life if only God (or someone else) will cure them or at least delay death. The promises vary from giving up smoking or alcohol, living a better life, being a kinder person or a better parent, to contributing to a church or worthwhile charity. 4. Forth stage: Depression When illness and its effects can no longer be denied and the individual loses hope for a miracle, they experience a profound feeling of loss. The fact that they are dying, i.e. losing their life, is often less important than what the loss of life means to them. A once strong and athletic individual who valued strength, athletic prowess, and the ability to support a family, is not deeply in debt, has no family, once firm muscles are now flabby, each day brings greater weakness, a once strong individual is now almost completely dependent on others. When the individual thinks about their past life and all the things that had been planned, he/she realizes that all of the dreams have to be abandoned. As they become overwhelmed by it all, they become deeply depressed. Depression experienced by the dying is of two types: reactive depression, and preparatory depression. The first type, reactive depression, results from the individuals feelings about how they differ from what they were in the past. This type of depression may be alleviated by enlisting the individuals help in making plans for those who have depended on them in the past. The second type, preparatory depression, as the term implies, prepares the individual for the next stage of dying, acceptance. This individual is about to lose everything-himself, his hopes and dreams, and those he loves. The tendency of caregivers is to try to provide a sense of cheerfulness, but this is of no help. These individuals should be encouraged to express their grief. This is a time when procedures involving touch may be especially beneficial. Not only the nursing staff, but family and friends may help the individual by holding and squeezing their hand, stroking their brow, providing a bed bath and/or back rub, and changing their position. Family and friends may need encouragement and specific instructions to carry out even simple measures, such as handholding. A person sitting quietly and relaxed in the room can be of benefit. In some cultures a family member is an indispensable part of the clients cares as the individual delegates all responsibility for their well being to them. In American culture responsibility is vested in the health care professionals. Therefore we have an obligation to guide the individuals family and friends so they will

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do what they can, by doing so, they will also help themselves by translating their grief into action. 5. Fifth stage: Acceptance Providing the individual does not die suddenly and is given some help in passing through the first four stages, they usually reach the stage of acceptance. They are no longer angry or depressed and have gone through a period of grieving. Not all individuals reach the stage of acceptance and some may go on fighting until the end. Despite the tendency of families, nurses, and physicians to admire the courage of these individuals, they may be unable to achieve a peaceful death. It is important to recognize behavior accordingly. In the stage of acceptance, death may not be feared, it may even be welcomed. In the earlier stages of dying the individual may benefit from verbal communication in which they have their questions answered honestly and to say what they thing and feel. In the stage of acceptance nonverbal communication plays a larger role; this includes touching, sitting quietly with the individual, attending to their physical care, relieving their pain, and through the manner and tiing of actions the nurse and others demonstrate that they do care about the individual. During this stage the family may need more psychological care than the individual, as the dying person may ignore or turn away from them with the result that the family member(s) feel rejected. Small acts of kindness and attention to the needs of the relatives for food, fluids, and rest help to make a difficult time more tolerable. Irrespective of the stage of dying or who is responsible for the care of the individual, the dying person can be expected to experience fear and to benefit from being treated as an individual, making their own decisions, and having their hopes sustained. The Dying Individuals Bill Of Rights (The American Journal of Nursing): I have the right to be treated as a living human being until I die I have the right to maintain a sense of hopefulness however changing its focus may be. I have the right to express my feelings and emotions about my approaching death in my own way. I have the right to participate in decisions concerning my care. I have the right to expect continuing medical and nursing attention even though cure goals must be changes to comfort goals. I have the right to not die alone. I have the right to be free from pain. I have the right to have my questions answered honestly.

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I have the right not to be deceived. I have the right to have help from and for my family in accepting my death. I have the right to die in peace and dignity. I have the right to retain my individuality and not be judged for my decisions that may be contrary to the beliefs of others. I have the right to expect that the sanctity of the human body will be respected after death. I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face death.

4. CLINICAL PRACTICE GUIDELINES: Symptom control: Individuals with a terminal illness commonly experience physical discomfort and mental distress. Many fear that their discomfort will be protracted and that no one will control it. Relieving discomfort and reassuring individuals that their discomfort will be controlled enables them to life as fully as possible and to focus on the unique issues presented by the approach of death. When survival is expected to be brief, the severity of symptoms often dictates initial treatment choices. When a symptom is less distressing then the fear that the symptom will worsen, reassurance that effective treatment is available may be all the individual needs. If a symptom is sever, immediate therapy may be required. Whether diagnostic tests are appropriate depends on how burdensome the test is and how useful the findings may be. Because a symptom can have many causes and because individuals may respond differently to therapy as their condition deteriorates, treatments must be closely monitored and continuously reevaluated. During periods of altered drug metabolism, special care must be taken to avoid inadvertent overdose of drugs. Physical symptoms: Pain About half of those individuals dying of cancer have severe pain. Of these individuals, only some have obtained adequate relief. Severe pain is less common among individuals with other terminal conditions. Often, pain persists not because it cannot be controlled but because individuals and their physicians have misconceptions about pain and the drugs used to control it.

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The approach to pain control is the same regardless of what the terminal illness is. Treatment must be individualized because individuals perceive pain differently, depending in part on such factors as fatigue, insomnia, anxiety, depression, and nausea. A supportive environment can help control pain. The most available and appropriate analgesic gave by the least invasive route possible should be chosen. Choice of an analgesic depends largely on pain intensity. Analgesics should be administered regularly rather than as needed; controlling pain after it recurs is more difficult than preventing it, partly because pain generates anxiety. Sustained-or continuous release formulations make regular administration easier. In hospice units, nurses, individuals and family members become competent at making dosing or scheduling adjustments. Pain modification techniques such as hypnosis, guided mental imagery, counseling for stress and anxiety, and relaxation methods may help relieve pain. In one study, individuals with spiritual and religious well being perceived pain as being less intense. In cases of severe, persistent pain, the ability to sense pain, if it occurs in a suitable location, may be eliminated with neurosurgery or anesthetics. A referral to CSH Pain Specialist is recommended. Dyspnea For dying individuals, dyspnea is one of the most feared and most distressing symptoms. Its cause should be treated if it can be identified (e.g. antibiotics for pneumonia or thoracentesis for a pleural effusion). Dyspnea in terminally ill individuals should be suppressed when its physiological origins cannot be relieved. Oxygen may be psychologically comforting to the individual and to family members even when it is not physiologically beneficial. When breathlessness occurs, an opioid can be used to slow respiration and relieve mild chronic symptoms, enabling the individual to sleep more comfortably. Carbon dioxide retention or decreased oxygen levels often produce dysnea, even though oxygen levels are still physiologically adequate. In such cases, blunting the medullary response may eliminate symptoms without producing adverse effects. Morphine, 2.5 mg, IV, every 2 to 4 hours, prn or by continuous drip may be used if the oral route is unavailable or too slow. Benzodiazepines may help relieve anxiety. Useful nonpharmacologic measures include ventilation from an open window or a fan at bedside, relaxation techniques, and massage. Caregivers with a calming presence can help clients stay calm.

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Anorexia Although common among dying individuals, it is usually more distressing to family members than to the individual. Counseling may be needed to help family members accept anorexia and understand the futility of tube feedings or parenteral nutrition. Some steps can be taken to increase an individuals food intake. For example, if a full meal try is overwhelming, small portions, specially prepared foods, and a flexible meal schedule are recommended. Foods with strong flavors or smells sometimes stimulate the appetite. Low-dose corticosteroids (e.g. dexamethasone, 1 mg, PO, quid; or prednisone, 5 mg, PO, tid), megestrol acertate, or tricyclic antidepressants may also improve an individuals appetite and sense of taste. Metoclopramide may help because it enhances gastric emptying. However, it may not produce maximum therapeutic effect for 1 or 2 weeks, which may be too slow for individuals near death, and it may induce Tardive Dyskinesia. Methylphenidate can improve appetite, but because it can cause dysphoric agitation, the starting dose must be low and subsequent doses increased gradually, and individuals must be monitored closely. Only rarely should dying individuals receive tube feedings or parenteral nutrition. Before starting either, the physician should discuss indications for discontinuation with the individual and family members. Discontinuation may be difficult to accept, because food and water often symbolize caring and nurturing. However, the individual and their family members should be told that dying persons might be more comfortable without the artificial administration of food and water. Sips of water or easy-to-swallow foods (e.g. sherbet, gelatin) may be more appropriate. After the decision to forgo artificial administration of food and water has been made, supportive care is imperative. Such care includes providing good oral hygiene (brushing the teeth, swabbing the oral cavity, applying lip salve, and providing ice chips for dry mouth). Oral hygiene is a physically and psychologically comforting service family members can perform for their loved one. Nausea and vomiting Many dying individuals experience nausea, often without vomiting may be caused by constipation, reduced gastric emptying, bowel obstruction, central opioid effects, increased intracranial pressure, gastritis, peptic ulcer, hypercalcemia, uremia, or toxic drug effects. Specific treatment may be warranted if the cause is easy to treat (as for hypercalcemia or constipation), especially if treatment makes an individual more comfortable. As with

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analgesics for pain control, antiemetics should be given regularly (not as needed when symptoms are severe) to prevent nausea and improve the individuals comfort. Nonspecific treatment (e.g. with phenothiazine such as prochloperazine) is almost always indicated. Phenothiazines are mose effective because they act on the chemoreceptor zone in the medulla. However, they may have anticholinergic effects. Prochlorperazine, 5 to 10 mg, PO, tid to qid, can be given prophylactically. If vomiting precludes oral administration, the drug can be given as a suppository (25 mg, big) or by IM injection (5 to10 mg, q 3 to 4 hrs; maximum dose, 40 mg/day). Metocloramide (10 to 20 mg, PO, q 6 to 8 hrs, or 1 to 2 mg/HR. by Subcutaneous infusion) can be used when nausea and vomiting are caused by decreased gut motility, because the drug increases peristalsis and relaxes the pyloric sphincter. Other helpful antiemetics include corticosteroids (e.g. dexamethasone, 4 mg, PO, a 8 hrs, or prednisone, 5 mg, PO, tid) and antithistamines (e.g. Hydroxyzine, 10 to 25 mg, IM, tid, or dimenhydrinate, 50 mg, PO, q 4 to 6 hrs). The addition of lorazepam, 0.5 to 2 mg, sublingually may help relieve nausea due to nonspecific or multiple causes. Ondansetron (4 to 8 mg, IV or PO, q 6 to 12 hrs) can control nausea and vomiting due to chemotheraphy or surgery. However, this drug is much more expensive than other antiemetics. If vomiting due to obstruction occurs in an individual who is near death, conservative treatment without relief of the obstruction is recommened. Sometimes, slowly peristalsis or slowing the gut with morphine and managing dry mouth with ice chips is preferable to performing continuous gastric suction or surgery. Nasogastric suctioning, except as a short term measure, is difficult for sentient individuals to endure. Octreotide, 150 micrograms, IM, bid or 300 micrograms/day as a continuous sub-cutaneous infusion combined with an opioid ( with dose adjustment based on individual response) is effective nonsurgical care for bowel obstruction. This combination can stop secretions, reduce distention, and alleviate cramping. Constipation Clinical staff often underestimate how important regular bowel movements are to a dying persons comfort. Constipation is common among dying individuals because they are inactive, consume little dietary fiber, are dehydrated, or are receiving opioids or anticholinergic drugs. Laxatives should be given prophlactically to prevent fecal impaction. A stool softener (soluble or insoluble fiber or docusate sodium) is usually given first. However,

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most individuals receiving opioids also require a stimulant laxative (e.g. casanthranol, senna, cascara sagrada, and bisacodyl). If the individual does not have a bowel movement within 48 hours, of initiating the above therapy, an osmotic laxative (e.g.lactulose, magnesium salts, phosphate enema) can be used. Osmotic laxatives stimulate gastrointestinal function indirectly by increasing the fluid content of feces. Lactulose, a semisynthetic disaccharide that is not hydrolyzed by human intestinal enzymes, is an especially effective osmotic laxative for many bedridden individuals; however, it is expensive. Sorbitol is usually as effective and is much less expensive. If an individual has not had a bowel movement in 3 days and stool is detected during rectal examination, a glycerin or bisacodyl suppository should be administered. If no bowel movement occurs, a saline enema should be administered. Diarrhea If diarrhea occurs, an abdominal examination should be performed to rule out impaction. All laxatives, including stool softeners, should be discontinued. If diarrhea is severe, the individual should be given clear liquids and bland carbohydrates. Other foods can be added as symptoms permit. For severely dehydrated individuals, electrolytes may be given PO, IV, or sub-cutaneously to make the individual comfortable more quickly. Often, diarrhea must be suppressed with nonspecific treatment: opioids, loperamide, 4 mg, PO, initially, then 2 mg per diarrheal stool (up to 16 mg/day), or diphenoxylate-atropine 2 tables (5 mg [2.5 mg eash as diphenoxlyate]), PO after each diarrheal stool, up to quid. However, more specific treatment may be needed: For carcinoid tumors or dumping syndrome after gastrectomy, octreotide, 150 to 300 micrograms, SC, BID, or 300 micrograms continuous IV infusion/24 hrs.; For fungal infection due to immunosuppression, clotrimazole, 10 to 20 mg, PO, TID, or fluconazole (first dose is 200 mg, PO, then 100 mg, PO, once daily for 14 days); For Pancreatic insufficiency, pancreatic enzymes such as pancreatin, 1 to 2 tablets with meals and half the does with any snack. Zinc oxide helps relieve irritation around the anus, and corticosteroid cream( for as few as 1 to 2 days) helps relieve maceration or inflammation. Pressure sores Many dying individuals are immobile, poorly nourished, and

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cachectic; therefore, they are at great risk of developing pressure sores. The most important preventive measure is rotating the individual every 2 hours using specialized mattress or a continuously inflated air suspension bed. Use of urinary catheter is justified only when the individual experiences pain with bedding changes or when the individual or family members strongly prefer it. Psychological symptoms and concerns: Confusion Confusion is common during the terminal stage of illness. Causes include drug therapy, hypoxia, metabolic disturbances, and intrinsic central nervous system disease. Confusion is treated if the cause can be determined and if treatment enables the individual to communicate more meaningfully with family and friends. If the individual is comfortable and less aware of the surroundings, withholding treatment may be preferable. Sedatives (e.g. benzodiazepines may help agitated individuals, and low doses of haloperidol [0.25 to 0.5 mg IM, q 4 to 8 hrs. or at bedtime]) may help individuals who have disquieting dreams or threatening hallucinations. Newer antipsychotics, such as risperidone (0.5 mg, PO, at bedtime or BID) or olanzapine (2.5 mg, PO at bedtime) may have fewer adverse effects than haloperidol. Sadness and depression Most dying individuals experience sadness. Sadness may be due to regrets about life or preoccupation with legal, social, or financial problems. Providing psychological support and allowing the individual to express concerns and feelings is the best and simplest course of action. Helping the individual and family members settle unresolved matters may decrease anxiety. A skilled social worker, physician, psychologist, nurse, or chaplain can help with conflicts that separate an individual from family members, friends, church, or God. Vegetative signs, including sleep disturbance, should be evaluated; drug therapy may be warranted. Antidepressants are reserved for the few individuals who have persistent, clinically significant depression. Such individuals may benefit from a low dose of an antidepressant (e.g. paroxetine, 10 mg. PO) given once daily in the morning or at bedtime. Individuals with depression and agitation are usually given a sedating tricyclic antidepressant (e.g. amitriptyline, 10 to 25 mg, PO at bedtime), supplemented as needed with another appropriate sedative. During the last weeks of life, a sedating antidepressant sometimes provides restful sleep while alleviating depression. For individuals who are near death, the usual concerns about possible cardiac and neurologic effects are not as important.

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Individuals with depression and significant insomnia can be given trazodone, 25 to 50 mg, PO daily at bedtime, increased in 25 to 50 mg/day increments every 3 days, as tolerated, to a maximum of 300 mg daily. Adverse effects include excessive daytime sedation. Sedating tricyclic antidepressants (e.g. amitriptyline, doxepin)are effective alternatives for management of insomnia ; however, bothersome anticholinergic effects occur. Selective serotonin reuptake inhibitors, which have fewer adverse effects are appropriate when depression is not associated with sleeplessness. Paroxetine, 10 mg PO, fluoxetine, 10 mg PO, and sertraline, 25 mg PO- all given once daily in the morning- and venlafazine, 25 mg PO, BID to TID, are most commonly used. For individuals who are withdrawn or who have vegetative signs, methylphenidate, initially 2 mg once dialing in the morning (with dose adjusted to individual response), may help. This drug has a rapid onset of action and fewer adverse effects than most antidepressants, but it may cause agitation. Anxiety and agitation Anxiety and agitation can result from treatable conditions such as pain, respiratory distress, sleep deprivation, a full bladder, fecal impaction, and nausea or from drug therapy (e.g. corticosteroids, opioids). Supportive therapy, including listening and talking to the individual, should precede and supplement drug therapy. Sometimes symptoms of anxiety and agitation can be managed with gentlereassurance. Medication, guided imagery, prayer, music therapy, and massage are often helpful. If drug therapy is indicated, benzodiazepines are the drug of choice. Lorazepam, 0.5 mg PO, SC, or sublingually, q 4 hrs is effective. The dose and interval are adjusted as needed for psychosis or severe agitation, haloperidol, 0.25 mg PO or IV, q 4 to 6 hrs or chlorpromazine, 10 mg IV or 25 mg PO or rectally, q 6 to 8 hrs can be used for acute cases, an dthe does increased as needed. For maintenance dose of antipsychotic, olanzapine (2.5 mg PO at bedtime) or reiperidone (0.5 mg PO at bedtime) many have fewer adverse effects than haloperidol. If a crisis occurs and no intravenous accecss has been established, an injection of lorazepam, 1 to 2 mg IM, or diazepam, 2 to 5 mg IM cam calm an individual while the physician determines what therapy is appropriate for longer-terminal illness, a bolus infusion of midazolam, 5 mg, SC, followed by 1 mg/hour, is effective but expensive. The dose is increased or decreased based on the individuals level of consciousness and the recurrence of symptoms. Stress As death approaches, individuals may feel stress due to fear of

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abandonment and separation, anxiety, feelings of hopelessness, or loss of self-esteem because their body image is altered. Stress is greatest when drying is unexpected or when interpersonal conflict keep individuals and family members from sharing their last moments together. Such conflicts can cause anguish for the dying individual and can lead to excessive guilt or an inability to grieve among family members. When a spouse or long-term partner dies, the survivor may be overwhelmed by the prospect of making legal or financial decisions or of managing the household. Death of a spouse or partner may reveal cognitive impairment or other deficiencies in the survivor for which the deceased person had compensated. Stress is even greater for the survivor if friends or family members do not help. Physicians and other health care practitioners should identify these high-risk situations so that they can mobilize the resources needed to prevent undue suffering and dysfunction. Usually, the best treatment for dying individuals and family members with stress is compassion, information, counseling, and occasionally, time-limited psychotherapy. In addition to the physician, members of the health care team, such as social workers, nurses, and chaplains, can offer such help. Sedatives should be used sparingly and only briefly. The team approach to care helps prevent and relieve stress; no one caregiver can be available 24 hours/day, and skills and perspectives from several disciplines are needed to manage the different aspects of care. Palliative care of hospice teams should anticipate potential problems and make appropriate arrangements, such as ways to obtain supplies or opioids in an emergency. When death is impending, an experienced team member can comfort family members and may prevent an inappropriate call to the emergency medical system due to panic. Team members may feel stress and grieve with the individual or family member because they become so involved. This involvement can be mitigated by a nurturing work environment and a staff support group that meets regularly to share responses to dying individuals and their families. Grieving Grieving is a normal process that usually begins before an anticipated death. From individuals, it often starts with denial caused by fears about loss of control, separation from loved ones, an uncertain future, and suffering. Staff members can help the individual accept the prognosis by listening to their concerns, helping them understand that they can remain in control, explaining what the future holds, and assuring them that their pain and other symptoms will be controlled.

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Financials concerns: Obtaining adequate financial coverage for care of the dying can be difficult. Medicare regulations exclude supportive care except in a hospice setting, or by a hospice service. To qualify for hospice care, individuals must have a 6month prognosis, which physicians are often reluctant to certify. Terminally ill individuals with a prognosis of more than 6 months may not be easily admitted to a nursing home, even if they have a certified need for a skilled nursing level of care. Nursing homes do not like to admit dying individuals for several reasons; including high costs, nursing needs, and the effect on the other residents. Physicians should ensure that a core team member is familiar with local care services, financing options, and the financial effects of choices to be made. Legal and ethical concerns: In some cases, care of a dying individual seems to be directed more toward hastening death than toward prolonging life. Whether such an approach should be construed as good medical care or as a criminal act (i.e. homicide or assisted suicide) it is frequently debated. Certain situations require a decision between actions that may hasten death and those that may prolong life. For example, an individual or surrogate may request discontinuation of parentreal hydration and nutrition or refuse treatment expected to yield long disease-free remissions, or an individual may develop suffocating dyspnea that can be relieved only with strong sedation which can accelerate death. Requests from an individual or surrogates that seem contrary to the individuals interests should be referred to consultants within the institution or agency. A request may be honored or denied, or a different action taken. Most medical actions that may hasten but not directly cause death are necessary for relieving pain or other suffering. When initiating such treatment, they physician must inform the individual and family members that the action may shorten life. They physician should be clear that the treatment is for pain and symptom relief, not for causing death. However, good pain management rarely shortens life and may even extend it. In most cases when treatment has shortened life, the foregone life would have been so brief and so anguished that a slight extension of life would not have been in the individuals best interest. Nevertheless, deciding what constitutes wrongful death is sometimes difficult.

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Wrongful death cases are only rarely brought to court, for several reasons: 1. Most persons, including prosecutors, judges, and jurors, consider motivation and usually find compassion rather than malice in a situation that could have had no better outcome. 2. The means of death are agents ordinarily used treatment (e.g. analgesics, sedatives, and anesthetics); not those associated with crime (e.g. poisons, guns, and knives). 3. The means of death are not as certain to result in death as are those typically used in criminal acts. Assisting with suicide is a criminal act in more states, but the laws vary substantially and are rarely invoked. The U. S. Supreme Court has ruled that states can prohibit physician-assisted suicide but has not ruled that states must prohibit it. Therefore, the state governments must decide. The American Medical Association and most other medical and professional organizations oppose its legislation. Physicians have not been charged with homicide or attempted homicide for giving dying clients large doses of opioids for pain relief or for allowing individuals to refuse life-sustaining treatment, as long as the plan of care evolved in an appropriate, ethical fashion with informed constant from and an open dialogue with individuals and family members. Physicians who do not provide life-sustaining treatment for individuals with terminal illness should document the decision process thoroughly, provide care in a reputable setting, and be willing to discuss the issues honestly and sensitively with individuals, family members, and other health care practitioners. A physician should not use treatment conventionally considered a means of homicide (e.g. lethal injection), even though the physician considers it a means of relieving suffering. Health care providers must always be clear that their plan of care was not intended to cause death. Most individuals with terminal illness should execute an advance directive. Advance directives are legal agreements that allow the individual to establish values and treatment preferences to be honored in the future when competency or capacity has lapsed. Advanced directives may be in the form of a living will, which expresses the individuals preference for medical care, or a durable power of attorney, in which the individual designates another person to make health care decisions. Advanced Directives at this facility must be updated at least yearly.

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Spiritual concerns Individuals who are dying often ask what their life means, who they really are, why the illness has affected them, and what will happen to them when they die. Individuals may question Gods existence and love or may feel abandoned by God. Some feel guilty or worry that their behavior caused their illness. Thus, dying can precipitate a spiritual crisis. Unresolved spiritual distress can lead to despair and hopelessness, which in turn can lead to anxiety, depression, and for some, a desire to die or to commit suicide. Individuals need help working through this distress so that despair can be transformed into hope and serenity. Dying individuals do not always need to hope for a cure; instead they can hope for having time to reconcile with loved ones, sharing time with family, finishing a personally important project, or making peace with God or a Higher Power. When personal distress is relieved, individuals can die more peacefully. Dying individuals may review their lives; this process may elicit positive and negative emotions as they try to resolve pasts hurts, reexamine relationships, and recount accomplished goals. They need to find meaning and purpose in their lives and in their illness. They often need to reconcile themselves with themselves, with others, and for some with God or a Higher Power. Belief in an afterlife and possible reunion with loved ones can comfort individuals and family members. Physicians, nurses, social workers, psychologists, chaplains, family members, and friends can listen and offer support, and doing so may help them deal with their own feelings of loss. Individuals who are religious need opportunities for prayer, devotional reading, and religious ritual, such as receiving a chaplains blessing. Other spiritual resources include medication, guided imagery, music, and art. Individuals may need physical space and privacy for these practices. Hospice provides an excellent environment for spiritual practices. Each hospice team includes chaplains and others who are skilled at helping individuals and family members with their spiritual needs. Concerns at the time of death: The last moments of life can have a lasting effect on family, friends, and care givers. Therefore, when death is imminent, health care team members should try to make the death as comfortable and as meaningful as possible and to help family members prepare for it. Family members should be told exactly what will happen when the individual dies. If the individual is expected to die at home, family members should be told whom to call (e.g. the physician) and whom not to call (e.g. ambulance service/paramedics). They should also be informed how to obtain legal advice and arrange for burial services.

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The setting should be peaceful, quiet, and physically comfortable. Stains or tubes on the bed should be covered. In some individuals near death, noise breathing (known as the death rattle) develops because of bronchial congestion or palatal relaxation. If this breathing distresses the family or friends present, scopolamine (0.3 to 0.6 mg sub-cutaneously PRN), atropine (0.4 to 0.6 mg IM, sub-sutaneously, or nebulized q 6 to 8 hrs), or glycopyrrolate (0.2 mg IV PRN or as continuous infusion) can dry the individuals secretions and reduce the noise. Central nervous system irritability, including agitation and restlessness, may develop; it can be relieved with a sedative. Family members should be encouraged to touch the individual (e.g. hold their hand) as well as talk with the person, pray, or sing if desired. Depending on the desires of the individual and family members and on feasibility, supporters such as clergy and friends should be encouraged to be present, and cultural, spiritual, religious, or ethnic rites of passage should be preformed. A physician should make the official determination of death as quickly as possible to lessen family members anxiety and uncertainty. Family members or funeral directors should be given a completed death certificate promptly. Members of the care team (e.g. physicians, nurses, psychologists, social workers, chaplains) ensure that family members psychological and spiritual needs are met by providing appropriate counseling and ensure that family members have a comfortable environment where they can grieve together and have an adequate time to be with the body. Friends, neighbors, and clergy may also provide psychological and spiritual support. Care team members should be aware that there are cultural differences in behavior at the time of death. Often, arranging for someone (e.g. a nurse, a volunteer) to be with the body when family members visit is helpful. This person can offer to help notify clergy or funeral directors, can reassure family members that the individual was comfortable and received the best care possible, and can contact the most closely affected survivor a few weeks later to answer questions, note whether the survivor is adjusting appropriately, and offer condolences. The health care system should ensure that death did not result from wrongdoing. Physician should know when local laws require that a death, even when expected, is to be reported to the coroner or police. At this facility, policies are in place, which require the death to be reported to the Senior Special Investigator. The possibility of an autopsy can be discussed before or shortly after the individuals death.

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Often, a physician chooses not to raise this issue, but family members may ask about it because they have strong feelings for or against and autopsy. This discussion is better handled by the individuals physician, not by a covering physician or MOD unfamiliar with the family. Organ donation should be discussed in advance and included in the individuals Advance Directive, if appropriate. Usually, the body must be attended to promptly by persons licensed to do so, so that it does not present a risk to public health. Hospital Policy and legal requirements shall be followed in all cases regarding the performance of an autopsy. The individuals cultural, religious, and personal preferences should be considered when decisions about preparation of the body, religious rituals, and time of burial, autopsy, and organ donation are made.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 307 Effective Date: August 31, 2006 SUBJECT: ESCORTING INDIVIDUALS OFF UNIT 1. PURPOSE: To provide appropriate supervision and follow up while outlining security measures and staff requirement for escorting Individuals off the unit.

2. POLICY: 1. Individuals who are at risk or on a high activity level are to be escorted at all times when off the unit. Licensed nursing staff shall escort the Individual off grounds only if: A. There is physicians order for 1:1 for clinical reasons (e.g. high risk for suicide observation) B. During emergency tr4ansport or after hours transport when corrections cannot provide escort until a relieve is provided usually within one hour by Corrections. C. Non ambulatory Individuals need assistance to transfer from wheel chair to a transporting vehicle without a lift. D. All Individuals escorted off grounds shall be transported in both wrists to waist and ankle restraints except if it is medically contraindicated per signed physicians order. 2. Unlicensed nursing staff may be used to escort Individuals within the hospital. 3. The ratio of staff for activities within the same compound shall be 1:6 on the acute units and 1:8 on the ICF units. 3. PROCEDURE: NURSING ACTION A. Make a list, with duplicate of Individuals names, destination and expected time of return B. Take one list to the activity and KEY POINTS A. For proper accountability of Individual and their location.

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leave the other on the unit with the shift lead C. Count the Individuals and compare names on list with I.D. badges before leaving unit D. Instruct Individuals to remain as a close group during transit E. Escorts shall position themselves so that the group may be observed while in transit. Position one staff in front, one at the rear, and any additional staff along the line. Observation shall be from the rear when there is only one escort. F. Staff shall closely supervise their Individuals during the activity G. Staff must escort (one-to-one) any Individuals leaving the activity for any reason, suck as toileting. If only one escort, ask other staff present at activity to observe your group until you return H. If Individual misplaces I.D. badge, initiate a search of the Individual and activity area. If not found notify Corrections and Program management immediately. I. Assemble and count your Individuals, using the list when the activity is complete. J. Upon return, count Individuals as they enter the unit. Collect I.D. badges K. Notify shift lead immediately if a Individual is missing and follow Administrative Directive 15.5, Unauthorized Absences.

C. I.D. badges must be worn for all off unit activities. Dining rooms are considered off unit except for meals. D. Allow sufficient space to prevent crowding

F. To ensure appropriate Individual behavior and that they do not leave the activity area

I. To ensure that Individuals are not left in activity areas.

K. For immediate follow up and notification of proper authority per CSH policy.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 308 Effective Date: August 31, 2006 SUBJECT: FALL PREVENTION 1. PURPOSE: This policy will provide guidelines for the prevention of falls by the individual/client population of this facility. This policy will provide guidelines for post-fall assessment, treatment, and intervention. 2. POLICY: 1. All individual/clients at this facility shall be screened for Fall Risk 2. All individual/clients who are at High Risk for falls shall have an individualized Nursing Care Plan for Prevention of Falls 3. All individual/clients who are at High Risk for falls shall be appropriately referred for evaluation of any/all potential causes of falls. 3. GENERAL INFORMATION: Fall prevention, especially in the elderly, is an essential component of Health Promotion. Nursing Staff play a key role in the promotion of health through individual/client teaching and health education. The risk of falling increases with age and is greater for women than for men. Failure to exercise regularly results in poor muscle tone, decreased strength, and loss of bone mass and flexibility. A decrease in bone density contributes to falls and resultant injuries. Two-thirds of those who experience a fall will fall again within six months. A recent history of falls should be listed as a problem in the individual/client record and the problem of potential for injury should be addressed in the care plan. Risk factors: The following conditions represent risk factors that increase the potential for falls, especially in older adults: -Previous falls -Fear of falling -Cardiac arrhythmias -Transient ischemic attacks -Stroke -History of fractures -Orthostatic hypotension -Incontinence of bowel or bladder -Visual and auditory impairments -Dizziness

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-Parkinsons Disease -Delirium -Dementing illnesses -Depression -Musculoskeletal conditions (such as myopathy and deformities) Environmental factors:

-Dehydration -Acute and subacute medical illness -Use of restraints -Hypoglycemia -Polypharmacy (multiple medications -Problems with mobility/gait

The following environmental factors have been associated with an increased risk of falling: -Dim lighting -Poor or weak seating -Glare -Use of full-length side rails -Uneven flooring -Bed height -Inadequate assistive devices -Wet or slippery floor -Inappropriate footwear -Lack of safety railings in room or hallway -Malfunctioning emergency call systems -Lack of grab bars in bathrooms -Poorly fitting or incorrect eye wear -Poorly positioned storage areas

Complications of falls: The following significant complications may arise as a result of falling: -Abrasions, contusions, lacerations -Ecchymosis (brusing) -Hemorrhage (internal and external bleeding) -Anemia, secondary to bleeding -Concussion -Subdural hematoma -Fracture, sprain, or dislocation -Fear of falling resulting in loss of confidence, decreased independence, and isolation NURSING ACTION A. Each individual/client will be assessed for fall risk on admission B. Each individual/clients fall risk will be re-evaluated within the first week of admission, as part of the complete Admission Nursing Assessment process C. Every individual/clients fall risk will KEY POINTS A. Use the appropriate, approved form

C. Each individual/clients risk status

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be reviewed at the Quarterly Team Conference D. Each individual/clients fall must be re-evaluated as indicated by changes in medications, onset of acute medical illness, ect E. Individual/clients who are at risk for falls shall have a current and appropriate Nursing Care Plan completed F. Individual/clients who are at risk for falls shall have this risk noted on their chart, on the RAND and other appropriate locations G. Individuals clients who are at risk for falls will be referred to the Physician for appropriate treatment and/or referral H. When an individual/client fall occurs a post-fall evaluation will be completed by the unit RN within 72 hours. Copies will be sent to appropriate riskmanagement staff/committees, the unit physician will be informed, as well as Program Management I. The individual/Client will be assessed for injuries and appropriate medical treatment provided prior to beginning of the post fall-assessment J. The findings of the post-fall assessment will be the basis for appropriate referrals to determine the potential cause(s) of the fall(s), as well as appropriate nursing care plans for the prevention of future falls.

should be periodically reviewed (e.g. AWOL risk, Suicide risk, Fall risk) D. As the individual/clients clinical condition changes, so does the risk for falls E. The Nursing Care Plan should always be individualized and should address the individual/clients current needs F. The individual/clients fall risk should be highlighted so that staff are alerted to this risk. G. Other Departments/Services may be beneficial in reducing the risk for falls, depending on the clinical status of each individual/client H. The post-fall evaluation will assist in the prevention of future falls for this individual/client as well as others

I. The care, treatment, and safety of the individual/client is always the first priority. J. Appropriate nursing care plans will be initiated as soon as possible to insure individual/client safety

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 309 Effective Date: August 31, 2006 SUBJECT: FEEDING OF INDIVIDUALS 1. PURPOSE: This policy and procedure will provide guidelines for the appropriate supervision and assistance which nursing staff shall perform during Individual meal times. 2. POLICY: 1. Mealtime shall be properly supervised by all nursing personnel with a minimum of 3 staff present without counting those staff providing 1:1 supervision. For the purpose of observation appropriate supervision, there shall never be less than three staff at any meal, whether in the cafeteria or in the courtyards (i.e. cookouts, BBQs). 2. Nursing staff shall observe the eating habits and monitor the food intake of Individuals in the dining room. Level of care nursing staff will assess Individuals appetite, tolerance of foods, cultural and religious preferences, food likes and dislikes, and notify physician and the dietitian. 3. Nursing staff shall feed and assist the Individual who is unable to feed self. 4. Nursing staff shall document food intake daily on the Daily Care Flow Sheet: (the sheet(s) shall be taken to the dining room at each mealtime. At the conclusion of the Individuals meal, the staff member shall document the Individuals meal intake on the sheet. 5. During meals, all available staff shall monitor, circulate and observe the Individuals in the dining room. Pertinent observations and information shall be shared at the Change of Shift Report so that continuity of care and observation can be consistent on all three shifts. 6. Nursing staff shall notify the physician and dietitian of the Individuals weight loss or gain of 5% in 30 days. Documentation of notification shall be made to the dietitian on the Nutritional Screen for High Risk Individuals referral. Date and time of notification of the physician an dietitian shall also be noted in the I.D. note of the Individuals clinical record 7. Nursing staff shall be observant for all shall document Individual complaints of dry mouth/throat. Such complaints shall be considered for an open problem (e.g. Altered nutritional status, R/T difficulty swallowing, A.E.B. complaints of dry mouth/throat), and appropriate Nursing Care Plan(s)

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Nursing staff shall provide appropriate Individual education on the importance of drinking fluids during meals, and on the side effects of medication(s) which include dry mouth/throat. Individual education shall be documented on the Wellness and Recovery Individual/Family Heath Education (CSH 71536)

3. GENERAL INFORMATION: Individual meals provide oral nutrition and satisfy one of the basic human needs. Food is a basic need that affects the physical, mental, and emotional well being of every person. It contributes to the general health of the individual by developing an maintaining a physically sound body and emotionally stable personality. Assisting our Individuals with oral nutrition requires time, patience, knowledge, and understanding. Most of our Individuals eat without assistance, however it is the responsibility of the nursing staff to provide a socially meaningful mealtime to our Individuals. 4. IMPLEMENTATION AND INTERVENTION: NURSING ACTION A. Nursing employee assigned to plasticware duties is responsible for giving each Individual a complete set of plasticwares consisting of one spork and one knife. KEY POINTS A. Nursing staff assigned to this duty shall be responsible for ensuring an accurate count of plasticwares. No Individual shall be sharing his/her plasticware with other Individuals. Exceptions to those Individuals unable to receive a full set of placisware shall be Individuals who have a current Denial of Rights. B. To ensure that the Individual is eating the right diet as ordered. C. Helps determine whether Individuals nutritional and fluids needs are being met. D. Ensures an organized and pleasant atmosphere in the dining room.

B. Closely monitor and record all Individuals diets using the Daily Care Flow Sheet C. During meal, observe Individuals ability to swallow, tolerance to diet, fluid and food intake, and ability to feed self D. Provide assistance as needed and encourage good table manners. No horse playing while eating and not exchanging of food between Individuals. E. Record percent of diet eaten on the

E. Establish an appropriate Nursing

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Daily Care Flow Sheet (MH 5504) F. Document in the chart and notify the physician and dietitian of any changes in eating habits.

Care Plan F. Documentation facilitates communication among health care professionals

Additional steps for infirm or physically handicapped Individuals: NURSING ACTION KEY POINTS A. Remove any unpleasant odors and A. Unsightly, odor filled room can sight(s) in Individuals room (e.g. decrease Individuals appetite bedpan, urinals) then set up chair. Place bed in upright back position if the Individual is unable to be up in the chair B. Assist with oral hygiene and wash B. Reduces spread of microorganisms hands and face and oral hygiene improves taste and increases appetite. C. Assist Individual to comfortable C. Position minimizes risk of aspiration sitting position. If Individual is unable to sit, turn Individual on side with the head of the bed elevated D. Assess tray for completeness and D. Prevents Individual from taking correct diet. Arrange tray in line with incorrect diet Individuals vision when possible E. Place napkin under chin F. Ask Individual about any religious or F. Sitting or standing near Individual cultural preferences before beginning during feeding promotes a feeding. Begin feeding by assisting psychologically comforting and caring Individual to eat slowly in small environment. portions. Vary food by serving small bites from different dishes G. Provide fluids as needed/requested. G. Prevent Individual from filling up on Encourage Individual not to drink all liquids. Drinking fluids adds moisture to liquids at the beginning of the meal aid swallowing for Individuals with dry mouth/throat H. Remove tray as soon as Individual H. Prevents potential for attracting is finished. Return tray to cafeteria as insects and/or rodents soon as possible I. Assist Individual to wash hands and I. Mouth care after meals prevents perform mouth care dental caries J. Assist Individual to resting position. Leave him or her comfortable and leave his or her bed area clean and tidy K. Wash hands K. Reduces spread of microorganisms

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 310 Effective Date: June 21, 2007 This Policy replaces NPP 310 dated August 31, 2006 SUBJECT: LEGAL REQUIREMENTS FOR NURSING DOCUMENTATION 1. PURPOSE: The purpose of this policy is to present strategies to improve documentation. Specific dos and donts of charting are discussed. A legible, accurate medical record is a crucial health care document. It communicates important information about the individual to a variety of professionals. In the event of a lawsuit the medical record may form the basis for a plaintiffs care or the nursing staff members defense. 2. POLICY: 1. Nursing services at Coalinga State Hospital shall use the Wellness and Recovery Model Support System (WaRMSS) for documenting in the individuals medical record. 2. The WaRMSS Manual contains the minimum requirements for the documentation of client care and provides documentation formats or forms. Hospital wide documentation requirements may exceed and may take precedence over the minimum requirement of WaRMSS after approval by the Medical Records Committee. 3. Documentation by licensed nursing staff shall reflect the Nursing Process: Assessment, Outcome Identification, Planning, Implementation, and Evaluation. 4. Documentation in the medical record shall be done by licensed nursing staff, except as outlined below: -Students may document as a part of their training when co-signed by licensed nursing staff or nursing instructor -IPRNs, working under an intern permit employed by Coalinga State Hospital may document, but will require a co-signature by a Registered Nurse -PLPTs may document but will require a co-signature by a licensed nursing staff.

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-Non-licensed Nursing Staff employed by Coalinga State Hospital and who have completed the nurse assistant training and certification course may document on flow records. The PTA may not do total documentation, but may record observations on the IDN if they personally observed a situation. 5. Changes in an individuals physical or mental condition and abnormal lab results shall be reported immediately to a Registered Nurse who will assess and report promptly to the attending physician as appropriate. The date, time, and method of notification including whatever information was relayed to the physician or MOD, shall be entered in the IDN. 6. Errors in documentation in the clinical record shall not be obliterated by use of white-out or any other means. 7. All documentation in the clinical record shall be done in black or dark blue ink except as started below: -Red ink shall be used on the Medication Administration Records to discontinue medication/treatment. -Red ink shall be used to document Allergies/Alerts on the; Physicians Order Sheet, Medication Record, Physical treatment profile, Immunization Record, Discharge Summary, Nursing Assessment, RAND and Sticker Alerts. -Red ink shall be used to note physicians orders and to draw the red line on the Physicians Order sheet to note the 24-Hour Audit Check (see NPP 524 Transcription Review of Charts & Medication Orders). 8. Felt tip pens shall not be used. 9. Do Not use ditto marks in the progress notes. (See Nursing Policy 200, for other abbreviations and symbols that are not to be used in documentation) 10. Use clear, simple, concise terms. 11. Be sure all forms are stamped with legible addressograph plate or if addressograph plate is not available, print individuals name, birth date and CSH # on each form. 12. All entries must be signed by the person making the entry with the first name initial and full last name plus civil service classification. If signature is not legible (to others), print full name and title besides or below signature. 13. All entries must be dated and include the time the entry was written. All Late Entries must also include date and time written. 14. All entries must be keyed to the proper focus # Correcting mistaken entries in documentation: 1. Draw a single diagonal line through the entry so that it is still readable. Do not obliterate the entry. Write Error above or beside the original words. 2. Place the date and your initials next to the words Error.

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DATE

TIME

PROB NO.

ALL ENTRIES SHALL BE SIGNED WITH THE NAME AND TITLE

4-9-06

0800

4-9-06

0900

Individual became hostile and attempted to strike out at his staff member when requested to go to dining room. Unit physician notified and individual was placed in Restraint for striking out behavior. ----------------------Josie Smith, P.T. Correction for Error: Attempts to counsel were ineffective.------------------------------------Josie Smith, P.T.

Correcting errors of omission: 1. Late entries are those not made at the expected time of recording or observation. When making late entries: -Insert an asterisk (*) in the margin or between the lines of the note in chronological order to correspond with the corresponding observation action or event. For example, SEE NOTE of (current DATE and TIME). -Asterisk (*) and enter in chronological order the current date and time. Begin the entry using the example below: Late entry for (enter: date, and time of event) then begin the correct entry.
DATE TIME PROB NO. ALL ENTRIES SHALL BE SIGNED WITH NAME AND TITLE

4-9-06

0800

*SEE 4-13-06

NOTE @ 1300

S&R release

Individual became hostile and attempted to strike out at his staff member when requested to go to dining room. Attempts to counsel were ineffective. Unit physician notified and individual was placed in Restraints for striking out behavior.--------------------------------------Josie Smith, PT Observed in day hall responding to unseen stimuli. When asked

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4-12-06

1300

4-13-06

1300

What he was responding to he stated God speaks to me by way of the TV. He is telling me to save the world. -------------Josie Smith, PT Late Entry for 4-9-06 @ 0900 Individual appears to be less agitated and hostile. States he is no longer fearful of the food in the dining room. Removed from Restraint ----------Josie Smith, PT

Procedure for adding late entries: 1. 2. 3. 4. Add the entry to the first available line. Label the entry Late Entry to indicate it is out of sequence Record the time and date of the entry In the body of the entry, record the time and date it should have been made

Identify late entries correctly: If the time of an entry does not correspond with the event being recorded, explain why. Late entries may result when: -Important information should be added to the medical record after progress notes have been completed; -The medical record is not available for charting at the time the nursing staff member needs it, the nursing staff forgets to write progress notes on a particular chart -Do not ask other nursing staff members to leave some blank lines so that you can insert y our progress note, it is better to add this information as a Late Entry. Late entries should not be squeezed into an existing note or placed in the margins. The late entry should not be added in such a way as to appear suspicious. When writing late entries note the reason why the entry is being added to the record. Plaintiffs attorneys scrutinize late entries. The attorney may attempts to prove that the nurse tried to alter a record to cover up an error instead of making an addition.

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3. GENERAL INFORMATION: Examples of inappropriate documentation: Writing crowded around existing entries; Changes in slant, pressure, uniformity or other differences in handwriting; Erasure or obliteration; Use of different pens to write one entry; Misaligned typed notation; Impressions or lack of impressions from writing instruments on the following pages; Ink offsets or lack of impressions from writing instruments on the following pages; Additions on different dates written in the same ink, while original entries were written in different ink. Healthcare professionals who have been named in a malpractice suit involving altered records may sue the person who falsified the records. Types of tampering: -DO NOT TAMPER WITH MEDICAL RECORDS! Tampering with the record involves: 1. Adding to the existing record at a later date without indicating the addition is a late entry. 2. Placing inaccurate information into the record. The truth and nothing but the truth should go into the medical record. 3. Omitting significant facts. The omission of significant information in the medical record has serious consequences. The old adage If you didnt chart it, you didnt do it holds true. 4. Dating a record to make it appear as if it were written at an earlier time. 5. Rewriting or altering the record. 6. Destroying records. 7. Adding to someone elses note. Chart only care you provide or supervise: Nursing staff should sign only those notes describing care they have given or supervised. Unlicensed staff (e.g. PTAs) are generally not involved in writing progress notes. However, PTAs may document the completion of tasks on flow sheets. The licensed nursing staff is expected to document the additional information such as assessments. Avoid using the medical record to criticize other health care professionals: Do not use the medical record as a forum to criticize other healthcare professionals. Discuss your concerns with the Unit Supervisor or designee.

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Unit Supervisor or designee should be alerted to staff issues to intervene as appropriate. Be precise in documenting the information you report to the physician: Nursing staff are obligated to report serious symptoms to the physician. It is a legal must to chart every substantive conversation you have with a physician about a client, particularly any conversation in which you question a physicians orders. Always document on the clinical record the time of a phone call informing a physician of a change in the individuals condition or a critical abnormal laboratory value. Document individual/client acts: Examples are as follows: -An individuals refusal or inability to provide accurate and compete information. -Noncompliance with medical or nursing interventions such as: A. Staying in bed. B. Dietary restriction. C. Return appointments. D. Abuse or refusal of medication. Write neatly and legibly: One important purpose of documentation is to communicate with the health care team. Sloppy, illegible handwriting creates confusion and wastes time. More seriously, injury to the individual may result if crucial information is misunderstood or not communicated because of illegible handwriting. Simple, effective solutions to the handwriting problem include emphasizing printing instead of writing and asking the healthcare professional to scan and proofread their notes before they close the medical record. Use proper spelling and grammar: Progress notes that are filled with misspelled words and incorrect grammar can create negative impressions. They imply that the nursing staff member has a limited education or intellect or is careless and distracted when charting. Spelling and grammatical errors can be prevented in a number of ways: 1. Keep a dictionary in charting areas. 2. Post a list of frequently misspelled words. Individualize the list by selecting terms and medications used frequently on the unit.

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3. Write clear and concise sentences. Avoid useless and unnecessarily long words. 4. Clearly identify the subject of the sentence. Do not be afraid to include the word I, as in I spoke with the individual It is sometimes very difficult to determine what actions were preformed by nursing staff as opposed to the client, physician, or other healthcare professional. Document in black ink and use military time: The use of black or dark blue has become the trend in healthcare facilities. Red and green do not photocopy well. To further define the exact time of day, military time or the 24-hour clock (1300 hours instead of 1:00 PM) has become the standard in healthcare facilities. This eliminates the use of AM and PM and the potential for confusion if the AM or PM is inadvertently omitted. Make sure that the individuals name is on every sheet: Avoid the possibility of inserting the wrong pages into a different individuals chart by stamping or labeling every side of each page with the individuals identifying information. Use authorized abbreviations: NPPM Approved Abbreviations and Symbols identifies the approved abbreviations. This list should be available to all healthcare workers who document in the medical record. A major purpose of the chart is communication between healthcare workers. This cannot be accomplished when abbreviations cannot be deciphered by anyone other than the author. The Medical Records Committee reviews the list of abbreviations annually to be sure it reflects current practice. Be alert for abbreviations that could have more than one meaning e.g., CVA could mean cerebral vascular accident or costoverterbral angle. When in doubt, spell it out. Transcribe orders carefully: Refer to NPPM Transcribing of Medications Orders. Chart promptly: Chart as close as possible to the time you make an observation or provide care. If you normally write notes while events are fresh in your mind, you wont have to deal with even the suggestion that your recollections at the end of the shift were uncertain, confused, mistaken, or otherwise unreliable. When charting is left until the end of their shift, details that are important to note are

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often forgotten. Information that is charted immediately is more likely to be accurate and complete. Chart after the delivery of nursing care, not before: Avoid documenting the performance of a procedure before performing it. The information in the record may be inaccurate and will not reflect the individuals responses to the intervention. Charting in advance will also affect the credibility of the medical record.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 311 Effective Date: August 31, 2006 SUBJECT: MOUTH CARE 1. PURPOSE: To outline proper guidelines for mouth care, promote self-esteem, comfort and cleanliness, prevent infection and other oral complication. Keep mouth and dentures in good condition. 2. POLICY: 1. Nursing staff shall teach the principles of good oral hygiene to all Individuals and provide equipment as necessary. 2. Nursing staff shall provide partial to full assistance, as needed, to Individuals who are unable to care for self. 3. Care shall be given after each meal and at bedtime 4. Each Individual shall have an individual toothbrush and toothpaste. 3. DEFINITION: Mouth care is an act of brushing teeth or dentures and cleansing the surrounding tissues with appropriate solution while observing for any abnormalities after each meal and at bedtime or every 2-4 hours in an unconscious Individual. Assess the following: 1. Assess the condition of the Individuals mouth. 2. Determine whether or not the Individual had dentures. 3. Inspect the gums for swelling or inflammation. Note whether the gums seem puffy, protrude down into the spaces between the teeth to determine if the gums bleed easily or are discolored. 4. Inspect the mouth for loose teeth or untreated dental caries. Note foulsmelling breath, which may indicate infection is present in the mouth. 5. Asses the Individuals usual hygienic habits related to tooth care, frequency of brushing the teeth, frequency of flossing the teeth. 6. Assess the Individuals knowledge of proper methods of caring for the mouth and teeth. 7. Assess the physical condition of the Individual in relation to ability to participate in own care,. If the Individual has impairment of the upper

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extremities, assistance with oral care may be required. Provide health teaching to the Individual with poor knowledge of oral hygiene. 8. Assess factors that would increase the need for oral care (Such as chemotheraphy, antibiotics, vomiting, nutritional deficiencies, HIV infection, and herpes. Aplastic anemia and unconscious Individual.) 4. PRECAUTIONS: 1. The fluid, blood, and moist body fluid/substances of all Individuals shall be treated as though they were contagious. Refer to A.D. # 10.23 Standard Precautions. 2. Nursing personnel, having direct contact or the potential for contact with exposure to blood, body fluids, or potentially infectious material of Individuals, are expected to practice STANDARD PRECAUTIONS according to the guidelines established by the CSH Infection Control Program. 5. OUTCOME CRITERIA: 1. Individual will be free of dental disease 2 Individual will develop proper oral-hygiene techniques and preventive care. 6. EQUIPMENT: 1. 2. 3. 4. 5. 6. Toothbrush Dentifrice (toothpaste) Water and mouthwash solution Emesis basin/sink Towel Drinking straw

7. IMPLEMENTATION AND INTERVENTION: Bed Individual or physically handicapped Individual: NURSING ACTION A. Wash hands and assemble equipment, wear gloves B. Place Individual in comfortable position C. Drape towel over Individuals chest D. Place emesis basin and wipes conveniently for use E. If Individual has partial in place have him/her remove it and place in KEY POINTS A. Refer to A.D. # 10.23 Standard Precautions

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paper towel F. Wet toothbrush with water and place toothpaste on brush

G. Brush Individuals lower teeth from gum line up and the upper teeth from gum line down H. Rinse mouth frequently with mouthwash I. After brushing rinse with mouthwash J. Rinse brush and store in parts cabinet

F. Do not apply toothpaste directly from tube to brush; use a paper towel if the toothpaste is used by other Individuals G. Hold brush at a 45 degree angle to gum line. Use gentle, short strokes H. To remove debris

J. This prevents toothbrush from coming into contact with each other. Refer to NPPM# 1203 Storage and Handling of Toothbrushes and Toothpaste

8. DENTURE CARE: Equipment: 1. 2. 3. 4. 5. Toothbrush Dentifrice/commercial denture cleaner Denture cup Towel Emesis basin

9. IMPLEMENTATION AND INTERVENTION: NURSING ACTION KEY POINTS A. Wash hands and assemble equipment B. Line sink with paper towels and fill B. This will cushion and protect the with water dentures should they fall C. Have Individual remove dentures and place in denture cup D. Instruct the Individual to rinse mouth with mouthwash and gently massage the gums with the toothbrush E. Brush the dentures under running E. Use only moderate pressure to water, using denture cleanser or prevent scratching the dentures toothpaste F. Assist the Individual in replacing the F. Wet dentures are easier to replace dentures if necessary than dry ones

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 312 Effective Date: August 31, 2006 SUBJECT: NAIL CARE 1. PURPOSE: Care of nails is part of daily personal hygiene that improves Individuals self esteem and help in early detection of infection or other complications associated with nails and other health problems. 2. POLICY: 1. As part of assisting our Individual with ADL, nursing staff shall on a weekly basis inspect all Individuals nail. For ambulatory Individuals this should be done at shower time 2. Individuals who are able to do their own nail care shall do so under direct staff supervision only. 3. Nursing staff shall report all abnormalities observed while assisting those Individuals who are unable to care for self, and during shower for ambulatory Individual. 4. Refusal to maintain nail care shall require a specialized treatment plan approved by the I.D. team, Program Management and the Individuals Right Advocate. 3. EQUIPIMENT: 1. 2. 3. 4. Nail clipper and nail file Gauze bandage and cotton balls Wash clothes and towels Basin for water

4. PRECAUTIONS: 1. Individuals with diabetes, peripheral vascular disease, thickened, or otherwise abnormal toenails are to be brought to the unit physicians attention for possible referral to the Podiatry Clinic. 2. Nail clippers shall be cleaned between Individual use. Immerse in a 70% Isopropyl alcohol solution for at least ten minutes or other disinfectant approved by the Infection Control Committee. 3. Standard precautions is to be applied whenever blood or body fluid exposure is predicted.

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5. IMPLEMENTATION AND INTERVENTION: NURSING ACTION A. Wash hands before and after procedure B. Explain procedure to Individual C. Wear Gloves, wash hands/feet with water and soap D. Dry thoroughly E. Clean and trim nails KEY POINTS A. Standard precaution B. To gain cooperation and relieve anxiety. C. For ambulatory Individuals this can be done in the shower D. Especially between the toes E. Form rounded ends on fingernails. Toenails cut straight across. Nails should extend only slightly beyond the end of fingers or toes. F. To prevent injury

F. Smooth rough edges with nail file or emery board G. Apply lotion as ordered H. Teach need for proper nail care to H. This could be done as a group Individuals with poor personal hygiene activity problems, diabetes and vascular disease I. Clean non-disposable equipment with soap and water and disinfect with an approved disinfectant J. Document in IDN note

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 313 Effective Date: August 31, 2006 SUBJECT: NURSING ASSESSMENT: INITIAL, ANNUAL & UPDATE 1. PURPOSE: This nursing policy will outline the policies and procedures to be followed by Registered Nurses when performing the Initial, Annual, and Periodic Nursing Assessments of individuals at this facility. 2. POLICY: 1. The Behavioral Systems Model is utilized by nursing services at CSH as the framework for providing care to the forensic, psychiatric individual in a biopsychosocial, holistic manner. 2. Nursing Assessments shall be completed by a Registered Nurse (RN) 3. The Initial Nursing Screening assessment shall be completed by a Registered Nurse in the Admission Suite prior to transfer to the unit. 4. Nursing Assessments (Initial, Update, and Annual) are completed on the Nursing Assessment Form by a Registered Nurse. 5. Nursing Assessment Updates (PARTS A through E) shall be completed: A. Annually from original admission date B. Within 8 hours of transfer C. On return from court if out longer than 14 days D. Whenever clinically indicated (e.g. whenever behavioral and/or medical changes impact significantly on the subsystems) E. Prior to each individuals Team Conference, the RN/Case Manager completes the assessment as part of his/her preparation to provide input for the Team Conference 6. A Pain Rating assessment will be included with all assessments. 7. A containment risk assessment shall be included in all nursing assessments. Risk management issues should also be addressed in each nursing assessment/update. 8. The Nursing Assessment Update or Annual cannot be substituted for the RN Monthly Summary. The Nursing Assessment Form is a comprehensive biopsychosocial, spiritual, physical, and cultural summation of the individuals status as part of their forensic psychiatric admission to CSH. This assessment is a totally separate focus from the RN Monthly Summary, which is an evaluation of the nursing process to the individuals current nursing care plan(s) and the Integrated Treatment Plan.

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3. GENERAL INFORMATION: The Nursing Assessment is the beginning phase of the nurse-individual relationship. Assessment involved the nurses inquiry into various aspects of the individuals life: biopsychosocial, spiritual, physical, and cultural. It is an ongoing process of data collection and interpretation that is evident at the initial entry into the hospital and throughout the course of treatment at updates. The assessment data may be collected by other qualified individuals, members of the ID Team, or data provided by the individual or significant others when appropriate. Using the Behavioral Subsystems to establish the individual profile, the Nursing Assessment is completed as follows: PART A: REGULATOR PROFILE The Biophysical, Psychosocial, Socio-Cultural, Family/Significant others, Developmental, and Physical Environment sections shall be completed within 8 hours of admission to the unit. The Regulator Profile identifies the impact of internal and external regulators that influence subsystems efficiency and will be completed after PART B using the following rating: 1= Minimal, 2= Moderate, 3= Major. PART B: CURRENT SUMMARIZATION OF BEHAVIORAL SUBSYSTEMS Current Summarization of Behavioral Subsystems is started within 8 hours of admission and shall be completed by the RN/Case Manager by the 72 Hour Conference. PART C: ASSESSED ENVIRONMENTAL/EDUCATIONAL NEEDS Assessed Environmental/Educational needs shall be started within 8 hours by the RN and completed by the RN Case Manager by the 72 Hour Conference. All individual education shall be documented on the Wellness and Recovery Individual/Family Heath Education Record CSH 7156. PART D: NURSING DIAGNOSIS A Nursing Diagnosis, based on the assessment, shall be established within 8 hours by the RN and completed by the RN Case Manager by the 72 Hour Conference. PARTY E: INTIAL DISCHARGE PLANNING Initial Discharge Planning, including barriers to discharge, shall be started by the RN within 8 hours and completed by the RN Case Manager by the 72 Hour Conference. 4. INITIAL NURSING ASSESSMENT:

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Procedure: NURSING ACTION A. The Admission Suite RN will complete Initial Nursing Screening assessment. KEY POINTS A. Screening of vital signs, pain rating assessment, biophysical, psychosocial, alerts, communicable diseases, and special needs, including a containment risk assessment will be done in the Admission Suite prior to transfer to any unit B. The assessing RN shall sign with full signature, date, and time when PART A of the Assessment was completed in the shaded area after the Physical Environment impact rating.

B. RN on the admission unit will complete PART A, C, D, and E and start PART B of the Nursing Assessment within 8 hours of admission to the unit. Check appropriate box to designate this as the Initial assessment C. The RN/Care Manager will review and update PART A, C, D, E, and complete PART B of the Assessment by the 72 Hour Conference on assigned individuals D. The RN/Case Manager will sign with full signature, time, and date when completed

C. After completion of PART B, go back and complete the impact ratings of PART A.

D. the RN/Case Manager will start the Nursing Acuity Outcome Log at this time.

Under the Coping Methods exclude the 1370 individual for the following: Accepts responsibility for crime, and States relationship between mental illness, his crime and use of illicit drugs and importance of medication compliance. For the 1370 individual write Not Applicable as the individual has not been convicted of a crime and is at CSH to get ready for the court process. 5. NURSING ASSESSMENT UPDATES/ANNUALS: Procedure: NURSING ACTION A. Nursing Assessment Updates (PARTS A through E) are completed within 8 hours of transfer: When transfer from one unit to another, review the prior Assessment. If a full assessment was completed within the past 12 months and the information is still KEY POINTS A. Nursing Assessment Updates should be completed by the RN/Case Manager assigned to the individual whenever possible. Original admission date is indicated on the Addressograph stamp.

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current, the assessment can be updated by noting that Assessment is still current followed by date and full signature on PART E under original signature. On return from court if out longer than fourteen days Annually from original admission date. As clinically indicated B. Indicate on Assessment form that this is an Update by checking the appropriate box. Document in IDN that Assessment was reviewed and/or completed. If there was no change from the previous assessment, reflect this in the IDN

B. Indicated when Assessment was completed by time, date, and full signature.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 314 Effective Date: June 21, 2007 This Policy replaces NPP 314 dated August 31, 2006 SUBJECT: WELLNESS RECOVERY PLANS (NURSING) 1. PURPOSE: Wellness Recovery Plans are an interdisciplinary team plan based on observations and assessments and provide a road map for future care. The purpose of the plan is to provide a core of information on the Individuals expected outcomes, and planned interventions. The plan serves as a communication tool for staff involved in the Individuals care. Nursing staff, whose contact with one another is limited, rely heavily on the Wellness Recovery plan to ensure continuity of care for the Individual. The plan should guide care, as well as document the planning phase of the nursing process. 2. POLICY: 1. Nursing Services shall provide individualized, goal directed nursing care to all Individuals through the use of the Nursing Process (Assessment, Outcome Identification, Planning, Implementation, and Evaluation). 2. The Registered Nurse: a. Formulates a plan through observation of the Individuals physical condition and behavior and through interpretation of information obtained from the Individual and Wellness Recovery Team members. b. Formulate a plan in collaboration with the Individual which ensures that direct and indirect nursing care services are provided for the Individuals safety, comfort, hygiene, and protection and for disease prevention and restorative measures. c. Performs skills essential to the kind of nursing action to be taken. Explains the health treatment to the Individual and teaches the Individual how to care for health needs. d. Delegates tasks to other nursing services personnel based on their legal scopes of practice and clinical skill capability. Clinically supervises nursing care being given by nursing services staff. e. Evaluates the effectiveness of the plan through observation of the Individuals physical condition and behavior, signs and symptoms of illness, and reactions to treatment and through communication with

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the Individual and Wellness Recovery Team members. Modifies the plan as needed. f. Acts as the Individuals advocate by initiating action to improve healthcare, changing decisions or activities which are against the interests or wishes of the Individual. Creates opportunity for Individuals to make informed decisions about health care before it is provided. Nursing personnel intervene as guided by the Wellness Recovery Plan goals and interventions in providing care to the individuals. The medical section, Focus 6 of the Wellness Recovery Plan is individualized based on the Nursing Assessment database, the individuals medical conditions, and are consistent with the Wellness Recovery Plan. A preliminary goal and interventions is established and developed by the RN within 8 hours of admission to the unit, then re-evaluated at the 72 Hour Conference. Preliminary plans of care will be established within 8 hours of identification of problem. Once the Team meets for the Wellness and Recovery Treatment Planning Conference, a consensus must be reached regarding the goals for all identified problems. The Wellness Recovery Plans goal must be consistent with the presenting medical conditions identified by the physician. Whenever a problem is added, changed, or resolved by a mini-team, the RN will be present. The RN will insure that a plan of care is written within 8 hours. The RN may utilize the resource binders (available on the units) as guidelines to write the plan. Other resources for guidance may include the RN Preceptors and HSS. (Health Maintenance) problems do not require a plan. However, only appropriate Health Maintenance problems can be used. When a TC (Temporary Condition) is opened, a brief plan of care with expected outcomes will be identified in the RNs IDN Note. The RN will accomplish this by use of a APIE Note. An RN may call the MOD and take a telephone order to open an emergency physical or psychiatric problem. The RN will record the problem on the Biopsychosocial Profile for Psychosocial or Physical Problems. The RN must initial next to date opened and sign the form with date and full signature. The RN will then initiate a Plan of care, and Individual Problem Plan. A plan of care for Individuals placed into seclusion or restraint may be written in an APIE note or on Side B on the Seclusion and Restraint form.

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Then outcome criteria (or goal), developed and established by the Wellness Recovery Team, states the expected achievement of the Individual in specific enough terms that any member of the treatment staff can readily determine when the outcome criteria is met. This outcome criterion (goal) can be written in terms of small measurable gains upon which further objectives can be built. The nursing goal is consistent with the Wellness Recovery Team goals. 1. There should be progressive plans written in simple language in order to meet the outcome criteria. 2. The outcome criteria must be one that the Individual realistically can be expected to achieve given the resources available. The Individual and/or significant others should be included in planning the outcome criteria whenever possible. 3. The plan of care is meant to be a collaborative effort between the RN, PT/Primary Counselor, Wellness Recovery Team, and the Individual. Using the short-term Individual care goal developed by the Wellness Recovery Team, the RN in collaboration with nursing services staff, develops and implements interventions that meet that goal. 4. Individual education is given special consideration and must be addressed in each Wellness Recovery plan 5. The length of time that the Individual can reasonably be expected to achieve the outcome criteria is identified within the Target Date section of the Wellness Recovery Plan. 6. The Wellness Recovery Plan shall be reviewed, revised, and/or updated at each conference and whenever clinically indicated. 3. GENERAL INFORMATION, DEFINITIONS: The care plan must be an objective statement that is written in a simple, realistic individualized manner that permits a measurement toward the desired outcome, and is time limited. It needs to adhere to the following definitions: OBJECTIVE- means that the statement should address what can be observed by the senses, without bias, prejudice, or opinion. It is what is real and observable, and different observations would be able to perceive the same data. It is what can be seen, heard, touched, smelled, or tasted. SIMPLE- is a direct statement using the least number of words to make it clear and easy for both staff and Individual to understand. REALISTIC- is a specific behavior, task, or physical condition that is expected to be displayed, that is within the Individuals capabilities, and have a reasonable prospect of success.

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INDIVIDUALIZED- means that the expected outcome, and planned interventions are specifically designed to address the needs of that particular Individual. MEASUREABLE- indicates that the expected outcome can be observed and measured by another person and is compared with the initial (or subsequent) assessments. The behavior that is observed can be quantified. This covers such parameters as frequency, duration, and amount. (It can also include specific lab value indexes and weight ranges that are indicators of specific behaviors. We cannot measure attitudes and motivations). TIME-LIMITED- refers to a circumscribed period of time in which the interventions will be followed, and progress toward the expected outcome or goal will be measured and evaluated. The length of time that the Individual can be reasonably expected to achieve the outcome criteria needs to be recorded as the target date. The length of time may not exceed a quarter. Goals are often a series of small steps that help the Individual progress toward a long-term goal. It is better to keep the time frame short, and move on to the next step as each goal is met. The Individual will develop a sense of success, and the Wellness Recovery Team will be able to see progress much more readily. The medical conditions Focus 6 of the Wellness Recovery Plan is an essential component of the work that nursing services staff does in providing care and treatment for our Individuals. The Wellness Recovery Plans are based on observations and assessments and provide directions for future care and treatment of the individuals. The purpose of the plan is to provide a core of information on the Individuals medical condition and the expected outcomes, and planned interventions. The Wellness Recovery Plan Focus 6-medical conditions fulfill several functions: Documentation: The plan of care documents the planning phase of the nursing process. Communication: It serves as a communication tool for everyone involved in Individual care. Common goals: It is instrumental in directing nursing services staff to work toward common goals that are individualized to the Individuals needs Continuity: It helps ensure continuity and consistency in care

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The Wellness Recovery plans are written guidelines of nursing care documenting specific goals, interventions, and projected outcomes. The Planning phase of the Nursing Process is the time to develop a plan of care and determine what approach nursing staff is going to use to help stabilize, lessen, or eliminate the effects of the Individuals problem. The nurse applies the skills of problem solving and decision-making to identify specific Individuals needs. There are three steps in the Planning phase: setting priorities, writing goals, and planning nursing actions. During the Treatment Planning Conference, each member will identify what modalities their particular discipline will provide in helping the Individual achieve the identified short-term goals. The RN will indicate, in general, what modalities will be provided by nursing services staff. The RN is responsible for developing and implementing nursing care. This must specifically spell out the interventions, step by step, what nursing services will provide in helping the Individual meet the short-term goal. Setting Priorities: All open problems must be addressed within the Wellness Recovery Plan. Nursing services staff, the Wellness Recovery Team, and the Individual prioritize the Individuals problems collaboratively. The highest priority medical condition should be treated first. Subsequent problems are ordered in priority. Priority setting does not mean that one problem must be totally resolved before another problem is considered. Problems can frequently be approached simultaneously. Projected Outcome: The Wellness Recovery Team develops the Individuals long and short-term goal(s). Based on the medical condition, the RN writes the nursing specific short-term goal consistent with the Wellness and Recovery Treatment Plan (WRP). Examples: Diabetes: Short-Term Goal: Individual will be able to verbalize how daily exercise can help in controlling his blood sugar level by target date. Short-Term Goal:

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Individual will be able to verbalize ways that can help in controlling blood sugar levels by target date.

Substance Abuse: Short-Term Goal: Individual will verbalize relapse prevention plan by target date Short-Term Goal: Individual will be able to verbalize three coping skills in preventing relapse by target date. ADDITIONAL EXAMPLES: Thought Disorder: Long-Term Goal: Individual will identify and demonstrate behaviors that promote management of mental health Short-Term Goal: Individual will develop a relapse prevention plan as demonstrated by: -Stating s/s of mental illness -Identifying his delusions and developing coping skills for them -Verbalizing risk/benefits and knowledge of treatment

Short-Term Goal: (To be accomplished by the next WRP) Individual will state 3 strategies to prevent relapse Delusion/Hallucination: Long-Term Goal: Individual will verbalize understanding of his mental illness and demonstrate its management by: a. Identifying s/s of relapse b. Complying with medication regime c. Complying with and participating in treatment regime Short-Term Goal: (To be accomplished by the next WRP) 1. Individual will identify four symptoms of mental illness 2. Individual will identify his medications and verbalize two reasons for their use

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Short-Term Goal: (To be accomplished by the next WRP) Individual will identify and state: a. Three signs and symptoms of mental illness b. Two reasons for medication compliance Constipation: Long-Term Goal: 1. Individual will verbalize and demonstrate measures to prevent constipation 2. Individual will experience normal bowel movements QD Short-Term Goal: (To be accomplished by the next WRP) Individual will have one bowel movement QD without straining Short-Term Goal: (To be accomplished by the next WRP) Individual will have one bowel movement QD without straining The advantage to writing the goal directly onto the WRP is that it will provide direction and clarity to nursing services staff in carrying out the plan of intervention for the specific outcome desired for a specific problem number. The goal is designed to guide the team and the Individual as to what the team endeavors to help the Individual accomplish. A goal statement also assists nursing staff to clearly determine if and when the desired outcome has been achieved. The goal may actually be a learning objective, if the medical condition relates to a lack of Individual knowledge or skill. Each progressive short-term goal established requires a series of nursing actions or interventions designed to help the Individual reach the goal. Planning Intervention: The planning and development of interventions defines what nursing services will do to help the Individual reach the desired outcome. Remember that our Individuals are here for treatment, and treatment must be directed at the problems that are interfering with the Individuals health and ability to function safely in the community. Our main task as members of the Wellness and Recovery Team is to come up with treatment options that are effective in diminishing the problems that require treatment and/or hospitalization. Wellness Recovery Plans are developed to specifically address problems that staff can focus on. Nursing actions, or interventions, may be thought of as instructions for all nursing staff caring for the Individual. The RN provides a

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set of instructions for other nursing services staff on how they are to provide care for a particular Individual. Within the Wellness Recovery Plan are interventions that identify specific nursing care and treatment which nursing personnel have the authority to initiate for a particular Individual. The care and treatments are designed to help the Individual meet one or more goals and lessen an identified problem. They are often written in the form of an order with the frequency of treatment and the date clearly indicated. It is expected that other nursing personnel are accountable for implementation and documentation of nursing orders. (These are part of the plan and just changed to being met and new goals/interventions are identified as needed.) The following suggestions may be helpful as you begin to write the interventions. Nursing action(s) or intervention(s) are designed to help the Individual meet the goal identified by the Wellness Recovery Team. List the interventions sequentially Interventions are phrased in the manner that describes what nursing services staff will do to help the Individual reach the goal. Interventions are specific so that anyone can follow the directions Nursing action(s) or intervention(s) should be phrased to demonstrate how nursing staff would work to reduce or alleviate the Individuals problem behavior. This problem would have been identified in the medical conditions listed by the physician. Interventions should be realistic and appropriate for the nursing staffs level of skill and experience for helping that specific Individual. Interventions should be realistic and appropriate for the nursing staffs level of skill and experience for helping that specific Individual. Whenever possible, the intervention(s) should be important and valued by the Individual, the nursing staff, physician, and Wellness Recovery Team. It should be mutually acceptable so that all the members of the team agree that the intervention is important, realistic, logical, and relevant.

Essential Elements of the Wellness Recovery Plan Are: The Registered Nurse is a member of the WRP team. Interventions may be added with collaborative input by other disciplines. Outcome criteria are based on the nursing assessment and shall be realistic, and measurable. The goal must be consistent with the therapy goal identified by the Wellness Recovery Planning Team at the time of the Conference. -8N.P.P No. 314

The Individual, as far as possible, should be included in establishing the outcome criteria. The RN uses the medical condition to develop the plan of care. The medical condition provides the basis for selection of interventions for delivering Individual care that are designed to achieve outcomes, for which the nurse is accountable. The plan of care should reflect current standards of nursing practice. The plan of care shall include nursing actions or interventions that are designed to help the Individual reach the Individuals goal established by the Wellness Recovery Team and will restore and/or maintain the Individuals highest level of functioning. The plan of care will include biopsychosocial aspects, as appropriate. The scope of the plan shall be determined by the anticipated needs of the Individual and shall be revised as needs of the Individual change. Medications requiring nursing interventions must be addressed. Develop a teaching plan. Individual education is given special consideration and addressed in each nursing care plan. Everything we do is geared to discharge. The nursing care plan should include plans to assist the Individual in meeting their discharge criteria as established by the Wellness and Recovery Team. There is no longer a requirement to address discharge specifically.

Temporary conditions and acute care situations: An APIE Note will be used when a TC (Temporary Condition) is opened for an acute care situation. When a problem develops that meets the criteria for a temporary condition, the nurse must immediately notify the physician and initiates the documentation requirements for temporary conditions. The IDN to reflect the TC will use the APIE Note format to specifically capture the RNs assessment of the condition and the plan of care to be taken for that condition. If the problem does not meet the criteria for a temporary condition, the RN must notify the physician and obtain a telephone order to open a problem as outlined in the mini-team process (e.g. assaultive or suicidal behavior). Temporary Conditions (TC) may be identified and recorded by either a physician or a Registered Nurse. The RN shall notify the physician when a temporary condition has been identified. Conditions may be designated temporary for duration of 10 days of less with an automatic closure of the condition on or before the 10th day. If the condition exists longer than 10 days, a problem must be opened by the physician. Temporary Conditions require recording of the planned treatment in a narrative entry including interventions and preventative treatment measures

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by the RN in the IDN using the APIE format. The Physician will also accomplish this in the Physicians Progress Note. Recording TC entries: Record the entry date and time and Enter TC in the number column and begin the entry with descriptive words or phrases. EXAMPLE: 7/10/05 0830 ENTER TC Laceration This will serve to differentiate entries for more than one TC occurring at the same time. Include a description of the condition or problem and the Individuals input if applicable. Indicate the physician was notified or will be notified of the temporary condition. Record the plan for intervention, observation, preventative treatment measures, etc. A plan is required for each identified condition/problem. Subsequent entries to the same temporary condition shall be entered with date and time and the TV in the number column. Begin with the identifying, descriptive word or phrase, record actions, results and updates of plans. EXAMPLE: 7/12/05 1045 0830 ENTER TC Laceration Recording EXIT TC identifies the final entry for a given temporary condition. Only a physician may exit a temporary condition. However, it is permissible for the physician to give a telephone order to the Registered Nurse to exit a Temporary Condition and to discontinue related physician orders. Nursing staff should exit the Temporary Condition in the Wellness and Recovery/Discipline Specific Notes at the time the physician exits the Temporary Condition in the physicians progress notes or at the time of the telephone or verbal order by the physician. In order to develop and initiate a timely plan of care for an acute care situation(s) and to address when a TV is opened, use of APIE Charting will be utilized for charting of TCs. Use the APIE format each time the TC problem is addressed until TC is closed. Problem Oriented Charting (APIE) reflects certain aspects of the nursing process and consists of the following format: A: assessment (what you think is going on based on the data) P: plan (what you are going to do) I: Intervention E: Evaluation Non-temporary conditions:

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Conditions requiring oral or parenteral antibiotics. Any condition requiring other than topical antibiotics, regardless of duration of the condition for which why are prescribed, shall not be designated as a temporary condition. Chronic recurring temporary conditions: Conditions which recur more than once per quarter shall not be designated as temporary conditions even if they are short term conditions. After the first occurrence these conditions should be listed in the Wellness Recovery Plan. Conditions requiring seclusion or restraint: Such conditions shall be keyed to the appropriate problem number in the Wellness Recovery Plan. Legal implications: Plans of care should have the following characteristics: Completeness- each problem identified through observation and assessment must be addressed in the plan of care. Realism- failure to follow the plan can be interpreted as breach of the institutions own standard of nursing care. Therefore, the plan of care must be realistic so that they can be complied with. Currency- as the Individuals condition changes, the plan of care must be updated. Failure to follow the plan simply because it is outdated may still be difficult to defend in a court of law. The Wellness Recovery Plan is reviewed, revised, and/or updated at the Quarterly Conference.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 315 Effective Date: August 31, 2006

SUBJECT: NURSING DISCHARGE SUMMARY 1. PURPOSE: The Nursing Discharge Summary serves as a communication tool between Coalinga State Hospital and receiving facilities for promoting continuity of care and treatment. 2. POLICY: 1. The Nursing Discharge Summary Nursing Discharge Summary shall be completed by the RN in timely readiness prior to the Individual leaving. The RN shall verbally explain discharge instructions/teaching to the Individual. The pink copy of the Discharge Summary will be provided to the Individual unless clinically contraindicated. 2. A Nursing Discharge Summary is to accompany every Individual who is discharged from Coalinga State Hospital even for a one-day court visit with the following exceptions: a. Hearings b. Department 95A Conservatorship Hearings c. Probate Consrevatorship Hearings d. Clinic appointments at outside medical facilities 3. The yellow copy of the Nursing Discharge Summary will be placed in an envelope and given to the Individuals escort, Correctional Officer, next care provider, or family member to hand carry to the accepting facility or mental health agency. 4. If the Individual is going to a continued court hearing a prior Nursing Discharge Summary, that had been completed within the past 30 days, may be photocopied and sent along with the Individual provided there have been on changes in the Individuals condition or treatment since the summary was last completed. If there are no changes, the Registered Nurse shall sign and date the from again and write NO CHANGE. The unit shall provide a copy of this Nursing Discharge Summary and the Immunization and Communicable Disease Flow Sheet (MH 5667 Side 1 and Side 2) to the HSS. If there are any changes in the Individuals condition or treatment, a new Nursing Discharge Summary shall be initiated and completed 5. The Shift Lead will insure this document is completed in a timely manner.

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6. All sections of the Nursing Discharge Summary are to be addressed. DO NOT LEAVE ANY SECTION BLANK. Specify None, N/A, or Not applicable as appropriate. 7. The form is meant to serve as a tool to pass on information that another facility or caretaker would need to know to continue in the care for the Individual. Present the information in a format that would best facilitate this. 8. A photocopy of the Immunization and Communicable Disease Flow Sheet (MH 5667 Side 1 and Side 2) shall be attached to the Nursing Discharge Summary (MH 5741B). 9. If the Individual is on Clozaril (Clozapine) a Clozapine Data form shall also be completed and included in with the Nursing Discharge Summary. Section One of this form shall be completed by the unit RN. Section Two shall be completed by the Psychiatrist. A CBC blood level shall be drawn as a STAT the day before the Individual is discharged so that the results can be included with this discharge packet. 10. The RN is responsible to insure the document is complete, legible, and accurate. 11. As a Quality Control measure, once the Registered Nurse has completed the Nursing Discharge Summary, the nurse shall contact the HSS. The HSS shall then review the form for completeness and legibility. If all required components are evident, the HSS will sign their full name, title and date on the document in the area below the signature of the RN to indicate the document is complete and accurate. If components are lacking, the HSS will inform the RN to include the required information. 12. The RN with the assistance of the HSS will make one photocopy of the Nursing Discharge Summary, Immunization and Communicable Disease Flow Sheet, and the Clozapine Dataform. The RN shall be responsible for placing the original documents back into the Individuals chart. 13. The Registered Nurse shall be responsible for reviewing the discharge instructions with the Individual prior to discharge. 3. GENERAL INFROMATION: When preparing the document, the RN is advised to print clearly and legibly. Press firmly to insure the information records onto the first (yellow) and second (pink) copy of the NCR paper. The Nursing Discharge Summary shall contain but not be limited to: a. List of all medications, dosages, times of administration, and duration of order (including such items as lotrimin crme, magic shave, ect. if these were part of the Individuals treatment orders) b. List of all treatments (including topical treatments), times of administration, and duration of order

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c. The last date and blood level of labs drawn for all medication levels being closely monitored (e.g. lithium, digoxin, tegretol, Phenobarbital, diliantin, ect.). Also state when the next blood level is due if applicable. d. Identify Individuals level of cooperation with taking his medication (e.g. cooperative, unable/unwilling to take medication, needs prompting, attempts to cheek/refuses) e. Identify all ALERGIES and ALERTS. Do not leave these sections blank. If there are no allergies or alerts write NO KNOWN ALLERGIES, NONE, or NOT APPLICABLE f. When identifying ALERTS (e.g. Homicidal, Suicidal, Self-Abuse, Assault, Arson, AWOL) elaborate all alerts within the Nursing Treatment Summary section including the most recent and/or significant dates of this behavior. Provide any known precursor or trigger events that may contribute to the behavior g. Diabetic progress-blood sugar stability, FBS results, frequency of fingerstick cheeks and results, insulin sliding scare regimen, diabetic diet, Individual teaching, special care needs. h.Individuals with a positive PPD should be identified within the ALERT section. Elaborate further details within the Nursing Treatment Summary section. Include the date of the positive PPD reading, date and clinical impression of the last Chest X-Ray, treatment provided, and follow-up treatment still required (e.g. list start and stop dates of INH therapy) f. Specify diet and nutritional needs g. Check pertinent boxes associated with Ongoing Treatment elaborating further in the summary section as needed h. List the DSM IV-R Axis I through IV in the Nursing Treatment Summary section. Include the list of all open medical and psychiatric problems including progress or regress, nursing interventions, behavioral precautions, brief description of the Individual, and brief description of their crime with Penal Code and maximum date of commitment, equipment needs, and other pertinent continuing care needs i. A second (or more) page can be used and labeled Nursing Discharge Summary Continued if more space is needed to complete the summary than is allowed in the Nursing Treatment Summary section j. Describe Special Instructions provided to Individual, family, or accepting facility. Review the Wellness and Recovery Individual/Family Heath Education Record to apprise the accepting caretaker or facility of pertinent teaching provided to the Individual, and what further follow-up teaching or reinforcement may be needed. Emphasize the Individuals level of understanding.

4. PRECAUTIONS:

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The Registered Nurse preparing the Nursing Discharge Summary and documents will insure that the original documents Nursing Discharge Summary, Immunization and Communicable Disease Flow Sheet, and the Clozapine Data form shall remain in the chart. Only a photocopy of these documents are to be sent to the court or accepting facility. Since the Nursing Discharge Summary is a form that comes prepared with NCR paper, the nurse is advised to press hard and write legibly to insure that the information comes through on the NCR copies. The Nursing Discharge Summary is highly regarded by accepting facilities as the most pertinent tool for assisting with maintaining the continuity of care between facilities. It is important that the most current, and updated information be provided on this document.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 316 Effective Date: August 31, 2006 SUBJECT: NURSING PROGRESS NOTES 1. PURPOSE: The Individual depends on the WRP Team to communicate with one another to ensure that the best quality of care is delivered. All of the team members must have the same information about the Individual to ensure an organized and comprehensive plan of care. The clinical record is designed to facilitate care, enhance continuity of care, and help coordinate the treatment and evaluation of the Individual. Progress Notes are used to: a) effectively communicate specific information about the Individuals care, b) avoid fragmentation of care, c) avert unnecessary repetition of tasks, d) prevent therapies from being delayed or omitted, e) insure the interventions are directed toward the Individuals maximum recovery, f) reflect the Individuals status in relation to the desired outcomes, and g) compare the Individuals response with the desired outcomes as defined by the plan of care. 2. POLICY: 1. Nursing notes shall substantiate implementation, interventions, and response to the nursing care and the response to the integrated treatment intervention plan of the WRP team reflecting: a. Changes in the Individuals condition b. The clinical course of treatment, including the outcome and progress or lack of response to care and treatment 2. Psychiatric Technician/Licensed Vocational Nurse Weekly Progress Notes shall be used to document weekly notes. Registered Nurse Progress Note shall be used to document monthly notes (and Weekly note if done by RN on an Acute unit). NOC Shift Notes are written in the IDNs. 2. The PT/LVN Progress and RN Progress notes shall address all opened psychiatric and physical conditions consistent with the Nursing Care Plans including Individuals response to the plan of care. Make reference to the status of health maintenance problems, temporary conditions (TCs), response to prescribed treatment, and prns. Identify pertinent issues, and appointments. 3. Nursing Progress Notes are to be written:

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Type of Note Unit acceptance note for admission to hospital or transfer from another unit Transfer note Daily progress note for Individuals new to the hospital Daily progress note for Individuals transferred to another unit Weekly progress note (starting 7 days after admission)

When Shall Note Be Written Upon arrival

Who Shall Write Note RN and/or PT/LVN

Prior to transfer Every shift for 7 days

RN and/or PT/LVN RN, PT, or LVN

As often as the Individuals behavior warrants

RN, PT, or LVN

Acute: each shift 30 days then weekly thereafter.

PT, LVN or RN

ICF: Weekly for the duration of hospitalization (Begins upon transfer to ICF from Acute) Monthly progress Within the first summary month of hospitalization and monthly thereafter. NOC Shift Monthly Starting with first month PRN Changes in Individuals condition/special observation orders Antibiotic Therapy Weekly and on conclusion of therapy Treatment Plan Whenever Modifications Treatment Plan changed or Discontinued

PT or LVN

RN

RN, PT, or LVN RN, PT, or LVN

RN

RN or LVN

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Discharge Note

Day of discharge

RN, PT, or LVN

RN monthly progress note: SECTION I: BEHAVIORAL SUBSYSTEMS 1. Registered Nurse Progress Note for RN monthly progress recording (and Weekly Note by RN on an Acute unit). Progress note From:_____ To:_____ (documented in IDN). NOC Shift RN use an IDN. 2. Determine the appropriate medical conditions by assessing the Individual, reviewing the current focus of treatment from the team conference, psychiatric technician weekly progress notes, and other WRP team progress notes, and other WRP team progress notes as appropriate. 3. Rate all open problems and medical conditions that have a major impact on treatment. 4. Indicate problem number and describe the behavioral changes or medical conditions in the narrative. SECTION II: OVERALL RATING 1. Indicate previous and current overall behavior and medical conditions. 2. Review and update RAND and acuity to assure consistency with progress note. SECTON III: CARE NEEDS REQUIRED 1. Review care needs required for psychological, emotional, social, spiritual, recreational, skin problems, dietary problems, sleep problems, physical limitations, and elimination problems. 2. Address narrative all care needs required 3. Address in narrative all open temporary conditions, PRN usage, medication changes and any critical lab/consults/evaluations. Address in narrative all other physical problems.Make reference to the status of any health maintenance problems of TCs (Temporary Conditions). 4. The RN/Case Manager should also address the Individuals response to the nursing care plan interventions and progress toward the established WRP team goals. ADL SKILLS: Address in IDN 5. PT/LVN weekly progress note: 1. Psychiatric Technician/Licensed Vocational Nurse Weekly Progress Note) for weekly progress reporting. Indicate the time frame for this progress note Weekly note from ________ to ________ (use IDN). NOC Shift PT/LVN use the IDN . 2. Address in narrative Individuals physical and behavioral responses to the Nursing Care Plan Interventions for all open problems. Make

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reference to the status of any health maintenance problems and Temporary Conditions (TCs) 3. Record the status of all open temporary conditions. Make reference to the status of any health maintenance problems. SECTION II: ADL SKILLS address in IDN Recommendation for writing progress notes: The following information is provided to help nursing services staff with writing the PT Weekly IDN and RN Monthly notes for assigned Individuals. Prior to writing the Weekly Note or RN Monthly progress note, nursing services staff attempt to discern the Individuals perception of their care by discussing with the Individual their current status of the open problems. Include the Individuals input in those areas and the Individuals reaction to the care given, along with staff observations. Use quotes for Individuals verbalizations. Be brief, concise, pertinent, and non-judgmental. Record changes and new observations. Only chart on pertinent behavioral level changes in the Individuals behavior, relationships, and type of interactions with peers, staff, WRP Team, effectiveness of medication, and progress or regression of the Individual observed on a particular shift. The RN will evaluate and document the Individuals progress towards meeting the goals or outcome criteria of the established plan of care. Entries are to be based on objective, measurable information (e.g. Individual punched wall twice this week. This is a reduction of 5 times from the previous week). One of the most important professional functions of the registered nurse is evaluation of the Individuals responses to nursing care as an ongoing part of the nursing process. Documentation needs to reflect that decision-making ability involved with making complex, sophisticated decisions concerning Individual care. Documentation must clearly communicate the nurses judgments and evaluations. The ability to make a difference in the Individual outcomes must be demonstrated in practice and in charting. The monthly summary should provide an overview of the Individuals behavior and physical problems as they relate to the Individuals current treatment plan.

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The RN and the PT/LVN should keep each other appraised of the behavioral and medical issues and interventions, how the Individual care plans are working and/or discuss revision of the plan as needed. Both should be working together on the planning and designing of the Individual care plan. The Individual needs to be included in this planning and evaluation off the effectiveness of the plans whenever possible. LATE ENTRIES: Identify late entries correctly. Late entries result when: Important information should be added to the medical record after progress notes have been completed The medical record is not available for charting at the time the nursing staff needs it The nursing staff forgets to write progress notes on a particular chart. Late entries should not be squeezed into an existing note or placed in the margins. The late entry should not be added in such a way as to appear suspicious. When writing late entries note the reason why the entry is being added to the record. The following approach is recommended: 1. Add the entry to the first line available 2. Label the entry Late Entry to indicate it is out of sequence 3. Record the time and date of the entry 4. In the body of the entry, record the time and date it should have been made.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 317 Effective Date: August 31, 2006 SUBJECT: PAIN MANAGEMENT 1. PURPOSE: This nursing policy will provide guidelines for appropriate assessment, evaluation, and treatment of pain. a. To provide an organized and comprehensive approach for the assessment and management of pain b. To provide support and care for persons experiencing pain c. To reduce the incidence and severity of their pain d. To educate the Individuals about the importance of asking promptly for pain evaluation in order to receive effective treatment (since pain is easier to prevent than to try and control once it becomes intolerable) 2 POLICY: 1. Pain assessment is considered the 5th Vital Sign, and shall be included each time that a Individuals temperature, pulse, respiration and blood pressure (T-P-R, B/P) are assessed and recorded. 2. All Individuals shall be assessed by a Registered Nurse for the presence of pain on admission on the Initial Nursing Assessment, when a significant change in condition has occurred, and/or at least monthly. 3. All nursing staff are responsible for the screening of pain. If during the screening process it is determined the Individual has current pain, or has had pain in the recent past, the Individual will be referred to the Registered Nurse for further assessment. 4. The Registered Nurse shall assess each Individual for pain when screening questions are affirmative for pain, when a significant change in conditions occurs. The Individual may have more than one pain site of pain. Each site will be assessed independently. 5. At the time of admission, all Individuals shall be informed of their rights to have relief from pain. All Individuals will receive information about treatment of pain upon admission to CSH and annually thereafter on a 1:1 basis, or in Therapeutic Community meeting. The Pain Management Brochure will be utilized to assist with this education. 6. Nursing personnel are expected to provide Individual teaching/instruction regarding pain management to assist with gaining Individual cooperation with the procedure and to promote Individual involvement and partnership

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in their treatment. All Individual teaching shall be documented on the Wellness and Recovery Individual/Family Health Education Record. 7. When pain is an identified problem, a nursing care plan will be established. Individualized pain management goals will be identified and regular assessments will take place until the problem is resolved. Pain assessment includes: location, precipitating factors, quality of pain, radiation, severity, timing including onset and duration, character (includes intensity), and frequency, effects of pain assessment should also include other dimensions such as age specific, cultural, psychological and/or spiritual distress. SOAP format will be used to describe the pain management status. 3. GENERAL INFORMATION: Fear and reality of pain are major problems for the Individual and the Individuals family. Pain may arise from actual or potential tissue damage, from disease, trauma or from surgical procedures. Substances released from injured tissues can cause breakdown of body tissue, increased metabolic rate, water retention, blood clotting, and delayed healing (i.e. Individual may not cough due to chest pain or digestive and bowel function may be impaired do to pain). According to the American Pain Society (APS), pain is the most common reason individuals seek medical attention and pain is often under treated. According to the International Association for the Study of Pain, Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage or both. Pain may include a range of physical and mental sensations, such as aching, tightness, numbness, and burning. These sensations may vary in severity, persistence, source, and management. Unrelieved pain can have negative physiological and psychological effects. For example, pain interferes significantly with mobility, sleep, eating, concentration, and social interactions, impairments of activities of daily living, causing anxiety and distress, as is the case with long term hospitalized Individuals. The Nursing Practice Act, Section 2725, states that the registered nurse provides direct and indirect Individual care services that insure the comfort of Individuals. The nursing function of appropriate pain management includes, but is not limited to assessing pain and evaluating response to pain management interventions using a standard pain management scale based on Individual self-report. Each Individual experiences pain in a different way. It is felt that the Individual knows bet about the intensity of this pain an dhow effectively different therapies relieve the pain. There are many important assessment areas staff must check when asking Individuals about their pain. Some people fear that if

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they admit that the pain is increasing, their conditions is worsening. Some Individuals feel that if they admit their pain is being relieved that their pain medication will be stopped and then their pain will return. Other aspects to consider , a Individual with chronic pain may not show severe pain in the way a Individual first experiencing pain might. Also, some cultures teach people to not tell others if they are experiencing pain. Some Individuals and staff have a fear of addiction, tolerance and side effects. Some clinicians have inaccurate and exaggerated concerns about addiction, tolerance, respiratory depression, and other opioid side effects, which lead them to be extremely cautious when using these drugs. Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with psychological dependence (addiction). Addiction is a pattern of compulsive drug use characterized by a continued craving for an opioid and a need to use the opioid fro effects other than pain relief. Tolerance for side effects of opioid medications except for constipation. Any Individual on an opioid medication needs to have a bowel care plan in place. 4. DEFINITIONS: Pain can be classified as either acute or chronic, acute pain is usually causes by an injury and lasts less than six months. Chronic pain is a persistent pain state existing beyond an expected time for healing, usually lasting six months or longer. Acute pain is the normal, predicated physiological response to an adverse chemical, thermal, or mechanical stimulus and is associated with surgery, trauma, and acute illness. It is generally time-limited and is responsive to opioid therapy, among other therapies. Chronic pain requires a comprehensive treatment; relying on the adequacy of past and present pain treatment geared toward treatment planning. It includes assessment of physiological, sensory, affective, cognitive, behavioral and sociocultural components. Pain Management is comprehensive, Wellness and Recovery approach to care for the needs of a Individual in acute, chronic, or cancer pain. When clinicians consistently observe a disparity between Individuals verbal selfreport of their pain and their ability to function, further assessment should be performed to ascertain the reason for the disparity. Severe pain should be considered a medical emergency, and timely aggressive management should be provided until the pain becomes tolerable. Pain Assessment:

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Pain screening assessment is now required as a fifth vital sign and is to be assessed at the same time as other vital signs are taken. Pain is to be assessed and treated promptly, effectively, and for as long as the pain persists. Pain assessment is performed in a manner that is appropriate to the Individual. The pain assessment shall be noted in the Individuals chart in a manner consistent with other vital signs. The Individual has the right to appropriate pain assessment and management. The Individuals self-assessment of his or her pain is included in the pain assessment and/or reassessments. ATTATCHMENT A PAIN ASSESSMENT GUIDELINES provides the pain management process of action steps to take when there is no pain, pain rating level 1-4, pain 5 or greater, and ongoing, chronic pain. Use of a pain scale lets the Individual describe pain in a way that is meaningful to the Individual. Some Individuals respond best to word scales; others find that pictures or number scales help them describe their pain intensity accurately. The scale helps the Individual quantify their current levels of pain. Pain assessment scales on a 1-10 scale are provided for standardized use. Pain scales used at CSH are the Nonverbal/Descriptive Pain Scale, Numeric Rating Scale, Wong-Baker FACES Scale, and the Visual Analog Scale. (SEE ATTACHMENT B Pain Scales) The Wong-Baker FACES Scales is most particularly used on the hearing impaired u nit. It is best used for cognitively impaired Individuals and those with limited language skills. Pain intensity rating scales: Non-Verbal/Descriptive Pain Scale Rating 0 2 4 6 8 10 Observations No signs of pain. Relaxed, calm expression Least pain. Stressed, tense expressions; Only aware of pain when thinking about it Mild pain. Guarded movement, grimacing; Can be ignored somewhat. Does not interfere with daily activities Moderate pain. Moaning, restless; Able to continue with some physical activity. Serious. Increased intensity of above behavior; Cant concentrate and can only do simple things. Excruciating-Perspiration on upper lip/body; Cannot function. Must take care of pain

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Numeric Rating Scale

0 1 No Pain

10 Worst Possible Pain

WHEN IS PAIN SCREENED and/or ASSESSED? Whenever staff take a set of vital signs (blood pressure, temperature, pulse, respirations) the Individuals physical pain level must be established When the Individual verbalizes having pain and/or when staff observe the Individual is in distress When pain medication is given, a pain rating is obtained before the PRN is given, within one hour after the PRN medication was given, and follow-up rating two hours after the medication. Appropriate follow-up action is needed if pain persists. When the Individual sustains an injury After surgery or dental extraction Monthly weights and vital signs Individual being prepared for Sick Call or to be seen by the MOD All health care staff are required to record pain screening results each time vital signs are recorded for each Individual. Using the zero to ten pain screening scale, if a Individual develops or complains of new pain (pain rating 1-4) the Registered Nurse will assess the Individual using the seven dimensions of pain assessment, document using SOAP format and notifies a physician. (See ATTACHMENT C for SOAP not writing criteria). The SOAP Note format is designed to guide the RN to evaluate the seven dimensions of pain assessment. SUBJECTIVE - provides for the Individuals self-report of pain from their perspective and perception using the seven dimensions Using the PQRST or OLD CART acronym focuses on the dimensions of pain evaluation. LOCATION of pain: Individual identifies where the pain is located

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PRECIPITATING Factors: any factors that relieve or aggravate the pain; quote Individual directly. Record their perception of whether medications or treatments have been effective. QUALITY of pain: What does the pain feel like? RADIATION of pain: Does the pain radiate to other parts of the body? SEVERITY of pain: Have the Individual evaluate the intensity of their pain by showing the Individual pain rating scales (1-10). TIMING of pain: onset, duration EFFECTS of pain on Individuals functioning: Individual identify effects of pain on daily functioning, daily activities OBJECTIVE = Observed physical responses to pain by staff, set of Vital Signs; assessment of physical pain site; physical symptoms observed psychosocial, cultural, or age-specific responses to pain; affect/mood/behavior. ASSESSMENT = Area of pain; baseline of behavior that seems to indicate pain PLAN = Action steps taken; physician notification; nursing care plan initiation if not open, or review/update current care plan; change of shift report; ID Team notification; provide summation for the Treatment Planning Conference Report. If a Individual develops or complains of new pain (pain rating 5 or greater) or if he or she is being treated for ongoing acute or chronic pain but it is not controlled, the RN will initiate the Registered Nurse PAIN EVALUATION tool CSH 7315 (SEE ATTACHMENT D) and notify the physician. Place evaluation in IDN sequence. Provide NCR copy for physician. Explore these points with the Individual: (Utilize the Pain Assessment Descriptive Prompts tool to assist with the pertinent descriptions. See ATTACHMENT E) Does the pain have a pattern? If so, does it vary? When was the pain most intense in the past 24 hours? Does anything relieve the pain or make it worse? Does the Individual take pain medication to manage the pain? If so, is it effective? Does it cause any unpleasant adverse reactions? Does the pain interfere with your daily activities: for example, sleeping or eating?

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Identify the Individuals acceptable level of pain. Utilize the Pain Management Flow Sheet CSH 7317 (SEE ATTACHMENT F) to document the non-pharmacological and/or pharmacological intervention(s). Identify the pain rating prior to giving medication or providing treatment(s). Evaluate the pain rating one-hour after and then again two-hours after the medication or treatment(s). Notify the physician if the pain rating remains above Individuals acceptable rating. The Individual is encouraged to be a part of their treatment. Provide the Individual the Personal Pain Control Record (SEE ATTACHMENT G). With this document, Individual is able to monitor the effectiveness of their pain medications and/or treatment(s). ASSESSING NON-VERBAL INDIVIDUALS: Although nothing is more reliable than the Individuals self-report of pain, nursing staff must rely on other information if the Individual cannot use a painrating scale. If, for example the Individual has a painful condition, or has undergone a painful procedure, nursing staff my have enough information to justify administering analgesics. Other pain indicators include: Distressed facial expressions and behavior- frowning, grimacing, crying, and expressions of fear or sadness. Look for muscle contraction around the mouth and eyes. Unusual movements (such as restlessness or slow, guarded, or rigid movements) or the absence of movement Attention-seeking behavior, such as repetitive banding or outbursts Vocalizations, such as groaning, moaning, crying, or noisy breathing. First, try to determine a baseline of behavior that seems to indicate pain. Evaluate changes in behavior after administration of an analgesic. After giving pain medication, evaluate the Individuals response in 30 to 60 minutes (depending on the drug and administration route) and follow-up again in two hours. Cultural aspects of pain management: Be sensitive to age-specific and culturally appropriate assessments. Keep in mind that cultural mores and personal values can affect the Individuals beliefs about pain and response to pain. Even if the Individual bears pain stoically, the Individual may admit to having pain if you ask the Individual directly, so always ask, and believe what he or she says. The Individuals self-

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report is the most accurate indicator of the existence and intensity of pain. Dont second-guess your Individual or assume that he or she is exaggerating because he or she is laughing or sleeping. Culture is the framework that directs human behavior in a given situation. The meaning and expression of pain and influenced by peoples cultural background. Pain is not just a physiologic response to tissue damage but also includes emotional and behavioral responses based on an individuals past experiences and perceptions of pain. Not everyone in every culture conforms to a set of expected behaviors or beliefs, so cultural stereotyping (assuming a person will be stoic or very expressive about pain) can lead to inadequate assessment and treatment of pain. Many studies have shown that Individual from minority groups and cultures different from that of health care professionals treating them receive inadequate pain management. Healthcare professionals need to be aware of their own values and perceptions as they affect how they evaluate the Individuals response to pain and ultimately how pain is treated. Even subtle cultural and individual differences, particularly in nonverbal, spoken, and written language between healthcare providers and Individuals impact care. To be culturally competent, you must: Be aware of your own cultural and family values Be aware of your personal biases and assumptions about people with different values than yours Be aware and accept cultural differences between yourself and Individuals Understand the dynamics of the difference Adapt to, and respect diversity You must Listen with empathy to the Individuals perception of their pain. Explain you perception of the pain problem. Acknowledge the differences and similarities in perceptions, Recommend treatment, and Negotiate agreement. Questions that staff can use to help assess cultural differences in order to better assess and work out an appropriate pain management plan with a Individual include: What do you call your pain? Do you have a name for it? What do you think caused your [pain]? Why do you think it started when it did? What does your [pain] do for you? How severe is your [pain]? Will it have a long or short course? What are the most important results you hope to receive from the treatment? What are the main problems your [pain] has caused you? What do you fear most about your [pain]?

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Individual teaching key points: Help the Individual to understand why effective pain management is important and how uncontrolled pain can hamper recovery. Be open and flexible when assessing and planning for Individual (AND FAMILY IF APPROPRIATE) teaching and teach on the Individuals level. Consider his or her values and beliefs, culture, literacy, education level, language, emotional barriers to pain, relief, physical and cognitive function and limitations. Assess the Individuals level of comprehension and retention, and plan followup teaching sessions as appropriate. Document testing and the Individuals response to teaching in the IDN. Staff teaching key points: An overview of pain management will be provided during New Employee Orientation and WorkSite orientation to the policies and procedures for pain management. Updates and training awareness programs will be provide during National Pain Awareness Week (last week of February/first week of March).

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 318 Effective Date: August 31, 2006 SUBJECT: INDIVIDUAL TRANSFER, ACCEPTANCE, AND/OR DISCHARGE NOTE 1. PURPOSE: The Individual Transfer, Acceptance, and/or Discharge Note is utilized to clearly delineate, identify, and document Individual movement within this facility to another unit, or movement from, or to, another facility. 2. POLICY: Transfer Note: 1. When transferring any Individual, a Nursing Transfer Note shall be done by a licensed nursing staff member (RN/Case Manager or PT/Counselor). The note shall be documented on the Wellness and Recovery Note (IDN) with overprint Transfer Note identified as blue in color on the day of transfer. 2. The note shall be identified and labeled as TRANSFER NOTE 3. The Transfer note serves as a communication tool between the units to assist with maintaining continuity of Individual care. The note shall contain at least the following: -Pertinent Individual identification information and reason for transfer -Current psychiatric behavior -Current medical status -Summary of Individuals nursing care status, including the nursing care being provided as outlined on the nursing care plan(s) Identify nursing interventions that have been helpful for this Individuals problems as identified on the Physical Profile and Psychiatric Problem list -Identify current ALERTS, RISKS including precursor events that may trigger the behavior -Indicate issues needing follow-up by the accepting unit or facility, e.g. blood tests to be drawn, significant lab results, appointments, PPD reading, teaching or instruction, equipment needs -Provide recommendations and instruction for continuing care of the Individual -Whether or not the Individual is being transferred with medication, property, ect -Indicate the transferring and receiving units level of care. Make an entry below the transfer notation as show in the example below:

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Date 3-4-05

Time 1420

Prob. No. 0

Transfer from Unit 1 to Unit 2

3. POLICY: Unit Acceptance Note For A Transferred Individual: 1. A Unite acceptance note: shall be done by a licensed nursing staff member (RN/Case Manager or PT/Counselor). The note shall be documented within the Wellness and Recovery Note (IDN) with overprint Unit acceptance note for a transferred Individual identified as pink in color as soon as practical after the Individual has been admitted to the unit. 2. The note shall be labeled as UNIT ACCEPTANCE NOTE FOR A TRANSFERRED INDIVIDUAL. 3. The unit acceptance note shall contain, but not limited to: -Statement indicating the Individual has been received and orientated to the unit -All clinically pertinent information has been reviewed -A statement that risks & precautions have been reviewed and brought to the attention of the Psychiatrist or MOD ( if appropriate) Discharge Note: 1. A Discharge Note shall be done by a licensed nursing staff member RN/Case Manager. The note shall be documented on the Wellness and Recovery Note (IDN) NURSING DISCHARGE SUMMARY on the day of discharge. 2. The note shall be labeled as NURSING DISCHARGE SUMMARY 3. The discharge summary shall contain, but not be limited to: -Statement of the Individuals status and condition at time of discharge -Specific discharge instructions given to Individual, family, and or accepting facility. Include follow up care and available resources as applicable. -To whom the Individual is being discharged -Statement identifying Individuals understanding of the discharge instructions and/or interventions utilized to assist Individual with understanding the instructions -If personal property, funds, and medication was given. 4. A yellow copy of the Discharge Instructions shall be provided to the Individual, family, or escort in an envelope.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 319 Effective Date: August 31, 2006 SUBJECT: PROTECTIVE MECHANICAL SUPPORT DEVICES 1. PURPOSE: To provide guidelines for the application of various types of mechanical support devices, while preserving human dignity and promoting a safe environment for individuals and staff. 2. POLICY: 1. Protective Mechanical Support Devices (PMSD) shall only be used when ordered by a physician 2. Protective Mechanical Support shall only be used in such a way as not to cause physical injury and insure the least possible discomfort to the individual 3. Protective Mechanical Support shall be applied in a manner such that they can be readily removed in case of fire or other emergencies. 4. Protective Mechanical Support shall not be used as a substitute for more effective medical and nursing care for the convenience of staff 5. Protective Mechanical Support shall be keyed to either a physical problem on the Physical Treatment Profile or to an identified Temporary Condition (TC) 6. Protective Mechanical Support may be used as ordered for the protection of individuals during treatment and/or diagnostic procedures 7. Each physicians order for Protective Mechanical Support shall include the following: a. The length of time that the protective mechanical support device(s) are to be used (not to exceed 45 days, depending on the needs of the individual) b. Either the problem number from the Physical Treatment Profile, or TC c. The type of protective mechanical support device to be used d. The body part to be supported/restrained e. The reason for the application of the PMSD f. The duration of the application (not to exceed 110 minutes followed by 10 minutes release for exercise, range of motion, personal needs, ect) 8. If the Protective Mechanical Support is ordered for 45 days, the monthly physicians progress note shall include justification for the continued use

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9. Upon initial placement of Protective Mechanical Support nursing observation and documentation shall include but not be limited to: a. Date, time and type of PMSD being applied b. Description of status of the affected body part(s) at the time of application c. Signature and title of staff person applying the PMSD 10. When Protective Mechanical Support is used for clinical reasons other than for treatment procedures (e.g. blood draw, insertion of catheter, ect), a nursing care plane shall be written (see Nursing Policy Nursing Care Plans). When Protective Mechanical Support is utilized for treatment procedures, keyed to a T.C. the nursing care plan shall be written in the S.O.A.P. note format 3. TYPES OF MECHANICAL SUPPORT DEVICES: The following mechanical support devices are available from Central Supply: -Body Holder -Limb Holder -Posey Belt -Wheel Chair safety belt (2 types, sizes) -Sleeved Jacket -Security Wrist Restraint -Ventilated Heel Protector -Leather Cuffs and Belt Restraints (for 5-Point, Wrist-to-Waist, & Ankles) 4. DEFINITIONS: POSTURAL SUPPORTS: Postural Supports are a method other than orthopedic braces used to assist individuals to achieve proper body position and balance. Postural Supports may include soft ties, wheel chair seat belts, Posey Belt, or Body Holder. Postural Supports shall only be used to improve individuals mobility, independent functioning, or prevent individual from falling out of bed/chair, or to achieve appropriate positioning and body alignment, rather than restrict movement. MEDICAL SUPPORTS: Medical supports are an intervention used to protect individuals from undergoing treatment and/or diagnostic procedures (e.g. intravenous therapy or tube feeding) or to protect the individual who is infirm, sedated, or markedly confused secondary to cognitive or neurological impairment. Types of medical treatment or diagnostic restraint devices may include soft ties, Posey belts, Posey mittens, Helmets, arm splints, or leather cuffs and belts. 5. PROCEDURE:

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NURSING ACTION : A. Obtain physician order for type of mechanical supportive device to be used B. Obtain appropriate device from Central Supply C. Explain procedure and reason for use of mechanical support device to the individual D. Apply device

KEY POINTS: A. Ensure that order contains all required components.

C. To alleviate apprehension and ensure cooperation of the individual D. Ensure that device does not restrict circulation, cause pain/discomfort, or unnecessarily restrict movement E. Follow guidelines in Policy section of this policy and Nursing Policy Nursing Progress Notes F. Follow guidelines in Policy section of this policy and Nursing Policy Nursing Care Plans

E. Document condition of body part prior to application of device, where applied, duration of application ect. F. If the mechanical support device is to be used for other than a diagnostic/medical procedure (i.e. Postural Supports), complete Nursing Care Plan G. Remove device as indicated in physicians order. Long-term mechanical supports should be removed per policy for range of motion and circulation checks H. When mechanical support device(s) are no longer necessary, or if device becomes soiled, contact Central Supply for all appropriate cleaning, and/or return/replacement procedure I. Nursing staff shall ensure all mechanical support devices are used to appropriately, for the purpose ordered by the physician, and are kept secure at al times

G. Document skin condition, circulation, ect, observations for each removal. If adverse conditions exist, notify Registered Nurse and physician immediately H. Ensure that returnable devices are appropriately and promptly returned to Central Supply.

I. Unused mechanical support devices shall be appropriately cleaned, disinfected, and kept in a secure location when not in use

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N.P.P No. 319

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 320 Effective Date: August 31, 2006

SUBJECT: SAFETY, SECURITY, AND SUPERVISION OF INDIVIDUALS, VISITORS, AND THE ENVIRONMENT 1. PURPOSE: This policy will provide appropriate guidelines to promote twenty-four hour safety, security, and supervision. This policy will also ensure nursing staff awareness of their responsibility for the safety practices for individuals, staff, and visitors. 2. POLICY: 1. Basic supervision of individuals shall be a concern of all nursing employees, regardless of assignment 2. All nursing staff have a responsibility for the safety of individuals and staff in their work area 3. Nursing staff shall be aware and abide by the safety practices outlined in Administrative Directives, Infection Control Manual, and the Safety Program Manual 4. Nursing staff shall provide continuous supervision of individuals: A. While courtyards are open B. While in possession of sharps, shavers, and restricted or controlled items In addition the employee will be close enough to intervene in case of an emergency (refer to A.D. Supervision of Individuals 5. Within the parameters of safety and security required for CSH, each individual has a right to privacy in his sleeping room unless clinically contraindicated. 6. Nursing staff shall conduct inspections in all high-risk areas every 15 minutes 7. Nursing staff shall conduct fire, life, health and safety checks on all treatment units every 30 minutes (refer to A.D. Supervision of Individuals) 8. As part of the Change of Shift procedure there will be an environment check conducted by the oncoming and departing Shift Leads or designees which will include a physical walk through of the unit; a check of all individuals to ensure that they are not in distress; a check of individuals in seclusion or restraints; a check of all rooms, sharps, tools.

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9. All nursing staff are responsible for providing a safe environment for individuals and reporting any and all safety hazards. 10. Nursing staff when identifying problems, shall immediately notify the supervisor/Shift Lead of those findings 11. Individuals exhibiting unusual signs of behavior shall be reported to the Shift Lead and to a Registered Nurse who will assess and when indicated reported immediately to the physician. 12. Should closer nursing observations be required e.g. vital signs with pain rating assessment, neuron check, ect. the Registered Nurse shall report the individuals nursing care needs to the Shift Lead with specific instructions as to type of observation indicated and frequency of interventions needed. The Shift Lead in collaboration with the RN will then make a written assignment based on the individual care needs for that day. If condition is temporary, then specific instructions shall be in the I.D. notes labeled as temporary condition,(e.g. SOAP Note format) If condition is likely to last longer than 10 days then a specific nursing care plan with nursing interventions shall be made based on the assessed needs of the individual 3. COMPETENCY/TRAINING: 1. All new nursing staff shall attend New Employee Orientation. On-site orientation shall be provided upon assignment to the Program (refer to A.D. Orientation/Mandated Training). Specific on-site orientation shall include but not limited to: Location of Emergency Preparedness Manual Location of Material Safety Data Sheet (MSDS) Manual or MSDS specific to the work site Hazardous Material within the work site Illness & Injury Prevention Program (IIPP) Individual Safety Plan Location of CSH hospital administrative and policy manuals: Administrative Directives, Nursing Policy and Procedure Manual, Infection Control Manual, Pharmacy and Therapeutics Manual, Emergency Preparedness Manual Unit resource books Sharps/tool and contraband procedures Emergency equipment location and procedures Fire watch procedures Plasticware counting procedures Disposal and handling of syringes, needles, and lancets Employee Assistance Alarms Mechanical and electrical equipment within the work site -2N.P.P No. 320

Evacuation Plan Location of Safety bulletin Boards The Work-Site Safety Representative Key Control Suicide Precautions and Seclusion or Restraint protocols and expectations Role and duties of employees assigned to 1:1 observation Med Room orientation and competency evaluation 2. Staff assigned to perform supervision or environmental inspections shall have documented evidence of appropriate orientation prior to assignment. 4. EMPLOYEE EXPECTATIONS FOR INDIVIDUAL SAFETY AND SECURITY 1. Formal counts of all individuals shall be made each day at 0230, 0600, 1145, 1615, and 2145 hours. Count Slips shall be used to document this count (refer to A.D. Individual Counts). 2. Random searches, searches for cause, and Team Search searches (refer to A.D. # 15.18 Search/Seizure Policy and Procedures) will be conducted as necessary in an effort to eliminate contraband, unauthorized items, and to provide a safe and therapeutic environment. 3. All placticware will be counted prior to individuals entering the Dining Room for meals and prior to them leaving (refer to NP&P # xxv Storage and Handling of Plasticware) 4. All individuals shall be in direct line of sight while in possession of sharps, shavers, and all other restricted items. 5. Items allowed in individual possession will no impede the safety of others (A.D. 15.16 Individual Allowable Items/Contraband) 6. Each Grounds Presence Team will be responsible for checking the grounds prior to being opened for use and after they close as well as being alert for unsafe conditions while making rounds (A.D. # 15.22 Grounds Presence) 7. The primary emphasis in behavior management shall be on the use of positive measures to promote socially desirable behavior. All efforts shall be made to protect the individual from harming themselves or others. 8. During the admission procedure and at each Team Conference, all individuals shall be evaluated and placed in a suicide risk category by the physician. 9. For all individual assaults the physician/MOD and NOD are notified. Upon receiving a Special Incident Report number for the incident, the staff member shall also notify the Department of Corrections Watch Office (Ext. 7781) and the Standards Compliance Office (Ext. 7407) of the incident and identify the SIR # assigned to the incident. The Special Investigator shall be notified for acts of aggression and/or assaults. The NOD or HPO shall be notified for injury photos. 10. Standard Precautions shall be used for all individuals care (A.D. Standard Precautions)

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11. Stairs are to be well lighted and free from clutter

5. PROCEDURE: Basic individual observation: NURSING ACTION 1. Staff assigned basic individual observation are to observe for unusual behaviors and assure individuals are free of physical distress. Observe all sleeping individuals to make sure they are breathing. View skin to assure individual is present. 2. Document unusual behaviors in the ID notes and notify the Shift Lead/designee, Registered Nurse, and attending physician as appropriate. KEY POINTS 1. Use of bed board, RAND, or some other form of personal recognition should individually identify all individuals. Observation at night should be made in pairs to assure employee safety. Accomplish observation with the least amount of disruption as possible to clients. 2. Should closer observation be required, the RN must assess and provide instructions as to the observations required. The Shift Lead/designee will them make written assignments based on the client care needs for that shift.

Environmental safety: NURSING ACTION KEY POINTS 1. Conduct change of shift rounds with 1. Check all individuals, rooms, oncoming and departing shift sharps, tools, equipment and other leads/designees. items that my pose a potential danger or hazard to staff or clients. Check courtyard before and after use. Document checks in units Daybook. 2. Make environmental/safety rounds 2. See guidelines for Change of Shift every 15 minutes in high-risk areas and and rounds in A.D. every 30 minutes in other areas to which individuals have access

6. GENERAL SAFETY: 1. Each first-line supervisor will make daily informal inspections. This should be a quick walk-around with visual inspection to ensure there are no obvious hazards in the work area. Hazards detected should be corrected by assigned personnel or by initiating a Plant Operations Work Order Request when necessary (refer to A.D. 18.3 Safety Program)

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2. Nursing staff shall be particularly alert to and clean up any liquid spills that could cause slips or falls; or pick up loose items such as paperclips, pencils, ect., that could be used for contraband activity by the individual. 3. Nursing staff shall be alert for and report to the supervisor/Shift Lead broken furniture or equipment, frayed electrical cords, ect. the Shift Lead shall initiate a Work Order Request Visitor safety: 1. Visiting of individuals is under the directions and supervision of the Department of Corrections (refer to A.D. Visiting of Individuals) a. Nursing staff provides supervision during Childrens Visiting on Saturdays Childrens Visiting is permitted only by pre-approved authorization by the ID Team and will be supervised by using staff on a 1:1 ratio No physical contact between individuals and children will be permitted unless approved by the ID Team b. No money or property may be exchanged between visitors and individuals in the Visiting Centers c. All individuals are subject to search by the Department of Corrections when leaving the Visiting Center if contraband is suspected. 2. SUPERVISION OF CHILDRESNS VISITS (16 and Under) CSH EXPECTATIONS OF NURSING STAFF The Duty of the staff assigned to Childrens Visits is to insure children safety. CSH Nursing staff upon arrival to supervise Childrens Visits are to check with the Department of Corrections staff. Identify your assignment. Sign-in and identify your unit number Childrens Visits Types: Regular Childrens Visit is permitted by pre-approved authorization of the ID Team and is supervised by CSH staff on Saturday afternoons from 1300-1600. Special Childrens Visit is permitted by pre-approved authorization of the ID Team and requires supervision by CSH staff on a 1:1 ration. The 1:1 assigned on a Saturday all-day visit is required for the morning from 08001100 hours only. Once the afternoon Regular Childrens visiting starts, the assigned staff takeover unless the individual has a current physician order for enhanced supervision.

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No physical contact between individuals and children will be permitted unless approved by the ID Team. (Confirmation will be verified on a Special Visitation Request form). -No money or property may be exchanged between visitors and individuals in the Visiting Center -You are expected to be alert, cognizant, and observant to all individual and visitor movements and activities -Be visible to the visitors and individual(s) -You are not to be occupied with other activities that will take your attention away from safeguarding the participants. You are not to take or have any reading materials with you in the Visiting Center. You are not to be reading while on duty. -Do not socialize with other staff -Department of Corrections staff has overall responsibility for the activities of the Visiting Center -Inform the Correctional Officer if you need to leave the area (e.g. restroom break) -Take immediate action to prevent any inappropriate, dangerous, suspicious behavior or activity and then report to Department of Corrections Staff. (Alert Shift Lead of unit so that the individuals Treatment Team can be alerted for follow-up) -On Saturdays, as the oncoming nursing staff for afternoon Regular Childrens Visits arrives, notify the oncoming staff of any concerns or suspicious behavior. 3. To reduce the possibility of spreading infection between individuals and visitors, visitors are asked to notify the Visiting Room if they have an infection that could spread to the individual. a. Visitors with a contagious disease are not allowed to enter the Visiting Center b. Individuals in isolation shall not see visitors at the Visiting Center c. Approved visits shall take place in the Isolation Room under nursing supervision. Visitors shall follow all isolation precautions as instructed by nursing staff. 7. ATTACHMENT: Attachment #1 Guidelines for Change of Shift and Rounds

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 321 Effective Date: August 31, 2006

SUBJECT: SPECIAL INCIDENT REPORT 1. PURPOSE: 1. To outline the procedures to be used in making Special Incident Reports and define what constitutes a special incident and/or Headquarters reportable incident 2. To report and document events that have an adverse affect on safety, care, treatment, and rehabilitation of individuals served by the hospital. 3. To monitor the appropriateness and effectiveness of follow-up actions to minimize and/or prevent a recurrence of similar incidents. 4. To provide data analysis for continuous quality improvement activities. 2. POLICY: 1. A Special Incident Report (SIR) shall be completed for: a. Any occurrence which is either physically or psychologically harmful to Individual(s) b. Any occurrence which is inconsistent with the Individuals expected behavior conditions c. An occurrence which adversely affects or has the potential of adversely affecting the operations of the hospital d. All medication errors (refer to NPM Medication Errors) e. Whenever a Individual is placed in seclusion and/or any form of restraints f. Elder and Dependant Adult Abuse (see Special Order # 701 outlining the procedures for staff to follow when reporting instances of observed or suspected elder or dependent adult abuse) g. Child abuse (There is no Statute of Limitations on the requirements to report child abuse) h. Communicable diseases i. Unusual occurrences 2. A Special Incident Report (SIR) is to be initiated by the employee who witnesses, discovers, or who has fist hand knowledge of the incident (referred to as the reporting employee). This person is responsible for initiating the SIR, completing the Wellness and Recovery (IDN) note. 3. An immediate assessment of the Individual shall be made as clinically indicated by a Registered Nurse

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4. Both the RN and Shift lead/designee with be responsible for insuring the physician/MOD and NOD are promptly notified and will insure all components and requirements for the SIR occurrence are dealt with in an expedient manner. 5. The Unit Supervisor/Shift Lead will insure the SIR is written in an objective Legible, coherent manner and that the necessary components of writing an SIR are addressed. The Unit Supervisor/Shift Lead may request that the staff member rewrite the SIR if the document fails to read in a legible, coherent manner and/or lacks the necessary information required. 6. Whenever an assault occurs, unit staff shall call the Special Investigator (see page When to notify the Special Investigator) and notify the Department of Corrections Watch Sergeant. The NOD will take pictures of all significant injuries. 7. the NOD will reflect the SIR # in the HSS 24-Hour Report and provide a brief description of the incident. 8. The CNS Office will be notified of all SIRs and will assign a SIR Tracking number 9. The original copy of Special Incident report shall be reviewed by the Unit Physician and Program Management then forwarded to the CNS Office no later than three (3) working days after the date of the incident 10. Headquarters Reportable Incidents must be forwarded to the Executive Directors office within 24 hours of the incident. If the incident occurs on a weekend or holiday the SIR shall be delivered to the Executive Directors office on the regular workday. 11. Copies of all SIRs dealing with alleged Individual abuse will be forwarded to the Special Investigator. 12. A Post-Incident Critique will be conducted for each incident involving MAB physical intervention. The recording of the Post Incident Critique is no longer done in the ID note but needs to be recorded on the reverse side of the SIR at the LEVEL 1 Review 3. DEFINITIONS: Special Incident - Any occurrence that is potentially or actually physically and/or psychologically harmful to a Individual and/or is inconsistent with the Individuals expected behavior, condition, treatment, or care plan Any occurrence or attending circumstances which adversely affects or ahs the potential of adversely affecting Individual health, safety, well being, and/or the operation of the hospital which may, or may not, be Individualrelated. Headquarters Reportable Special Incident (Refer to A.D. # 2.09 and Special Order # 227.01)

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Any special incident, which creates significant health hazard, puts Individuals health and safety in immediate jeopardy, or creates significant problems to Hospital operation. Any matter of public concern, of interest to the news media, to the Legislature for pending legislation, or of sufficient concern to warrant the attention of Headquarters officials. Headquarter Reportable Sirs: 1. Injuries which require hospitalization a. Only employee injuries, which are of very serious nature, e.g. loss f limb, life, ect, shall be reported to DMH Headquarters 2. Property damage in excess of $500 3. Any successful unauthorized absence/escape of any Individual a. Special circumstances include other Unauthorized Absence (UA) attempts which put the Individual or Hospital personnel in significant jeopardy, which creates significant problems in Hospital operation, or which creates significant concern to warrant the attention of Headquarters officials. 4. Contraband when contraband involves staff, weapons, or illegal substances 5. Sexual incidents which are achieved by force, threat, or exploitation, or when the incident involves a staff member 6. Alleged or suspected Individual abuse and/or neglected by Hospital employees, service providers, or any other persons 7. Denial of any rights, as specified in the Welfare and Institutions Code, Section 5325, not justified by good cause, shall be reported 8. Pregnancies of Individuals if conception is alleged to have occurred in the Hospitals buildings or on the Hospital grounds 9. Births to Individuals 10. Outbreaks of, or undue prevalence of, any communicable disease per Public Health Office guidelines 11. Medication errors or adverse drug reactions that necessitate a Individual transfer to a higher level of care 12. Complaints made by a Individual family, conservator, guardian, or other interested person, which raise questions about the Individuals health, safety, well being, or treatment program 13. Loss or theft of valuable Individual property and incidents involving Individuals funds 14. Internal labor strife and civil rights demonstrations 15. Major fires, floods, bomb threats, or any other events or conditions which threaten or are a danger to Individuals or staff, cause damage to structures, or are serious deterrents to the effective operation of the hospital 16. Unusual or unexpected Individual deaths

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4. GENERAL INFORMATION: An incident is any event that is not consistent with the routine of the unit or routine care of a Individual. The Individual or staff may be at risk when anything unusual occurs in a health care area. Examples of incidents include Individual falls, accidental needle-stick injuries, medication administration errors, accidental deletion of ordered therapies, and carelessness in performance of a procedure that leads to injury or a potential risk for Individuals injury. Reporting of incidents helps the identification of high-risk trends in nursing care or daily unit operations that warrant correction. Incident reports are an important part of a units quality improvement program. It is used for monitoring and tracking. When an incident occurs, the nursing staff involved in the incident or the staff member who witnessed the occurrence completes the incident report. The report is completed even though an injury does not occur or is not apparent. The nursing staff member observing the incident will take steps to remove the individual from risk and write the report describing details of the incident. A physician will examine the individual to determine whether an injury has been sustained. The nursing member documents only an objective description of what happened and follow-up care that occurred. Documentation on the Special Incident Report should be clear, concise, and legible. Printing legibly prevents misinterpretation. Accurate and complete description of what had occurred also assists the staff to develop a baseline of the Individuals behavior, will assist in determining antecedents, help alert staff to patterns, and promotes future planning and protection of Individual, care, environment, and security issues. The following questions should be answered in documenting Special Incident Report Checklist: Answer all the following questions: WHO? WHAT? WHEN? WHERE? HOW? WHO? Are all the individuals directly involved in the incident accurately identified? Individual(s), staff, visitors involved; how many staff members were required to assist; witnesses Who committed the incident? Who was involved in the incident? Who was the victim? Who discovered the incident? Who wrote the report?

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 WHAT? Is there an accurate description of what happened during the incident? Exactly what occurred; include Individuals statements as well as actions. Was there property damage, injuries? Was there a clear and present danger? What happened? What objects were used during the incident? What time did the incident occur? What contraband was used during the incident? What injuries occurred? What first aid or treatment was administered to the injuries? What immediate actions did staff take? What further actions or follow-up was required? WHEN? Are the time(s) and date(s) included? Record time per 24-Hour clock and also record general activity milieu where incident occurred, e.g. before breakfast, after visitor left, ect. When did the incident occur? When was the incident discovered? When were the appropriate parties notified? WHERE? Is the location of the incident and the immediate area adequately described? Identify the specific location and any additional circumstances, e.g. dim lighting, wet floor, secluded area, ect. Where did the incident occur? Where were the items used in the incident discovered? Where were the items used in the incident obtained? HOW? Is there a description of how the incident stared, progressed, and ended? Address how incident took place in a sequential event, step by step manner. (e.g. Individual A hit Individual B with right fist. Individual A yelled Stop messing with me at Individual B, ect). How did staff intervene? Use common terminology, e.g. redirection, active listening, ect. WHY? Review incident. Talk with Individual and staff to determine activating event or action; note contributing factors, e.g. loud noise, hectic milieu, ect. An SIR should be written in common ordinary language and limited to what has been directly observed, rather than inferred! 1. Indicate who was notified e.g. NOD, MD, PMOC, SSI, CDC, ACNS, POD. 2. The name of all involved Individual(s) shall be used on the SIR. However, you may not use their names in the I.D. notes. Use only CSH number for identification in the I.D. Notes. DO NOT label I.D. Notes as Special Incident Report.

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3. The Unit Supervisor/Shift Lead or designee is responsible for insuring that the incident has been assessed by a Registered Nurse as indicated, brought to the attention of the physician for comments and signature when applicable, the HSS is notified of all SIRs, and that significant occurrences are immediately reported to Program Management/POD. 4. The Unit Supervisor or designee shall check for completeness, approved coding, and that adequate information is provided to describe the incident. The Unit Supervisor/designee will forward the SIR to the Designated Program Management person immediately after review by the physician. 5. The investigation/finding(s) portion of the form (reverse side) shall be completed by the Program Director or designee and forwarded to the CNS Office no later than three (3) working days after the date of the incident. Guidelines for Filling out A Special Incident Report: The Special Incident Report (MH 2506) is used. This form has been printed on NCR paper to reduce charting, so exert enough pressure when writing. The staff member, who witnessed the incident, finds the error, or who found the Individual at the time of the incident files the report prior to the end of his or her shift. The staff member describes specifically what happened in concise, objective terms. Do not interpret or attempt to explain the cause of the incident. Do not state the Individual punched the staff member as he was delusional or was suffering from some mental disorder. Record the details of the incident in objective terms. Describe exactly what you saw or heard. For example, unless you saw a Individual fall, it is advisable to write, Found Individual on floor. The staff member describes objectively the Individuals condition when the incident was discovered. Use your senses (e.g. what did you see, here, or smell) Use concise phrases and you make your sentences as short as possible Use exact quotes to record the Individuals description of the occurrence whenever possible Document a physical assessment of the Individual, with particular attention to any injuries that resulted. Include set of Vital Signs and pain rating assessment. If no injury resulted, this should be clearly documented. Any measures taken by nursing staff, physician, or other staff at the time of the incident are reported. The incident is reported to the RN, physician, and the NOD. Significant SIRs are promptly reported to a member of Program Management/POD. The CNS Office is called to obtain an SIR# The report is submitted as soon as possible to the appropriate management for review. Do not admit to liability or blame. Avoid pointing fingers at other healthcare -6N.P.P No. 321

professionals. No staff member is blamed in an incident Do not include explanation as to how the incident could be avoided in the future. However, do verbally share your suggestions for changes with your Shift Lead, Unit Supervisor, or NOD Procedure For Completing The Special Incident Report: Page 1 of the SIR form: 1. Write an objective description of the incident: Progress Notes should contain an actual description of the incident. Chart only what you observe first hand. Each staff member who knows about the incident should write a separate report. If a Individual injury occurs in another department, it is that departments responsibility to document the details of the incident. If needed use another Special Incident Form as a continuation sheet and remove pages 2 & 3. Do not use the name of Individuals in the ID note. CHS # is permissible to use in the ID note as a means of identifying an differentiating Individual(s) involved. Do not label the ID note as SIR Avoid writing incident report completed after describing the incident. This destroys any possibility that the incident report can be kept confidential. This statement also serves as a red flag to a plaintiffs attorney. When a medication error occurs only chart a description of what medication was given and any observations of signs or symptoms. Do not chart that an error occurred. Addressograph pages one with primary Individual the white copy is placed in the Individuals chart. If multiple Individuals are involved, complete pages 1 & 2 for each Individual and discard pages 3 & 4 except for primary Individual. Page 2 (pink ID Note) is attached to the back of the Special Incident Report on the primary Individual. If a Individual is not involved then the white page is discarded after a description is written. Information about the incident and its effect on the Individual must be included in the medical records for the use of the Treatment Team in properly treating the Individual as a result of the occurrence. Do not include in a Individuals medical record any additional information, which is not necessary to the continued treatment of the Individual. Page 2: 1. Heading (First three rows)

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On the first row enter the date and time of the incident (not the time the incident is being reported).Always use military time, e.g. 1410, 2300, ect

If the time is unknown then write unknown On the second row enter Coalinga State Hospital, the Program and Unit where the Individual is assigned, and the incident number provided by Central Nursing Services. If no Individual is involved then enter not applicable The Special Incident number will be entered under Incident Number in the upper right corner Central Nursing Services staff or Program Management will assist the employee whether to check the Yes or No box regarding Headquarters reportable. Special Incident Report Type: Check all applicable boxes. See Alphabetical List of Definitions page 4 attached to the SIR If an injury occurred during an Aggressive Act(s), the reporting individual will also check Medical/Health and Safety and then describe the type of injury, e.g. slip, trip, fall; sports injury; motion; lifting; repetitive; exposure to disease; needle stick. Explain in narrative who was injured and if the injury was a result of the aggressive act or if the staff were injured putting the Individual into restraints Describe the actions taken to provide care at the scene, such as helping the Individual get back to bed or assessing for injuries. Document the time of the incident and the name of the physician who was notified. The progress notes should also describe the treatment and follow-up care provided to the Individual and the Individuals condition was closely monitored after the incident. If the case should end up in court, the jury may be asked to determine if the Individual received appropriate care after the incident. Document any statements made by the Individual: Location of Incident, check only one box

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Under the categories Other Home Unit and Off Unit write in the specific location. Individual/Other (Information about others involved, e.g. Individual, staff, visitor, ect) Write in the name and CSH identification number of all Individuals involved (not primary Individual whose addressograph is on the SIR) Check the appropriate box under Involvement and Injury/Condition Severity The checkboxes for the primary Individual is located within the addressograph box. Reporting Employee: The employee reporting the Special Incident Report will print his or her name and include a Title, Date, and the Time the incident is being reported. Notifications: Check each individual that was notified Always notify the NOD Always notify the Senior Special Investigator and Corrections in the case of an assault Page 3: Physicians Report: -The Physicians report is on page 3 Level 1 Review: The Unit Supervisor, Service Area Supervisor, or designee completes this section. If additional pages are needed a Continuation Review Page is attached to the Special Incident Report on page. The instructions are printed right on the page and include: 1. A description of the activity at the time of the incident Include the following when relevant: 1. Reaction of Individuals guardian or conservator 2. Individuals relevant program plan 3. Intervention strategies used at the time of the incident 4. Precipitating event or history impacting the incident

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5. Staffing considerations impacting the incident 6. Staff injury 7. Early warning signs

Precursors to the incident: Staff actions relating to the incident that was different from medical or nursing interventions. Interventions that are not listed on page 2: E.g. crowd control: The individual completing this section needs to provide his or her name; signature; title; telephone number (not extension); date; time Level II Review: This section is completed by the Program Director, Support Services Manager, or designee. The section has instructions printed right on the page and include. A narrative of the investigation and findings and specify the type of action taken or planned to prevent recurrence such as: - Personnel action - Staffing training - Wellness and Recovery Team follow-up - Safety and physical plant correction - Administrative - Individual reaction - Reaction of family or guardian - Individuals medication, diagnosis, and current legal status - Results of x-ray or interventions ordered by physician if not listed on Page 3 - Number of staff on duty and whether staff level was normal at the time - Any early warning signs and whether they were noticed - Any other pertinent information or issues - Include a target date for completion Level III Review: This section is to be completed by the Executive Director or designee 5. PROCEDURE: NURSING ACTION A. Stamp Special Incident Report with KEY POINTS A. The addressograph of the primary

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Individuals addressograph in lower right hand corner

B. Print or write legibly

C. Check box for type of incident D. Complete top of form with Hospital, Program, and Unit number. E. Indicate location, date and time of incident F. Describe in detail what Happened. If needed, use another Special Incident form as a continuation sheet and remove pages 2 & 3. If multiple Individuals are involved complete pages 1 & 2 for each Individual and discard pages 3 & 4 except for primary Individual G. Have a Registered Nurse assess the Individual as indicated. Record the behavioral and medical aspects of the incident. Sign with full name and title on the IDN form page 1 of the SIR H. List all medical/administrative personnel notified.

Individual involved is stamped on the SIR. Additional Individuals, staff, or visitors involved in the incident are recorded in the Individual/Other section of Page 2 of the form B. It facilitates review if all information is organized, legible, and words spelled correctly C. Check all applicable boxes

E. Be as specific as possible F. Include names of all Individuals involved; antecedent behavior observed, interventions used, outcome of intervention, injuries sustained by Individual employee.

G. Do not refer to the Special Incident in the ID Notes. Insure signature is legible.

H. HSS/ACNS to be notified immediately of all special incidents. The HSS will take any required pictures I. Indicate type of restraint/seclusion if I. A Post Incident Critique will be used. Document when the Post conducted for each incident involving Incident Critique was conducted under MAB physical intervention and the investigation and findings section of recorded on the level I Review section the Special Incident Report J. Notify the SSI on all assaults J. SSI will determine if assault is a felony or misdemeanor K. Call the CNS Office for an SIR K. The tracking number you receive tracking number from the CNS is entered in the upper right-hand corner of the SIR form L. Page 1 original copy stays in the L. The two pink copies goes to the chart Unit Supervisor M. Have original copy of the incident M. The Unit Supervisory will review for Reviewed and signed by a physician Completeness at the Level I review and where appropriate. send to Program Management for Level ll review. Level lll will be completed if Headquarters reportable.

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When to Notify The Special Investigator: Identify level and extent of injury. For all assaults, notify the Senior Special Investigator (SSI). If contact was made but no injury or minor injury to Individual or staff, notification by voice mail is sufficient. If Individual or staff sustain injury, the person witnessing the even must call the SSI immediately either directly by phone or reach via the Telephone Operator. The SSI will advise if the incident is a felony or misdemeanor and will instruct specific action to take. The person witnessing/having first hand knowledge of the even will initiate the SIR. Side memorandum listing all witnesses must be included. Take all efforts to preserve crime scene. Do not clean up the crime scene until the SSI arrives on scene or advises that the crime scene be cleaned. Notify the Watch Sergeant of Corrections describing the level and extent of injury to Individual(s) or staff. A photocopy of the Special Incident Report(s) must accompany contraband and evidence placed in the Evidence Drop Boxes Proper chain of evidence shall be maintained on all contraband evidence, or other confiscated items until such time as the item(s) are turned over into the custody of the Office Investigations. The person finding the suspected item(s) shall be the person drafting the Contraband Report, Special Incident Report, and the side memorandum listing the witnesses.

Common Mistakes: The following is a list of common mistakes with writing and SIR. The reporting individual is signing his or her name and not printing his or her name In the SIR Type: Miscellaneous box FF: Failure to follow policy/procedures is for staff only not Individuals The SIR Type: Sexual Incidents (verbal) is not used for sexual harassment incidents between two employees With medication errors some staff are identifying the ID note as a med error. Charting should only be description of what medication was given and any observations of signs or symptoms The Involvement and Severity Code for the primary Individual, located directly above the addressograph, are not being completed The physician is writing his or her ID note at the bottom of the ID note (Pages 1 & 2) and not the tope of the Review page (Page 3) of the SIR form. - 12 N.P.P No. 321

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 322 Effective Date: August 31, 2006 SUBJECT: VITAL SIGNS 1. PURPOSE: The purpose of this policy is to discuss the meaning of routine vital signs, explain the importance of monitoring body temperature, list the types of thermometers and routes for measuring temperature, describe the physiology of the pulse, explain the technique for assessment of the pulse, describe the assessment of respirations, define the term blood pressure, state the rationale for blood pressure measurement, describe the newest addition to a set of vital signs-pain assessment- as the fifth vital sign, identify nursing responsibilities related to the assessment of vital signs, and describe the role of new technologies in the assessment of vital signs. 2. POLICY: The taking of Vital Signs consists of obtaining the temperature, pulse, respirations, blood pressure, and the newest fifth vital sign pain assessment. Verbal and written description will be presented and communicated in this sequential order (TPR, BP, and Pain Assessment). Oxygen Saturation (SPO2) shall be taken as clinically indicated. 1. Nursing personnel are expected to know the normal range of each vital sign. During the shift, whenever there is a question about the well being of any individual, the taking of vital signs is to be accomplished as often as deemed necessary. A physicians order is not required. The assessing of vital signs becomes a required part of the overall picture when assessing an individuals condition. It is used to establish trends and make comparison of changes in condition. Do not wait for the next routine time if an untoward trend is developing or suspected. 2. Nursing staff shall obtain and document a full set of vital signs for the following situations including but not limited to: a. Upon admission to the hospital, then daily for 7 days b. During the annual physical examination c. Upon re-admission, transfer to unit from court visit or other hospital, or any intrahospital transfer to another unit d. Monthly on all individuals/clients e. Individuals in restraint and/or seclusion as near the beginning of the shift as possible and every eight hours while in restraint and/or seclusion

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3.

4.

5.

6.

7.

f. Individuals who complain of feeling ill before calling to the attention of HSS and physician/MOD g. In preparation for those individuals to be evaluated for Sick Call by the Medical physician or MOD h. Every shift while on antibiotics for 3 days unless otherwise ordered by unit physician i. Before and after surgery or invasive diagnostic procedures j. While on medications that alter cardiovascular, respiratory, or temperature control status (e.g. antihypertensives, digitalis, antipyretics, cardiotonics, bronchiodialtors, ect.) k. Within one hour after administration of a PRN medication given specifically for its effect on vital signs (e.g. antipyretics, antihypertensives, cardiotonics, bronchodilators, ect.) l. Medically fragile or individuals receiving oxygen shall have vitals taken every shift unless otherwise ordered by the physician m. Twice a day for a minimum of three (3) weeks starting three days prior to the first dose of Clozapine (recorded on the Clorzapine Medication Record) n. Whenever the individuals perception of health stare changes (e.g. individual verbalizes, I feel funny, or Im feeling faint) o. Throughout a medical emergency p. Immediately after a fall (if a Fall Risk Assessment is completed), take a complete set of vital signs including orthostatic Blood Pressure readings Nursing personnel are expected to exercise clinical judgment and take vital signs as warranted by the individuals condition. Vital Signs shall also be taken when requested by the Shift Lead, RN/Case Manager, NOD, or Physician Vital signs on admission shall be recorded on the Initial Screening Assessment (Identification/Admission Note, Nursing Assessment), and Vital Signs Record vital signs shall be recorded on: a. Vital Signs Record b. Monthly Vital Signs Record All abnormal vital signs or deviation from the individuals normal baseline are to be reported to the Medical Physician/MOD, Shift Lead, RN/Case Manager, and NOD. Abnormal Vital Signs are to be documented in the IDN (Wellness and Recovery Notes MH #5624) including physician notification and action taken. This information shall be reported at the Change of Shift Meeting to the oncoming shift to assist with maintaining continuity of care. Vital signs influenced by medication shall be recorded on the MAR (Medication and Treatment Record MH 5764) [e.g. Apical pulse shall be individuals prior to receiving cardiac or antihypertensive drugs; the blood pressure shall be taken at least weekly while giving beta blockers such as Propranolol (Inderal)]. (Refer to the P&T Manual for further parameters. The Apical Pulse rate will be taken for one full minute prior to the administration of digitalis preparations or other cardiac drugs. Record on -2N.P.P No. 322

the MAR (MH #5764). If the pulse is 60 or below, or irregular, withhold the medication the and promptly notify the physician immediately. 8. The individual is to be assessed for pain every time the individuals pulse, blood pressure, temperature, and respirations are checked. 9. Nursing personnel are to provide client teaching/instruction regarding the taking of Vital Signs to assist with gaining individuals cooperation with the procedure and to promote individual involvement and partnership with their treatment. Document all client teaching in the IDN notes. 3. ASSESSMENT: The accurate Assessment of vital signs is an important and crucial part of nursing care. Nursing personnel are expected to know how to take vital signs, interpret the data, communicate this data to others, and plan nursing interventions appropriately. The taking of vital signs as a part of the nursing process (assessment, nursing diagnosis, planning nursing intervention, evaluation) utilizing a deliberate problem-solving approach. Assessment is a systematic way of collecting data. It determines nursing diagnosis for development of the individual care plan. Taking vital signs means gathering data for the database. 1. The usual adult temperature range is 96.4 to 99.4 F, with the average being 98.6 F. temperature regulation is diminished in the elderly. Because the elderly are generally less active their temperatures are usually subnormal, the circulation is slower, and there is less power to compensate for fluctuations in external temperature. Fever is an elevation of body temperature beyond the normal range. Causes may be viral or bacterial infection, drug reaction, brain lesion, or reaction to other body pathology. 2. Blood pressure is influenced by problems with cardiac output and peripheral resistance. Hypertension occurs when the arterial pressure is significantly above average for the person involved. Obesity, heredity, or nervousness may cause primary hypertension. Secondary hypertension is unknown etiology buy may accompany some other pathologic systemic condition. 3. Certain factors influence the regulation of breathing. Chemical factors depend on the presence and amount of carbon dioxide that stimulates the chemoreceptors on the medulla and stimulates breathing. Physical factors include lung inflation, which stimulates nerve receptors and allows passive expiration to occur. This causes blood pressure changes to occur which in turn, causes breathing to become slower and shallower. 4. The Pulse rate is also governed by the medulla. The rate increased during conditions such as hemorrhage and shock. The elasticity of the vessels also affects the rate. During atherosclerosis, the plaque lining the vessels hardens

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and constricts the diameter. This constriction diminishes the amount of blood able to be pumped through the vessels. 5. All individuals will be assessed for pain. When pain is an identified problem, individualized pain management goal will be established and regular assessments will take place until the problem is resolved. Pain assessment includes: location and intensity; but in most cases should include other dimensions such as psychological and spiritual distress. 4. OUTCOME CRITERIA: Nursing staff will recognize the interrelationships between vital signs, physiological activity, and pathophysiological changes and will utilize the nursing process problem-solving approach to analyze the findings and take appropriate action. 5. THE TAKING OF VITAL SIGNS- GENERAL INFORMATION: Temperature, pulse, respiration, blood pressure, and pain assessment (considered the fifth vital sign) together comprise a set of Vital Signs. These are considered vital because they are indispensable indicators of an individuals current stare of health. Even when the individual seems to be in a state of high- level wellness, it is often important to assess the vital signs as a means to establish baseline data with which to judge the significance of any future deviations from what appear to be the characteristic or normal. Obtaining the oxygen saturation level (a.k.a. Pulse Ox or SpO2 level) is an important indicator of respiratory functioning. Temperature: The Tempa-dot (disposable chemical dot thermometer) may be used for routine temperature taking, monthly vital signs, and screening purposes. However, if a temperature is greater then 99.5 or less than 96, or when there are signs and symptoms of infection, the Welch Allyn/LifeSign Vital Signs Digital oral thermometer shall be used to confirm and/or monitor the individual. Types Of Thermometers Used At CSH:

TYPE SCREENING Temperatures

Temp-a-Dot

Welch Allyn/ LifeSign Monitor Yes

Yes

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DEFINITIVE (confirm abnormal screening and follow individuals with infections) Confirm Abnormal Temperature Advantages

No If temperature greater than 99.5 or less than 96 recheck with Welch Allyn Can screen many individuals rapidly Fair accuracy Screening for outbreaks; Monthly VS

Yes

Not needed

Takes TPR, BP Expensive; Bulky For use in an emergency, rapid, and frequent monitoring All units

Disadvantages Best Used For

Where Located at CSH

All units

Tempa-Dot (Disposable Chemical Dot Thermometer) NURSING ACTION A. Wash hands before and after procedure. B. Explain the procedure to the individual. KEY POINTS A. Prevents spreading contamination. B. Ensure the individual has not had hot/cold drink(s), smoked within 30 minutes, or has undergone unusual exertion. C. Opening protective case activates the dye dots. If thermometer dots are blue upon opening, it has been exposed to 96F or higher. Place in freezer to restore effectiveness.

C. Remove thermometer from is protective wrapping. Be sure the thermometer has been stored in a cool, dry place such as a refrigerator and that it remains sealed until use.

D. Place thermometer in the individuals mouth under the tongue. Have the individual keep his/her mouth closed.

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E. Position thermometer under the individuals tongue on either side of the mouth as far back as possible. F. Have individual close mouth on the thermometer.

G. Leave in place for one full minute. H. Remove thermometer and wait then seconds before reading the temperature. I. Read the temperature as the last dye doe that has changed color. J. Discard thermometer in the biohazardous waste container. Axillary Temperature: NURSING ACTION A. Explain procedure to individual. B. Pat axilla dry if moist/damp. C. Place the thermometer in a sheath and place in the axilla and ask individual to fold arm across his/her chest. D. Leave in place for 7 to 10 minutes. E. Remove thermometer, discard sheath in biohazardus waste container.

E. An oral temperature is accurate when the thermometer is placed under the tongue next to a major artery. F. Heat pocket at the posterior base of the tongue, adjacent to the molars, is more accurate because of the proximity of the pocket to the larger blood vessels. G. Take pulse, respiration, BP, and pain assessment during this time. H. To ensure accurate readings. I. If temperature is above 99.5 or less then 96 recheck with the ABCO digital thermometer.

KEY POINTS A. Client teaching assists with gaining individuals cooperation. B. Moisture in the axilla may cause an incorrect reading. C. This wind like position provides a large axillary pocket and prevents displacement of the thermometer. D. The normal range is 96.6 to 98.4F.

Rectal Temperature: NURSING ACTION A. Explain procedure to individual and provide privacy. KEY POINTS A. A rectal temperature is taken for individuals fro whom the oral method is -6N.P.P No. 322

B. Wash hands before and after procedure. C. Apply sheath and lubricant the distal inch.

inappropriate (e.g. comatose), when clinically indicated, when Neuroleptic Malignant Syndrome (NMS) is suspected, or when ordered by the physician. B. Prevents spreading contamination.

C. A lubricant will reduce the friction. Gloves should be worn and the thermometer should be held in place to prevent accidental breakage or other trauma to the individuals rectum. D. Position individual on side with top D. Allows visualization of the anus and leg flexed and separate buttocks. Insert placement of the thermometer at the thermometer about 1 to 1 inches. correct angle. E. Hold in place until sensor records E. Holding the thermometer prevents the reading. displacement and insures accurate reading. The normal range for a rectal temperature is 98.6 100.4 F. F. Remove thermometer and discard sheath in the biohazardous waste container. Welch Allyn/Life Sign Vital Signs Monitor Digital Oral Thermometer Key Points: The Welch Allyn/Life Sign Vital Signs monitor is capable of taking an automatic Blood Pressure, oral temperature, and pulse oximetery. It is located on all units, Admissions Suite, and in the Employee Clinic (refer to the Welch Allyn/LifeSign Vital Signs Monitor Operations Manual). Taking a 4 Second Oral Temperature: The oral probe has a blue tip. Remove the probe from the holder and load the probe cover. Hold the probe under the individuals tongue for approximately 4 seconds. When the temperature measurement is complete, a tine will sound and the temperature will be displayed. Replace the probe in the holder before attempting to take another temperature measurement. 6. PULSE: General Information: 1. Use the fingertips when taking the clients pulse, preferable the third and fourth (the middle and ring) fingers. The thumb and index fingers have pulses of their own which can be mistaken for that of the client. -7N.P.P No. 322

2. Common pulse sites are the temporal, carotid, brachial, radial, femoral, and pedal. 3. The pulse should be taken in addition with vital signs whenever the temperature or blood pressure is taken, as well as prior to administration of digitalis preparations, Inderal, etc. 4. When taking pulses determine the rate, rhythm, and amplitude.

Definitions: 1. Rapid, accelerated: Above normal range for age and activity. Associated with fever or inflammation, increased physical activity, etc. 2. Tachycardia: Very rapid pulse over 120 beats per minute; may be too fast to count. May occur sporadically as in paroxysmal tachycardia (more than 140 beats per minutes), toxic thyroid condition, or advanced infection, increased physical activity. 3. Bradycardia: Below 60 beats per minute. May occur in aged person with digitalis overdose or beta-blockers e.g. Inderal. 4. Irregular, intermittent: Variations in force and frequency; may have occasional skipped beats. If a skipped beat is at a regular interval, not the

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5.

6.

7. 8.

pattern of beats. Found in heart disease, anxiety, increased caffeine, nicotine intake. Dicrotic pulse: A double beat or second weak wave between usual heart strokes. The weak beat is not counted as a regular beat. Indicative of low arterial tension. Bouding, full: Higher or harder pulse then usual; disappears quickly. Result of shortened ventricular systole and reduced peripheral pressure, inflammation, or fever. Thready: Weak, scarcely palpable beat; little appreciable relaxation between beats. Observed with faintness, shock, and heavy hemorrhage. Unequal: Pulse rate not the same between wrists, wrist and ankle, or wrist and apical. May indicate weak heart contractions, obstructed, or poor circulation.

Procedure: NURSING ACTION A. Explain procedure to individual. KEY POINTS A. Client teaching assists with gaining individuals cooperation. B. With individual in a comfortable B. Never use your thumb or index position, gently press the third and finger to take a pulse because the fourth (middle and ring) fingers over the pulsation in the thumb and index artery artery. can interfere with an accurate reading. C. After locating pulse, count the beat C. If pulse is irregular or if individual for 30 seconds and multiply by two (2) has a history of heart problems, take for the rate. pulse for a full minute. Assess the rhythm and amplitude. D. Record the pulse rate, rhythm, and D. Describe pulse amplitude by using amplitude. the following: 3+ = Bounding, increased 2+ = Normal 1+ = Weak, thready 0 = Absent Apical Pulse: NURSING ACTION A. Position the individual in a supine position and provide privacy. B. Warm the stethoscope in hand and place over the apex of the heart. (Normally located at the fifth intercostal space at the midclavicular line). C. Move the stethoscope until the KEY POINTS A. The supine position promotes comfort and ease of location the heart sounds. B. cold stethoscope can cause the rate to increase. The Apical Pulse is best heard in this area because the heart is close to the chest wall. C. There is a first (lub) and a -9N.P.P No. 322

loudest beats are heard and count for a full minute. D. Record (document) findings and report as appropriate (MD, NOD, etc.).

second (dub) sound for each heartbeat. D. Indicate Apical Pulse with the letters AP after reading.

Respirations: Definitions: 1. Abnormal or diaphragmatic: Chiefly the diaphragm is used for breathing, causing rise and fall in abdomen; chest walls appear nearly at rest. May be formal, but extreme splinting of chest wall may indicate pleurisy, pericarditis, or fractured ribs. 2. Apnea: Temporary absence of breathing. May occur in profound sleep or in coma, heart and kidney disease, or brain injury. 3. Cheyne-stokes: Gradual increase in rate and depth followed by gradual subsiding and a period of apnea. Result of disturbance of respiratory center and usually a forerunner of death. 4. Costal or thoracic: Muscles of chest and ribs expand the chest cavity markedly. Occurs when peritoneum or diaphragm is inflamed. 5. Labored or dyspneic: Difficult and usually audible breathing with dilated nostrils, anxiety, gasping, and air hunger. Usually accompanied by pain and insufficient oxygen from problems in lungs, circulation, or hemoglobin. 6. Rapid: Above normal rate for age and activity. Usually ratio to pulse is 1:4. Occurs in fever, infection, or as in labored respirations, described above. 7. Slow: Below normal rate for age and activity. Usually associated with increased intracranial pressure, coma, or depressant drugs. 8. Stertorous: Rattling, bubbling, or moist breathing sounds. May be snoring, mouth breathing, or may be caused by fluid in lungs. 9. Stridulous or strident: High pitched crowing or barking sound during inspiration. Indicates obstruction in glottis or respiratory passage as in diphtheria. Respirations: NURSING ACTION A. Explain procedure to the individual. B. Count the number of times the individual takes a breath for 30 seconds. If abnormal, count respirations for a full minute. Note respiratory rate by watching the rise -10KEY POINTS A. Note indications of acute or chronic respiratory problems. B. A complete cycle of inspiration and expiration constitutes one respiration. The best time to assess the respiratory rate is immediately after taking the pulse since an N.P.P No. 322

and fall of the individuals chest. Multiply 30 second count by 2. C. Record rate and rhythm, and report as appropriate

individual who is aware that the respiratory rate is being taken can alter it. C. For complete assessment, not the character of the respirations as well as the rate.

7. BLOOD PRESSURE: General Information: Blood pressure varies with age, sex, altitude, muscular development, emotional state, and time of day. Blood pressure may also vary from one arm to the other. The cuff bladder should be 20% wider than the diameter of the extremity being used. For accurate readings the individual should be in a relaxed position for 5 to 10 minutes and the arm should be supported at heart level. Do not apply cuff over clothing. The interval between systolic and diastolic pressures should be noted regularly. This measurement is called the pulse pressure. Because diastolic pressure remains relatively constant, the pulse pressure usually is considered to be a good indicator of stroke volume. In hypovolemic shock, the pulse pressure often is decreased. Report a steady decrease in pulse pressure to the physician. Procedure: NURSING ACTION A. Clean earpieces of stethoscope with alcohol. C. Explain procedure to the individual. D. Apply the sphygmomanometer cuff to the individuals arm above the antecubital fossa. E. Locate the brachial pulse with fingertips. F. Place the diaphragm of the stethoscope firmly overt the artery so that sound can be transmitted without distortion. KEY POINTS B. To prevent cross contamination.

D. Do not use the arm on the same side an A V shunt or mastectomy.

F. The edges of the diaphragm should all be flat against the skin to limit the amount of extraneous noise, but not so hard that the N.P.P No. 322

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G. Inflate the cuff to a point about 20 to 30 mm Hg above the last systolic reading or until pulsation can neither be felt nor heard. Do not leave the cuff inflated any longer than necessary. H. Determine the systolic pressure by slowly releasing the pressure valve. Note the position of the arrow on the gauge. I. Determine the diastolic pressure by noting the point at which the first muffled sound is heard (Diastolic IV) and the point at which the sounds and fluctuation of the gauge cease (Diastolic V). J. The blood pressure also may be measured by the palpation method. Apply the cuff to the upper arm and locate the radial pulse. Inflate the cuff. The radial pulse will be obliterated at this point. As the cuff is slowly deflated, note the point at which the radial pulse is again palpable. The reading at which the first beat is felt is the systolic reading. If is generally 10 mm Hg below the systolic measurement by auscultation.

arterial pulse is modified or obliterated. G. Pressure exerted by the inflated cuff prevents blood from flowing freely through the artery.

H. Systolic pressure is the point at which blood in the artery can first be heard.

I. Diastolic pressure is indicated as the point at which blood flows freely in the artery and is equivalent to the amount of pressure normally exerted on the wall of the arteries when the heart is at rest. J. Occasionally the blood is not audible through the stethoscope. This may happen in the critically ill individual or one who is extremely obese. Diastolic pressure is not measurable by the palpation method.

Pain Assessment: Pain assessment is now required as a fifth vital sign and is to be assessed at the same time as other vital signs are taken. Pain is to be assessed and treated promptly, effectively, and for as long as the pain persists. Pain assessment is performed in a manner that is appropriate to the individual. The pain assessment shall be noted in the individuals chart in a manner consistent with other vital signs.

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Under the new standards, an individual has the right to appropriate pain assessment and management. Use of a pain scale lets the individual describe pain in a way that is meaningful to the individual. Some individuals respond best to word scales; others find that pictures or number scales help them describe their pain intensity accurately.

Pain Intensity Rating Scales: The scale helps the individual quantify their current levels of pain. No Pain 1 2 3 4 5 6 7 8 9 10 Pain as bad as it can be

It is now required that all health care staff record pain assessment each time vital signs are recorded for each individual. Using the zero to ten pain assessment scale, a recording of pain e.g. 2/10, is acceptable. The Registered Nurse is required to take appropriate action based on deviations from normal. If pain is rated more than 4/10 or is unacceptable to the individual, notify physician. Progress notes should clearly delineate the plan and rationale for the pain treatment. Descriptive Pain Intensity Scale:

No Pain

Mild

Moderate

Severe

If your client is currently in pain, determine and document the location, duration, character (including its intensity and radiation, if any), and frequency. Explore these points with the individual: Does the pain have a pattern? If so, does it vary? When was the pain most intense in the past 24 hours? Does anything relieve the pain or make it worse? Does the individual take pain medication to manage the pain? If so, is it effective? Does it cause any unpleasant adverse reactions? Does the pain interfere with you daily activities, for example: sleeping, or eating?

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Also conduct a physical assessment and examine the painful site. Document your findings. Assessing non-verbal individuals: Although nothing is more reliable than the individuals self-report of pain, you must rely on other information if your client cannot use a pain-rating scale. If, for example, the individual has a painful condition, or has undergone a painful procedure, you may have enough information to justify administering analgesics.

Other pain indicators include: Distressed facial expressions and behavior frowning, grimacing, crying, and expressions of fear or sadness. Look for muscle contraction around the mouth and eyes. Unusual movements (such as restlessness or slow, guarded, or rigid movements) or the absence of movement Attention-seeking behavior, such as repetitive banging or outbursts Vocalizations, such as groaning, moaning, crying, or noisy breathing First, try to determine a baseline of behavior that seems to indicate pain. Evaluate changes in behavior after the administration of an analgesic. After giving pain medication, evaluate the individuals response in 30 to 60 minutes (depending on the drug and administration route). Make sure your assessments are culturally appropriate, keeping in mind that cultural mores and personal values can affect the individuals beliefs about pain and response to pain. Even if the individual directly, so always ask, and believe what he or she says. The individuals self-report is the most accurate indicator of the existence and intensity of pain. Dont second-guess you client or assume that he or she is exaggerating because he or she is laughing or sleeping. Teaching Points: Help you client understand why effective pain management is important and how uncontrolled pain can hamper recovery. Be open and flexible when assessing and planning for client (And Family If Appropriate) teaching and teach on the individuals level. Consider his or her values and beliefs, culture, literacy, education level, language, emotional barriers to pain relief, physical and cognitive functions and limitations.

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Pulse Oximeter: General Information: The Oximeter used at this facility is the SIMS BCI 3301 Oximeter. If provides fast, reliable SpO and pulse rate measurements. It will operate accurately over an ambient temperature range of 32 to 131F (0 to 55C). It is portable and lightweight, weighing only 9 ounces (225 grams) without the batteries. It uses three standard alkaline batteries (type LR 14) or three rechargeable (type KR27/50) NiCad C cell batteries. Battery life is approximately twentyfour (24) hours in continuous mode or eighty (80) hours in spot check mode. It automatically turns off after the individuals finger is removed from the sensor. A low battery indicator lights when about two hours of battery use remains.

Procedure: Nursing Action A. Make sure the equipment is in good working order and that the sensor is attached to the oximeter before using. Key Points A. Hold the connector rather than the cable when connecting or disconnecting the finger sensor to the oximeter. DO NOT use excessive force, unnecessary twisting or kinking when connecting, disconnecting, storing, or when using the sensor. B. The index finger is commonly used. Be sure to fully insert the individuals finger into the sensor.

B. When placing the sensor on the individual, allow the cable to lie across the palm of the hand and parallel to the arm of the individual. Place the sensor on the distal end of the finger. C. To begin measurement, press the I key. When turned on, the oximeter goes through the following power-up sequence: The pulse strength barograph segments light one at a time. The oximeters software revision is momentarily displayed The client number for spot check printouts it momentarily displayed. The format for the client number display is P followed by the number. For example, P 14 means the client number is 14. After a few seconds the % SpO value,

C. If normal functioning does not occur, see Operators Troubleshooting Chart (in NP&P #610 Pulse Oximetry) for help.

1. Press on

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pulse rate, and pulse strength barograph should be shown.

2. % SpO value displayed 3. Pulse rate displayed 4. Pulse strength barographs sweeping with pulse 5. Low battery indicator

D. The SpO display shows the individuals blood oxygen saturation, calculated as a percentage. The pulse rate display shows the individuals pulse rate in beats per minute (BPM). The pulse strength barographs show the individuals pulse strength; the barograph is scaled logarithmically to indicate a wide range of pulse strengths. E. Press the O key to turn off the E. This feature extends the battery use oximeter. The oximeter turns off time. automatically two minutes after the sensor is removed from the individuals finger or after the sensor is disconnected from the oximeter.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 323 Effective Date: August 10, 2007 SUBJECT: WEIGHT AND WAIST CIRCUMFERENCE MEASUREMENT 1. PURPOSE: This policy will provide guidelines to assist with maintaining and/or achieving the individuals ideal Body Mass Index (BMI) and to monitor the individual for signs of nutritional alterations so that pertinent follow-up can be provided. 2. POLICY: The individuals weight, height, and waist circumference shall be taken on admission and recorded on the Identification/ Admission note and Nursing Assessment form and on the Height/Weight Record. If there is a physician order to frequently monitor the weight, the same time of day shall be used for those individuals. Calculation of each individuals BMI requires measurement of individuals height in inches. All individuals shall be weighed and a waist circumference completed at least monthly and recorded on the Height/Weight Record and on the Monthly Weight & Vital Signs Record. The Monthly Weight & Vital Signs Record shall be reviewed by the physician and Dietitian then sent to Nutritional Services, Standards and Compliance, and the Central Nursing Services office monthly. Unplanned weight changes, which exceed 5% of the individuals weight or waist circumference, shall be reported to the physician, dietitian and RN: -An ID note shall be made and labeled as Weight and or waist circumference change Note. Individuals with nasogastric, gastric feedings, or eating difficulties shall be weighted weekly or as ordered by the physician Individuals with a history of water intoxication shall have their weight taken and recorded as ordered by the physician. Observe water intoxication precautions. If patients refuse monthly weights, vitals, or waist circumference measurement, the RN will be notified. The RN will speak with the individual regarding the refusal. If individual continues to refuse, the RN will document in the IDNs the counseling with the individual. The WRP team will be notified of the individuals refusal.

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3. GENERAL INFORMATION: Body Mass Index (BMI) is a measure that takes into account an individuals weight and height to gauge total body fate in adults. An individual with a BMI of 26-27 is about 20 percent overweight, which is generally believed to carry moderate health risks. A BMI of 30 and higher is considered obese. The higher the BMI, the greater the risk of developing additional health problems. Heart disease, diabetes and high blood pressure are all linked to being overweight. A BMI of 30 and over increases the risk of death from any cause by 50 to 150 percent, according to some estimates. Scales should be balanced for accuracy of measurement before weighting individual(s).

4. PROCEDURE: Weighing and measuring waist circumference on the Individuals: NURSING ACTION A. Balance/Zero out scale. Explain procedure to individual. be sure individual removes shoes and any heavy clothing Waist circumference. Explain procedure to the individual. KEY POINTS A. Weighing individual on same scale, at same time frame, assures accuracy of weight measurement To determine an individuals waist circumference, locate the upper hipbone (lateral aspect) and place a measuring tape around the abdomen (ensuring that the tape measure horizontal). The tape measure should be snug but should not cause compression of the skin.The individual should be instructed by staff of the proper placement of the tape measure for the correct measurement, and then permit the individual to proceed with the measurement. B. Record data on: a. Nursing Assessment b. Height/Weight Record c. The ideal time for obtaining baseline weight is 0700 C. Record results on: a. Height/Weight Record b. Monthly Weight and Vital Signs Record D. The physician and dietitian should

B. A base line weight and waist circumference on admission to be recorded.

C. Take weight and waist measurement monthly or as clinically indicated and record D. Unit physician and Dietitian should

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review the monthly weight record.

E. Send copies to the Nutrition Services, Standards & Compliance, and Central Nursing Services.

take appropriate action and make their plans known to the treatment team for follow though recommendations. E. Keeps all pertinent health care providers appraised to insure appropriate follow-up as needed.

Additional Weight Change and waist circumference changes Documentation: A. Record and report any unplanned weight change greater than 5% or waist circumference to the physician, dietician, RN and at Change of Shift report and the Unit Supervisor should monitor trends of weight variances. B. Use the Comments Section of the Monthly Weight and Vital Signs Record (CSH xxxx) to record: Newly identified pertinent medical diagnosis or treatment orders A. An ID note as Weight Change or waist circumference Note needs to be written and discussed in the Wellness & Recovery Team meetings for team members to identify the problem and make recommendations. B. This information is intended to assist nursing staff in altering the dieticians, physician, and nursing staff of pertinent concerns. Appropriate Nursing Care Plans should be developed as necessary. The RN should collaborate with the Dietician to establish an optimal plan of care.

Mechanically altered diet orders (e.g. chopped or pureed diets) Age specific, cultural, or religious dietary concerns or needs Difficulties with eating, gagging All individuals on altered diets are to episodes, potential for choking have a Dysphagia Risk Assessment episodes. completed by an RN no less than every six months.

Calculating Body Mass Index (BMI): Body Mass Index (BMI) is an indication of total body fat in meter squared (kg/m). It is most accurate in determining whether an individual is overweight or obese than assessing body weight alone. To determine and individuals BMI, multiply their weight (in pounds) by 703, and then divide by their height (in inches) squared. Weigh (in pounds) x 703 __________________ Divided by Height (in inches) squared

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Diagram for proper waist circumference measurement

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Nursing Care POLICY NUMBER: 334 Effective Date: August 31, 2006 SUBJECT: DYSPHAGIA 1. Purpose: Identify those individuals who may be at risk for choking and/or aspiration. 2. Authority: Standard of Nursing Practice 3. Policy: Dysphagia is identified to swallow or difficulty in swallowing. Appropriate dysphagia management ensures adequate nutritional support for an individual experiencing swallowing problems thereby improving the quality of life and nutritional WELLNESS of that individual. Dysphagia management includes an early identification system for individuals who may be at risk for aspiration and/or choking. This is achieved through comprehensive clinical evaluation, consistent implantation of therapeutic plans, and monitoring of plans to ensure the timely implementation of therapeutic plans, and monitoring of plans to ensure the timely implantation of needed intervention. The dysphagia program includes assessment of clients, development of treatment plans, monitoring of these plans and staff education/training. 4. Procedure: DYSPHAGIA MANAGEMENT: A feeding/Swallowing Screening will be completed for all individuals within 7 days of admission and at least yearly by a Registered Nurse. The findings of the screening will be documented in the IDN notes. In the ICF Program, an annual screening will be completed for all individuals receiving nutrition orally approximately one (1) month prior to their annual WRP meeting. Individuals residing in Acute will receive a screening WRP within 24 hours of admission to the acute unit. The screening will identify those individuals who may be at risk for choking and/or aspiration. For individuals not identified or currently determined to be at risk, a dysphagia evaluation will recommended.

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A comprehensive evaluation will be completed within 7 days for newly admitted individuals and within 24 hours, or the next business day when physical intervention by staff is required for a choking episode. An evaluation may also be indicated when swallowing difficulties are observed by staff during meals one referral is made as a result of the routine screening completed by the registered Nurse. Individuals who are identified as at risk for choking as a result of the dysphagia evaluation will: -Have a Choking Alert sticker placed on their record. -Have an open choking related condition identified on the physical treatment profile. -Have a health care objective and plan summarizing the treatment. -Be identified on a list which is posted in the dining room, residence office, and any day training sites that utilize food on either side of the dining room. Nursing Action A. RN Key Points A. Completes the feeding/swallowing screening as scheduled above. Notifies the physician screening. If indicated, recommends the individual be referred for a comprehensive dysphagia evaluation. A. Completes a health care objective and plan summarizes the treatment. B. Orders a dysphagia evaluation indicating the reason for the consult. A dysphagia evaluation shall be ordered immediately following a choking incident when physical intervention by staff is required. B. Reviews the Dysphagia Screening and orders diet modifications, adaptive equipment, additional consultations as needed. C. Notifies RN immediately of a choking incident that required physical intervention by staff. C. Includes the individuals name on a list of individuals who are at risk for choking. Ensures the list is posted in the dining room, residence office, and any day training sites that utilize edibles. C. Ensures a dysphagia evaluation is

B. Physician

C. Unit Supervisor/Designee

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D. WRP Team

completed when residence staff observes indicators for possible swallowing problems. D. Reviews the appropriateness of the treatment plan for clients identified at risk for choking as needed and at least annually at the WRP. D. Develops an individualized treatment plan for individual indicating who is responsible for implementation. D. Documents WRP Team discussion and rationale for recommended revisions related to choking alerts status in IDN Narrative.

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SECTION 4 TREATMENTS AND PROCEDURES

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 400 Effective Date: August 31, 2006 SUBJECT: SPONGE BATH FOR REDUCING TEMPERATURE 1. PURPOSE: To reduce body temperature. 2. AUTHORITY: Nursing Procedures, Springhouse Corporation, Springhouse, Penn. 3. EQUIPMENT: A. B. C. D. E. F. G. H. I. Basin of tepid water 26-34 degrees C (89-93 F) Sheets Ice bag with cover Towels Wash cloths Moisture proof pad Gloves Vital signs equipment Thermometer (for verifying solution temperature)

4. METHOD: NURSING ACTION KEY POINTS A. Explain procedure to the Individual A. Relieves anxiety, elicit cooperation B. Give antipyretic medication as B. There is a more rapid reduction of directed by physicians orders, 15-20 fever when sponging is combined with minutes before starting sponge bath. administration of antipyretic medication C. Put gloves on, place moisture proof sheet under Individual, and the sheet over him. D. Have Individual remove all clothing except undershorts. E. Apply covered ice bag to head E. Relieves headache, nasal congestion, and promotes Individual comfort F. Take temperature, pulse respiration, F. This serves as a baseline for & B.P before starting sponge bath determining effectiveness of treatment.

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G. Use the same sequence for sponging as for giving a bed bath H. Place a cold wet compress (washcloth) on neck, groin and axiillae. I. Expose the body area to be sponged. J. Using 2 washcloths alternately, pat each area so that solution is uniform over skin surfaces. K. If the Individuals skin feels cold to the touch, stop the treatment in that area. L. Bathe each extremity 5 minutes; bathe entire back and buttocks 5-10 minutes; bathe trunk and abdomen 5 minutes M. Watch for shivering, cover the Individual and wait a few minutes before proceeding with sponge. N. Stop procedure if cyanosis, mottling and chill occur O. Dry skin with towel P. Remove sheet. Place dry comfortable clothing on Individual Q. Record complete Vital signs 30 minutes after sponge bath is finished

H. The application of cold over superficial lard blood vessels aid in lowering body temperature

J. Vaporization of water removes heat from the surface of the skin K. Excess heat loss will induce thermogenesis. L. The fever sponge should not exceed 30 minutes

M. Shivering may raise heat production N. These symptoms indicate a change in vasomotor tone

Q. Post sponge temperature indicated whether or not treatment has been effective.

5. RECORDING: In the Medication Administration record, record the time, treatment, and duration of the sponge bath on the vital signs record the vital signs of the Individual taken before and 30 minutes after the treatment. Also note the Individuals reaction to the procedure in IDNs. Document teaching on Wellness and Recovery Individual/Family Health Education Record.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 401 Effective Date: August 31, 2006 SUBJECT: RETENTION CATHETER (FOLEY) INSERTION AND CARE 1. PURPOSE: A retention catheter has a balloon hear the tip, to e inflated after insertion so the catheter will remain in place. This is used for the following reasons: 1) To relieve acute urinary retention when voluntary bladder control is not reestablished by internal catheterization; 2) To protect suture lines and raw areas after bladder, prostatic, or urethral surgery; 3) To prevent clot obstruction in urinary tract hemorrhage; 4) To monitor renal function in seriously ill Individuals; 5) To treat urinary infections associated with residual urine or vesicoureteral reflux; 6) To relieve severe incontinence or frequency. 2. AUTHORITY: A. Obtain from Central Supply: 1. Foley catheter (size specified by physician) 2. Gravity drainage set 3. Appropriate size syringe and sterile water 4. Disposable catheterization tray containing: a) 14 Fr. Vinyl urthral catheter b) Packet providone-iodine swabsticks c) Vinyl gloves (2) d) Lubricating jelly (water soluble) e) Underpad f) Fenestrated drape g) 1100 ml. Graduated collection tray B. Have available: 1. Adhesive tape 2. Larger syringe and sterile saline if large balloon catheter is used 3. Plastic bags for waste 3. PROCEDURE: Catheter insertion: ACTION A. Review physicians orders B. Wash hands before procedure RATIONAL- PRECAUTIONS A. Ensure procedure is valid B. To prevent cross contamination

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C. Follow N.P. Catheterization of Male Individual, regarding instructions for insertion of a catheter. D. Insert the catheter eight inches E. Use syringe filled with sterile water and inject into small side tube to fill balloon at catheter tip. F. Give gentle pull on catheter to be sure the balloon is inflated and will hold the catheter in place G. Keeping the end of the catheter and the end of the drainage tube sterile, connect catheter to the gravity drainage set. H. Initial emptying of the bladder after catheterization should be limited to 1000cc. Clamp catheter for 15 minutes if more urine than this. I. Tape the catheter securely to the thigh, but without exerting tension or pull on the urethra

D. To insure the balloon is inserted beyond the sphincter E Do not over inflate the balloon

F. The balloon les in the neck of the bladder and keeps the catheter in place G. A retention catheter may be allowed to drain or may be clamped off with periodic release to develop bladder control. H Complete emptying of a full bladder may cause spasms, cramping, discomfort and shock. (collection container only hold a volume of 1100cc) I. Tension on the catheter exerts pressure on the neck of the bladder causing a painful straining to urinate. Tubing is not to be compressed by the weight of the Individuals buttocks or thigh. J. Prevent constriction of glands which results in swelling. K. To prevent cross contamination

J. Retract prepuce if one is present K. Wash hands after procedure Continuing care of catheter: ACTION A. Wash hands before and after procedure B. Apply Betadine Ointment daily around the urinary meatus C. Observe sterile techniques at all times. At entry into the drainage system is preceded by thoroughly cleansing the connection to be opened with an alcohol sponge. D. Never elevate the drainage bag to bladder level E. Empty the bag through the bottom

RATIONALE-PRECAUTIONS A. To prevent cross contamination B. An indwelling catheter is a route for bacterial infection and a source of irritation to delicate tissues C. Make every effort to prevent bacterial contamination and infection of the bladder.

D. Avoid back flows of urine E. Do not use urometeres and other

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vent into an appropriate container to measure urine output, or to collect specimens for chemical analysis F. When the Individual is out of the bed catheter ad tubing is taped securely to the thigh, without exerting pull on the urethra. There is no need to disconnect the drainage set. G. the catheter is to be checked frequently to determine that it has not been displaced and is flowing freely H. Irrigation of the catheter is done only with a physicians order I. Change retention catheter upon written orders of a physician

special containers to measure hourly output, as none has a completely closed system. F. Prevent traction on the catheter tubing. Prevent risking infection unnecessarily.

G. Avoid urethral trauma and urinary tract infection

J. Never use catheter plugs. Use an external clamp to occlude the catheter or drainage tube for bladder training or other purposes.

I. Replacement ensures patency, reduced odor, and helps prevent contamination and growth of organisms in the urethra. Avoid any unnecessary disconnection of the drain system. J. To prevent contamination leave the catheter connected to the drainage system even when the catheter is clamped

4. SPECIMENS FO RCULTURE AND SENSITIVITY: A. EQUIPMENT 1. Obtain from Central Supply: a) Safety Syringe 2cc with #22 needle b) Sterile alcohol sponge c) External tube clamp d) Procedure gloves 2. Obtain from Laboratory: a) Sterile urine specimen container, with label addressographed 3. Have Available a) Laboratory Slip addressographed and marked for cultureCath. Specimen B. PROCEDURE ACTION A. Wash hands before and after procedure B. Put on gloves C. Apply clamp to drain tube just beyond catheter connection for about RATIONAL-PRECAUTIONS A. To prevent cross contamination B. To prevent cross contamination C. To allow urine to collect in catheter

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five (5) minutes prior to collecting specimen D. Using alcohol sponge, clean the area of catheter between the connecting tip and side arm E. Insert sterile needle into the catheter and aspirate 2ccs of urine F. Withdraw needle and place urine in culture container. Cap container aseptically and label. Send to Lab immediately or refrigerate for Lab pickup G. Secure needle in protective sheath and dispose of needle in sharps container

D. To prevent introduction of contamination into catheter or urine specimen E. Be careful to avoid entering the lumen of the side arm F. Protect specimen from outside contamination that would confuse identification of organisms causing bladder infection and give false positive results of cultures. G. To prevent cross contamination and accidental injuries

5. COMPLICATIONS RESULTING FROM RETENTION CATHETERS: -Urethritis: Sommucopurulant discharge from the meatus is to be expected. This can be minimized by ordinary cleaning (with soap and water of the meatus and adjacent catheter. Notify the physician immediately of any discharge, especially when associated with tenderness and fever. -Voiding around the catheter: This is indicative of obstruction, mal-position of the catheter, or severe bladder spasms. Notify the physician unless the trouble is readily found and corrected. This may require a change f catheter, but do not do a bladder irrigation without an order. -Urinary tract infection: Cloudy urine, flank pain, or fever occurring during retention catheter drainage are indicative of invasive infection, or obstruction in the catheter system or the upper urinary tract. Notify the physician immediately if such symptoms are apparent. Bacteremi may occur with urinary tract infection. The symptoms are fever, often with chills, hyperventilation, hypotension and prostration. -Removal of catheter with balloon Inflated: A Individual who removes his retention catheter requires careful attention. This accident is apt to be complicated by bacteremia, severe bleeding or urethral rupture with extravasation. Notify physician immediately and insert new catheter if ordered.

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6. REMOVAL OF RETENTION CATHETER

ACTION A. Review physician orders B. Wash hands before and after procedure. C. Wear procedure gloves during procedure D. To remove a retention catheter, withdraw the fluid with a syringe or cut off the end of the side arm. The fluid in the balloon will drain out and the catheter will slide out easily. E. If the balloon does not empty or the catheter does not come out easily, notify the physician F. Discard catheter and other disposable equipment per ICM G. Clean reusable equipment and return to Central Supply 7. RECORDING:

RATIONALE- PRECAUTIONS B. Prevent cross contamination C. Prevent cross contamination D. Be sure the balloon is emptied before the catheter is withdrawn.

E. Prevent trauma to the urethra

F. Beware of contaminated articles and contraband G. Central Supply sterilizes equipment

A. In the Wellness and Recovery Notes, the person performing the procedure will record the time, procedure, appearance of urine, condition of catheter, specimens sent to the laboratory, bladder irrigations, catheter care and any complications that occur. Include the Individuals reaction and tolerance to the procedure. B. IN the Daily Care Flow Sheet, record the amount of urinary output every eight (8) hours and every twenty-four (24) hours.

8. GENERAL: All instructions apply to the insertion of the retention catheter. Retention (Foley Catheters) come in various sizes and types with various sized balloons. The physicians order must specify the catheter and balloon sized. The 5cc balloon is used routinely while the 30cc balloon is used principally after prostatic surgery. A three-way Foley (with additional side arm and channel opening into the bladder) is available for continuous bladder irrigation. The connection between the catheter and the tubing is never broken, except when absolutely necessary to remove clots obstructing drainage. Irrigations are done under absolutely sterile conditions.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 402 Effective Date: August 31, 2006

SUBJECT: CATHETERIZATION AND THE CARE OF A CATHETERIZED MALE INDIVIDUAL 1. PURPOSE: Catheterization is the insertion of a sterile tube into the bladder for the following reasons: A. to relieve urinary retention; B. to obtain sterile urine specimens for diagnostic laboratory procedures; C. to install medication or irrigate the bladder; D. to determine if the failure to void adequate amounts of urine or none at all is a result of an inability of the bladder to expel urine or failure of the kidneys to excrete urine. If catheterization is done to determine residual urine, it must be done within five minutes of the Individuals voiding. Condom catheter is an external appliance applied to the penis to relieve incontinence and to prevent skin maceration related to incontinence. Gravity collection bag is attached to the leg of the catheterized Individual, which gives the Individual greater mobility. With a order, leg bags may be worn during the day and are replaced at night with a standard gravity drainage device. 2. AUTHORITY: Modic, M.B., Calbrase, D., Stakes, R.A., Vandepttee, S., Nursing Procedures., Renal & Urological Care. Third Edition 1999. Springhouse Corporation. Springhouse, Pennsylvania. 3. GENERAL: A physicians order is required for all types of catheterization or external (condom) catheter. Thy physicians order must specify the catheter and balloon size. Retention (Foley) catheterizations, In and Out catheterizations and instillation of medications are performed by licensed nursing staff or y the physician. With the treatment team and physicians prior approval, a Individual may be instructed in the techniques of self-catheterization. If selfcatheterization is approved, a physicians order must be obtained and a

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nursing care plan written. A Individual that gives a history of performing prior self-catheterization must be observed on time by a licensed nursing staff or physician to assess technique. Sterile aseptic techniques and equipment are used when entering the urinary bladder. Clean technique and equipment are used when applying a condom catheter. Insertion of a catheter should be performed with extreme care to prevent injury and infection.

4. EQUIPMENT: Retention Catheterization: Obtain from Central Supply: 1. Foley catheter (size specified) 2. Sterile gravity drainage set with bag 3. Appropriate size syringe and sterile normal saline solution 4. Washcloth, towel, soap and water 5. Sterile cotton tip applicators 6. Intake & Output sheet 7. Safety syringe 2cc and #22 needle (for specimen collection) 8. External tube clamp (for specimen collection) 9. Sterile disposable catheterization tray containing: a) Ureteral catheter, 14-18 French b) Antiseptic prep solution, 50ml c) 2 pair sterile gloves d) Specimen containers e) Waterproof underpad f) Waterproof tray g) 5 large absorbent balls h) Sterile waste soluble lubricant package i) Sterile drape Have Available: 10. Adhesive tape 11. Larger syringe and sterile saline if large balloon catheter is used 12. Clear plastic bags for medical waste 13. Sterile urine specimen container, with addressographed label and Laboratory slip In & Out Catheterization: A. Obtain from Central Supply: 1. a) b) c) Sterile disposable catheterization tray containing: Ureteral catheter, 14-18 French Antiseptic prep solution, 50ml 2 pair sterile gloves

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d) e) f) g)

Specimen containers Waterproof underpad Waterproof tray 5 large absorbent balls

1. Sterile waste soluble lubricant package 2. Large irrigating tip syringe, 50cc if needed 3. I & O sheet 4. Obtain from Pharmacy: 5. Medication as ordered Have Available: 2. Goose-neck lamp/additional light source if needed 3. Extra specimen cups as necessary 4. Clear plastic bag for medical waste 5. Laboratory request forms Condom catheter: A. Obtain from Central Supply: 1. Self adhesive external urinary catheter of appropriate size 2. Gravity collection bag 3. Vinyl gloves B. Have Available: 1. Adhesive tape 2. Clear plastic bag for medical waste Gravity Collection Bag: Obtain from Central Supply: 1. Leg bag and straps (for day time use) 2. Gravity collection bag (for night time use) 3. Vinyl gloves Have Available: 1. Adhesive tape 2. Clear plastic bag for medical waste 5. PROCEDURE: Catheterization of male Individual: NURSING ACTION A. Review physicians orders and allergies KEY- POINTS A. To determine if catheter size or type has been specified. If the Individual has

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B. Wash hands before and after procedure C. Explain procedure and the purpose to the Individual D. Screen the bed or close door E. Prepare a work area. Adjust light as needed to provide visualization F. Place the Individual in a horizontal recumbent position with hips firmly supported G. Cover the Individuals chest and drape.

allergies to Betadie and/or Latex consult with the physician for alternatives B. To prevent cross contamination C. To elicit cooperation and minimize anxiety and discomfort D. Assure the Individual his respect, dignity, and privacy E. Poor lighting is a major cause of contamination F. Position allows exposure of genital area. Gravity will aid flow of urine when bladder is higher than end of the catheter G. Embarrassment and chilliness can cause the Individual to become tense, making introduction of the catheter more difficult. H. Equipment is arranged inside tray in order of use to increase the speed of performance I. Provides clean working area and reduces chance of introducing bacteria into urinary tract.

H. Arrange equipment to avoid contamination of sterile items. Open sterile catheterization tray I. Expose genitalia and retract prepuce if present. Picking up sterile underpad corners, lay pad under the penis and on the top of the scrotum across upper thighs. J. Put on sterile gloves; prepare contents of the tray by lubricating the catheter tip 1 to 2 inches K. Open packet of swabsticks. Hold penis with foreskin retracted, using the disinfectant swabsticks as ordered cleanse glans from meatus outward. Discard swabsticks repeat cleansing. L. Place collection basin between Individuals legs on the towel. Holding the penis directly behind the glans with thumb and forefinger, apply gentle tension and raise the penis vertical to the body. M. Hold the lubricated catheter 2 to 3 inches from the tip and insert the tip into the meats. When reaching the sphincter ask the Individual to take deep breaths and lower the penis

J. Keep everything within the tray to maintain sterility K. Using the swab sticks will keep one gloved hand sterile to handle the catheter. Use one downward stroke. Do not cleanse with a circular motion. L. Keep the channel f the urethra straight to allow easier passage of the catheter.

M. Be gentle as trauma to the urethra or bladder may result in cystisis. Do not force catheter entry. Deep breaths will help the Individual to relax. Lowering the penis slightly helps straighten the

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slightly. Continue inserting the catheter, urethra, which aids in easier passage into the urethra 6 to 7 inches or until of the catheter. urine begins to flow n the male the most common causes of difficult catheterization are sphincter spasm and inadequate lubrication of the catheter. In either case, if undue difficulty is passing catheter into bladder is encountered, stop procedure and notify the physician. N. Collect urine specimen for Lab as N. Letting urine flow prior to collecting ordered. Allow some urine to flow into the specimen will minimize the amount the collection container first, then into of organisms introduced from the the sterile specimen bottle. Finish catheter insertion in the specimen. The emptying the bladder into the collection amount of urine is measured for container. recording on the Intake and Output sheet. O. If more than 1000cc is obtained, O. Prevent possibility of shock clamped catheter for 15 minutes before allowing urine flow to continue. P. Upon tapping the catheter to the thigh, avoid exerting tension on the urethra. Q. Replace prepuce back into natural Q. Prevents constriction of the glans, position which could result in swelling R. Wash hands S. Record amount of urine on the I & O sheet T. Encourage Individuals with T. This will help flush the urinary unrestricted fluid intake to increase system and reduces sediment intake to at least 3000 ml per day formation Placement of balloon, catheter care, complications and gathering specimens of retention catheter. (Follow steps as outlined in this procedure, catheterization of a male Individual Section lll. A. 1-20) ACTION RATIONALE A. Use syringe filled with sterile water A. To inflate balloon and retain catheter and inject into small side tube to fill in place. balloon at catheter tip. B. Gently pull on catheter to assure balloon placement. C. Retain catheter in place as ordered. Notify the physician if pain, swelling, redness or changes in urine characteristics.

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D. Gather needed supplies and explain the procedure and its purpose to the Individual E. Provide privacy F. Assure adequate lighting for visualization of the perineum and catheter tubing G. Each shift; assess the catheter for any 0roblems of drainage or signs of infection. Check the urine drainage for mucus, blood clots, sediment, and turidity. Pinch the catheter between two fingers to determine if the lumen contains any material. H. Inspect the catheter at the ent4rance of the urinary meatus for encrusted material and supportive drainage. Also inspect the tissue around the meatus for irritation or swelling. I. Once within 24 hours clean the catheter. Put on procedure gloves. Then use a sterile gauze pad or cottontipped applicator saturated with anticeptic soap to clean the outside of the catheter and the tissue around the meatus. Observe sterile technique at all times. Apply Betadine ointment daily round the urinary meatus. J. Catheter should be changed per orders K. Empty the bag through the bottom vent into a gravity collection container. L. Never elevate the drainage bag to the bladder level or use catheter plugs.

G. Record findings in the IDN. Notify the physician if any of these conditions exist. This may warrant obtaining a urine specimen

I. To avoid contaminating the urinary tract, always clean by wiping away from, never toward, the urinary meatus. Do not pull on the catheter while cleaning, this can injure the urethra and the bladder wall and expose a section of the catheter that was inside the urthra, so that when the catheter is released, the newly contaminated section will reenter the urethra.

L. If the drainage bag is elevated above the bladder it increases the incidence of infarction and can damage the bladder wall and urethra.

Complications: A. Urethritis: some mucopurulent discharge from the meatus is to be expected. This can be minimized by daily cleaning. A. Notify the physician of any discharge, fever or tenderness.

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B. Voiding around the catheter: is indicative of an obstruction, malposition or the catheter or severe bladder spasm C. Urinary tract infection: cloudy urine, flank pain or fever can be indicative of an invasive infection or obstruction in the catheter system or the upper urinary tract. Bacteremia may occur with urinary traction infections, these symptoms include fever, often with chills, hyperventilation, hypotension and prostration. D. Accidental removal of inflated catheter balloon: requires careful attention. This can be complicated by bacteremia, severe bleeding or urethral rupture with extravasation. Gathering specimens: A. Gather supplies B. Wash hands, explain procedure to Individual C. Put on gloves D. Apply clamp to drain tube just beyond catheter connection for about 5 minutes prior to collection of specimen. E. Using alcohol sponges, clean the area of catheter between the connecting tip and side arm. F. Insert sterile needle into the catheter and aspirate 2 ccs of urine G. Withdraw needle and place urine in culture container. Cap the container aseptically and label. Place specimen container in specimen laboratory plastic bag. Send immediately to the Clinical Laboratory H. Secure needle in protective sheath and dispose in puncture resistant container. Removal of retention catheter: A. Review the physicians order

B. Notify the physician unless the problem is readily found and corrected. This may require a change of catheter. C. Notify the physician immediately if such symptoms are apparent.

D. Notify the physician immediately.

D. To allow urine to collect in catheter.

E. To prevent introduction of contamination into catheter or urine specimen. F. Be careful to avoid entering the lumen of the side arm G. Protect specimen from outside contamination that would give a false laboratory result

H. To prevent cross contamination and accidental injuries

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B. Gather supplies and explain procedure to the Individual C. Wash hands and put on gloves D. Attach a syringe to the luder-lock mechanism on the catheter. Pull on the plunger of the syringe. E. Grasp the catheter with the absorbent cotton and gently pull it from the urethra. Before doing so, place a bedpan at the bedside. F. Measure and record the amount of urine in the collection bag before discarding it G. After catheter removal assess the Individual for incontinence (or dribbling), urgency, persistent dysuria or bladder spasms, fever, chills, or palpable bladder distention

D. This deflates the balloon by aspirating the injected fluid

G. Report any of these conditions to the physician immediately

Placement and removal of in & out catheter: When the procedure is finished, gently remove catheter and discard appropriately per infection control policy. Placement and removal of condom catheter:

ACTION A. Review physicians orders

RATIONALE A. To ensure correct catheter is obtained. Catheters containing no latex are available for Individuals with a known latex sensitivity

B. Gather supplies and inform the Individual of the procedure. Select a proper sized catheter per Central Supply instructions. C. Provide privacy for the Individual. D. Put on gloves E. Follow manufacturer instructions and apply to dry skin F. Place inner flap against glands

G. Unroll the catheter up the shaft of the penis with as little wrinkling as possible H. Gently squeeze the catheter to

E. Do not use on irritated or compromised skin F. If the Individual is uncircumcised, the foreskin should remain in the natural position G. To prevent leaking

H. To ensure a proper fit and prevent

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properly seal the adhesive sheath to the skin I. Discard plastic collar

leaking I. Some brands do not have a collar. Do not push the plastic collar onto the penis.

Removal of condom catheter: A. Explain the procedure to the Individual. Put gloves on B. Condom catheter and gravity collection bag should be changed at a maximum of every 3 days, per orders or Individual somatic complaints. Nursing staff should assess the skin integrity of the penis after each condom removal and document assessment C. Slowly unroll catheter down the shaft of the penis D. Discard the used catheter and collection bag as medical waste. See ICM Section I-E Placement and care of gravity collection set and leg bag: A. Gather supplies and inform the Individual of the procedure. B. Provide privacy for the Individual C. Keeping the end of the catheter sterile remove the protective covering from the tip of the drainage tube. D. Clean the tip of the catheter with an alcohol sponge, wiping away from the opening to avoid contaminating the tube. E. If using a gravity drainage set connect the catheter

F. If using a leg bag, place the bag on the Individuals calf or thigh. Fasten the straps securely.

E. To prevent accidental contamination, when connection the catheter to the gravity drainage set the ends of both tubes should not be touched any closer than 2 inches form the end F. Leaving slack in the catheter to minimize pressure on the bladder, urethra and related structures. Almost all leg bags have a valve in the drainage tube that prevents urine reflux

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into the bladder, urge the Individual to keep the drainage bag lower than his bladder at all times because urine in the bag is a perfect growth medium for bacteria. Caution the Individual not to go to bed or take long naps while wearing the leg bag. Encourage the Individual to empty the bag when its only half full. Instruct the Individual to periodically inspect the catheter and drainage tube for kinking or compression. G. Discard at a maximum of 7 days, each time the catheter is changes and/or as ordered. Instillation of medications: A bladder instillation is performed to apply medication to the ladder lining, disinfect urine, or neutralize excess acidity or alkalinity. For this reason, it is retained as long as possible or per physicians order ACTION A. Prepare equipment and catheterize according to procedure B. Place medication into the sterile container C. When the urine stops flowing, attach barrel of syringe to the catheter and slowly pour in medication D. Pinch off catheter, leaving medication in the bladder. Remove catheter slowly and carefully E. Discard disposable equipment as directed in ICM RATIONALE

B. Maintain sterile technique

D. Prevents urethra trauma and back flow of medication E. Prevent cross contamination

RECORDING: A. In the Wellness and Recovery Notes, the person performing the procedure will record the time, procedure, condition often perineum and urinary meatus. Note the character of the urine and any sediment, condition of the catheter and the Individuals response to the procedure.

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B. On the Intake and Output record the time and amount of urine obtained C. Document Individual teaching in the Wellness and Recovery Individual/Family Heath Education Record.

INFECTION CONTROL A. Prevention of urinary tract infection is vital to the catheterization procedure. Meticulous hand washing is essential. Strict adherence to sterile technique during the procedure is also necessary. Cleansing the area around the meatus must be done in a downward motion on the male to avoid contamination of the urinary meatus. When connection the drainage bag to the catheter, the ends of both tubes should not be touched ay closer than two (2) inches from the end. B. Daily catheter care is essential. If the system is closed, it will not be accessed from the outside. If the system is open, it may be accessed. Opening of the system is discouraged and should be preceded by cleaning both ends of the tubing with a bactericide agent.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 403 Effective Date: August 31, 2006

SUBJECT: BED BATH 1. PURPOSE: A. B. C. D. E. F. G. To thoroughly cleanse the disabled Individual To promote comfort To stimulate peripheral circulation To prevent skin irritation and breakdown To assess the Individuals condition To teach good person l hygiene To promote improvised self-esteem

2. EQUIPMENT: A. Obtain from Central Supply, Pharmacy or designated storage area: 1. Wash basin (label with Individuals name and umber, if it is to be reused) 2. Lotion and soap 3. Mouth care equipment, as indicated 4. Any items related to Individuals comfort B. Obtain from Laundry: 1. Towels as needed 2. Gown or clean underclothes and clothes 3. Bed linen 4. Laundry bag (mark bag appropriately if soiled or contaminated) C. Have available: 1. Warm water 2. Laundry bag or hamper 3. PROCEDURE: ACTION A. Wash your hands. Explain the procedure to the Individual B. Offer Individual the bedpan C. Clear area to be used and arrange RATIONALE-PRECAUTIONS A. To minimize anxiety and gain cooperation B. Provides for his comfort during bath C. Eliminate unnecessary time the

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bath articles conveniently D. Wash your hands. Put on gloves. Give mouth care or offer the Individual the opportunity to brush his teeth. E. Place clean linen on a chair or other convenient location and have container for dirty linen available. F. Remove bedspread and blanket

Individual is exposed D. Protect the Individual from cross contamination

E. Organize equipment and use good body mechanics to prevent unnecessary strain F. Fold and place on chair if to be reused G. Place clean blanket across G. To provide privacy and dignity, to Individuals chest, tuck upper corners minimize the amount of shaking of the under his shoulders, or have him hold it covers and prevent the distribution of while removing the top sheet airborne bacteria and lint H. Place all discarded linen in provided H. Damp bed linen is chilling and container. Remove and discard uncomfortable. Individuals gown I. Use bath towel to protect the bed and I. Protects Individuals modesty and clean sheet from getting wet and as a comfort drape when exposing the chest and abdomen. J. Expose only the area to be washed K. Prevents chilling of Individual and protects bed from getting wet. Individual may not wish to have soap used on his face L. Fold washcloth around the hand to L. To prevent cross contamination keep the cold, wet ends from dragging across the Individual. Begin with the face and wash around the eyes without soap, washing from the bridge of the nose outward and after using a different part of the washcloth for each eye. M. Use firm gentle strokes to cleanse M. Firm strokes with gentle pressure thoroughly, especially where body stimulate the muscles, skin circulation. surfaces are in contact and body The movement of limbs and joints secretions during bathing, even passively, can be of value as exercise for the immobile Individual. N. Rinse and dry each area thoroughly N. Keeping skin clean and dry aids in before proceeding. Change bath water the prevention of pressure sores. if it becomes cold or soapy. O. Rinse and dry each area thoroughly O. Keeping skin clean and aids in the before proceeding. Change bath water prevention of pressure sores if it becomes cold or soapy P. Observe Individuals skin for P. Bacteria and yeast reproduce in rashes, discoloration, swelling, warm, moist areas.

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pressure areas, abrasions, vermin or unusual conditions. Q. Proceed in this order to bathes arms, chest, abdomen, legs and feet. Whenever possible, immerse hands and feet in basin. Give attention to nails while the cuticle is soft. R. If Individual is capable, place the bath basin and equipment within his reach and leave him while he washes his genitalia. If he is unable to do so, the nursing staff completes the bath. S. Change the bath water put the side rail that the Individual will be facing and turn the Individual to the side. Keeping Individual covered with blanket as much as possible , wash back, including the area down over his buttocks. Dry thoroughly. Apply massage lotion to back and other pressure areas. If not contraindicated (e.g. cardiac condition, ect.) and rub until dry. Put sleeve of gown on arm that is turned. T. While Individual is turned begin changing bottom bed linen making up the exposed have of the bed. Push soiled linen tight under the Individuals back. Place the clean sheet on the bed as soon as possible, and tuck side under mattress. Help the Individual turn over the clean hump of linen, and put the bed rail up. Finish putting gown on. U. Complete making up the bottom of the bed, pulling the sheet tight to remove creases and wrinkles. Change pillowscase and replace any other items related to his comfort, e.g. sheepskin, rings, or other items. Position Individual on his side or back while replacing top sheet and blanket. V. Be sure Individual is comfortable; ask what personal belongings he wants at hand and place water pitcher and cup where he can reach them. Assist Individual with personal grooming (i.e.,

Q. Immersion of hands and feet give the Individual a feeling of cleanliness and promotes circulation. Nails are easier to trim when soft. R. It is of particular importance that the genitalia be washed since this is one of the areas more likely to promote the growth of bacteria and yeast. S. Good back care is important in the prevention of pressure areas especially for Individuals who are confined to bed or have limited mobility. Provide privacy and dignity.

T. Beginning the bed making while the Individual is still on his side will eliminate the need for unnecessary use of energy. The side rail can be used for support and protects him from falling.

U. Creases and wrinkles are not only uncomfortable to lie on, but can also be a source of pressure sores.

V. Provide for Individuals needs before leaving him to reduce his dependency.

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hair), as necessary. Ensure urinal is within reach of the Individual. W. Fasten call bell where the Individual can reach it. Leave, side rails up or down as physicians orders or condition dictates. X. Take dirty laundry container and bath basin to appropriate areas for cleaning Y. Wash hands. RECORDING

W. Provide for Individuals comfort and safety. Orders should be specific in relation to some conditions, e.g. restraints X. Be alert for contaminated linen and place bath basin in designated storage area.

In the Wellness and Recovery Notes record observations and anything unusual about the Individuals condition, attitude, or behavior as well as how the Individual tolerated the procedure. Document Individual educated on Family/Individual Education form.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 404 Effective Date: August 31, 2006 SUBJECT: DRESSING CHANGE 1. PUROSE: To provide guidelines for dressing change(s) utilizing the most current, evidenced based, nursing practice techniques. 2. POLICY: All dressing changes shall follow appropriate Standard Precautions, or sterile technique, as indicated for the type of wound. 3. DEFINITION: The process, by which a soiled dressing is removed, the wound cleansed, and a sterile dressing applied. Purpose of Dressing: 1. Absorb drainage. 2. Splint or immobilized wound and surrounding tissue 3. Protect the wound from mechanical injury 4. Promote homeostasis, as by a pressure dressing 5. Prevent contamination by body excreta 6. Provide physical and mental comfort 7. Wet-to-dry dressings provide debridement 4. PRECAUTIONS: 1. The fluid blood and moist body substances of all individuals shall be treated as though they were contagious. Refer to standard Precautions (Administrative Directive), Biohazardous (Infectious) and Sharps Waste (Administrative Directive), and CALOSHA Blood Borne Pathogens Standard Exposure Control Plan (Infection Control Manual). 2. In all reasonably anticipated exposures to blood or other potentially infectious material, personal protective equipment and engineering controls shall be used. a. Protective barriers, Personal protective equipment (PPE), suck as gloves, masks, gowns, goggles, and caps, are to be worn by an employee as situation warrants for protection against a hazard.

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General work clothes (e.g. uniforms, pants, shirts or blouses) are not intended to function as personal protective equipment protection against a hazard. b. Gloves shall be worn in all cases for touching the moist body substances, mucous membranes, or non-intact skin of other persons; for performing venipuncture, finger sticks, and other invasive procedures; for handling items or surfaces visibly soiled with blood or other moist body substances. c. Engineering controls (e.g. sharps disposal containers, needleless injection systems, Safety Loc syringes, Carhill valve and bag-valve mask devices, laboratory bags) are maintained in all locations of expected exposure and replaced on a regular schedule as needed. 3. Wet-to-Dry dressings are considered a sterile procedure and sterile technique should be followed at all times during this type of dressing change. 5. ASSESSMENT: 1. Assess the extent of wound healing, any potential or present problems, and the reaction of the individual to the wound. 2. Asses the skin under the dressing frequently to ensure its integrity. Determine whether the dressing is too tight. Be alert for wrinkles in the dressing, and ensure the proper anatomical alignment of body parts. 3. Assess the allergy status of the individual. If the individual is allergic to adhesive tape, an alternate method of securing the dressing will have to be used, such as hypoallergenic or paper tape, or binder. Check for allergies to iodine (or shellfish if an iodine-based skin cleanser is used). 6. CLIENT OUTCOME / PLAN: 1. Allay fear and anxiety regarding the wound 2. Observe and evaluate the healing process 3. Prevent or reduce infection 7. EQUIPMENT: 1. 2. 3. 4. 5. 6. 7. 8. Sterile dressings as indicated Suture set (sterile tray with hemostat, forceps, and scissors) Antiseptic solution and/or medication as ordered Appropriate (Regular & Biohazardous) waste receptacle Tape (hypoallergenic, paper or adhesive) One (1) pair clean, disposable gloves, vinyl or latex One (1) pair sterile gloves One chux

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IMPLEMENTATION AND INTERVENTION: NURSING ACTION A. Check for physicians order B. Explain procedure to individual KEY POINTS A. To prevent error B. To provide understanding and ensure cooperation C. Ask the individual if he/she is C. To prevent allergic reaction and allergic to adhesive tape and if so, use further complications. Individual paper or hypoallergenic tape allergies (of all types) should be listed on the record D. Prevent contamination of the wound D. Wearing gloves has the advantage by careful hand cleansing before and of protecting both the individual and the after the dressing change. Put on clean nurse from infection. If hands become disposable globes for the procedure contaminated, hand washing shall be done after the procedure. E. Loosen tape and remove the outer dressing by touching only the outer surface and place in the appropriate waste receptacle. F. Remove the inner dr4essing with F. If the dressing adheres to the forceps and dispose of in appropriate wound if maybe moistened with sterile waste receptacle water or normal saline G. Put on sterile gloves and cleanse G. Sterile forceps may be used for this the wound with ordered solution. Work cleansing process. Maintain sterility from the center of the wound outward. during sterile dressing change Use a new sterile swab for each stroke. procedures. H. Apply ointment if ordered H. To reduce infection and promote healing I. Apply sterile dressing I. The thickness of the dressing will depend on the amount of drainage. Large bulky dressings should be avoided J. Remove gloves and place in J. Wash hands after removing gloves appropriate waste receptacle K. Leave the individual neat ad clean

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8. DOCUMENTATION: Appropriate documentation should include the following: Date and time of procedure Problem number Appearance of wound (e.g. inflammation, edema, redness, size) Character and amount of drainage Cleansing solution (if ordered), also record on MAR Ointment (if ordered), also record on MAR Individual response to procedure (e.g. cooperativeness) Client teaching and response (e.g. level of understanding), also record on Wellness and Recovery Individual/Family Health Education Record Signature and Title

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 405 Effective Date: August 31, 2006 SUBJECT: EVENING CARE OF BED INDIVIDUAL 1. PURPOSE: To promote comfort. To induce restful sleep, the bed Individual is helped to use the bedpan or urinal, to wash his face and hands and to brush his teeth. All Individuals are given back care and their beds are straightened or changed as needed. Provide a clean, safe environment for the Individual during the night. 2. EQUIPMENT: A. Obtain from Central Supply or from designated storage area: 1. Bedpan or urinal 2. Basin with warm water 3. Emesis Basin 4. Toilet and mouth care articles 5. Lotion 6. Cup of mouthwash or water 7. tissues 8. Wastes bag B. Obtain from Laundry: 1. Linen or gown as needed 2. Hand towels 3. Washcloth 3. PROCEDURE: NURSING ACTION KEY POINTS A. Assess Individual for readiness for sleep. Does he need pain medication? Is he anxious, frightened. B. Assess Individuals usual pattern when preparing to sleep, i.e. snacks, TV, listens to music C. Assess safety issues, is the C. Ask Individual to call for assistance. Individual confused, sedated, frequent May need 1:1 observation falls at night, vision problems D. Provide privacy, offer Individual D. Allows for elimination prior to

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bedpan or urinal E. Remove bedpan or urinal after use F. Wash hands and allow Individual to wash hands after using bedpan or urinal G. Provide equipment for Individual to wash hands and to brush his teeth

sleeping. Provides for Individuals privacy. E. Prevents possible spills or contamination F. Prevents contamination

G. To refresh the Individual for sleep. If he has dentures which he removes t night provide a labeled container for their safekeeping. Reduces possible periodontal disease.

Procedure for Individual who is unable to help himself: ACTION A. Turn and fluff pillow under the Individuals head. Remove extra pillows or rubber disposable rings. B. Remove restricting binders elastic stockings, ect., if allowed C. Turn the Individual on the side or abdomen, and untie gown. D. Wash back and dry. Then rub the entire back with lotion E. Observe pressure points for any signs of skin breakdown. F. Brush away any food particles. Renew under sheet, if necessary. Tighten and straighten sheets. G. Replace pillows, rings, ect., and fasten gown H. Straighten top bedding provide extra blankets, if needed. Leave the bed rolled down, unless contraindicated for Individuals condition I. Remove unnecessary equipment and leaven the room in order J. Dispose of waste and linen per Infection Control Manual. RATIONAL-PRECAUTIONS A. Provides comfort

B. Do not remove if ordered by physician. Prevents circulatory constriction. C. Use the position which provides the most comfort D. Relieves numbness and aching of back and buttocks due to sitting or laying all day E. Prevent dermal ulcers from developing F. Provides comfort and contributes to more restful sleep G. Provides comfort H. Provided comfort and a normal sleeping position

J. Be alert to contamination and contraband items.

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4. RECORDING: In the Wellness and Recovery Notes record any unusual observations and the Individuals skin condition.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 406 Effective Date: August 31, 2006 SUBJECT: EAR IRRIGATION 1. PURPOSE: To provide guidelines for the proper administration of ear irrigation 2. POLICY: 1. Ear irrigation may only be administered on the current order of a licensed physician or other licensed clinician who is legally authorized to write orders. 2. Ear irrigation may be administered by the Registered Nurse. The RN is expected to be familiar with: The Individuals diagnosis and nursing implications associated with the diagnosis, purpose of ear irrigation and its therapeutic effects, and possible untoward effects The nursing considerations for ear irrigation Method of application Individual teaching Adverse side effects Contraindications for ear irrigation 3. The RN is responsible for insuring the ear irrigation is administered safely and that the Individual, through education and therapeutic counseling is assisted to understand and participate in this form of treatment intervention. 4. The Individual is to be assessed on a continual, ongoing basis to provide the physician with data that assist in establishing the diagnosis, supports the need for ear irrigation, and identifies if a therapeutic effect is being achieved ad maintained. 3. DEFINITION: Ear Irrigation- irrigation of the external ear canal delivered through a stream of solution for removal of a foreign body, cerumen, or preventing local inflammation of the canal.

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4. COMPETENCY/TRAINING: 1. Nursing practice requires that Nursing Services staff continue to update their knowledge base concerning medications and treatments and for developing and maintaining skills that enables this staff person to administer all types of medications/treatments correctly. 2. All level of care nursing staff personnel are required to attend the Principles of Medication Administration at the time of hire and the Medication Re-certification class annually. 5. SAFETY PRECAUTIONS: 1. Inspect external ear with the otoscope to assess the condition of the canal before irrigating. DO NOT irrigate if Individual has a perforated eardrum. 2. DO NOT irrigate the ear if a foreign body such as a bean or piece of corn is present (will absorb water & make removal difficult). 3. Irrigation should be done with liquid warmed to body temperature to avoid vertigo (dizziness) or nausea in Individuals. 4. The greatest danger during administration of ear irrigation is rupture of the tympanic membrane. Fluids must not be instilled under pressure or with the ear canal occluded by the irrigation device. 5. Nursing personnel, having direct contact or the potential for contact with exposure to blood, body fluids, or other potentially infectious material of Individuals or staff, are expected to practice STANDARD PRECAUTIONS according to guidelines established by the CSH Infection Control Program. 6. ASSESSMENT: 1. Review the physicians order for the specified solution, purpose of treatment and amount of irrigation. 2. Assess Individuals level of cooperation and understanding of procedure in order to perform the procedure safely ad to provide health education. 3. Assess the external auditory canal for signs of redness, swelling, abrasions, edema, discharge, occlusion, foreign body, or tumors. 4. review medical record for history of ruptured tympanic membrane or visualize Individuals tympanic membrane using the otoscope. 5. Observe the tympanic membrane for ay abnormalities (a dull, bluish or pearly gray, translucent appearance should be present). 6. Ask the Individual if he/she is experiencing discomfort. Note Individuals ability to hear. 7. Review Individuals knowledge of purpose for irrigation and of normal care of the ears. 7. PLAN: 1. Allay the Individuals fear and anxiety

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2. 3. 4. 5.

Prevent further damage and infection to the ear Provide Individual teaching on proper care of ears Offer a thorough explanation of what will occur during the procedure Obtain the Individuals cooperation in remaining still during the examination and procedure. 6. Skin overlying the meatus and canal becomes clear, without redness, swelling, tenderness or discharge. Canal is clear of cerumen and foreign material. 7. Warn Individual that the irrigation may cause sensation of dizziness, ear fullness, and warmth. 8. EQUIPMENT: 1. 2. 3. 4. 5. Obtain prescribed irrigating solution Curved basin, towels, & cotton balls Otoscope Disposable Gloves Water pic is used in the clinic for ear irrigation on the lowest pressure setting 6. Syringe-type: 4oz. stainless steel 9. IMPLEMENTATION AND INTERVENTIONS: NURSING ACTION KEY POINTS A. Wash hands before and after A. Reduces transfer of procedure, arrange supplies and apply microorganisms, helps the nurse to gloves perform procedure smoothly. B. Assist Individual to a sitting or lying B. Position minimizes leakage of fluids position with head turned toward around neck and facial area. Solution affected ear. Place towel under will flow from ear canal to basin Individuals head and shoulder and have the Individual hold basin under affected ear C. Gently clean auricle and outer ear C. Prevents infected material from canal with moistened cotton applicator. reentering ear canal. Do not force drainage or cerumen into the ear canal. D. Examine ear(s) prior to procedure D. Findings provide baseline to monitor effects of medication or solution E. Place a rounded speculum on the E. The larger speculum provides better end of the otoscope. Use a speculum visualization that will comfortably fit into the external auditory canal. Check to see that the light is working. F. Gently pull the pinna Upward and F. Pulling the ear and inserting the

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Backward. Insert the speculum just inside the external opening. To visualize the entire canal, tilt the otoscope and change body position

G. Fill irrigating syringe with solution (approximately 50ml.) H. Slowly instill irrigating solution by holding the tip of the syringe 1cm above the opening to the ear canal. The fluid should be directed toward the superior aspect of the ear canal. Allow the fluid to drain out during instillation. Continue until canal is cleansed or solution is used I. Do not occlude the canal with the tip of the syringe. J. Irrigate until return fluid is clear or as ordered. Examine contents of basin and clean K. Dry outer ear canal with cotton ball. Leave cotton loosely in pace for 5-10 mins. L. Remove towel and leave Individual comfortable M. Emphasizes the importance of keeping foreign/sharp objects out of ears N. Clean all reusable equipment with soap and water, detergent, or bleach solution. Return equipment and discard disposable gloves/supplies visible soiled in the biohazards waste container. 10. EVALUATION: Documentation in IDN should include:

speculum along normal curves of the canal will minimize discomfort and the chance of trauma. DO NOT continue procedure if visualization of tympanic membrane is reddened, perforated, or foreign object is visualized. Contact the physician for further evaluation. G. Enough fluid is needed to provide a steady irrigating stream. H. Slow instillation prevents buildup of pressure in the ear canal and ensures contact of the solution with all canal surfaces. Discontinue treatment if Individual complain of severe pain, nausea, dizziness, or faintness.

I. Build up of fluid in canal under forced pressure could cause rupture of the tympanic membrane

K. Maintains comfort. Absorbs excess moisture in ear canal

N. Reduces transmission of infection.

1. After administration of ear irrigation, the Individual should be observed for desired results, expected side effects, and untoward reactions. 2. Observe, report to physician, and record in the ID Notes any adverse reactions and, or unexpected outcomes.

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3. Re-inspect condition of meatus and canal to determine if solution relieves symptoms and removes foreign materials 4. All treatments given must be charted on the Treatment record within one hour of administration 5. Document all Individual teaching in the IDN of the procedure, amount of solutions instilled, time of administration and ear receiving the irrigation.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 407 Effective Date: August 31, 2006 SUBJECT: COMPRESS FOR THE EYE- HOT AND COLD 1. PURPOSE: To provide proper guidelines for application of hot, warm or cold compresses to the eye. 2. POLICY: Licensed nursing staff shall initiate application of hot, warm or cold compresses to the eye to alleviate pain and discomfort, promote healing and prevent hemorrhage into the tissue with or without physicians order in emergency. Compresses shall be applied for 10-20 minutes bid to tid or per physicians order. Compresses are to be applied with clean clothes and not directly to the eye. Do not apply compresses to open laceration to prevent infection or further injuries to the eye rather ply an eye patch. 3. DEFINITION: Hot or warm compress are applied to the eye to clean and remove crust, expedite healing, relieve discomfort and inflammation. Cold compress is applied to the eye to controledema, ecchymosis, itching irritation and promote comfort. 4. COMPETENCY AND TRAINING: All level of care licensed staff are trained to apply hot, warm or cold compresses to eye during FIRST AID training at time of hire and subsequently every three years. 5. PRECAUTIONS: 1. Hot, warm or cold compresses shall only be used as indicated for specific conditions or as per physicians order. 2. Do not use cold compress to treat an eye infection 3. Do not apply ice directly to the eye. Ice cubes must be wrapped. 4. The fluid blood and moist body substances of all Individuals shall be treated as though they were contagious. Refer to Standard Precautions

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Administrative Directive and Biohazardous Wastes Administrative Directive. 6. ASSESSMENT: Assess the need for hot, warm or cold compress and review physicians order as applicable. Assess the need for Individuals education, cooperation and ability to understand. Assess Individual level of anxiety and provide reassurance. 7. EQUIPMENT: 1. Two (2) clean washcloths or sterile 4x4 sponges and two (2) non-sterile gloves. 2. Basin from Central Supply. 3. Warm and hot compress. 4. COLD: Cold compress &/ice cubes. Ice cubes should be wrapped, and never exposed directly to any tissue. 5. Towels (1-2). 6. Thermometer (utility). 8. IMPLEMENTATION AND INTERVENTION: Hot/warm compresses to the eye: NURSING ACTION A. Check physicians order B. Wash hands with soap and water C. Identify the Individual D. Position Individual supine with one pillow E. Explain the procedure to Individual F. If only one eye is affected turn Individual to affected side G. Place towel under head H. Apply gloves and place warm or hot compresses gently over closed eyelid of the affected eye. I. Repeat as applicable J. Instruct Individual to keep hands away from eyes K, Provide a soothing quiet environment L. dispose of compresses and gloves in biohazardous waste container KEY POINTS A. To prevent error and administer proper treatment B. Standard precaution C. Always identify by the I.D. photo

F. To prevent any solution from entering the non-affected eye G. To protect pillow and bed

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Cold compresses to the eye: A. Check physicians order B. Wash hands C. Identify the Individual D. Position Individual supine with one pillow D. Explain the procedure to the Individual E. If only one eye is affected turn to affected side F. Place towel under head G. Apply cold compress or wrap ice cubes in clean cloth H. Place cold compress or wrapped ice cube gently over closed eyelid of affected eye I. When ice melts or compress becomes warm, repeat process for time ordered by physician J. Remove encrustation on eyelid with moistened sponges as they become softened K. Instruct Individual to keep hands away from eyes L. Provide a soothing, quiet environment conducive to relaxation and treatment process M. Clean all reusable equipment with soap and water, detergent, or bleach solution and return to Central Supply. Discard soiled gloves and supplies in biohazardous waste container. 9. EVALUATION: Documentation should include: 1. 2. 3. 4. 5. Problem number Date & time and reason for treatment Individual response to treatment. Signature and title of employee All Individual teachings done and Individuals level of understanding Signature of employee with title A. To prevent error and administer proper treatment C. Always identify by the I.D. photo

D. to allay fear and apprehension E. to prevent any solution from entering the non-affected eye F. To protect pillow and bed

H. To reduce inflammation, pain and promote healing I. Maintain desired temperature.

J. To avoid injury. Do not rub aggressively or pull at hard encrustation

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 408 Effective Date: August 31, 2006 SUBJECT: EYE IRRIGATION 1. GENERAL: In an emergency situation when a chemical has accidentally been introduced into the eyes this is deemed a medical emergency. A physicians order is not required when a chemical has accidentally been introduced into the eyes. Irrigation should never be delayed. Immediate and prolonged washing with plain water will prevent scarring of the cornea more effectively than any other treatment. If possible, irrigation of the eye should continue while transporting Individual to Unit 1, Urgent Care Room (UCR). 2. PURPOSE: A. To remove secretions from the conjunctival sac (only small amounts of solution are required) B. To treat infections, using a prescribed solution C. To relieve itching and swelling D. To provide moisture on the surface of the eyes of an unconscious Individual E. To irrigate chemicals or foreign bodies, from the eye (large amounts of solution are required) 3. EQUIPMENT: Obtain from Pharmacy, Central Supply, Storeroom, and/or Laundry: Normal saline solution or other ordered irrigating solution kept at room temperature Sterile gauze (4x4s) Emesis basin Facial tissues Pad to protect bed Bag for waste material Bath towels Disposable gloves

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4. PROCEDURE: NURSING ACITON RATIONAL-PRECAUTOINS A. Explain procedure and purpose to A. To allay anxiety Individual B. Wash hands, wear disposable gloves C. The Individual may sit or lie down C. To make Individual comfortable D. Have Individual tilt head toward the D. To prevent cross contamination to side of the affected eye unaffected eye E. Wash eye ICSHes and lids with E. Any materials on the lids or ICSHes prescribed solution at room can be wasted off before exposing temperature; place a curved basin on conjunctiva. the affected side of the face to catch the outflow F. Evert the lower conjunctiva sac. (If F. The inner part of the lower lid is less feasible, have Individual pull down sensitive than the cornea. (This lower lid with his index finger.) involves the Individual and gives him a sense of control. G. Instruct Individual to look up; avoid G. To prevent eye injury, never touch touching eye with irrigating implement cornea H. Allow irritating fluid to flow from the H. This prevent s the solution from inner canthus to the outer canthus flowing toward the lachrymal sac, duct, along the conjunctiva sac. and nose (which would aid in transmitting an infection) I. Use only enough force to flush secretions from conjunctiva (allow Individual to hold basin near the eye to catch fluid) J. Occasionally have Individual close J. This allows upper lid to meet lower his eye lid with the possibility of dislodging additional particles. K. Pat and dry Individuals face with K. Makes Individual comfortable. Avoid gauze putting pressure on the eyeball L. Warn Individual against rubbing L. To prevent further irritation eyes M. Examine contents of basin and M. Look for particles, mucus, ect empty (document any findings) N. Discard disposables in proper N. Be aware of contaminated and containers contraband items

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5. RECORDING: In the Wellness and Recovery Note: A. If this is an ordered treatment, record in the Treatment Record, time, treatment, amount ad type of solution used. B. When used as a first aid measure, record time, treatment, amount and type of solution used, character of return and flow and the effect on Individual. Refer to physician for evaluation and treatment.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 409 Effective Date: August 31, 2006 SUBJECT: WARM FOOT SOAKS 1. PURPOSE: This policy will provide guidelines for the safe administration of warm foot soaks, as ordered, to those individuals who are assessed to have a need for: a) relief from muscle spasms, b) relief from pain or inflammation, or c) need to have calluses and/or toenails softened in a therapeutic and safe manner. 2. POLICY: 1. A prerequisite to using ay heat application is a physicians order which should include the body site to be treated and the type, frequency, and duration of application. 2. When medication is to be added to the foot soak, the treatment nurse will follow the physicians order and as directed by pharmacy or label on the box. 3. GENERAL INFORMATION: Immersion of a body part in a warmed solution promotes circulation, lessens edema, increases muscle relaxation, and can provide a means to debride wounds and apply medicated solution. The nurse positions the individual comfortably, places waterproof pads (Chux) under the area to be treated, and heats the solution to about 40.5 to 43 C (105 to 110 F). After immersion of the extremity it is usually necessary to remove the cooled solution and add heated solution after about 10 minutes. 4. PRECAUTIONS: Keep the solution at a constant temperature. Never add a hotter solution while the body part remains immersed. In no case shall any water be used for foot soaks that exceed 110 F. 5. EQUIPMENT: 1. Foot tub (filled with a sufficient amount of water to cover the feet) 2. Pitcher filled with water

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3. 4. 5. 6.

Utility thermometer Bath towel Medication as ordered by physician (e.g. Epsom salts) Gloves

6. IMPLEMENTATION AND INTERVENTION: NURSING ACTION KEY POINTS A. Check physicians order for desired A. Ensures safe use of moist heat solution, body part to be soaked, and desired temperature. B. Wash hands B. Reduces transmission of microorganisms C. Identify the individual using two C. Use individuals photo I.D. and one forms of identification other form to be certain of identity D. Explain procedure to individual D. Minimizes individuals anxiety and promotes cooperation during the procedure. Promotes health care education for effective foot care. E. Check the temperature of the water E. This must be done to prevent burns. in the foot tub Plant Operations maintains the hot water temperature between 105 to110 Notify the Shift Lead if the temperature falls out of this range. F. Add medication if ordered F. Follow mixing of solution as directed by Pharmacy or label on the medication box. Apply as per physicians orders. G. Assist the individual as needed with G. Prevents falls immersing his/her feet into the tub H. Maintain temperature constant H. Therapeutic effects of soak can throughout soak for 15 to 20 minutes. only be obtained from constant temperature I. After 10 minutes, remove body part, I. To prevent burns and insure safety, empty cooled solution, add newly prepare fresh, warm solution and follow heated solution, and re-immerse body steps previously identified in #5 and #6. part. J. After 15 to 20 minutes, unless J. Ensure complete dryness specific time frame ordered for treatment, remove individual from soak. Thoroughly dry the feel with bath towel. (Clean gloves are required if drainage is present) K. Drain solution from basin. Clean all K. Reduces transmission of equipment with detergent-germicide microorganisms solution and place in proper storage

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area. L. Teach the individual the principles of good foot care.

L. Stress the importance of proper footwear. Individual teaching should include a daily change of clean socks and foot washing with thorough drying.

7. EVALUAITON AND DOCUMENTATION: 1. Date and time. 2. Problem number. 3. Record type of procedure performed, location, and duration of application. Note temperature used. 4. Describe condition of skin, note any unusual conditions (i.e. ingrown toenails, lesions, ect). 5. Document individuals response to therapy. 6. Health care education provided. 7. Signature and title of employee. 8. Report all individual complaints and any unusual observations at Change of Shift Report.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 410 Effective Date: August 31, 2006 SUBJECTS: TUBE FEEDING (NASOGASTRIC) 1. EQUIPMENT: 1. 2. 3. 4. Feeding ordered by physician 50ml of water Absorbent pad Gavage bag with tubing and flow regulator clam (if a gavage bag is unavailable, us a bulb syringe or a catheter tip syringe) 5. 50ml syringe 6. Stethoscope 7. Gloves 8. Basin 9. Suction source 10. I.V. standard 2. PREPERATION OF EQUIPMENT: A. After obtaining from the pharmacy, the unopened cans of formula may be stored and are to be administered at room temperature. Hot formula may coagulate formula proteins and clog tubing. Heat may change the chemical composition of the formula. It may burn or irritate gastric mucosa. Chilling the formula is avoided because it increases viscosity of the liquid, which may clog the tube. Cold formula may also cause vasoconstriction, which reduces the flow of gastric digestive secretions, which may cause cramping, nausea, vomiting and distention. B. Wash hands C. Close the gavage-tubing clamp and pour the appropriate amount of formula into the gavage bag. Squeeze the drip chamber and fill half way. Remove the cap from the distal end of the tubing. Open the clamp and run the formula through the length of tubing and clamp the tubing. D. All air in tubing is removed so that it does not enter the Individuals stomach and cause distention and discomfort. 3. PROCEDURE: NOTE: if Individual shows any signs of respiratory distress discontinue feeding immediately and re-assess placement of feeding tube and Individual status.

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NURSING ACTION A. Approach and identify Individual. Explain the procedure and provide privacy B. Wash hands C. Bring assembled equipment to Individuals room maintaining a clean technique. D. Elevate the head of the Individuals bed to semi-fowlers or high position unless contraindicated E. Place towel or Chux on Individuals chest F. Put on disposable gloves G. remove cap or plug from distal end of feeding tube and use syringe to inject 10-15 ml of air through the tube while auscultating the Individuals stomach with a stethoscope H. Aspirate stomach contents I. Re-install the aspirated stomach contents into the stomach J. NEVER GIVE A FEEDING UNLESS YOU ARE SURE THE TUBE IS PROPERLY POSITIONED IN INDIVIDUALS STOMACH K. Gavage Bag Feeding a) Connect the gavage feeding bag tubing to the feeding tube. Depending on the type of tube used you may need an adapter to connect the two tubes. b) Open the regulator clamp on the gavage bag tubing and adjust the flow rate. c) Initially administer feeding slowly & increase rate as tolerated. d) After administering the appropriate amount of feeding flush the tubing

RATIONAL- PRECAUTIONS A. To gain Individual confidence and lessen anxiety and embarrassment. Assure Individuals identity B. To avoid cross contamination C. The equipment need not be sterile. Since the stomach is not a sterile cavity, however, clean technique is necessary D. Prevent aspiration of feeding by gastroesophageal reflex and to aid digestion E. Protect Individuals gown from spillage F. Prevent cross contamination G. To check tube patency and position. To be sure it has not become displaced. Listen for hissing or gurgling sound (air passing through the stomach) H. Confirm proper position and patency of the tube I. To prevent the loss of electrolytes ad gastric juices J. Administering a tube feeding through a misplaced tube can cause formula to enter the lungs leading to suffocation and death K. To prevent air from entering stomach. Prevents sudden stomach distention, which can cause nausea, vomiting, cramps, or diarrhea. Maintain tube patency by removing excess sticky formula, which could occlude the nasogastric tube. To prevent air from entering the stomach causing gastric distention.

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with about 100ml of water e) Close the regulator clamp on the gavage bag tubing. L. Catheter Tip Syringe f) Attach the syringe to the feeding tube g) Fill the syringe with formula and allow formula to flow through. The height at which you hold the syringe will determine flow rate. When the syringe is empty, pour more formula into it. h) Disconnect the syringe from the feeding tube and plug off nasogastric tube M. Kangaroo Pump Place amount of formula in Kangaroo Pump gavage bag. Check patency of tube following N.P. 328. Set up pump to rate as ordered by Physician. N. Observe Individual & respiration throughout the procedure O. Cover the end of the feeding tube with its plug or cap. Then release the tubing or clamp on the tubing. Secure tubing. P. Leave the Individual in semi- or high-fowlers position for at least 30 minutes Q. Rinse all re-usable equipment with warm water and store in a brown paper bag labeled with the Individuals name. R. Change feeding/equipment every 24 hours S. Wash hands SPECIAL CONSIDERATION A. When ready to administer, shake the can well immediately before opening. Once opened, dispense the prescribed volume and discard any unused formula.

L. Prevent excess air form entering the stomach, causing gastric distention and discomfort. Prevent air from entering stomach. NOTE: No more than 500 cc of fluid is given at one time.

O. To prevent leakage and tube contamination

P. To prevent gastroesophageal reflux and to aid digestion. To prevent aspiration and suffocation. Q. To prevent bacterial growth

R. to prevent bacterial growth S. To prevent infection RATIONAL-PRECAUTIONS A. Agitation corrects separation, which could alter the content of the planed feeding and potentially clog the tube. Immediate use and discard ensures the formula is not a vehicle for microbial contamination/growth.

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B. Aspirate stomach contents 2 or 3 hours

C. During continuous feeding, assess the Individual frequently for abdominal distention. D. If diarrhea occurs, notify the physician so that the underlying cause can be determined and corrected, e.g., alternating the prescribed medications, changing the formula and/or administration rate/volume, switching to a fiber containing formula, administering antidiarrheal medication, or correcting a low serum albumin. Also ensure that proper infection control and equipment practices are being followed. E. If constipation occurs, notify the physician so that the underlying cause can be determined and corrected , e.g., altering the formula, adding fluids, ordering a bulk forming laxative, increasing Individual activity, or changing a medication. F. Assess hydration and increase fluid intake as necessary if fluids are not contraindicated. G. Drugs may be administered through the feeding tube, except for entericcoated drugs. Crush tablets or open and dilute capsules in water prior to administering. Flush the tubing with water after administering drugs. H. Monitor blood glucose to assess glucose tolerance. Also monitor serum electrolytes and other blood studies as ordered by the physician.

B. a) To verify adequate gastric emptying and decrease vomiting and aspiration . b) To maintain acid-base balance. c) The nutritionist will be able to calculate the caloric intake accurately by knowing the amount of feeding returned. C. Distention may cause nausea, vomiting and is uncomfortable. D. Diarrhea is the most common complication. Common causes are: too high infusion rate or volume, lack of fiber, altered gastrointestinal flora (e.g. due to medication or contamination), hypoalbuminemia, or hyperosmolar solutions (Isotonic formulas are best tolerated.)

E. Irregular bowel movements can result from the low fiber content of the formula, inadequate fluids, medication or lack of activity. The feeding should be stopped and evaluated if obstruction is suspected. F. Dehydration may cause constipation G. Avoid need for discomfort of I.M. Injections

H. To determine response nutritional support.

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4. DOCUMENTATION: A. Document the feeding on the Medication Administration Record (MAR) including: 1. The time the food product was opened & administered 2. The amount and type of formula given 3. The amount of water given 4. The time(s) that the tubing was changed B. Record total I. & O. don the Intake and Output flow sheet C. Record amount of residual feeding aspirated and returned on the IDNs. D. In the IDNs record the placement and patency of the tube, the amount of residual feeding (if any), the Individuals reaction to and the tolerance of feeding, including any cramping, diarrhea or abdominal distention. Also note the results of blood tests. REFERENCE: Nutrition Care Manual Feeding and Liquid Supplements

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 411 Effective Date: August 31, 2006

SUBJECT: PEG FEEDINGS/GASTROSTOMY 1. PURPOSE: To provide safe, continuous or intermittent PEG (Percutaneous Endoscopic Gastrosomy) tube feedings to supply the body with nutrients and fluids to promote healing, fend off infection, and sustain organ function, without complication. 2. POLICY: 1. PEG or Gastrostomy tube feedings are to be done by licensed Nursing staff. 2. Notify Dietician for Health Risk Assessment by sending the Referral for High Risk Nutritional Screening CSH. 3. GENTERAL INFORMATION: 1. Individuals who have an intact functional GI tract, but are unable to consume adequate calories to meet metabolic needs, are the types of Individual your unit may receive with a PEG tube. A PEG tube is a type of Gastrostomy tube. A PEG tube however is sutured in place where a regular Gastrostomy tube may only have a balloon holding it in place. The basic Nursing care remains the same for both. PEG tubes are being seen more often as their placement is less invasive than the regular gastrostomy tube. 2. The liquid nutrient solution used for gastric tube feedings comes in various formulas. Tube feeding solutions are usually installed intermittently but may be given continuously. 3. Tube feedings contraindicated in Individuals with absent bowel sounds, suspected intestinal obstruction, ad intractable vomiting. Tube feedings formulas are supplied by the dietary department to the program dining facility. The formulas may be stored un-refrigerated until opened. Must be refrigerated after opening and contents must be used within 24 hours or what remains must be discarded within 24 hours. The formula/water strength will be prepared by the nursing staff per physicians order just prior to actual start of feeding. If the strength of the formula is changed by

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the physician, let the formula run out at prescribed rate and then prepare and deliver the new feeding according to the new physicians order. 4. Frequent or large volume feedings can cause bloating and retention. Dehydration, diarrhea, or vomiting can cause metabolic disturbances. Glycosuria, cramping, and abdominal distention usually indicate intolerance to feedings. 5. If diarrhea occurs with tube feedings, decrease rate to last tolerated level. Also, assure that the feeding is not cold and that proper storage and sanitation practices have been followed. Diarrhea may also be secondary to infection caused by enteric pathogens like Clostridium difficile, predisposing illness like diabetes or Crohns disease, intestinal atrophy, motility disorders, and partial bowel obstruction. Notify a physician. 6. If constipation occurs a more diluted concentration may be needed. Check with the physician. Alert the Dietician. 4. PRECAUTIONS: Nursing personnel, having direct contact or the potential for contact with exposure to blood, body fluids, or the potentially infections material of Individuals or staff, are expected to practice STANDARD PRECAUTIONS according to guideline established by the CSH Infection Control Program. 5. INDIVIDUAL PREPARATION: 1. Assess the knowledge/anxiety level of the Individual when deciding how much preparation is needed. 2. Explain the procedure to the Individual. This helps allay the Individuals anxiety. 6. EQUIPMENT: 1. 2. 3. 4. 5. 6. Feeding formula and free water (as ordered by physician) Tap water flush 60cc or less Stethoscope Towel Feeding formula bag if applicable 60cc cath tip syringe (replace ever 24 hours)

7. PROCEDURE: NURSING ACTION A. Wash hands before and after procedure. B. Assist Individual to semi-fowlers position. Provide privacy. C. Explain procedure to Individual in KEY POINTS A. To prevent infection B. To promote digestion and prevent Esophageal reflux C. To gain Individual cooperation.

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way he or she will understand. Expose tube. Place basin under tube. Remove plug or clamp. D. Remove plunger of syringe. Hold barrel of syringe and place the catheter tip in to opened plug of the Gastorstomy tube. Slowly pour tap water flush (as ordered by physician). Cap and secure Gastrostomy tube to area of comfort for the Individual. E. Once ordered amount of feeding is instilled, remove cath tip, flush Gastrostomy tube with 60cc or less (as ordered) into barrel or syringe. Allow water to flow in by gravity. F. Clamp the tube and remove syringe. Rinse and insert plug back in place if any. G. Apply dressing over gastrostomy tube site and secure H. Instruct Individual to rest quietly for about hour in sitting position to prevent leakage and gastric reflux. I. Clean equipment and wash your hands to prevent infection. Document amount of solution and level of Individual tolerance including residuals if ordered J. Just prior to each feeding, check for residual amount of feeding left in the stomach.

Maintain right of privacy. Discard dressings if any D. If no resistance, pour ordered amount of formula into barrel of syringe and allow to flow in by gravity. Give slowly and tilt syringe to remove air bubbles. DO NOT FORCE.

E. To remove particles and solution from tube; to promote patency flush with water before and after feeding.

F. Avoid air-entering stomach

G. To avoid skin irritation H. Tape date and time on feeding syringe to know when to discard. Syringe is replaced every 24 hours to prevent bacterial growth I. Document skin condition around site and any interventions to maintain skin and integrity. Do not ignore any signs of skin breakdown. Take appropriate action as clinically indicated. J. The Med/Surg physician may order residual frequency and parameters to be followed if amount of residual is evident, hold feeding and notify physician. A clue that your Individual may require a pump instead of a bolus feeding is that he or she may have diarrhea or abdominal discomfort after a bolus feeding. Consult with the Med/Surg physician or the MOD if these symptoms occur.

8. CLINCAL COMPETENCY: Unit Supervisor will insure clinical competence of licensed nursing staff providing this procedure.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 412 Effective Date: August 31, 2006 SUBJECT: TREATMENT OF PEDICULOSIS (LICE) AND SCABIES 1. PURPOSE: This policy shall provide guidelines for nursing personnel, in collaboration with the Med/Surg physicians and Public Health staff, in the care ad treatment of Individuals with the parasitic infestation of lice or scabies, to prevent infestation of others, and to prevent occurrence of re-infestation through effective health teaching. 2. POLICY: 1. When Pediculosis or Scabies is suspected, contact the Med/Surg physician ad request examination to confirm the diagnosis. These conditions are rarely emergent and can usually wait for examination by the unit Med/Surg physician. 2. Due to specific required guidelines, consult the Public Health Officerwith all issues. 3. Effective treatment for lice/scabies infestation requires a physicians order for medication 4. Permethrin should NOT be stockpiled on units. It should be ordered only in amounts needed to treat specific Individual(s). 5. It Nits are found on eyebrows/eyelashes, contact physician for appropriate ophthalmic ointment. 6. If irritation or sensitization occurs after application of medication, discontinue use and do immediate, thorough washing with water and notify physician. 7. Prior to use of Ovide as alternative to Nix, check Individual for sensitivity to the product or any of its components. 8. If Ovide is used, warm Individual to stay away from lighted cigarettes, open flames, electric heat sources while hair is wet. Ovide lotion is flammable. 3. DEFINITION: Pediculosis is the infestation of human beings by lice (Pediculosis humanus, var. capitis or corporis or Phthirus pubis). Scabies is an infectious disease of the skin produced by the burrowing action of the human parasitic mite (Sarcoptes scabiei).

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4. EQUIPMENT: 1. 2. 3. 4. 5. 6. Fine tooth comb Medication prescribed by physician Appropriate linen receptacle Cotton-tipped swabs/applicators two bath towels Wash cloth or face towel (to assist with shielding eyes from shampoo)

5. IMPLEMENTATION AND INTERVENTION (For all Infestations): NURSING ACITON A. Check physicians order KEY POINTS A. To prevent error and to ensure proper treatment to the type of parasitic infection B. Always identify by I.D. photo C. Stress the importance good hygiene to prevent recurrent attack D. Follow NPPM Handling Procedures for Linen and Clothing and A.D. Standard Precautions E. Contacts need to be investigated and treated. Public Health Nursing will provide consultation on contact investigation and infection control precautions.

B. Identify the Individual C. Explain the procedure to Individual D. Bag all exposed dirty clothing, bed linens, and towels as contaminated linen. E. Follow reporting procedures Administrative Directive Reporting of Diseases/Conditions. Notify Public Health and NOD.

6. PEDICULOSIS CAPITIS (HEAD LICE): Pediculosis capitis (head lice) refers to infestation of the head, eyebrows, eyelashes, and beard caused by Pediculosis humanus var. capitis. Clinical features include minute white nits (eggs) attached to hair shaft in series usually on the occipital and temporal areas of the scalp. Saliva of the louse produced marked itching with resultant excoriation. Secondary infection with crusting may occur with osterior occipital nodes being enlarged and tender. The head louse is a small, elongated insect 2-3 mm in length and is usually found grasping the hair shaft near the scalp with its specially adapted claws. Treatment: Permethrin 1% (Nix) Cream Rinse is used. It is a synthetic pyrethroid. After a regular shampoo, towel dry the hair, then apply the Permethrin Crme Rinse. Saturate the hair and scalp for 10 minutes followed by rinsing. Nits

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should be combed after treatment. One application of Nix should be adequate if procedure is followed meticulously. If live lice persist seven days after treatment, a second application may be performed. Treatment with Nix may temporarily exacerbate pruritus, erythema, edema of scalp. Use (Malathionbased) Ovide, which is applied for 8-12 hours fro treatment failure. Treatment failure refers to continued presence of live lice 7 days after the second treatment with Permethrin 1%..

NURSING ACTION KEY POINTS A. Thoroughly wash hair with regular A. Permethrin (Nix) is intended for use shampoo, rinse with water, and towel after hair has been washed with regular dry shampoo. B. SHAKE WELL BEFORE USING. B. A single treatment is sufficient to Apply a sufficient volume of Nix to eliminate head lice in 99% of all saturate the hair and scalp. Nix should Individuals. Nits are usually killed and remain on the hair for 10 minutes will not hatch. Remove nits with fine before being rinsed off with water. tooth comb after hair is dry C. If Ovide is used for treatment C. Hair should remain uncovered and failure, it should be applied on dry hair should be allowed to dry naturally after in amount just sufficient to thoroughly Ovide application. After 8-12 hours, the wet the hair and scalp hair should be shampooed with regular shampoo and rinsed. Using a fine tooth comb, remove dead lice and eggs. If lice are still present after 7-9 days, repeat with a second application of Ovide. D. Follow CONTACT ISOLATION D. Wear gloves while handling infected requirements got pediculosis for 24 material. A separate room may be hours after start of effective therapy considered but is not necessary E. Bag all clothing, bed linens, towels, E. Use appropriate yellow infectious ect., which have come into contact with (contaminated) linen bags. See A.D. the infested person, particularly hats, Standard Precautions and NPPM headbands, pillowcases, towels, and Handling Procedures for Linen and other articles, which may have had Clothing. Only authorized staff should contact with the hair bag and deliver infectious linen. F. Clean Individual combs, brushes, F. If any material (e.g. gross dirt or oil) curlers, ect., thoroughly with hot, soapy is left on items, disinfection will not be water. Rinse, and then immerse and effective. Refer to NPPM- Disinfection soak in a solution of isopropyl alcohol. of Commonly Shared Grooming Allow to air dry. Supplies. G. Examine all other Individuals on the G. Consider treating those without unit for head lice or nits and those visible evidence of infection who have Individuals from other units who may shared hats, towels, pillows, combs, or have shared hats or towels. have had head to head contact. Request treatment orders for all with

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H. Follow reporting procedures of A.D. Reporting of Diseases/Conditions Notify Public Health and the NOD I. If still not effective after the second Ovide treatment, consult with the Public Health Office.

visible lice or nits. H. Public Health Nurse will consult on infection control measures.

7. PEDICULOSIS CORPORIS (Body Lice): Pediculosis corporis (body lice) refers to the infestation of the body caused by Pediculus humanus var. corporis. The body louse lives in the seams of the undergarments but feeds on the skin. The nits may remain viable for one (1) month. Clinical appearances are long pruritic excoriation on the body. Bites from body lice cause characteristic minute hemorrhagic points on the skin. Treatment: Pediculoss corporis may be treated with compete bathing, and washing the linen and clothing in very hot water. Laundering of clothing in which the lice ad their nits are found should be above 52C (126F) for ten minutes or discard the clothing when practical. No medication ordinarily needs to be applied to the skin or hair. NURSING ACTION A. Have Individual take a warm bath. If crusted lesions are present they should be soaked in warm water. KEY POINTS A. Crusted lesions may represent a secondary bacterial infection, so consult physician. The use of pesticide shampoo or lotions is usually unnecessary since these lice live in clothing, not the skin. B. Good hygiene is the best prevention of body lice C. Use appropriate yellow infectious (contaminated) linen bags. Hot water laundering is the primary treatment of body lice. D. Ask physician to confirm diagnosis. Examine entire unit.

B. Have Individual put on clean clothing. Change all bedding and towels. C. Bag all clothing, bedding, and towels, which have come into contact with the Individuals skin D. Examine the skin and inner seams of clothing which contacts skin of other Individuals who have had close contact or share clothing with infected person for lice or nits. E. Follow CONTACT ISOLATION requirements for pediculosis for 24 hours after start of effective therapy.

E. Masks are not needed. Wear gloves when handling infected material. A separate room may be considered but

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F. Follow reporting procedure of A.D. Notify Public Health and NOD

is not necessary. F. Contacts who are suspected to have exchanged clothing, need to be investigated and treated y the above method (no medication necessary). Public Health Nurse will consult on infection control measures and contact investigation

8. PEDICULOSIS PUBIS (Pubic Lice Crabs): Pediculosis pubis (pubic lice or crabs) refers to investation of the perineal area caused by Phthrius pubis. Chief symptom is marked as itching of all affected areas. Lice may infest pubic, chest, axillary hair, beard, and eyeICHSes. Reddish brown dust formed from excretion of the insects may be found on the underclothing. Erythematous macules and papules with excoriation and secondary infection may be seen. Pediculosis pubis may be more resistive to treatment. The nits are difficult to remove from areas with heavy hair growth. It is most commonly sexually transmitted. Treatment: Permethrin 1% (Nix) Cream Rinse is used for treating both head and pubic lice. It is a synthetic pyrethroid. After a regular shampoo, towel dry the hair, then apply the Permethrin Crme Rinse. Saturate the hair and scalp for 10 minutes followed by rinsing. Nits should be combed or removed by forceps after treatment. One application of Nix should be adequate if the procedure is followed meticulously. If live lice persist seven days after treatment, a second application may be ordered. Treatment with Nix may temporarily exacerbate pruritus, erythema, or edema of scalp. Emphasize the need for treatment of sexual partners to prevent re-infestation. NURSING ACTION A. Apply a sufficient quantity of the medication to the dry hair and skin of the pubic area; (include chest, axillary hair and beard if infected) KEY POINTS A. Sexual contacts with affected Individual should be treated simultaneously. Arrange this with physician. DO NOT APPLY MEDIATION to eyebrows/eyelashes. Get a prescription for appropriate eye ointment. B. Masks are not needed. Wear gloves when handling infected material. A separate room may be considered but is not necessary. See Section 12 under Disease Specific Isolation Precautions regarding appropriate

B. Follow CONTACT ISOLATION requirements for pediculosis for 24 hours after start of effective therapy.

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isolation precautions. C. Have Individual put on clean clothing. D. Bag all clothing, bed linens, towel, D. Use appropriate yellow infectious ect., which may have come into contact (contaminated) linen bags. Only with the infested person. authorized staff should bag and deliver infectious linen. E. Follow reporting procedure of A.D. E. Sexual and other intimate contacts Notify Public Heath and NOD need to be investigated and treated if infected. Public Heath Nurse will consult on infection Control measures and contact investigation 9. SCABIES (Typical, Non-Crusted): Scabies is a cutaneous infestation with the tiny human itch mite Sarcoptes scabiei. Scabies occurs as a result of direct contact with the infected person (including sexual contact), or occasionally by contact through very recent soiled bed linen, clothing, ect. Both male and female parasites live upon the skin. The female parasite burrows into the superficial skin to deposit her eggs. The burrow is seen most commonly between the finders but may occur in any natural fold of the skin or in pressure areas. Pruritus occurs and the scratching of the skin may produce secondary infection. Primary symptom is itching at night. Treatment: Permethrin (Elimite) formulated as a (5%) cream is not the recommended treatment of choice for scabies. It is applied form the neck to the soles of the feet for at least 12 hours, then washed off. If hands must be washed during this time period, an application to the hands must be reapplied after each washing. Individuals should be advised that itching, mild burning and/or stinging may occur after application of Elimite. Pruritus may persist for 1-2 weeks after successful treatment and should not be assumed to represent treatment failure. It is secondary to the Individuals reaction to the products released by the death of the parasites. Individuals diagnosed with scabies need to be in CONTACT ISOLATION for 24 hours. NURSING ACTION KEY POINTS A. Have Individual take a warm bath if A. Without crust, medication penetrates crusted lesions are present. Allow the effectively. Crusted lesions may skin to dry and cool before treatment is represent secondary bacterial infection, applied. or atypical scabies.

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B. Apply PERMETHRIN (ELIMITE) CREAM TO DRY skin in a thin layer to Individual(s) entire body from neck down to soles of feet. Rub in thoroughly C. Follow CONTACT ISOLATION precautions for Scabies for 24 hours after start of therapy. D. Have Individual put on clean clothing at beginning of the 12-hour treatment. E. Bag all clothing, bed linens, towels, ect., which have come into contact with the infested person within the 72 hours prior to treatment ad during treatment. F. After 12 hours, remove the medication by thoroughly washing. G. Have Individual again change clothing, bedding, and towels, at the end of 12 hour treatment. H. Identify all Individuals suspected of being sexual contacts or having intimate skin contact within the period of suspected infestation. I. Follow reporting procedure. Notify Public Health Office and NOD

B. Elimite contains 5% Permethrin. Nix contains 1% Permethrin.

C. Wear gloves when handling skin and infected material. Separate room may be considered but is not necessary. Masks are not needed.

E. Use appropriate yellow infectious (contaminated) linen bags. Only authorized staff should bag and deliver infectious linen.

G. CHANGE ALL BED LINENS AND CLOTHES DAILY FOR ONE WEEK H. Sexual and other intimate contacts should be treated regardless of visible signs or symptoms. I. Public Health Nurse will consult on contact isolation requirements and other infection control precautions, and on contact investigation.

J. Perform terminal cleaning of the Individuals room after completion of treatment 10. ATYICAL SCABIES (Crusted, Keratotic, or Norwegian Scabies): Individuals in long-term care facilities may have a number of different types of scabies. A severe variant of scabies known as crusted, keratotic, or Norwegian scabies can occur particularly in Individuals who are debilitated or immuno-suppressed including Individuals with HIV and in Individuals with Downs syndrome. Skin lesions consist of widespread hyperkeratotic, crusted nodules and plaques. The nails are frequently involved and demonstrate thickening and subungual debris. Secondary bacterial infection, septicemia, and death can occur. These individuals are heavily infested with thousands of mites and are highly contagious and require special control measures to prevent transmission of the disease. Transmission of mites can occur with much less direct skin contact when

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large numbers of mites are present on the skin of a Individual. Any person who has had contact with a crusted scabies Individual or that Individuals environment must be considered exposed and should be evaluated for preventive treatment. If crusted scabies is diagnosed or suspected, a consultation with the Public Health Officer or designee is required for proper treatment and control measures for Individuals and their contacts. Treatment: Effective management of scabies in long-term care facilities requires the application of safe and effective scabicide to symptomatic individuals and asymptomatic contacts of cases. If crusted scabies is diagnosed or suspected, a consultation with the public health officer or designee is required for proper treatment and control of Individuals and their contacts. Individuals with crusted scabies need to be in CONTACT ISOLATION until deemed noninfectious by the treating Med/Surg physician and the Public Health Officer or Public Health Nurse. The treatment of crusted scabies is more difficult and usually requires multiple applications of scabicides, therefore, a number of different regimens may be used. Follow all procedures, nursing action, and key points as outlined previously for scabies (typical, non-crusted) type. NURSING ACTION KEY POINTS A. Assign Individual to a private room. A. Isolate affected Individual during Have Individual take a warm bath the treatment period. Restrict contact soaking in tub for at least 10 minutes. with others until treatment regimen has been complete and scrapings are negative for live mites. Individual is to remain in a private room until skin scrapings are confirmed negative and public health clearance is obtained. B. Wear gloves and long sleeved B. Gloves and gown are to be worn by gown. The gloved areas around the everyone who attends Individual or wrist must be tight fitting. To insure the handles laundry or clothing. Remove wrist areas are snug fitting, use gown and gloves before leaving the surgical gloves. Apply the prescribed room. Wash hands and arms medication on the entire body from the thoroughly neck down to the soles of feet. C. Bag all clothing, bedding, and C. The Individuals room should be towels daily that have been in disinfected daily

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Individuals room. D. A complete terminal cleaning upon completion of treatment and prior to any other Individual using the room must be done. 11. EVALUATION (Applies To All Infestations): -Document the extent and areas of infestation including all actions taken and Individuals reaction to having this condition -Any broken areas of the skin from scratching or any other cause must be recorded ad treated to prevent infection of the areas. -The overall cleanliness of the Individual should be noted and recorded throughout care. -Record how the Individual tolerated the treatment and the apparent level of success.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 413 Effective Date: August 31, 2006 SUBJECT: COLD PACK TREATMENT 1. PURPOSE: Cold pack treatment is a form of therapy used after a sudden onset of acute inflammation or swelling. Vasoconstriction resulting from cold application reduces blood flow to the injured part and thus limits fluid accumulation and slows bleeding. The lower temperature also suppressed inflammation and produces local anesthetic response. When used appropriately, cold application can significantly lessen pain and immobility by reducing swelling of injured tissues. 2. POLICY: 1. No cold pack treatment shall be administered without a current order form a licensed physician, dentist, podiatrist, or person authorized to give such orders. 2. No Individual shall be left alone unsupervised while cold pack treatment is being applied. 3. Only licensed Psychiatric Technician or Registered Nurse can administer cold pack treatment. The treatment nurse is expected to be familiar with the nursing considerations, method of application, Individual teaching, and contraindications for cold pack treatments y consulting with medical doctor, pharmacy, or by reviewing the units nursing clinical skills book. 3. DEFINITION: A rubber or plastic device filled with ice chips and covered with a protective fabric before application to the Individuals body site. Vasoconstriction of peripheral vessels is caused by cold application. 4. ASSESSMENT: Consider during assessment: Ascertain if the Individual is coherent and able to voice concerns if the treatment is too cold. Determine mobility limitations. If the Individual is paralyzed, more intensive observations are necessary and time frames for treatment must be altered to meet individual needs.

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5. PLAN: Promote healing or reduction of pain and future complications 6. EQUIPMENT: 1. 2. 3. 4. 5. 6. Plastic bags, conventional ice bags or ice pack from Central Supply Protective covering for bags Ice chips, clean basin with ice and water for cold compress Bath blanket or face towel Screen (for privacy) if needed Gloves (if blood or body fluids are present)

7. IMPLEMENTATION AND INTERVENTIONS: NURSING ACTION A. Check physicians orders for location and duration of application B. Inspect and document condition of injured or affected part. Gently palpitate the area C. Consider time in which the injury occurred KEY POINTS A. Physicians order is required for all cold application B. Provides baseline for determining change in condition C. Cold-pack treatment should be applied quickly after an injury to prevent edema. Application of cold is most effective if started within 24 hours of injury. D. Determine if Individual is sensitive to cold extremes E. Organization prevents unnecessary delays F. To gain Individuals cooperation and compliance of treatment. G. Reduces spread o microorganisms H. Prevents further injury to body part. Avoids unnecessary exposure of body parts, maintaining Individuals comfort ad privacy.

D. Assess area to be treated for Sensitivity to temperature, light touch, and pain for adequate circulation. E. Prepare equipment and supplies F. Explain procedure to the Individual and assess his understanding of procedure. G. Wash hands and put on gloves H. Position the Individual carefully, keep body part in proper alignment and exposing only the area to be treated.

Cold Compress: I. Check temperature of solution I. Extreme temperature can cause

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and submerge gauze or face towel into filled basin, wring out excess moisture. b. Apply compress to affected area, molding it gently over site Prepare ice bag: J. Fill bag with water, secure cap and invert. -Empty water, then fill bag two thirds with small ice chips -Release excess air from bag squeezing its sides before securing cap -Wipe bag dry -Apply snugly over area. Secure with tape as needed

tissue damage. Dripping gauze or face towel is uncomfortable to Individual. b. Ensure that cold is directed over site of injury.

J. Checks for leaks -Bag can be easily molded over body part -Excess air interferes with cold conduction -Prevents skin maceration -Cold should be directly over injury

Prepare ice pack: K. a. Commercial packs are squeezed or kneaded. b. Apply pack directly over area K. a. Releases alcohol-based solution to create cold temperature. b. Some commercial packs have soft insulated coverings so they can be applied directly to the skin L. Do not reapply ice pack to reddened L. Continued use of ice pack worsens or bluish area. ischemia M. Remove gloves and dispose in M. Reduces transfer of Proper container microorganisms N. Check condition of skin every 5 N. Determines if there is an adverse Minutes for the duration of application reaction to cold O. At the end of the treatment time, O. Prolonged application of cold can usually 15 to 30 minutes (or as ordered result in diminished blood flow and by physician) remove the cold pack tissue ischemia or compensatory treatment and assess the area of vasodilation to provide warmth to the application for circulation. area being treated. P. Assist Individual to comfortable P. Provides comfort to Individual and position maintains relaxing environment Q. Dispose of soiled supplies in proper Q. Maintains neat environment and receptacle and wash hands reduces transmission of microorganisms

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8. EVALUATION: 1. After cold pack administration the affected area should be inspected for change in condition and appearance of skin. Report undesirable changes to physician immediately. 2. The Individuals response is important and should be noted. Untoward reactions to the application should be reflected 3. If area is edematous, sensation may be reduced and extra caution must be used during cold therapy. 4. Numbness and tingling are common sensations with cold applications and indicate adverse reactions only when sever coupled with other symptoms 5. Document Individuals response to health teachings, describe any instructions given and Individuals ability to demonstrate the procedure in the I.D. notes.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 414 Effective Date: August 31, 2006 SUBJECT: OXYGEN THERAPY 1. PURPOSE: This policy will outline the guidelines and procedures to be followed when providing oxygen therapy at this facility. 2. POLICY: 1. With a physicians order, any licensed nursing staff may administer oxygen 2. Unless specifically indicated by a physician order, with documentation supporting the specific necessity for the 1:1 observation, individuals will not be placed on 1:1. if an order is obtained it will be for a period not to exceed 24 hours, and the physician must personally see/reevaluate the individual and document the necessity for renewal prior to renewing the order each time it requires renewal. 3. The pulse oximeter shall be used for all individuals receiving O2 to monitor their oxygen saturation rate. 4. Oxygen administration up to 6 liters per minute via nasal cannula, 6 to 10 liters face mask or non-rebreathing mask, and up to 15 liters/minute via Venturi Mask may be given by a Registered Nurse to individuals with no history of Chronis Obstructive Pulmonary Disease prior to a physicians order in emergency situations. A physicians order must be obtained immediately thereafter. Indications for use may include but are not limited to: a. Check pain b. Shortness of Breath c. Respirations less than 8 per minute d. Status epilepticus e. Low pulse oximetry readings (Pulse Oxygen Saturation [SpO2] less than 90%) 5. Oxygen administration up to 2 liters via nasal cannula or up to 28% oxygen concentration by Venturi Mask may be giben by a Registered Nurst to individuals with a history of chronic Obstructive Pulmonary Disease prior to a physicians order in emergency situations. A physicians order must be obtained immediately thereafter.

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6. Check the Oxygen tank and tubing weekly and after each use. Replace the tank if Oxygen is below 500 lbs. replace the mask and tubing after each use. Complete the Oxygen Tank Check List. 7. The facemask must be attached to the green adapter on the oxygen tank to insure readiness for an emergency 8. Individuals requiring positive pressure breathing treatment and/or medication via humidifier or arterial blood sampling are referred to an outside medical facility. 9. Registered Nurses who are ACLS certified may insert a Laryngeal Mask Airway (LMA) in an emergency prior to obtaining a physicians order. 3. GENERAL INFORMATION: 1. Oxygen is delivered by nasal prongs or face mask to prevent or reverse hypoxemia and reduce the work of breathing 2. Oxygen tanks with gauge and masks are located on every unit in the Treatment Rooms and on all Emergency Carts. 3. Used oxygen tanks with less than 500 lbs. pressure should be returned to Central Supply for replacement. Mask, tubing, and oxygen supplies are obtained form Central Supply. 4. Post the Oxygen Tank Check List near the tank. The oxygen tank is to be check weekly and after each use to ensure its readiness for an emergency. Records must be retained for at least one year. Unit Supervisor/designee shall assure that policy is followed. The form is obtained from the Warehouse. TABLE OF GUIDELINES FOR TYPES AND USE FOR OXYGEN THERAPY Where When Oxygen Advantages Limitations Type Located Indicated Flow Range
Dries nasal passages unless used with humidifier. Less effective in mouth breathers. Difficult to regulate oxygen concentration inhaled.

Nasal cannula

Emergency Carts

Acute or chronic conditions; if longer use is needed, attach humidifier

1-6 L/min

Permits taking and eating, able to breathe through nose, more comfortably

Standard Face Mask

Oxygen tank attachment; Emergency Carts

Usually for Emergency conditions. If longer use is needed, consider humidifier.

6-10 L/min

Provides more concentration than nasal cannula

Difficult to regulate exact concentration

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Venturi Mask

Emergency Carts

Nonemergency, Short-term

3-15 L/min

NonRebreathing Mask

Emergency Carts

Emergency for maximum oxygen concentration

6-10 L/min

Consistent oxygen concentration (24-50%) via a mask with 7 different selections Gives maximum oxygen concentration

Depends upon correct oxygen flow rate and dilution setting for exact concentration Requires high flow rate

4. PRECAUTIONS: 1. Oxygen supports combustion, therefore, flames and sparks from all sources must be avoided. Smoking materials must be removed from client access. 2. OXYGEN IN USE signs must be posted; one on the room door and one in view of the individual. 3. NO electrical equipment is to be used in the vicinity of oxygen unless they are equipped with OSHA approved plugs and are necessary for individual care and treatment. 4. The oxygen tank must be secured to the carrier to prevent accidentally knocking it over and causing damage to the gauge. 5. When replacing the tank from Central Supply, remove the gauge prior to transport. Replace the gauge onto the new tank upon return to the unit. 6. The tank must be transported in its carrier. The tank has the potential to become a dangerous projectile due to the high pressure content. Proper transport of the tank is essential. Report improper transport to the supervisor. 7. The individual with Chronic Obstructive Pulmonary Disease (COPD) should receive only 2 liters of oxygen/minute vial nasal cannula, or 28% Oxygen concentration vial Veturi mask pending physicians order. Greater concentrations can remove the respiratory drive that has been created by the individuals low oxygen tension. Thus, ventilation becomes reduced and my lead to acute acidosis and carbon dioxide narcosis. 8. When oxygen therapy is being discontinued, watch for signs of hypoxia (e.g., change in mental acuity, restlessness, mental confusion, dyspnea; cyanosis is a late sign). 9. Give less than 6 liters of oxygen per minute via facial mask will cause carbon dioxide accumulation in the mask 10. Giving more than 6 liters of oxygen via nasal cannula may cause drying of the mucous membranes without additional clinical benefit. 11. 1:1 observation may be considered for individuals receiving oxygen, for the individuals protection. (See Policy Item # 2)

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5. ASSESSMENT: 1. Assess the respiratory patterns of the individual. Determine rate, ease of inspiration and expiration, presence of cyanosis, and breath sounds. 2. Assess the individuals history of respiratory problems/diseases 3. Assess the individuals history of tobacco use, duration, and frequency 6. PLAN: 1. Ensure that the individual receives the correct oxygen delivery device and oxygen flow rate 2. Observe for signs of inadequate oxygenation 3. Evaluate the individuals reaction and tolerance to oxygen therapy 4. Provide the prescribed treatment in a safe and therapeutic manner 5. provide health education to the individual regarding the safety and purpose of oxygen administration. 7. EQUIPMENT NEEDED: 1. Oxygen tank 2. Cannula or mask 3. Humidifier (plastic disposable with PSI Pressure Relief Valve, for long term use only) 4. Flow Meter 5. OXYGEN IN USE signs 6. Sterile distilled water (available in Emergency Cart) 7. Venturi Mask (located in Emergency Cart) 8. Non-rebreathing Mask (located in Emergency Cart) 9. Laryngeal Mask Airway (LMA) (located in Emergency Cart) 8. CLIENT TEACHING; 1. Explain the procedure and reason for oxygen therapy to the individual before brining the equipment into the room. This helps to ease anxiety and fears. (The individual may feel that a need for oxygen means the condition has worsened) 2. Teach the individual safety precautions with oxygen in the room 3. Explain to individual the necessity for the sign OXYGEN IN USE 4. Document all individual teaching utilizing the Wellness and Recovery Individual/Family Health Education Record

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Use of oxygen: NURSING ACTION A. Verify Physicians order KEY POINTS A. Use the six rights of medication administration: Right Client, Right Medication, Right Form, Right Route, Right Time, and Right Dose B. Maintain asepsis C. Choose appropriate mask or nasal cannula as ordered by physician. )See designated section for specific use of mask or cannula). D. Maintain safety precautions E. A loud popping sound occurs

B. Wash hands C. Assemble equipment at the individuals bedside. Transport the oxygen tank in a cylinder cart. D. Post OXYGEN IN USE signs E. Crack they oxygen tank by opening the valve allowing a small amount of oxygen to escape. Then immediately close the valve. F. Open the valve on the oxygen tank. G. Turn on the oxygen to the appropriate number of liters per the minutes.

F. Use the key provided G. Check the physicians order for the appropriate amount of oxygen to be provided.

Use of humidifier for long term therapy: (Nasal Cannula or Standard Face Mask Only) NURSING ACTION A. Fill the humidifier plastic container two-thirds full with sterile distilled water. Fill container only to marker. KEY POINTS A. Sterile distilled water is located in the top drawer of the Emergency Cart. Tap water causes mineral deposits. A humidifier is not necessary when oxygen is used in an emergency. A humidifier is used for long term therapy only. B. Screw the filled humidifier container B. A special oxygen regulator obtained to its adapter and connect it to the flow from Central Supply is required to use meter. Replace or refill humidifier as humidification. necessary. C. Open the valve on the oxygen tank D. Turn the oxygen to 2-3 liters per D. To ensure patency of the humidifier. minute and watch for bubbles in the distilled water. E. Then, place your hand at the E. Monitor humidifier water level and container opening to check for the refill as needed. airflow and humidity.

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Use of nasal cannula: A. Attach the connector tubing of the nasal cannula, connecting tubing to the oxygen tank outflow. B. Set the flow rate, as ordered A. Humidifier not need in an emergency. B. Avoid exceeding the safe limit of HIGH FLOW oxygen: 6 liters/minute via nasal cannula. C. Inspect skin behind ears periodically for irritation or breakdown. D. Do not over tighten the adjuster as this can result in pressure areas, and can also occlude the cannula prongs.

C. Place straight prongs of the nasal cannula in the individuals nostrils D. Hook the cannula tubing behind the individuals ears and then slide the adjuster upward under the chin to secure the tubing. Use of oxygen mask: A. Place the mask over the nose, mouth, & chin. Press its flexible metal edge so it fits the bridge of the nose. Adjust the elastic band around the head to assure a snug fit.

A. Without a seal, room air dilutes the Oxygen thus preventing the delivery of rescribed concentration.

Use of venturi mask: 9. GENERAL INFORMATION: The Venturi Mask delivers low concentrations of oxygen via mask (24-50%). It is often used with Chronic Obstructive Pulmonary Disease (COPD) individuals or individuals prone to CO2 retention. It is used when the individual can not tolerate a nasal cannula, are mouth breathers, or different concentration of oxygen is required due to the individuals specific needs. Venturi masks are best tolerated for relatively short periods because of their size and appearance. They also must be removed for eating and drinking. With improvement in individuals condition, a nasal cannula may often be substituted. Venture masks are mostly used for non-emergency or chronic conditions. NURSING ACTION A. Select the appropriate oxygen diluter (green for 24%, 26%, 28%, or 30%; while for 35%, 40%, or 50%). KEY POINTS A. To ensure the correct air/oxygen mix, oxygen must be set at the prescribed flow rate (flow rate as ordered by the physician). Prescribed flow rates differ for different oxygen

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B. Slip the diluter onto the multi-vent barrel C. Select the prescribed oxygen concentration by setting the indicator on the diluter to the appropriate percentage on the barrel. D. Firmly slide the locking ring into position over the diluter

concentrations. This information is printed on the mask or interchangeable color-coded dials. B. In order to select the oxygen concentration C. This ensures the correct air/oxygen mix

D. The locking ring keeps the diluter from accidentally moving to another oxygen concentration E. Connect supply tubing to the diluter E. This ensures that mask is flushed and to the appropriate oxygen source. and patent F. Adjust the oxygen flow to the F. Flow rates are recommendations appropriate level and check for gas only (flow rates are to be ordered by flow through the device the physician) G. Use of a humidifier other than those G. For short-term or emergency use, a recommended may create excessive humidifier is not required. backpressure, causing the relief valve to activate and thereby affecting gas flow to the individual H. Show the Venturi mask to the H. Decreases individuals fear individual and explain the procedure I. Place Venturi mask over the I. Ensures a secure fit individuals nose and mouth and under the chin. Adjust the elastic strap J. Check to make sure the individuals J. Exhaled gases would build up if air bedding does not obstruct holes for air holes were blocked entry.

Non-rebreathing mask: 10. GENERAL INFORMATION: The non-rebreathing mask is usually used in temporary or emergency situations to deliver the highest possible oxygen concentration. It may be used while transporting the individual to an acute care facility. Individuals receiving such high concentrations of oxygen are extremely acute and must be monitored continuously to assure correct oxygen saturation levels. Because this mask delivers a high concentration of oxygen to the individual it is contraindicated with COPD clients. Some COPD individuals depend on low oxygen concentrations to drive respiration. Increased concentration decreases the stimulus to breathe.

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Some indications for its use are individuals who are very short of breath, tachypneic, or hypoxic. This mask prevents room air inspiration as it fits snugly. The individual can get the exhaled gases out of the mask, but cannot breathe room air gases back in. this effectively maintains a high concentration. This is due to the built in valves or diaphragms found in the mask these are not to be removed. Use of the non-rebreathing mask: NURSING ACTION A. Attach the oxygen supply tubing to the gas (oxygen) source. B. Set the oxygen to the desired flow rate (usually 6-10 L/min) C. Check for flow through the device. Always verify proper function of the valves KEY POINTS A. To ensure that oxygen is used to fill the reservoir of the mask

D. Always check oxygen flow through inlet valve before placing the mask on the individual

E. Place the mask on the individuals face with the elastic strap below the ears and around the neck. Gently pull the strap ends until the mask is secure. Mold the metal strip on the mask to fit the face. F. Check for dryness of mucous membranes

C. Proper functioning of the valves ensures the individual is not rebreathing their own gases. The valve between the mask and the reservoir should rise on inspiration and lower on exhalation. The valve located on the external mask surface should open during exhalation. D. To ensure valve is working and the oxygen is filling up to the reservoir bag of the mask. If this is not done prior to application of the mask, the individual could suffocate. E. Correct application and placement of the mask ensures full benefit from use of oxygen and non-rebreathing mask. Place the strap below the ears decreases the chance for the skin to F. High concentrations of oxygen are usually used temporarily or in emergency situations. For short-term use humidification is not needed. G. Inspect skin beneath ears periodically for irritation or breakdown H. Do not over tighten straps, as this can result in pressure areas, and can occlude vessels in the neck. Proper fit ensures against the loss of gases into the room I. these actions reduce moisture

G. Ensure mask is tight fitting and well sealed. H. Maintain mask in secure position without being uncomfortably tight.

I. Remove mask periodically to dry the

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face around the mask

accumulation under the mask

Use of the laryngeal mask airway (lma): The standard Laryngeal Mask Airway (LMA) can be inserted by trial and error with relative ease, utilizing the following insertion technique transforms the process into a simple maneuver with minimal respiratory or hemodynamic consequences. Moreover, insertion of the reinforced LMA is very much less forgiving to deviations in insertion technique. THE LMA SHOULD ONLY BE INSERTED INTO AN UNCONSCIOUS INDIVIDUAL IN AN EMERGENCY. The deflated, lubricated LMA is best inserted with the head and neck positioned as for normal intubation. With an assistant (if possible) temporarily holding the mouth open until the widest part of the mask is past the teeth, or using the third finger of the inserting hand, the tip of the LMA is inserted into the mouth, pressing the tip against the hard palateas (palate) it is advanced cephalad into the pharynx with the right hand. Then, with the index finger positioned at the cuff/tube interface, the LMA is inserted as far as possible into the hypopharynx. Before removing the index finger, bring the other hand up to the connector and press gently but firmly in the cephalad direction. When resistance is felt, the tip of the cuff is positioned at the upper esophageal sphincter. After assuring that the black line on the LMA is facing the upper lip, the cuff is inflated. NURSING ACTION KEY POINTS A. Remove LMA from the Emergency A. Check cuff and valve to ensure rd Cart , 3 drawer. Make sure packaging proper functioning. is intact (item should be sterile). B. Lubricate with KY Jelly or other B. To ensure ease of insertion sterile lubricant. C. Evacuation all air from the cuff, C. If there is air in cuff prior to preferably using the LMA deflator. insertion, insertion will be more difficult. D. Make sure that LMA looks like the figure to the right prior to insertion:

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E. Press mask tip upward against the hard palate to flatten it out advance the mask into the pharynx using the index finger. CAUTION: Be sure to carefully fit the deflated LMA tip into the convexity of the hard palate as this is the KEY to successful insertion.

F. With neck flexed and head extended, press the LMA into the posterior pharyngeal wall using the index finger

G. Complete the insertion by exerting cephalad pressure by the nondominant hand prior to removing the index finger

H. Inflate LMA and secure in place with tape

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Synopsis of Insertion Technique 1. Check that the LMA is prepared properly. 2. Keep the neck flexed and the head extended with the non-dominant hand during insertion procedure. 3. Using the index finger to maintain a continuous cephalad pressure, slide the LMA over the hard plate and soft palate into the hypopharynx until definite resistance is felt. 4. Complete the insertion by exerting cephalad pressure by the nondominant hand prior to removing the index finger. 5. Inflate mask with air without holding the tube (a short outward movement is normal). 6. Secure LMA and bite-block with tape Setting the prescribed flow rate: NURSING ACTION A. Adjust the oxygen flow as ordered by Physician B. Remain with the individual for a period of time to ease fears and to assess individuals condition C. Check equipment at regular intervals for proper functioning and amount of oxygen available in tank D. Change cannula/mask, humidifier, and other equipment exposed to moisture EVERY 7 DAYS or sooner if needed. Record the date and time of equipment change in the chart KEY POINTS A. Total gas flow at the individuals face must meet or exceed peak inspiratory flow rate.

E. REPORT TO ONCOMING SHIFT: a. Individual/client status b. The number of libs. Of O2 remaining in the tank.

D. Individuals on intermittent oxygen, or other forms of oxygen treatment, should have a CHANGE OF EQUIPMENT EVERY 7 DAYS or sooner if needed, if it has been used. Date and time of equipment change must be documented. E. Refer to NP&P #vii Change of Shift Procedure

11. EVALUATION: Documentation in chart should include: 1. Date & time (include length of time on oxygen)

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2. Problem number 3. Procedure 4. Flow rate, (liters/minute) 5. Any abnormal conditions noted 6. Information given to physician 7. vital signs 8. Individuals symptoms prior to and after treatment 9. Type of delivery system (cannula/mask) 10. Individuals reaction 11. Individual Health teaching 12. PULSE OXIMETER AVAILABLE LOCATIONS: Continuous Vital Sign Monitor with Pulse Oximeter (Welch Allyn) on each unit Treatment room, Safety Center, Staff Development Center Small Pulse Oximeters (Pro Med) at Central Supply, Clinic Center, Admissions Suite, Med/Surg Clinic, HSS Office. Oxygen tank exchange from central supply: Used oxygen tanks with less than 500-lbs. pressure should be returned to Central Supply for replacement. Mask, tubing, and oxygen supplies are obtained form Central Supply. When replacing the tank from Central Supply, remove the gauge prior to transport. Replace the gauge onto the new tank upon return to the unit. The tank must be transported in its carrier. The tank has to potential to become a dangerous projectile due to the high-pressure content. Proper transport of the tank is essential. Staff coming from the unit will fill-out a requisition slip with a copy (using Central Supplys requisition form) Take requisition form together with the empty oxygen cylinder tank secured in its carrier to the EB Building Central Supply storage room. Exchanges should be one-for-on. That is, one empty oxygen tank in exchange for one full one. During business hours, coordinate exchange with Central Supply staff. After-hours, staff should make arrangements with the HSS on duty to coordinate the exchange. Staff HSS are to sign the Central Supply requisition slip and eave it in Central Supply Room on the desk. Copy the requisition slip to be given to the staff.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 415 Effective Date: August 31, 2006 SUBJECT: OXYGEN CONCENTRATOR 1. PURPOSE: This policy will provide guidelines for the safe, continuous or intermittent delivery of oxygen via the Oxygen Concentrator. 2. POLICY: 1. Oxygen shall only be administered upon the valid order of a physician, except in emergency situations 2. The Oxygen Concentrator is not to be used in emergency situations. Oxygen tanks are available for this purpose. The standard, portable oxygen tanks with attached tubing and nasal cannula shall be available for use by all individuals during oxygen therapy in case of emergency (e.g. electrical power outage). 3. The Oxygen Concentrator will be used for all individual prescribed oxygen therapy. Per manufacturer recommendations, the duration of oxygen therapy should be a minimum of 30 minutes, as shorter periods of operation may reduce maximum product life. (Refer to INVACARE operators manual) 4. As with all other forms/uses of oxygen safety precautions shall be strictly followed. NO SMOKING signs shall be posted and all forms of potential ignition sources shall be kept away from oxygen sources. 5. Unless specifically indicated by a physician order, with documentation supporting the specific necessity for the 1:1 observation, individuals will not be placed on a 1:1. if an order is obtained it will be for a period not to exceed 24 hours, and the physician must personally see/reevaluate the individual and document the necessity for renewal prior to renewing the order each time it requires renewal. 6. During oxygen therapy, all individuals shall have their oxygen saturation (SPO2) checked and recorded at least once each shift, or more frequently as ordered by the physician. The pulse oximeter shall be available and used for this purpose. 7. All staff assigned to a unit where an oxygen concentrator is in use shall receive orientation to the care and use of this equipment and the orientation shall be documented per hospital/Program/Unit policy.

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3. PRECAUTIONS: The following safety precautions shall be observed by all individuals and staff assigned one-to-one (or one-to-two, ect.) observation during oxygen therapy: NO SMOKING/OXYGEN IN USE signs shall be posted in the individuals room The oxygen concentrator, attached humidifier and tubing shall be kept in a secured area (accessible only to staff) when not in use. The oxygen concentrator shall be unplugged when not in use. Keep the electrical cord away from water and all other electrical hazards during use The removable foam air filter shall be cleaned any time that any visible dirt is noticed on the filter. Clean with warm soapy water, rinse thoroughly, dry thoroughly and replace filter. All tubing and humidifiers shall be replaced every seven days or more often if needed Never block the air openings of the concentrator and do not place it on a soft surface (e.g. bed) where the air opening may become blocked. Keep air openings free of lint, hair, ect. Keep the concentrator at least 12 inches away from walls, draperies, furniture, ect. to prevent restriction of airflow into the equipment Extension cords shall not be used with this equipment. Using the attached cord plug the machine directly into the wall outlet. Tubing (for delivery of oxygen to the individual) shall not exceed 50 feet in length. The manufacturer recommends the use of Crush-Proof oxygen tubing (supplied by the manufacturer) The oxygen concentrator is not able to deliver more than 5 liters per minute of oxygen. Individuals who require higher flow rates should not use this equipment. If the RED (shutdown) or YELLOW (less than 73% oxygen purity) OXYGEN PURITY INDICATOR light(s) on the front of the concentrator is/are activated, and the equipment does not self-fix within 5 minutes, the concentrator shall be turned off, then individual placed on oxygen provided by the portable tank for the duration of the prescribed treatment, and the equipment labeled and stored until the next working day when it shall be returned to Central Supply for repair/replacement.

4. PROCEDURE: NURSING ACTION KEY POINTS A. Obtain a physician order for its use A. No individual shall be placed on an oxygen concentrator until a physician has examined him or her and that -2N.P.P No. 415

B. Plug in power cord in individual room. DO NOT use extension cord(s).

C. All individuals shall have a new humidifier to prevent drying of respiratory mucosa D. Attach Cannula to the filled humidifier E. Turn the flowmeter to the setting ordered by the physician

physician has ordered oxygen therapy and documented the need for the treatment B. Do not start individual on the concentrator till the machine has been running at least 30 minutes. Note that the oxygen purity light (Green light) may turn on in as little as 5 minutes but wait for the full 30 minutes to be sure. C. Do not reverse the oxygen input and output connections. Fill humidifier with distilled water to the same level as one would for bottled water D. Masks shall not be used E. A maximum of 5 liters. Check orders. Check after a few minutes to see that the flow desired is being delivered. F. Environmental conditions and amount of use may indicated more frequent cleaning of the units filter. a. Clean the filter with warm soapy water, rinse thoroughly and dry thoroughly before you replace it. b. Do not operate the unit without a filter in place G. Clean with warm soapy water and rinse with a solution of 1 part vinegar to 10 parts water.

F. Clean the cabinet filter weekly

G. Clean Humidifier daily

5. ASSESSMENT: 1. Assess the respiratory patters of the individual. determine rate, ease of inspiration and expiration, presence of cyanosis or dyspnea. 2. Assess the individual using pulse Oxygen Saturation each shift so long as indicated Report any SPO2 readings below 90% promptly to the appropriate physician. 6. DOCUMENTATION / INDIVIDUAL-CLIENT TEACHING: 1. All individuals requiring oxygen concentrator shall have documented by the RN at least monthly in the IDN Notes, all teaching provided regarding machine function, disease process, and other items related to the concentrator.

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2. The Case Manager shall also document appropriate health teaching regarding the need for smoking cessation if indicated. 3. Additional documentation should include but not be limited to: Date and time of oxygen administration (include length of time on oxygen) Problem number Flow rate ( liters per minute) Any abnormal conditions noted Any information given to physician Vital signs, including pain assessment Individuals symptoms prior to and after treatment Individuals reaction to treatment

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 416 Effective Date: August 31, 2006 SUBJECT: ENEMAS 1. PURPOSE: A. B. C. D. E. To relieve distention and gas by absorption, (carminative) To soothe or lubricate rectal mucosa, (emollient) To apply absorbable or local medications, (medicinal) To soften impacted feces, (lubricating) To supply nutrition or fluid for rectal absorption, (nutritive)

2. EQUIPMENT: Obtain from Central Supply: 1. Disposable enema set containing: a. Moisture proof pad b. 1500 cc bag with tip c. Soap packet (discard if not to be used) d. Tissues e. Disposable bedpan f. Bath thermometer g. Disposable exam gloves Obtain from Laundry: 1. Bed Sheet 2. Bath towel Obtain from Pharmacy: 1. Enema ordered 2. Lubricant

3. PROCEDURE: ACTION RATIONALE-PRECAUTIONS A. Prepare solution in bag (solution A. Explain procedure to the Individual should be lukewarm). Take equipment as well as the necessity and purpose of to bedside retaining the solution B. Explain the procedure to the B. Explanation will help to minimize Individual; its purpose and how he can anxiety and illicit cooperation

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participate C. Maintain a private environment D. Put on disposable gloves E. Position the Individual on his left side, with right leg flexed if physically possible. Place moisture proof pad under the Individual and cover him with the bed sheet F. Clear air from tubing by running a small amount of fluid through and them clamp the tubing. Lubricate the tip of the rectal tube. G. Insert lubricated tip of tube gently four to six inches into the rectum. Have Individual bear down to relax the sphincter muscle while tube is being inserted. H. Unclamp the tubing. The bag is held no more than 8 to 12 inches above the rectum I. If the fluid does not flow readily, squeeze the tubing to milk the fluid through J. If the Individual complains of cramping stop the flow of fluid until the cramp ceases. Have the Individual breathe through his mouth K. When solution has run in, clamp the tubing. If the Individual is having difficulty retaining the fluid leave the tube in place. If the Individual is not experiencing difficulty, withdraw the tubing into the toilet tissue. L. Leave the Individual on his left side with the moisture proof pad in place. Make him comfortable and cover him. Instruct him to remain quiet and to relax, if possible. Leave a bedpan available. Place call light within his reach (if applicable). M. Bag contaminated disposable equipment in clean plastic bag. Tie with a single stranded knot and place in contraband trash for disposal. N. when solution is retained for the

D. Prevent self-contamination E. Anatomically the left side is more conducive to the gravity flow of the fluid. Provides Individual with warmth and privacy F. Air in tubing will distend the bowel and limit the space needed for fluid

G. To avoid pressure on the anal sphincter

H. To decrease or prevent stimulation of peristalsis and to introduce fluid slowly. The higher the container the faster the flow of fluid I. Do not increase the height of the container or move the tubing in and out as this will stimulate peristalsis J. Breathing through the mouth aids in the relaxation of the abdominal muscles K. Removing the tube will increase the stimulation of peristalsis.

L. Encourage the Individual to retain the enema for the specified amount of time. The bedpan provides security if he is unable to retain the solution.

M. All enema equipment is disposable and contaminated

N. Provide for Individual comfort

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ordered amount of time, or when necessary, put the Individual on the bedpan or toilet. O. When enema has been expelled, provide the necessary articles for cleaning or if the Individual is unable to clean himself, clean and dry him.

O. Provide for Individual comfort

4. VARIATION Oil Retention Enema ACTION A. Obtain from Pharmacy: Oil retention Enema commercially prepared. (given per physicians order and per instructions on package) B. Explain the procedure to the Individual, its purpose, and how we can participate C. Position the Individual on his left side whenever possible D. Provide privacy for the Individual and cover with sheet or bath blanket. Place moisture proof pad under the Individual E. Wear disposable gloves RATIONAL- PRECAUTIONS

B. Explanation will help to minimize anxiety and illicit cooperation C. This position is the most helpful in aiding gravity flow of fluids D. Minimize embarrassment, provide warmth and protect.

F. Insert and apply per instructions on the package G. Continue with retention Enema from letter L. p. 2

E. Prevent self-contamination. Standard Transmission-Based Precautions F. Different brands may have slightly different instructions G. Tube may be pre-lubricated. Facilitates entry of tube into the rectum

5. RECORDING: A. Note medication/treatment as administered on the Medication Record B. Record any unusual reaction/drainage in the IDNs C. Document any Individual education in the IDN Notes

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6. GENERAL INFORMATION: A physicians order is required. It must specify the type of enema and the time intervals. An enema may be given with a commercially prepared, disposable enema unit or by the bag and tubing which is attached to the rectal tube by a connecting tip. Both units are disposable. Types of Enemas Commonly Used for Adults Name Constituents Commercially prepared enema 90-120 ml of a hypertonic solution, such as sodium phosphate (see directions on the package) Saline 9 ml of sodium chloride to 1,000 ml of water Tap water 500-1000 ml of tap water Soap 20 ml of castile soap in 500-1000 ml of water Oil, e.g. olive oil 20-120 ml of oil (commercially prepared): mineral, olive or cottonseed 7. PURPOSE: To cleanse the bowel of feces by stimulating defecation 8. EQUIPMENT: Obtain from Central Supply: 1. Disposable enema set containing moisture proof pad, 2000 cc enema bag with pre-lubricated tip and soap packet 2. Disposable bedpan 3. Disposable gloves Obtain from Laundry: 1. Bath blanket or sheet 9. PROCEDURE: ACTIONS A. Explain to the Individual the procedure, its purpose, and how he can participate B. Put on gloves C. Place waterproof pad under Individuals buttock D. Position the Individual on his left RATIONALE-PRECAUTIONS A. to minimize anxiety and elicit cooperation B. Prevent cross contamination C. Protect bed D. Helpful in aiding gravity flow of fluid

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side, whenever possible, with knees flexed. E. Provide privacy for the Individual and cover with sheet. Place moisture proof pad under the Individual F. Prepare the equipment. Fill the bag with the ordered solution G. Clear the air from the tubing by running fluid through and then clamping the tubing H. Wear disposable glove I. Insert the lubricated tube 7.5 to 10cm (3 to 4 inches) into the rectum. Ask the Individual to bear down, to relax sphincter muscle during insertion of tube and then relax J. Hold the container 14 to 18 inches above the level of the Individual K. Unclamp tubing to introduce the fluid. If the Individual complains of cramping, slow the rate of flow by lowering the container or by clamping the tubing. Have the Individual take deep breaths or flex his knee L. When the solution has been instilled, clamp the tubing and gently remove from rectum. Inform Individual to retain fluid as long as possible M. Place Individual on the bedpan or assist him to the bathroom. Allow him privacy. If he used the bathroom, instruct him not to flush the toilet and to call the nursing staff when he is finished N. Discard the enema equipment and gloves in the contaminated trash container O. Wash hands P. Clean and dry the Individual or provide the material for him to use

E. Minimize embarrassment and provide warmth F. The solution should be warm but not over 41 degrees C or 105 degrees F G. Air in the tubing will distend the bowel and limit the space for fluid. H. Infection control measures I. Avoids unnecessary pressure on the anal sphincter

J. Flow rate is determined by the height of the container. The higher the container the faster the rate of flow K. A slower flow rate will decrease the feeling of fullness. Deep breathing and flexing the knees will help relax the abdominal muscles

L. Obtain better results

M. The enema return must be checked and documented

N. All enema equipment is contaminated and disposable O. Prevent spread of infection P. Maintain Individual comfort

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10. VARIATION: ACTION A. Following cleansing enema procedure in step 3. Prepare equipment B. Remove cap and attach administration tip C. Tip is pre-lubricated D. Wear disposable gloves E. Gently insert into rectum RATIONAL-PRECAUTIONS

B. Follow directions container C. Facilitate entry of tube into rectum E. If fecal matter is presented remove tube, check to see that end of tube is not plugged and reinsert F. See directions on container G. Obtain better results

F. Squeeze or roll-up container from bottom to expel liquid G. Encourage patent to retain enema until the urge to evacuate is strong. This usually occurs within five (5) minutes H. Continue with cleansing enema procedure beginning at number 10.

11. RECORDING: In the Wellness and Recovery Notes, record date, time, procedure, results (character and amount of feces returned), blood and/or mucus if present and the Individuals response. Document any teaching in the IDN notes.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 417 Effective Date: August 31, 2006 SUBJECT: CAST & LEG IMMOBILIZER- APPLICATION & CARE 1. PURPOSE: A. B. C. D. To immobilize and hold bone fragments in reduction To apply uniform compression of soft tissue To permit early mobilization To correct and prevent deformities

2. EQUIPMENT: Obtain from Central Supply: 1. Sling 2. Wheelchair 3. Crutches 4. Leg immobilizer 5. Stockinettes and synthetic casting tape or splint 6. Cotton wadding 7. Casting material 8. Cast protectors (moisture barrier for use when showering) 9. Basin 10. Exam gloves 11. Gown or apron 12. Scissors 3. PLAN: A. B. C. D. E. F. Ensure immobilization and desired anatomical position Prevent impairment of circulation Prevent pressure areas under the cast or immobilizer Prevent pressure on nerves Record observations of extremities in a cast and leg immobilizer Teach the Individual observations that should be made while requiring application of cast or immobilizer

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4. PROCEDURE : ACTION A. When a synthetic cast is applied it dries almost immediately. They also wear less and can get wet without fear of cracking or disintegrating. B. If bathing is allowed, place a protective covering, such as a cast protector over the cast. Make an effort to keep the cast as dry as possible. C. When assessing the Individual in a cast or leg immobilizer remember to check for: pulse distal to the cast, pain, pallor (unusual color-pale or cyanotic) or paresthesia (numbness) these are the four Ps.. D. Elevate cast extremities with all contours supported to prevent cracking. Ice may be applied to the cast to prevent or reduce edema E. Check the toes or fingers frequently, especially during the first 24 hours, for early signs of circulatory impairment. These signs include numbness and tingling, unusual color (pale or cyanotic), skin cool to the touch, obvious edema, and continuous blanching of the nail beds. If seepage of blood should occur through the cast material, encircle its exact perimeter with an ink pen or marker. Write the date and time so that further seepage can be evaluated. Any drainage and its progression must be called to the attention of the physician and noted in the chart. F. Proper body alignment and positioning are extremely important to the Individual in a cast. To promote maximum comfort, change the Individuals position frequently. Avoid pinching of skin and formation of pressure areas on bony prominence. Maximum chest expansion also must RATIONALE-PRECAUTIONS A. The synthetic cast is sturdier and so may not be easily removed by the Individual B. Excessive moisture under the cast may lead to tissue damage and promotes infection

D. Poor venous return is common to an injured part. Cold applications constrict blood vessels, anesthetize nerve endings and aid in blood coagulaiton E. A cast is not flexible and shrinks slightly as it dries; it may inhibit circulation and result in injury to the fracture area. Documentation will provide a baseline against which future developments may be weighted to determine the degree of seriousness of swelling and drainage. Leg immobilizer can be loosened to accommodate for early swelling in sprains or prior to casting in fractures.

F. Abnormal stress on the bones results in structural problems. In proper alignment, no strain is place on the joint, muscles or bones and connective tissue.

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be facilitated. G. Foreign particles under the cast may precipitate skin irritations and infections. Discourage the Individual who wishes to relieve itching under the cast by scratching with some object. If the Physician allows such practice devices used for scratching under the cast, they must be well padded and used with extreme care. H. The cast or leg immobilizers are usually supported by some means when the Individual is out of bed. Crutches or a sling are frequent aids to ambulating a cast. I. Exudates and secretions on the skin after cast removal should be removed carefully and gently so that trauma to the delicate skin is prevented. Wash the skin gently with mild soap and warm water.

G. Scratches under the cast can become infected because of the warm dark, moist environment. A musty odor coming from under the cast may indicate pus formation.

H. Unnecessary strain is undesirable during recovery from a fracture. The purpose of a hanging cast is to exert pressure from gravitational pull to keep the fracture aligned. I. After cast removal, the skin will be flaky, and the muscles may be atrophied, sore and stiff.

5. OBSERVATION: -Observe the Individual for signs and symptoms of aseptic inflammation that normally follow fracture of a bone 1. Elevated temperature within a few hours 2. Increased white blood cell count 3. Swelling at the fracture site 4. Pain in the area of the fracture 5. Bruising in the fracture area -Observe the Individual hourly for symptoms of nerve and circulatory impairment X 24 hours. Check toes or fingers for: 1. Color 2. Blanching 3. Change in sensation (increases numbness) or tingling since cast application 4. Edema 5. Temperature of distal extremities 6. Mobility 7. Pain 8. Skin irritations at the edges of the cast

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-Bleeding may occur if there is a wound or incision. Observe for bleeding at frequent intervals. Document and report any excessive or unexpected observations. 1. Bony prominence, such as heels, ankles, wrists, elbows and feet, may develop pressure areas if allowed to remain in contact with the bed for prolonged periods. Check frequently and relieve pressure areas by positioning or padding 2. Observe the cast and leg immobilizer frequently for signs of foul odor or a hot spot, signs that may indicate the beginning of infection. 3. Observe the cast frequently for signs of breakdown in the cast material 6. DOCUMENTATION: A. Daily Documentation (IDNs and/or Individual care flow sheet) Individuals initial and subsequent reaction and adaptation to the cast and leg immobilizer application. Appearance and condition of the affected area. (The documentation should reflect that the nurse knows the signs of circulatory impairment and takes precautions to avoid, recognize or alleviate them). Note psychological as well as physical responses.

B. Document health teaching to the Individual in the IDN notes. If demonstrations of care were offered and returned, assess the degree of understanding and anticipated compliance with medical restrictions. Note actions taken to avoid complications. 7. INFECTION CONTROL: A. Hand washing is essential before and after handling the client in a cast. Transmission of hospital-acquire infections must be avoided B. If a wound or incision is present under the cast, it is dressed using sterile technique before the cast is applied. The cast must be observed closely for signs of infection as healing progresses. C. Scratching under the cast or leg immobilizer may cause tissue breakdown and result in infection. Pressure on surrounding parts may also result in breakdown and eventual infection of otherwise healthy tissue.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 418 Effective Date: August 31, 2006 SUBJECT: TRACHEOSTOMY CARE: CLEANING OF INNER CANNULA 1. PURPOSE: To provide guidelines for care of the individual with tracheostomy and cleansing of inner cannula without compromising respiratory function, and preventing infection by using standard precautions. 2. POLICY: 1. Tracheostomy care shall only be provided by a Registered Nurse, LVN or Psychiatric Technician who has received training in and has demonstrated competency in tracheostomy care at Coalinga State Hospital. 2. Tracheostomy care does not require a physicians order. Nursing staff should always keep supplies at the individuals bedside for suctioning. Clean the new, recent tracheostomy stoma every 8 hours or more frequently if indicated by accumulation of secretions. The ties shall be changed every 24 hours or more frequently if soiled or wet. Care shall be taken to prevent accidentally dislodging the trach tube when changing the ties. 3. Sterile technique shall be maintained. Suction the trachea and pharynx thoroughly before providing tracheostomy care. 4. The blood & body fluids/substances of all individuals shall be treated as though they were infectious. Refer to Standard Precautions A.D. If accidental removal of tracheostomy tube occurs during care, immediately use Ambu bag and mask to ventilate the individual by mouth while covering the tracheostomy stoma. However, if the individual has complete upper airway obstruction, a gaping stoma or laryngectomy, mouth to stoma ventilation must be performed. 3. ASSESSMENT: 1. Identify the individual, using two forms of identification (e.g. individuals I.D. photo and one other form).

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2. Explain the procedure to individual regardless of the level of alertness or orientation. This helps to allay the individuals anxiety and elicits maximum cooperation. 3. Assess the individuals understanding/acceptance of this alteration to body image & his/her concerns regarding current treatment. Determine educational deficits when deciding what and how to provide health teaching to the individual. 4. Assess the tracheotomy for: a. Condition of the stoma e.g. redness, swelling, character of secretions, presence of purulence or bleeding. b. Examine neck for subcutaneous emphysema, which indicates air leaking into the subcutaneous tissue. c. Amount and color of exudate. d. Ability of individual to aerate the lungs successfully through the tube. 5. Assess the individuals breath sounds via auscultation and determine need for suctioning, (e.g. increased amount and viscosity of secretions and/or inadequate gas exchange and coarse adventitious breath sound, noisy breathing, prolonged expiratory sounds). 4. EXPECTED OUTCOME: 1. 2. 3. 4. 5. To facilitate the therapeutic exchange of gases To prevent the transmission of pathogenic microorganisms To prevent encrustation around the tracheostomy area. To provide physical and emotional comfort for the individual To allay the fears and anxieties of the individual concerning the altered breathing rout and loss of speaking ability. 6. To prevent accidental dislodging of the trach tube. 5. EQUIPMENT: Assemble the following equipment or obtain a prepackaged tracheostomy care kit: a. Hydrogen peroxide / 0.9% Sodium Chloride b. Tracheostomy cleaning tray c. Eye/face shield protection and gown d. Bottle of sterile water and sterile normal saline e. Packet of sterile 4x4 gauze pads f. Antiseptic skin solution or detergent g. Plastic bag h. Sterile towel i. Sterile gloves and sterile cotton tips swabs j. Tracheostomy tie tapes or available securing device

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6. INDIVIDUAL PREPARATION: 1. Observe the individual at all times. 2. Position the individual in supine position with head extended and a support under the shoulders. 3. Reassurance and clear explanations will help to allay the individuals anxiety. 4. Provide communication devices, such as writing materials, if individual is able to use.

7. IMPLEMENTATIONS AND INTERVENTIONS:

CLEANING OF THE OUTER TRACHEOSTOMY (NECK PLATE) AREA: NURSING ACTION A. Wash hands before and after tracheostomy care, and wear sterile gloves. KEY POINTS A. Use Sterile Technique and Standard precaution. Keep ties in place during procedure to prevent dislodging trach tube. B. Tracheostomy care is a sterile procedure. C. Provide sterile field.

B. Open all equipment using sterile technique. C. Place sterile towel on individuals chest under tracheostomy site. D. Open 4x4 gauze and pour hydrogen peroxide and sterile water respectively while having the rest of the gauze dry. E. Put on eye/face shield and wear gown as needed. F. Place tracheostomy tube tapes on sterile field. G. Clean the external end of the tracheostomy tube and stoma areas with gauze soaked in hydrogen peroxide twice and discard each time.

D. To remove mucus and crust which promote bacterial growth.

E. Follow Standard Precautions as well as sterile technique.

G. Hydrogen peroxide will help to loosen dried secretions.

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H. Repeat step 7 above using gauze soaked with sterile water. Then repeat again using dry gauze.

H. The ensures all hydrogen peroxide is removed and stoma area dried to prevent infection and irritation.

8. CLEANSING OF THE INNER CANNULA: NURSING ACTION A. Inner cannula shall be cleaned at least every 8 hours or more frequently if needed. KEY POINTS A. If there is a build-up of secretions, the inner cannula may need to be cleaned more frequently to facilitate air exchange. B. Keep tapes tied to prevent accidental dislodging during cleaning. Change tapes only after all other cleaning is completed.

B. Remove inner cannula and wash both inside and outside with hydrogen peroxide solution using brush or pipe cleaners. C. Rinse with sterile saline solution and replace the obturator into inner cannula before reinserting back into outer cannula, turn cannula to lock in place. D. Two staff are required for this step: one staff to hold trach tube neck plate in place, and one staff to remove and replace to tape. Cut soiled tape and remove carefully then replace with clean tape and tie at the side of the neck in a square knot, allowing two fingers to fit between the tape and the neck. E. All disposable equipment and soiled articles are placed in plastic bags and disposed of per policy. 9. SPECIAL PRECAUTIONS:

D. To prevent irritation, rotate pressure side. Tapes that are too tight will compress jugular veins, decrease blood supply to the skin.

A tracheostomy cuff may be used to hold the tube in place. The soft balloon is inflated with air to prevent accidental removal, or air leaks. KEY NOTE: The cuff must be deflated at regular intervals, e.g. once each shift, to prevent damage to the trachea.

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Spontaneous extubation of the tracheostomy tube requires immediate attention. The outer cannula should be replaced under sterile conditions by a physician. KEY NOTE: Accidental dislodgement of the tracheostomy tube may occur as a result of forceful coughing, confusion, or excessive movement. This requires immediate intervention. An extra tube, obturator and hemostat shall be kept at bedside. 10. EVALUATION: Documentation should include: a. Date and time b. Problem number c. Procedure/intervention performed d. Condition, reaction, findings, and individuals response e. Health teaching with an appraisal of the individuals understanding and acceptance of altered condition f. Appearance and amount of secretions g. Follow up care needed e.g. suctioning, assessing cuff pressure, stoma care, etc. h. Use of any ancillary devices, e.g. oxygen/mist collar, C-PAP, Tracheostomy button. NOTE: The documentation should indicate that the nurse know and understood the possible side effects of tracheostomy care and took measures to ensure that individual safety and well-being was maintained.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 419 Effective Date: August 7, 2007 This policy replaces NPP 419 dated August 31, 2006 SUBJECT: TRACHEOSTOMY SUCTIONING 1. PURPOSE: To provide a clear guideline for suctioning an individual with a tracheostomy in the event of ineffective coughing, excessive collection of viscous secretion with narrowing of the airway, respiratory insufficiency or stasis of secretion. 2. POLICY: 1. Tracheostomy suctioning shall be performed by a registered nurse, LVN or a Psychiatric Technician who has demonstrated competency at Coalinga State Hospital. It does not require a physicians order. 2. Nursing staff shall assess the need to suction tracheostomy individuals every 2 hours through auscultation. Sterile technique is maintained throughout the procedure. 3. The blood and body fluids/substances of all individuals shall be treated as though they were contagious. Refer to A.D. Standard Precautions for Infection Control. 4. Care shall be taken to prevent accidentally dislodging the trach tube during suctioning. The ties should remain the place until suctioning is complete. 3. ASSESSMENT: 1. Always identify the individual using two forms of identification. 2. Explain the procedure to individual regardless of their level of alertness or orientation. Since suctioning can be very frightening, instruct individual on how to cooperate. 3. Assess the individuals understanding/acceptance of this alteration to body image and his/her concerns regarding current treatment. Determine

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educational deficits when deciding what the Individuals health teaching needs are and how to provide them. 4. Assess the heart rate and auscultate breath sounds. Take vital signs to establish baseline. Suctioning will be discontinued if the heart rate drops by 20 beats per minute or increases by 40 beats per minute, an increase in blood pressure or any cardiac dysrhythmia is noted. RATIONALE: Suctioning may cause hypoxemia, trachycardia and increase blood pressure. Which may result in cardiac ectopy, bradycardia, hypotension and cyanosis. Vagal stimulation may also result in bradycardia. 5. Assess tracheostomy for: a. condition of the skin b. patency of tracheostomy tube. c. Amount and color of exudate. d. Ability of individual to aerate the lungs successfully (assess by auscultation of the lung fields). 4. INDICATORS FOR SUCTIONING: 1. Ineffective coughing. 2. Respiratory insufficiency, or stasis of secretion. 5. EXPECTED OUTCOME: 1. 2. 3. 4. To facilitate the therapeutic exchange of gases. To prevent the transmission of pathogenic microorganisms. To provide physical and emotional comfort for the individual. To allay the fears and anxieties of the individual concerning the altered breathing route dislodging the tracheostomy tube. 5. To prevent dislodging the tracheostomy tube. 6. EQUIPMENT: You may obtain a pre-packaged suctioning kit, or gather the following items: a. b. c. d. e. f. g. eye/face shield and protection gown bottle of sterile water and sterile normal saline suction kit or suction catheters: 14-16F and tubing suction machine sterile dressings and gloves plastic bag sterile towel, alcohol swabs

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h. 100% oxygen source (small oxygen tank), tubing, facial mask or resuscitation bag-mask i. Sterile 5ml syringe and 8 oz. plastic drinking cup j. Sterile water soluble lubricant jelly NOTE: Obtain supplies from Central Supply in advance. 7. PREPARATION: 1. Observe the individual at all times. Explain the suctioning procedure and how the individual should splint to help support the chest surgical incision as coughing will be induced during suctioning. Reassurance and clear explanations will help to allay the individuals anxiety. Provide communication devices, such as writing materials, if individual is able to use them. 2. Place the individual in the side-lying position to facilitate drainage and prevent aspiration of secretions. RATIONAL: Due to gravitational flow, secretions may collect in the tracheobronchial tree.

8. IMPLEMENTATION AND INTERVENTION: NURSING ACTION A. Wash hands, before and after tracheostomy. B. Open all equipment using sterile technique. Keep tapes tied during suctioning to prevent accidental dislodging of trach tube. C. Ventilate and oxygenate the lungs by either having the individual take several slow deep breaths or use Ambu bag, if individual is unconscious. D. Use sterile gloves and maintain sterility. E. Using sterile hand, remove suction catheter and attach to connecting tubing. Curl catheter around gloved fingers. F. Lubricate suction catheter by using sterile water or normal saline. G. Using sterile gloved hand, insert catheter into tracheal tube, with suction KEY POINTS A. Follow standard precautions, and sterile technique. B. To be sure all equipment are in functional state before sterile procedure is started to prevent interruption. C. Use oxygen, if ordered, because ventilation before suctioning helps to prevent hypoxemia.

G. Do not force if any resistance is encountered.

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off. H. When suction catheter is inserted to resistance, apply intermittent suction by opening and closing the suction port. Withdraw the catheter in a rotating motion. I. Ventilate the individual through own inspiration or Ambu bag approximately 4-5 times between suctioning. Give oxygen if ordered. J. Flush suctioning catheter after each suction by dipping the tip into a cup of sterile water. K. Do not suction more than 4 times in one episode or more than 10 seconds per suction. L. After suctioning, position individual to facilitate adequate ventilation. Leave suction equipment ready for emergency suctioning. M. Clean are and equipment. Ensure that individual is clean and comfortable. 9. EVALUATION:

H. DO NOT CONTINUOUSLY SUCTION FOR MORE THAN 10 SECONDS AT A TIME!

I. Suctioning removes oxygen, which must be replenished before continuing.

J. Prevent reintroduction of bacteria into the respiratory tract. K. May predispose to hypoxemia as well as being tiring and traumatic to the individual. L. If necessary, and while wearing gloves and mask, empty contents of canister into toilet, rinse with water, dry outside only and place canister in position for next use.

Documentation should include: 1. Date and time 2. Problem number 3. procedure/intervention performed 4. Condition of individual and his/her reaction/response to treatment 5. Health teaching with an appraisal of the individuals understanding and acceptance of altered condition 6. Note any change in vital signs 7. Appearance and amount of secretions 8. How condition is progressing, e.g. follow up care needed 9. Use of any ancillary devices used

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 420 Effective Date: August 31, 2006 SUBJECT: PRESSURE SORE (DECUBITUS ULCER), PREVENTION AND TREATMENT 1. PURPOSE: A. Prevent pressure on any one area of the body for excessive lengths of time. B. Ensure the Individuals comfort. C. Prevent the spread of pathogenic microorganisms. D. Alleviate the Individuals fear and anxiety regarding the pressure sore that has already developed. Assessment: A. Pathophysiological concepts: 1. The stages of decubitus ulcer formation are: Stage I: Reddening of the skin not relieved by massage or by relief of the pressure believed to have caused it. Stage II: Superficial tissue damage involving skin breakdown. Stage III: Ulceration involving the dermis, which may or may not include the subcutaneous tissue; stage that produces serosanguineous drainage. Stage IV: Ulceration into the deep structures with invasion of the deep tissue or structures such as fascia, connective tissue, muscle or bone. 2. Decubitus ulcers are a potential problem of the immobile. Those particularly at risk are the elderly, the obese, the emaciated, and the paralyzed, whose mobility is impaired. Contributing factors to decubitus ulcer formation are continuous exposure of the skin to moisture, circulatory impairment, a break in the skin, inadequate nutrition, dehydration, inhibited sensory reception, and a lack of natural adipose tissue, which normally pads bony prominences.

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B. Assessment of the Individual 1. Assess the general condition of the individual. Note nutritional status, ability of the Individual to eat, ability of the Individual to chew food thoroughly, and amount of adipose (fat) tissue. Also note the mobility of the Individual, circulatory status in extremities, urinary and bowel continence, sensory perception in extremities and trunk, and level of hydration. 2. Assess the condition of the client. Note the stage or amount of tissue destruction. Assess the kind of care or treatment the area has received before hospitalization and the effectiveness of this care. 3. Assess the Individuals entire body to determine of other pressure sores are evolving. Assess the presence of the other pressure areas, the degree of redness, or lack of sensation. Check all bony prominences, folds of skin, and any area that might have received pressure due to the presence of tubes or drains. 2. COMMUNICATIVE ASPECTS OBERVATIONS: A. Document any reddened or whitened area, wither of which may indicate irritation. Give special attention to these areas by message, turning to keep the individual from lying on these areas, and continued observation to see that further damage does not occur. B. Observe for systemic conditions that my encourage the formation of pressure areas: impaired circulation, fever, alteration of cell function. Observe for adequate intake of foods and fluids to meet systemic needs. C. Check the Individual frequently for environmental factors that encourage the formation of pressure areas: wrinkled bed linen, objects in the bed, top bed linen applied tightly enough to restrict movement, and pressure or irritation from cast, adhesive, tubing, braces, traction, and other equipment. D. Observe any drainage from an open pressure sore. Note the type of drainage, amount, and frequency of appearance. If persistent, culture and sensitivity tests may be needed to determine causative and effective means to destroy them. Promptly report to the physician stages II through IV. E. The prescribed treatment of pressure sores is the responsibility of the physician. Preventive measure should be planned, implemented, and evaluated by the nursing staff. 3. EQUIPMENT: (Obtain all necessary equipment as indicated by Physicians Orders; e.g.)

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A. Obtain from Central Supply: (as required per treatment ordered) i.e. 1. 4x4 sterile gauze 2. Sterile basin 3. Sterile towel 4. Sterile, disposable water proof drapes 5. Sterile gloves 6. Culture swab (if ordered) 7. Sterile dressing forceps 8. Op-site as ordered 9. Disposable decubiti measuring device B. Obtain from Pharmacy: (treatment as ordered by M.D.) i.e. 1. Solution as ordered 2. Medication as ordered 3. Duo-derm as ordered 4. PROCEDURE: NURSING ACTION A. Pressure sores are caused by prolonged pressure which restricts blood flow to the area resulting in tissue breakdown. KEY POINTS A. Massage will promote the circulation to the area bringing needed nutrition to the cells and preventing destruction of skin cells to lack of adequate blood supply. B. Lying in the prone position is an excellent means of relieving pressure on the bony structure of the back. Each alteration of position causes a shift in the areas receiving pressure. Evenly distributing pressure over the body will prevent excess pressure on one area, resulting in a pressure sore. Use padding judiciously. Pillows are the best form of padding.

B. The desirable aspect in the treatment of pressure sores in prevention. Frequent turning, relief of pressure, and encouragement of circulation to the skin overlying the bony prominences is essential to prevention and early detection. Turn Individual at least every 2 hours or as ordered. Each time the Individual is turned, check the skin closely for signs of pressure areas. Gently massage bony prominences with lotion. Place the Individual in a variety of positions, including prone. Be sure the Individuals breathing is not restricted and is comfortable.

C. There are a variety of methods for C. The physician has the responsibility cleansing a pressure sore. Use the to prescribe appropriate treatment for physicians preference as ordered. the care of decubitus.

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D. The use of rubber or other protective materials may cause the Individual to perspire. The more desirable bed covering is a sheep skin, air mattress, floating pad, egg crate mattress, or other coverings designed to decrease pressure areas.

D. Perspiration causes moisture buildup and further predisposes tissue breakdown. Special mattresses are designed to evenly distributing the body weight so that one area does not receive greater pressure than others.

CAUTION: The use of these devices does not eliminate the need for turning the Individual or massaging the pressure area:

E. Encourage bowel and bladder control if the client is able to cooperate. Offer the bedpan and urinal frequently. Change linen and give skin care as often as necessary to keep the Individual dry. F. Encourage adequate intake.

E. Moisture from incontinence causes maceration of the skin.

F. A deficient nutritional status is detrimental to the healing process. G. Hand washing has been shown to remove the majority of the pathogenic organisms present on the skin. Prevents spread of infection. H. For maximum effectiveness, enlist the Individuals cooperation and insure his comfort.

G. Wash hands carefully before and after caring for Individuals pressure sore.

H. Take equipment to bedside. Explain procedure to the Individual and place Individual in a position of comfort, allowing for maximum access to the pressure ulcer. I. Obtain culture, if ordered by physician. J. *To culture a pressure ulcer 1. Clean surrounding skin with antiseptic 2. Clean gross debris, necrotic tissue and pus from wound with sterile water or saline 3. If possible, use sterile syringe to aspirate fresh, deep pus, or drainage 4. If unable to aspirate, insert sterile

I. Culture must be obtained before medicated treatment to insure adequate specimen.

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swab deep into wound. If anaerobic culture is ordered, obtain special culture swabs and transport media from laboratory. L. Using sterile technique and sterile gloves, perform the treatment as prescribed by the physician. M. Discard materials per.

L. To prevent cross contamination.

M. Be aware of contaminated and contraband items.

5. RECORDING: Record the time, procedure, solution used, any measurements taken, observations and Individuals response to treatment as per MHDS. Document all Individual education on the IDN notes. 6. NURSING IMPLICATIONS: Because pressure sores are a side of ill health rather than a disease, nurses caring for the Individual may feel considerable anxiety. Many sores, however, arise before hospitalization, or before any medical care has been given. In spite of a better understanding of the problems of pressure sores, there is still some reluctance to admit and discuss their presence and treatment. Nursing staff are encouraged to use outside Nurse Wound Care consultants for difficult or intractable cases of decubitus ulcer. *Reference* Infection Control and Applied Epidemiology, Principles and Practice, 1996

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 421 Effective Date: August 31, 2006 SUBJECT: CARE AND USE OF NEBULIZER AND INTERMITTENT POSITIVE PRESSURE BREATHING DEVICE 1. PURPOSE: This policy will provide guidelines for the appropriate use and care of nebulizer and/or Intermittent Positive Pressure Breathing (IPPB) equipment for aerosol therapy at this facility. 2. POLICY: 1. The nebulizer and/or IPPB shall only be used for aerosol therapy upon the valid order of a physician, which must include all components of an order. 2. The nebulizer and/or IPPB are not intended for use in emergency situations. However, if the individual is currently on nebulizer treatment and has an order for PRN use, it may be used for a respiratory crisis. 3. The nebulizer and/or IPPB equipment in use a this facility includes a compressor designed for frequent, short-term usage. Do not leave the compressor on unless providing aerosol therapy. 4. The nebulizer and/or IPPB equipment will be provided by Central Supply via appropriate request. The equipment shall be returned to Central Supply, after appropriate cleaning, when no longer needed. 5. Each individual utilizing the nebulizer and/or IPPB shall have his/her own mouthpiece. These mouthpieces shall not be shared. 6. The Unit Supervisor/designee shall ensure that appropriate cleaning/maintenance is performed by unit nursing staff, per manufacturers guidelines, while the equipment is in use on their unit. 3. GENERAL INFORMATION: The nebulizer system provides a safe, effective and simple means of delivering medication in aerosol form, converting liquid topical medication into a mist that is inhaled into the bronchial tree for therapeutic reasons. Some of the droplets of the mist are microscopic, allowing deeper

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penetration throughout the lungs and maximum distribution of the medication. There are two basic therapeutic reasons for the use of aerosolized medication: 1.) Some medications are capable of reversing bronchospasms that occur in a variety of respiratory disorders. These medications act almost immediately on contact with the tissue of the respiratory tract to relax smooth muscles that cause these spasms, thus re-opening airways and restoring normal ease of breathing. 2.) Other medications are commonly used to thin and loosen secretions within the respiratory system, thus unblocking the path that air normally takes in entering and filling the lungs. When thick sputum is made thinner and loosened, it can be coughed up and expelled. Some of the different types of medications that are prescribed for aerosolized use are: A. Bronchodilators relax smooth muscles of the respiratory tract, and are considered topical because they work on contact with the lining of the bronchial tree. Smooth muscles tighten during bronchospastic attacks and make breathing difficult due to the resultant narrowing of the airways. B. Mucolytics chemically break down the viscid secretions that are difficult to cough up. Once thinned, these secretions become much easier to mobilize, thus unblocking airways of the respiratory tract. C. Wetting Agents these are used to hydrate (humidify) the secretions, making them thinner and loose. Are also used as mixers for other medications that need to be diluted, such as bronchodialators. D. Antibiotics a variety of antibiotics may be used to fight infection in the respiratory tract and are occasionally used in aerosol form. E. Steroids these are used to shrink swelling and lessen irritation of tissue and are occasionally used in aerosol form. 4. GENERAL PRECAUTIONS: 1. Always unplug equipment immediately after using. 2. Do not use near water. Do not place in or store equipment where is could fall or be pulled into a tub or sink. Do not place or drop into water or other liquid. 3. Do not leave unattended when plugged in. 4. Never operate equipment if it has been dropped or damaged, or dropped into water.

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5. Plug equipment into a properly grounded outlet only. Keep the cord away from heated surfaces. 6. Never block the air openings of equipment or place it on a soft surface (e.g. bed) where the air openings may be blocked. Keep the air openings free of lint, hair, or other debris. Never drop or insert an object into any openings. 7. Do not operate where other aerosol (spray) products are being used or where oxygen is being administered. 5. PROTOCOL: NEBULIZER EQUIPMENT NURSING ACTION A. Assemble equipment and appropriate medication. B. Take equipment and medication to the area where it is to be used (Individual bedroom, treatment room). C. Provide appropriate teaching to the individual regarding procedure. D. Place the compressor on a flat, firm surface and near an appropriate, grounded outlet. E. Attach the clear connecting tubing to the compressor (top front portion). F. Unscrew the nebulizer cup and place it on a clean, flat surface. G. Check physicians order for type and amount of medication prescribed, then pour medication into nebulizer cup. H. Screw the nebulizer cup back onto the nebulizer assembly. I. Have the individual hold the nebulizer assembly and plug the compressor into the grounded wall outlet. KEY POINTS A. Compare physicians order to medication in cassette. B. Ensure there is an appropriate place to put the equipment (e.g. nonsoft surface) and a grounded outlet to plug it into. C. Make sure that the individual understands and can/will cooperate. D. Ensure that air vents are not blocked.

E. Ensure tubing is clean and intact.

F. Staff may complete this nursing action in the medication room. G. Follow the six rights of medication administration.

H. Make sure that liquid does not spill out. I. Make sure individual holds cups and assembly level, so that liquid does not spill.

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J. Switch the compressor on, switch is located on the back portion of the unit.

J. When on, the air going through the nebulizer will create a hissing noise and you will see droplets forming inside the nebulizer cup. K. Nebulizer come with mouthpiece as standard equipment. May also be used with a mask, if ordered by the physician. Remove T-connector from the assembly and attach the assembly to the mask.

K. Instruct the individual to place the mouthpiece between his/her teeth and breath through it until all of the medication is used up. If using a mask, instruct individual to inhale and exhale through the mask, as prescribed by the physician. L. Keep the nebulizer cup upright at all times to ensure adequate nebulization of the medication.

L. Adequate nebulization of the medication is necessary to ensure that all medication is given as ordered.

Care and cleaning of the nebulizer equipment: NURSING ACTION A. The manufacturer recommends daily disinfection of the nebulizer assembly if used on a daily basis. CSH Infection Control Policy requires the same. B. Use an appropriate, Infection Control Committee approved disinfection solution. C. To clean calcium deposits, use a solution white vinegar (1/2 cup) to 1 quart of warm water. D. Soak the entire assembly in the solution for at east 15 minutes. E. The nebulizer assembly is considered a single use, disposable item. It is not to be shared between individuals, and should be appropriately disposed of after the individual has completed their prescribed treatment. Dispose in trCSH unless grossly contaminated KEY POINTS A. Each individual shall use his/her own nebulizer assembly, per Infection Control Policy and Practices.

B. Refer to Infection Control Policy for list of approved cleaning and disinfecting agents. C. Manufacturer recommends replacement of nebulizer assembly after 2 to 3 weeks of continuous use. D. Rinse after soak and allow to air dry. E. Consult with Central Supply for replacement nebulizer assembly if the individual remains on treatment for a prolonged period of time (e.g. longer than 2-3 weeks).

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with mucus or other bodily fluids, then dispose as Biohazardous Waste. F. The compressor unit is not disposable and should be returned to Central Supply for re-issue when no longer needed on the unit. The Unit Supervisor/designee shall ensure that it is properly cleaned prior to its return. F. DO NOT soak the compressor. SO NOT use water or any other liquid to clean the compressor. Wipe clean with a cloth.

Procedure: intermittent positive pressure breathing (IPPB): NURSING ACTION A. Check the physicians order. Follow the six rights of medication administration. KEY POINTS A. Ensure that there is a current complete order including but not limited to PIP settings (L/min), inspiratory flow rate (cm-H2O) and medication with dosage. B. Ensure there is appropriate place to put the equipment (e.g. non-soft surface) and a grounded outlet to plug it into. C. This action assures correct settings, minimizes risks of over hyperinflation of lungs and provides more time for individual focused teachings regarding procedure.

B. Assemble equipment. Take equipment and medication to the area where it is to be used (individual bedroom, treatment room). C. If applicable, pre-set PSI setting before initiation of treatment. To do this, pull regular knob (located in the front of compressor) to unlock the regulator, occlude mouthpiece to simulate a tight lip seal and adjust the settings accordingly. If unable to, adjust dials to lowest settings before initiation of treatment.

D. Provide appropriate teaching to the D. Make sure that the individual individual regarding the procedure. understands and can/will cooperate with the procedure. E. Place the compressor on a flat, firm surface and near an appropriate, grounded outlet. F. Attach the clear connection tubing to the compressor (front portion). E. Ensure that air vents are not blocked.

F. Ensure tubing is clean and intact.

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G. Unscrew the nebulizer cup and place it on a clean, flat surface. H. Check physicians order for type and amount of medication prescribed, then pour medication into nebulizer reservoir. I. Screw the nebulizer cup back onto the nebulizer assembly. J. Have the individual hold the water trap upright and plug the compressor into the grounded wall outlet.

G. Staff may complete this nursing action in the medication room. H. Follow the six rights of medication administration.

I. Make sure that liquid does not spill out. J. The water trap component serves as the holding device for the assembly. Holding it upright ensure that liquid does not spill. K. When the compressor is on, the mouthpiece emits aerosolized medication. L. IPPB devices come with mouthpiece as standard equipment. Ensure PIP settings are adjusted according to physicians order. Ensure the rate dial is adjusted to individuals comfort by asking the individual. M. Adequate nebulization of the medication is necessary to ensure that all medication is given as ordered. Intermittent rest periods provide opportunities for sufficient cough and deep breathing exercises.

K. Switch the compressor on, switch is located on the back portion of the unit. L. Instruct the individual to place the mouthpiece between his/her teeth and breath through it. Set PIP settings then adjust the rate dial to individuals comfort.

M. Keep the nebulizer cup upright at all times to ensure adequate nebulization of the medication. Give Individual intermittent rest periods lasting one minute to freely cough and deep breathe. Care for cleaning of the ippb equipment:

-Refer to manufacturers instructions/guidelines. 6. EVALUATION: Documentation should include the following: 1. Date, time and problem number 2. Vital signs, including pain and sp02, pre and post treatment 3. Medication and dosage, equipment used (IPPB or nebulizer)

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4. Tolerance to treatment 5. Other relative information 7. MAINTENANCE AND CLEANING RECORD FOR THE IPPB: Individuals Name: ____________________________ Unit: _______________ KEY POINTS: 1. Filters check for dust build-up. Weekly and/or as needed to clean, remove from their recessed areas and wash in warm soapy water and rinse. Absorb excess water from filter with dry towel and replace to their original locations. Change q 30 months. 2. Nebulizer assembly: End of the day use. Disconnect the modulator and water trap component from the nebulizer assembly. Unscrew nebulizer top, rinse with warm soapy solution, final rinse with warm water and allow to air dry for next days use. Ivory soap is recommended due to its water-based properties. Wipe the external part of the machine as needed with a cloth. 3. Rinse the nebulizer component with warm water after each treatment to wash off medication left in the nebulizer reservoir (refer to key point #2 for disconnecting the component). The manufacturer recommends an end of day use rinse with warm water and mild soap solution (refer to key point #2). 4. Compressor: wipe clean with a cloth as needed. 5. Oxygen tubing: change as needed and/or every 30 days. THIS FORM IS TO BE INITIALED AND DATED WHEN ITEMS ARE COMPLETED UNIT MAINTENANCE RECORD: Date: Air Filter C=Cleaned R=Replaced 02 Tubing replaced Filter 02 tubing replaced Q 30 d: Last ________________Next _______________ Additional copies of this form may be obtained from Central Supply as needed.

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Forward this form to Medical Services when complete to when individual returned to court. Keep copies of this record at unit level.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatments POLICY NUMBER: 422 Effective Date: August 31, 2006 SUBJECT: CARE OF THE INCONTINENT INDIVIDUAL 1. PURPOSE: The purpose of this policy is to assist the nursing staff with the individual who is experiencing incontinence and to provide guidelines for care of the incontinent individual. The therapeutic treatment plan will be developed in collaboration with the ID team. 2. AUTHORITY: Standard of Nursing Practice 3. POLICY: 1. Each individual experiencing incontinence shall receive appropriate, individualized treatment to alleviate these symptoms and prevent potential problems in a safe, structured, and secured environment. 2. Nursing staff will work closely with the ID Team to develop a collaborative treatment plan for care of the incontinent individual. 3. Incontinent individuals shall be cleaned and/or bathed immediately upon voiding or soiling being cognizant of privacy concerns. 4. A bowel or bladder training program shall be instituted as early as possible for all individuals with incontinence problems. 4. PRECAUTIONS: Nursing personnel having direct contact with or the potential for exposure to blood, body fluids, or other potentially infectious material of individuals are expected to practice STANDARD PRECAUTIONS according to guidelines established by the CSH Infection Control Program. 5. DEFINITIONS: Incontinence inability to control urination or defecation. Enuresis involuntary passage of urine, usually referring to involuntary passage at night, during sleep -1N.P.P No. 422

Encopresis involuntary passage of stool. 6. ASSESSMENT: 1. Determine if there are any physical causes attributing to incontinence. 2. Assess the individual for readiness to begin a bladder and bowel training program. 3. Assess the individual's skin to detect signs and symptoms of tissue breakdown. 4. Determine the individual's emotional status related to the incontinence and efforts to correct it. 7. ABNORMALITIES INCLUDE: -Lack of control -Hesitancy -Frequency -Retention of fluids -Prostatic hypertrophy -Diarrhea 8. PLAN: 1. Keep the normal physiologic acts of voiding and defecating intact. 2. Keep the individual as clean and dry as possible to prevent skin complications. 3. Avoid embarrassing the individual. 4. Promote a positive self-image for the individual. 9. IMPLEMENTATION AND INTERVENTION: Bladder Incontinence: NURSING ACTION A. Keep the skin clean and dry. Place an incontinence pad under the individual to absorb the urine. Change the pad/adult diaper as often as necessary to maintain a dry environment and to prevent tissue breakdown. KEY POINTS B. One of the major goals of a bladder retraining program is prevention of tissue breakdown. Hand cleansing is advised and wearing gloves may be appropriate if contamination is possible. -Dribbling -Urgency -Burning -Skin breakdown -Bladder infection -Fear of embarrassment

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C. Explain the bladder-training program using a pleasant positive approach. Provide privacy for the individual during elimination.

C. Speaking to the individual in a condescending or criticizing manner impairs the therapeutic nurse-patient relationship and may result in decreased cooperation with the bladder-training program. D. Catheters are a known major cause of Bladder infections.

D. An indwelling catheter should be used only as a last resort ( e.g. when the individual is in danger of skin breakdown or when a clean, dry condition is required for wound healing on the buttocks or perineal area). E. If necessary, move individual to a room near the bathroom. F. Examples of bladder training methods include the following: -Offering the bedpan or urinal at regular or preset intervals. -Limiting intake of fluids to certain times, followed by an attempt to void. -Forcing fluids for a brief period, waiting 30 minutes to an hour and then offering the bedpan. -Toilet every 2 hours while awake. -Avoid giving individual excess fluids after 1800 to prevent enuresis.

E. Allows individual to get to the bathroom in time to void. F. The objective is to rebuild the bladder musculature slowly by gradually reestablishing normal voiding patterns.

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G. Keep a BM and Void Log to assist in setting up best times to toilet the individual. -Use intermittent catheterization to establish a bladder evacuation pattern. -Clamp an indwelling catheter for progressively longer intervals prior to its removal. H. Keep the individual's environment pleasant and odor free. Offer fruit juices (particularly acidic type juices) to reduce the odor of the urine.

G. Use the I&O Flow Sheet and/or the Daily Care Flow Sheet as appropriate.

H. Every effort should be made to keep the individual in a positive frame of mind. Offering acidic juices decreases urinary infection and increases output. Work closely with Nutrition Services for specific treatment approaches.

Bowel incontinence: NURSING ACTION A. Create a positive atmosphere from the beginning of the bowel-training program. Show acceptance of the individual as a human being. Use of condescending or patronizing speech or manner with the individual will hamper the efforts to initiate a successful bowel-training program. KEY POINTS A. Fecal incontinence is embarrassing and a threat to the individual's ego and may contribute to skin breakdown.

B. Bowel training methods include the B. Follow the treatment plan as following: established by the I.D. Team. -Using rectal suppositories or enemas to regulate the time of bowel evacuation. -Sitting on the commode in the natural position for elimination. Ingesting bran and other high fiber dietary foods at certain times of the day or evening. -Digital rectal stimulation for neurological impaired individuals.

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11. EVALUATION: Documentation should include: 1. Measures used for keeping individual clean, dry, and comfortable. 2. Condition of the skin, with emphasis on the perineal area, thighs, and buttocks. 3. Individuals current status and progress towards meeting nursing objective and plans. 4. Changes in individuals condition. 5. Progress and success of /or alterations in the bowel or bladder training program. 6. Documentation should reflect that a continual reassessment of the retraining efforts was made and that the program was readjusted to meet the changing needs and abilities of the individual. 7. Individual Client education.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatments POLICY NUMBER: 423 Effective Date: August 31, 2006 SUBJECT: STOMA CARE 1. PURPOSE: To avoid any excoriation of the skin by digestive juices and to permit examination of skin around the stoma. To assist in the controlling odor and/or detect infection. 2. EQUIPMENT: Disposable stoma bad Soap and water Stoma wafer Towel and soft wash cloth Stoma adhesive paste (if available) Disposable gloves Plastic trash bag 1 inch hypoallergenic tape Wash basin Catheter/drainage tube protector (if needed)

3. PROCEDURE: Assessing a stoma: Stoma color The stoma should appear red, similar in color to the mucosal lining of the inner cheek. Very pale or darker-colored stomas with a bluish or purplish hue indicate impaired blood circulation to that area. Stoma size and shape Most stomas protrude slightly from the abdomen. New stomas normally appear swollen; but swelling generally decreases in size over 2 or 3 weeks or for as long as six weeks. Lack of size decrease may indicate a problem, e.g. blockage Stoma bleeding Slight bleeding initially when the stoma is touched is normal, but other bleeding should be reported. Status of peristomal skin Any redness and irritation of the

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(peristomal skin (the 5 to 13 cm [2 to 5 in.] of skin surrounding the stoma) should be noted. Transient redness after removal of adhesive is normal. Amount and type of feces The location of the ostomy influences the character and management of the fecal drainage. The farther along the bowel, the more formed the stool, since the large bowel reabsorbs water from the fecal mass. In addition, more control over the frequency of stomal discharge can be established. Complaints Complaints of burning sensation under the faceplate may indicate skin breakdown. The presence of abdominal discomfort and/or distention also needs to be determined. Determine the need for appliance change: Nursing Action A. Assess the used appliance for leakage of effluent. B. Ask the patient about any discomfort at or around the stoma. C. Assess the fullness of the pouch. Pouches need to be emptied when they are one-third to one-half full. Rational-Precautions A. Effluent can irritate the peristomal skin. B. A burning sensation may indicate breakdown beneath the faceplate of the pouch. C. When the fluid level in the bag becomes too high, the weight of it may loosen the faceplate and separate it from the skin, causing the effluent to leak and irritate the peristomal skin.

D. If there is pouch leakage or discomfort at or around the stoma, change the appliance. E. Avoid times close to meal or visiting hours. F. Avoid times immediately after the administration of any medications that may stimulate bowel evacuation.

E. Ostomy odor and effluent may reduce appetite or be visibly distressing. F. Changing the pouch is facilitated when the ostomy is least likely to function.

Changing a bowel diversion ostomy appliance: Nursing Action A. Approach and identify patient. Explain the procedure and provide privacy. B. Wash hands and assemble equipment. C. Have patient assume a relaxed position (Supine Fowlers) Rational-Precautions A. To gain patient confidence and lesson anxiety and embarrassment. B. To avoid cross contamination. C. Encourage patient participation and understanding so that eventually he will

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D. Put on disposable gloves. E. Remove wafer and bag slowly from skin and place in plastic trash bag. F. Wash skin with warm water and soap using a clean soft washcloth. Rinse well and pat dry. Observe stoma for its color and condition. Patient may take shower at this time; if stoma is draining, cover with a dressing and plastic such as Saran Wrap or Wick urine with a gauze sponge. G. Cut a circle in the center of the wafer approximately 1/8 to 1/4 larger than the stoma. Use precut hole guide provided in wafer package. H. Apply stoma-adhesive paste when needed around the circumference of the stoma (if available). I. Remove backing from the wafer and apply to skin pressing firmly. J. Apply 1 inch tape around the border of the wafer ( of tape on the wafer and the other on the skin). K. Apply stoma bag or pouch to the wafer using the specific brand instruction sheet provided with appliance. Apply appliance to belt (if needed) on a level with the stoma. L. Make sure that clamp at the bottom of the stoma bag is secure. M. Discard disposable item per ICM. N. Change stoma bag every 72 hrs or sooner if necessary (depending on amount of any discharge).

be able to change appliance himself. D. To protect staff from contact with body secretions. E. To prevent skin breakdown (Infection Control) F. To protect against infection.

G. Opening too small may irritate stoma. Larger ones may cause skin breakdown. H. To provide a better seal.

I. Body heat will help to form a seal. J. To provide a better seal and to prevent wafer from catching on clothing. K. To collect any discharge.

L. To prevent leakage M. To prevent cross contamination. N. To control odor.

Special considerations: Nursing Action A. Empty stoma bag according to the amount of drainage (urostomy = half full). B. Check system every shift for signs of leakage and change when Rational-Precautions A. To prevent break in seal from the weight of any discharge. B. To prevent skin breakdown.

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necessary.

Criteria for ostomy appliance: - Be odor-resistant. - Protect peristomal skin. The faceplate opening needs to fit closely around the stoma. - Stay secure for 3 to 5 days. - Be no allergenic (bags with adhesive backed discs). - Be readily available, affordable, and appealing to the patient. - Be invisible underneath clothing.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatment and Procedures POLICY NUMBER: 424 Effective Date: June 20, 2007 SUBJECT: ACTIVITIES OF DAILY LIVING SUPPORT 1. PURPOSE: To provide nursing services which prevent loss of functional skills and physical condition, and which support the individuals ability to live as independently and safely as possible. 2. POLICY 1. To assist each individual in achieving the highest level of self care as possible. 2. To record the individuals self-care performance in activities of daily living (i.e. what the individual can actually do for himself and/or how much verbal or physical help was required by staff). 3. Nursing Interventions that assist or promote the individuals ability to maintain activities of daily living functions. Activities of daily living support plans must meet professional criteria for nursing care plans.

3. GENERAL INFORMATION: 1. Range of motion: The extent to which, or the limits between which, a part of the body can be moved around a fixed point, or joint. Range of motion exercise is a program of passive or active movements to maintain flexibility and useful motion in the joints of the body. 2. Active range of motion: Exercises performed by an individual, with cueing or supervision by staff, that are planned, scheduled, and documented in the clinical record. 3. Splint or brace assistance: Assistance can be 2 types. 1) where staff provide verbal and physical guidance and direction that teaches the client how to apply, manipulate, and care for a brace or splint, or 2) Where staff have a scheduled program of applying and removing a splint or brace, assessing the individuals skin and circulation under the device, and repositioning the limb in correct alignment. These sessions are planned, scheduled, and documented in the clinical record.

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4. Training and skill practice: Activities including repetition, physical or verbal cueing, and task segmentation provided by any staff member or volunteer under the supervision of an R.N., P.T. and L.V.N. 5. Bed mobility: Activities used to improve or maintain the individuals selfperformance In moving to and from a lying position, turning side to side, and positioning himself in bed. 6. Transfer: Activities used to improve or maintain individuals self-performance in moving between surfaces or planes either with or without assistive devices. 7. Walking: Activities used to improve or maintain the individuals self performance in walking, with or without assistive devices. 8. Dressing or grooming: Activities used to improve or maintain individuals performance in dressing and undressing, bathing and washing, and performing other personal hygiene tasks. 9. Eating or swallowing: Activities used to improve or maintain individuals performance in feeding oneself food or fluids, or activities used to improve or maintain the individuals ability to take nutrition and hydration by mouth. 10. Amputation/prosthesis care: Activities used to improve or maintain Individuals self performance in putting on and removing prosthesis, caring for the prosthesis, and providing appropriate hygiene at the site where the site where the prosthesis attaches to the body ( i.e. stump or eye socket). 11. Communication: Activities used to improve or maintain the individuals self performance in using newly acquired functional communication skills or assisting the individual in using residual communication skills and adaptive devices. 12. Other: Any other activities used to improve or maintain the individuals self performance in functioning. This includes, but is not limited to, teaching selfcare for diabetic management, self administration of medications, ostomy care, and cardiac rehabilitation. 13. Process: Review the clinical record and the current are plan. Consult with facility staff.

Documentation: Plan of care will Identify if restorative or maintenance. 1. Nursing note at least weekly in IDNs by RN/SPT/LVN addressing functional ability in ADLs response care.

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2. RN will review care plans monthly 3. RN will review care plans monthly and quarterly, annually. 4. Assessments will reflect nursing recommendation and service provided on an annual basis. 5. Check off on ADL daily care flow sheet each time the activity occurs.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatments POLICY NUMBER: 425 Effective Date: August 31, 2006 SUBJECT: CPAP, CARE, USE, AND CLEANING 1. PURPOSE: To provide guidelines for the proper care, use and cleaning of the continuous positive air pressure (CPAP) system used in the treatment of adult obstructive sleep apnea. 2. POLICY: 1. All nursing services staff who work on the units with the CPAP machine will have documented the evidence that staff receives training on care and use of the CPAP machine. 2. Do not attempt to use any electronic equipment without a thorough working knowledge of how to handle, operate, and care for the machine(s). 3. Follow the users manual instructions for operating, testing and cleaning of the equipment. 4. Central Supply serves as the resource for operating, testing, and cleaning of the equipment. 5. Unless specifically indicated by a physician order, with documentation supporting the specific necessity for a 1:1 observation, individuals will not be placed on 1:1. If an order is obtained it will be for a period not to exceed 24 hours, and the physician must personally see/re-evaluate the individual and document the necessity for renewal prior to renewing the order each time it requires renewal. 6. The physician will order the specific settings for the individual based on the sleep study laboratory recommendation. 7. All licensed nursing staff who received the CPAP in-service use may set-up program or change settings as ordered by physician. 8. The CPAP machine ordered for the individual will be specific for that individual. It is to be sent with the individual upon transfer or discharge. Central Supply is to be notified whenever the location of the individual/CPAP

is changed. When the individual is issued the CPAP machine, it will be entered on the Patient Clothing and Property Card and will be taken with the individual at the time of his or her discharge. The CPAP machine will not be re-circulated to other individuals. 3. DEFINITIONS: CPAP (Continuous Positive Airway Pressure) - Nasal CPAP devices deliver air at specific flow rates in order to maintain pressure within the airway to eliminate apnea events. Sleep Apnea Is a symptom of a group of disorders characterized by cessation of breathing during sleep. To be classified as such, apnea must last for at least ten seconds and occur 30 or more times during a seven hour period of sleep. Obstructive Sleep Apnea (OSA) Occurs when respiratory effort is present but is ineffective because of obstructions to the upper airway.

4. GENERAL INFORMATION: Although the person who snores may appear to be sleeping restfully, their sleep may actually be interrupted by apnea, followed by brief awakenings which prevent them from getting enough time in the deepest stages of refreshing sleep. People who suffer from OSA often become accustomed to chronic fatigue and may unconsciously curtail and modify their family activities because of their general lack of energy.

5. RISK FACTORS: The individual may not be a good historian of past trauma or other health problems. A good physical assessment upon admission is therefore essential. If the individuals skull region bears scars, bruises or deformalitys, further investigation should be done to learn about the individuals sleep patterns. 6. PRECAUTIONS: 1. If the individual develops a head cold, he or she should still try to wear the CPAP, but if the individual has difficulty breathing with the CPAP contact the physician. Do not use the CPAP if the individual has an earache, sinus or middle ear infection. Contact the physician. 2. Avoid lotions to the face, as the emollient will cause deterioration of the mask

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatments POLICY NUMBER: 428 Effective Date: August 31, 2006 SUBJECT: CENTRAL VASCULAR ACCESS DEVICES (CVADs): CARE AND USE 1. PURPOSE: To ensure safe needle insertion procedure and maintenance of adequate access via the Port-A-Cath or other CVAD. 2. POLICY: 1. Accessing a Central Vascular Access Device must ONLY be done by a qualified RN, MD or Doctor of Osteopathic Medicine (DO), using aseptic technique. 2. The physician may only order a 1:1 with documentation supporting the specific necessity for the 1:1/ such an order will be for a period not to exceed 24 hours. The order may only be renewed after the physician personally sees/reevaluates the individual and documents the necessity for the 1:1 prior to re-ordering it. 3. COMPETENCY: When an individual with a CVAD is received on a unit, RN(s) of that work site will receive in-service training from the staff Development Center and will be provided a competency review and approval by the designated medical surgical physician. The unit supervisor will assure that all unit staff is aware of safety precautions for individuals with central vascular access devices. 4. DEFINITIONS: There are four major types of Central Vascular Access Devices (CVAD): 1. Non-tunneled Catheter - Large-bore catheter inserter into the sub-clavian vein, 6 to 8 inches long. Can have from one to four lumens, and are made of either soft silicone or stronger polyurethane. Of the four types, these have the highest infection rate.

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2. Tunneled Catheter Designed for long-term use, made of durable, medical-grade silicone, can remain in place for many years. (Examples: Hickman, Broviac, Groshong, Hohn, and Leanard catheters.) 3. Peripherally Inserted Central Catheter (PICC) Lines Inserted in a peripheral vein and threaded into the superior vena cava, best suited for individuals requiring daily infusion therapies for up to 6 months. Longer than other CVADs (20 to 25 inches, as opposed to 6 to 8 inches). 4. Implanted Ports Totally implanted under the skin, this type has no external parts. Considered a long-term CVAD, may last for 2,000 punctures. Best used for cyclic therapies (e.g. chemotherapy or antibiotics) and for treatments for chronic or long-term illnesses (e.g. cancer or cystic fibrosis) 5. GENERAL INFORMATION: Central Venous Access Devices are not inserted at this facility, however an individual may return from an outside facility with any one of these devices in place. The following information applies to al four types. 1. The tip of a CVAD should rest in the superior vena cava, with one exception: the tip of a femoral line rests in the inferior vena cava. Infusing medication through misplaced catheters can cause significant injuries, including pericardial effusion and cardiac tamponade. Placement in the right atrium is not acceptable for any device; the tip could trigger an arrhythmia as it floats across the senatorial (SA) node. A catheter tip migrating through the heart may become entangled in the tricuspid valve, necessitating valve replacement surgery. 2. For PICC catheters, measure the external length and document it for comparison with subsequent measurements. If there is any change at ll, notify the physician immediately. 3. Before using any CVAD, make sure that an X-ray had verified correct tip placement. The radiology report should confirm tip placement in the superior (or inferior) vena cava, or the junction of the right atrium and the superior vena cava (atrial/caval junction). This information should be on the intake and output flow sheet, and/or the medication administration record. Obtain blood return the CVAD before each use. 4. Flush the catheter routinely to remove any drug residue from the lumen and prevent the catheter from clotting if blood refluxes into the lumen. Use the SCSH method: Saline, Administer the drug (or withdraw blood). Saline, Herparine. Flush any CVAD using the positive-pressure technique: inject the flush solution, leave your thumb on the syringe plunger, and close the clamp. This helps prevent blood backflow and lowers the risk of catheter occlusion.

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Most CVADs have a volume of 1 to 3 ml, and should be flushed with a volume that is at least twice the volume of the catheter and extension tubing. Use only 10-ml or larger syringes. 5. Remember the larger the syringe barrel, the lower the pressure. Using a small barrel, hih-pressure syringe will increase the chance of breaking the catheter. 6. Use a 10-ml or larger syringe to obtain a blood specimen. Vacuum bloodcollection systems may also be used with all CVADs except PICC lines. These generate extremely high pressure that can rupture PICC catheters. Discard the first portion usual 5 to 10 ml of the blood specimen to prevent heparin or a drug from contaminating the specimen and causing inaccurate lab results. 7. The external end caps on NON-TUNNELED and TUNNELED CVADs should be changed at least once a week. Check the manufacturers recommendations for guidelines specific to the device. (NOTE: this does not apply to IMPLANTED PORTS, which do not have an external end cap.) To access an IMPLANTED PORT, you will push a special non-coring Huber needle through the skin. A traditional needle would core the septum, resulting in blood leakage and contact with air. A damaged port must be surgically removed immediately. 6. PRECAUTIONS: Many nurses incorrectly believe that transparent dressings are occlusive. These semi permeable membranes permit air to circulate through the dressing to prevent perspiration from collecting under the dressing. To make a transparent dressing occlusive, apply povidine-iodine ointment or antibacterial ointment to the site. The jellylike consistency of ointment occludes the wound. 7. FREQUENCY: Gauze Dressing Should be changed at least every 48 hours, whenever the dressing is no longer intact, and/or if you lift a gauze dressing to inspect the site, you must replace it. Transparent Dressing Should be changed every 3 to 7 days, or whenever the dressing is no longer intact. 8. EQUIPMENT: 1. One opsite (transparent) dressing.

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2. One alcohol swab stick 3. One beta dine swab 4. 4x4 gauze 9. PROCEDURE: 1. When changing a dressing, wash your hands, put on non-sterile gloves and remove the old dressing. 2. Discard the dressing and the gloves as per policy. 3. Wash hands, set up supplies, and don sterile gloves. 5. Inspect and palpate the catheter insertion site for swelling, redness, or any other sign of complications. 6. Then vigorously clean the same area with povidine-iodine and let the skin dry completely. 7. Apply new dressing.

10. SPECIFIC TYPES OF CVADs: The following pages list each of the four major types of central venous access device and the specific care and maintenance required for them. 1. Non-tunneled 2. Tunneled 3. PIXX Lines 4. Implanted port (e.g. port-A-cath) No tunneled CVAD Fast Access: General Information: Nontunneled CVADs can be inserted quickly and can handle any kind of I.V. therapy as well as blood collection, making them especially useful in an emergency. Some types are impregnated with heparin, chlorhexidine, or an antibiotic.

Insertion Information: Usually inserted by a physician (although a specially prepared nurse practitioner or physician assistant may do so in some circumstances). Observing strict aseptic technique, the practitioner first inserts a 14-gauge needle into the subclavian vein, using the clavicle as a guide. When venous blood return is observed in the syringe, the syringe is disengaged from the needle, and a wire is fed through the needle into the subclavian vein. The needle is then removed and discarded, and the catheter is fed over the wire

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into the subclavian vein and the brachiocephalic vein. After insertion, the site is covered with a dressing to prevent microorganisms from entering the venous system via the insertion site. Note: Out of the four types of CVADs, this type has the highest rate of infection, so meticulous nursing care is crucial. Nursing care and use: 1. Obtain blood return from a non-tunneled catheter (and any other CVAD) before each use. 2. Flush the catheter routinely to remove any drug residue from the lumen. Use the SCSH method whenever flushing a catheter. 3. If the catheter is not in use, flush it once a day with heparin. 4. Most CVADs have a volume of 1 to 3 ml; flush with a volume that is at least twice the volume of the catheter and extension tubing. 5. Flush any CVAD using the positive-pressure technique. 6. Use a 10-ml or larger syringe to abtain a blood specimen. Discard a portion (usually 5-10 ml) to prevent heparin or another drug from contaminating the specimen. 7. You may use a vacuum system for drawing blood from this type of CVAD. 8. Change the end caps of the catheter at least once a week, or follow the manufacturers recommendation specific to the device. Tunneled CVAD Catheters that stay awhile: General Information: Designed for long-term use, these catheters can remain in place for many years. Chronically ill individuals who require long-term I.V. therapy are candidates for these catheters, which are made of durable, medical-grade silicone to help avoid breakage. They are ideal for active individuals: once the catheter tunnel and cuff matures, these individuals can move about without restriction. Insertion information: Inserted by a physician in the operating room or interventional radiology suite, using a needle to locate the subclavian vein and advancing the catheter tip into the superior vena cava. The physician then utilizes a blunt-ended trocar to create a subcutaneous tunnel from the subcalvian vein down the chest wall. Catheter manufacturers recommend that the catheter exit the tunnel at the nopple level. Once the cuff heals into place, the sutures can be removed and no dressing is required unless the individual is immunocompromised and at high risk for catheter infection.

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Nursing care and use: -For the first 10 days after insertion, change a transparent dressing weekly, or whenever soiled or loose, use aseptic technique. -Change gauze dressings every 48 hours or whenever soiled or loose. -Once the cuff heals into place (and sutures are removed) a dressing is not necessary, unless individual is immunocompromised. -Teach individual to wash the catheter exit site with soap and water when showering and to inspect and palpate the site daily for signs of infection. -Most tunneled catheters should be flushed with 3 to 5 ml of heparin (10 units/ml) daily when not in use, and before and after each use, using the SCSH protocol [see general information section, page 435.2]. -EXCEPTION: closed-ended (groshong) catheters hav an internal valve designed to prevent blood reflux into the catheter. The manufacturer recommends less-frequent flushing with saline, not heparin. [See next page] -Blood may be drawn from tunneled catheters using a 10-ml (or larger) syringe or vacuum collection systems. -As with non-tunneled catheters, change end caps at least weekly. -Manufacturers of tunneled catheters provide repair kits if the catheters external portion breaks. Closed-ended or Groshong-type tunneled catheters: -Are designed to prevent backflow into the catheter when the catheter is not in use. -Fluids infuse though a slit valve on the side of the tip; when no infusion is flowing, the slit valve on the side of the sip; when no infusion is flowing, the slit valve remains in a neutral or closed position. -A back plug on the end of the catheter opens inward during blood aspiration and outward during an infusion and remains closed at other times. -Because of this design, DO NOT CLAMP as closed-ended catheter (e.g. when attaching extension tubing), as you would with traditional open-ended CVADs. The pressure from clamping could force the slit valve open, allowing bloo to leak into the lumen. -The catheter tip design protects the catheter from clotting; therefore routine flushing with heparin is not required. -Flush this type of catheter with 5 ml of 0.9% sodium chloride before and after each use and weekly if the catheter is not in use, as recommended by the manufacturer. PICC catheters another option for the long haul: General Information:

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This type of catheter is inserted into a peripheral vein and threaded into the superior vena cava. They can be used for all therapies and blood collection, and are best suited for individuals who require daily infusion therapies for up to six months. No recommended maximum dwell time has been established, and some individuals have used a PICC line for a year or more without any problems. PICC lines (such as #2 or #3 French catheters) may be difficult. Theses catheters also tend to infuse fluids more slowly and occlude faster then other CVADs. However, the incidence of a catheter-related infection is only about 1%. Insertions information: PICC catheters can be inserted by a physician or a specially prepared nurse in various settings. Before starting, the physician measures the individual to make sure the catheter is the correct length to reach its destination. It is then inserted into a vein in the antecubitin fosse (e.g. the basilica or cephalic vein), and advanced into tie superior vena cava. In some instanced, a PICC line is advanced only into the peripheral vasculature, in which case they are considered peripheral or midline catheters, not CVADs Nursing care and use: - After insertion, a transparent dressing is applies to the insertion sire so it can be observed without disturbing the dressing. -Proper placement of the catheter should be confirmed by x-ray. -Change the dressing 24 hours after insertion, then every 7 days or sooner if it becomes soiled or loose. -Measure and document the external length of the catheter with each dressing change. -If there is any change in the external length, notify physician immediately and recommend x-ray to check catheter position. -The purpose of a PICC dressing is twofold: 1. To anchor the catheter in place. 2. To act as a bacterial seal. -When applying a dressing, place the securing device on the catheter hub. -Most PICCs are open-ended and vulnerable to catheter occlusion. -Flush open-ended PICCs with heparin, 100units/ml (total volume, 3ml), after each use following the protocol. -Flush daily when not in use. -Follow manufacturers recommendations for maintaining closed-ended PICCs. -Collect blood specimens from a PICC catheter using a 10-ml (or larger) syringe. -DO NOT USE VACUUM-TYPE BLOOD COLLECTION SYSTEMS. They generate extremely high pressure which can rupture PICC catheters. -After a PICC catheter has been removed, the sire should be covered with an occlusive dressing to protect it from induction to prevent air embolism.

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Implanted ports (e.g. PORT-A-CATCH) out of sight: General Information: The type of CVAD is totally implanted under the skin and has no external parts. It is considered a long-term CVAD and may last for 2,000 punctures. They can handle both bolus injections and continuous infusions. The ports are composed of a metal or plastic housing that surrounds a self-sealing silicone gel. A silicone catheter is attached to the port housing. An implanted port minimizes infection and may be more convenient and cosmetically appealing to active young adults. However, they also have drawbacks: they must be surgically implanted and accessing them may be painful for the individual.

Insertion Information: Ports are usually inserted in the O.R or interventional radiology suite. The surgeon makes a subcutaneous pocket for the port housing, inserts the catheter into the subclavin vein, and advances it into the superior vena cava. (Depending on the therapy). The catheter can be inserted into any vein or artery, the brain, or the epidural space for pain control.) The insertion sire requires a dressing until it heals. Nursing care and use: -To access the port, first palpate the area to locate it. -Numb the area with a topical anesthetic cream, ice, or ethyl chloride spray, depending on the physicians order. -Using sterile technique, clean the area with alcohol followed by povidinge-iodine. -With the thumb and index finger of the no dominant hand, fell for the edge of the port housing and stabilize the port between the thumb and finger. -Push the Huber no coring needle through the skin and silicone gel until you hit the ports rigid back. -Confirm that the needle is correctly placed by checking for blood return, then flush with saline. -After accessing the port, cover the Huber needle with a transparent dressing and start the infusion, as per the physicians order. -Change the Huber needle and dressing every 7 days. -If an accessed port is not being used to infuse fluid, flush it daily with 5 ml of heparin (100 units/ml). -If the port is not accessed or in routine use, access and flush it every 28 days to maintain patency. -For blood drawing, use a 10-ml (or larger) syringe or a vacuum blood-collection system. Remember that may alter lab results.

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Troubleshooting complications: No matter what type of CVAD and individual has, it must be assessed frequently for symptoms of catheter complications or to initiate nursing interventions will compromise client care and could expose the nurse to a malpractice lawsuit. Three of the most common sources of trouble are: 1. Catheter-relates sepsis 2. Catheter Malpostition 3. Catheter Malfunction Quick tips for CVAD Assessment: -If you have any reason to believe a CVADs tip is out of position or occluded, do not attempt to use the CVAD. -Notify the physician and prepare the individual for x-ray or thrombolytic interventions, as indicated. Problem A. Catheter-related sepsis Signs and symptoms -Drainage from exit site. -Redness, pain at exit site -Fever spike -Sudden increase in heart rate -Decrease in external catheter length -Individual has sudden earache on side of catheter -Individual hears bubbling in ear when catheter is flushed -Inability to infuse fluids though catheter at the prescribed rate -Absence of substation free-flowing blood return -Individual must be repositioned to obtain blood return -Visible collateral chest veins.

B. Catheter tip in right atrium C. Catheter tip in jugular vein

D. Catheter malfunction (e.g. clot formation inside catheter tip, kink in catheter)

Documentation: The appearance of the area around the CVAD insertion sire shall be documented by the RN every shift and after every dressing change. The following items shall be considered at each assessment and shall be included in the Q shift/post dressing change documentation: -Accidental removal

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-Suspected blood clot -Absence of blood return -Disconnect with blood loss -Infiltration -Suspected air or catheter embolism -Persistent pain at insertion ste or in shoulder on same side of CVAD -Infection -Burning along tunnel while flushing or during infusion -pain or ringing in ear while flushing or during infusion -Swelling/edema -Resistance to flushing or during infusion, distended veins on same side as CVAD -Bleeding at the site. -Unsecured CVAD (e.g. broken sutures) A special incident report shall be completed if any of the following conditions occur: -Accidental removal -Absence of blood return in CVAD unresolved after troubleshooting (exception: peripheral CVAD) -Disconnect with blood loss -infiltration -Failure to follow policy and/or procedure.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatments POLICY NUMBER: 429 Effective Date: August 31, 2006

SUBJECT: GIVING OR REMOVING A BEDPAN OR URNAL 1. PURPOSE: To facilitate and encourage normal elimination of urinary abd bowel wastes for patient confined to bed. 2. EQUIPMENT: Obtain from central supply or from designated storage area: 1. Disposable bedpan or urinal 2. Disposable washbasin 3. Bedpan cover (towel) 4. Disposable gloves 5. Disposable wet wiped 6. Linen saver pad Obtain from the laundry: 1. Hand towel 2. Wash cloth

Have soap available. 3. PROCEDURE: Giving a bedpan: NURSING ACTION A. Provide screen or close door. B. Wash hands, and apply disposable gloves. C. Obtain bedpan from designated area or bedside stand. Make certain it KEY-POINTS A. To minimize embarrassment and ensure privacy. B. To prevent cross-contamination. C. Avoid cross-contamination.

is labeled with the patients name and number if bedpan is being re-used for the same patient. D. Turn bedding back, exposing as little of the patient as possible. E. Have patient flex his knees and raise buttocks, if possible. Assist him where it is necessary by placing hand under low back and lifting. F. If patient cannot use his legs to raise himself, turn him on his side. Position bedpan to buttocks and roll him onto his back with bedpan under him. G. Adjust the bed to the most comfortable position for the patient if orders allow. If possible, elevate the head of the bed slightly to prevent hyperextension of the spine. If elevation of the head is contraindicated, tuck a pillow or folded blanked under the patients back to cushion the sacrum against he bedpan and support the lumbar area. H. Leave the patient alone with the toilet tissue within easy reach (Unit 1 ensures patient has access to call bell). I. Dispose of gloves, wash hands per hand hygiene policy.

D. Maintain the patients privacy. E. Allows space for bedpan between the individual and bed. Check to ensure that he is not restricted from moving or certain types of posture. F. Be sure bedpan is in proper position.

G. Using the bedpan is difficult for most people. When permitted elevating the head of the bed aids in elimination.

H. Minimizes patient embarrassment.

Removing a bedpan: NURSING ACTION A. Apply disposable gloves. KEY-POINTS A. The patients condition and the physicians order will determine how much he is able to do for himself. B. The patients condition and the physicians order will determine how much he is able to do for himself.

B. Lower head of bed have patient flex his knees and rise up buttocks; then remove the bedpan. Assist and support the patient as necessary. C. If the patient is unable to care for C. Hold the bedpan to prevent it from and clean himself, hold the bedpan tipping as the patient turns. firmly and turn the patient to his side off the bedpan. D. Remove and cover bedpan and D. To protect bedding and prevent

place it to the side of the bed. E. Cleanse anal area with disposable wet wipe, then wash, and dry anal area and buttocks. F. Provide materials for patient to wash and dry his hands and position him for comfort. G. Empty contents of bedpan into toilet and flush. Discard per I.C.M. All disposable items will be discarded per I.C.M. III.C. H. Open door or remove screen. I. Measure and record contents if patients are on I&O and dispose of contents in toilet room. Return urinal to bedside stand. Disposable articles will be discarded per ICM.

odors. E. To prevent excoriation and breakdown of skin. F. To provide hygiene and comfort.

G. Eliminate risk of cross contamination and reduce the risk of communicable disease transmission.

I. Eliminate risk of cross contamination and reduce risk of communicable disease transmission.

4. RECORDING: Bowel Movement: 1. Record BMs on Daily care flow sheet (MH 5504) or if in RS and/or FBR on restrain flow chart/observation record. 2. Interdisciplinary note record pertinent observations not included on daily care flow sheet 3. If patient has no BMs x3 days report to physician in charge. Report any abnormalities to physician, I.e. diarrhea, bloody stool, clay colored stools, tarry stools, etc. Urine: 1. If intake and output recording is order, or necessary as a good nursing measure without an order, record volume of urine on the daily care flow sheet. 2. On IDNs, record total volume of urine plus observations of urine color and consistency every eight hours. 3. NOC shift will include total 24-hour volume in the IDNs. 4. Report to physician any abominates observed i.e. (continues concentrated urine, red ringed urine, insufficient or excess of urine output, i.e. urinary output less than 30 cc/hr.) Lab Specimens: 1. Any urine or stool specimen collected for laboratory studies will be delivered to the clinical laboratory with appropriate lab slip as soon as possible after collection. A staff person must carry the specimen. 2. Label specimen with contents, date, current time and time collected.

3. Record in IDNs, date and time specimens are collected and delivered to the clinical laboratory. Patient Teaching: -Document any patient education on the IDN notes.

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatments POLICY NUMBER: 430 Effective Date: August 31, 2006

SUBJECT: WOUND IRRIGATION 1. PURPOSE: This Nursing Policy will provide guidelines for appropriate and effective wound irrigation. 2. POLICY: Open wound irrigation requires a physician's order including type of solution(s) to use. Irrigation shall be performed under aseptic technique by a Registered Nurse or by a Licensed Vocational Nurse (LVN) who has demonstrated competence in this procedure. 3. DEFINITION: A wound is an injury to the tissue of the body causing disturbance of the normal tissue pattern. Irrigation is the cleansing of an area with a flowing solution. Using an irrigating syringe to flush the area with a constant low-pressure flow of solution, the gentle washing action of the irrigation cleans a wound of exudate and debris. 4. PRECAUTIONS: Nursing personnel, having direct contact or the potential for contact with exposure to blood, body fluids, or other potentially infectious material of individuals, are expected to practice Standard Precautions according to guidelines established by the CSH Infection Control Program. The fluid blood and moist body substances of all individuals shall be treated as though they were contagious. (Refer to A.D. 10.23 Standard Precautions) In all reasonably anticipated exposure to blood or other potentially infectious material, Personal Protective Equipment (PPE) and engineering controls shall be used. (Refer to NPPM #1200 Infection Control Program)

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5. GENERAL INFORMATION: The inflammatory and healing process occurs normally in a wound, however irrigation can help the desirable aspects of these processes. The presence of pathogens will increase the likelihood of a wound infection. Irrigating the area can help to remove pathogens from the wound. 6. CLASSIFICATION OF A WOUND: Abrasion - a wound that results from scraping or rubbing of skin or mucous membranes such as floor or carpet burn. Laceration - made by an object that tears tissues, producing jagged irregular edges such as a blunt knife, jagged wire, glass. Puncture - made by a pointed instrument such as an ice pick, bullet, knife stab, nail, or pencil. Ulcerated - localized areas of necrosis of the skin and subcutaneous tissues produced by pressure. 7. ASSESSMENT: Assess recent recording of signs and symptoms related to individuals open wound: a. Extent of impairment of skin integrity b. Elevation of body temperature c. Drainage from wound (color, amount) d. Odor e. Consistency of drainage f. Culture reports g. Size of wound (measure depth, length, and width) h. Dressing: dry and clean; evidence of bleeding, profuse drainage i. Comfort level and pain rating and identify symptoms of anxiety 8. PLAN: 1. Observe and note factors that may interfere with the healing process. 2. Prevent or reduce infection and promote healing. 3. Allow adequate nutrition through proper diet, such as protein and vitamin C.

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4. Communicate the appearance of the wound to health team members in correct terminology and on correct records. Recognize tissue changes that require urgent medical or nursing intervention and initiate action. 9. EXPECTED OUTCOMES: -Individual is comfortable after wound irrigation. -Wound begins to heal; dressing is clean and dry; wound is free of drainage and inflammation. -Skin integrity is maintained. 10. EQUIPMENT: Sterile irrigation tray (sterile 50 cc bulb irrigating syringe with syringe tip protector; plastic graduate with plastic graduate cover; waterproof underpad {chux}; antiseptic towelette; plastic drainage tray) -Prescribed irrigation solution -Clean (non-sterile) examination gloves. -Gown and other protective equipment if indicated. -Dressing supplies -Sterile gloves 11. IMPLEMENTATION AND INTERVENTION: NURSING ACTION A. Check physician's orders. KEY POINTS A. Open wound irrigation requires a medical order including type of solution(s) to use.

B. Assemble all equipment in the B. Increases efficiency. Do not use a individual's room or treatment area. solution that has been opened longer than Check expiration date on each sterile 24 hours. package and inspect for tears. Check the expiration date on each bottle of irrigation solution when opening a new bottle. C. Dilute the prescribed irrigating solution to the correct proportions with sterile water or sterile saline solution, if necessary. C. Solution should be at room temperature.

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D. Explain the procedure to the individual. Provide privacy. Position individual comfortably to permit gravitational flow of irrigating solution through wound and into collection basin. Position individual so that wound is vertical to collection basin. E. Place waterproof underpad (chux) under the individual.

D. Positioning individual during planning stage facilitates the treatment procedure.

E. To catch any spills and minimize need for linen changes.

F. WCSH your hands thoroughly. Wear gown or other Personal Protective Equipment (PPE) where appropriate. G. Put on clean examination gloves to remove soiled dressing. Discard the dressing and gloves in the red disposal bag. WCSH hands thoroughly. H. Establish a sterile field with all the equipment and supplies you will need for irrigation and wound care. I. Place sterile plastic drainage tray below the wound.

F. Protect your clothing from wound drainage and contamination.

G. Reduces transmission of microorganisms.

H. Reduces risk of introducing microorganisms into wound. I. Directing solution from top to bottom of wound and from clean area to contaminated area prevents further infection. J. Wound irrigation is a sterile procedure. K. Using a slow, steady stream of solution prevents trauma to granulation tissue.

J. Put on sterile gloves.

K. Fill the syringe with the irrigation solution. Hold syringe tip 2.5 cm (1 in) above upper end of wound. Using slow, continuous pressure, flush wound. Be sure the solution reaches all areas of the wound. L. Continue to irrigate the wound until you have administered the prescribed amount of solution. M. Keep the individual positioned to

L. Ensures removal of all debris. Note the amount of solution administered for potentially retained solution. M. Permits gravitational flow of irrigation

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allow further wound drainage into the basin. N. Dry wound edges with sterile gauze.

solution.

N. Prevents maceration of surrounding tissue from excess moisture. O. Disposal precautions as outlined in NP&P #1216.

O. Pack the wound, if ordered and apply a sterile dressing. Remove and discard your gown and gloves. P. Make sure individual is comfortable. Inspect dressing periodically. Q. Clean and return non-disposable equipment. R. WCSH hands thoroughly.

P. Determines response to wound irrigation and need to modify care

plan.

Q. Refer NPPM Policy 1206 Cleaning of Reusable Instruments. R. Reduces transmission of infection.

12. EVALUATION AND DOCUMENTATION: 1. Inspect dressing as clinically indicated. 2. Evaluate skin integrity. 3. Observe individual for signs of discomfort. 4. Observe for presence of retained irrigation solution. 5. Record wound appearance including baseline descriptions and course of wound healing. 6. Document the amount and character of drainage; measures taken to prevent infection. 7. Identify any complications of wound healing and actions taken to recognize or prevent these. Immediately report any evidence of fresh bleeding, sharp increase in pain, retention of irrigation solution, or signs of shock to the physician. 8. Record wound irrigation and individuals response in the ID notes. Report findings at Change of Shift Report. 13. CROSS - REFERENCE: ADMINSITRATIVE DIRECTIVES: A.D. #10.23 Standard Precautions NURSING POLICY & PROCEDURES: NPPM #1200 Infection Control Program, NPPM #vii Change of Shift Report, NPPM #309 Vital Signs, NPPM #705 Emergency Care of Wounds, NPPM #1216 Biohazardous (Infectious) Waste

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatments POLICY NUMBER: 431 Effective Date: August 31, 2006 SUBJECT: BLADDER IRRIGATION 1. GENERAL: A physician's written order is required specifying the type of irrigation, the solution and any medication to be used. Registered Nurses and Psychiatric Technicians who have had proper instruction may perform this procedure. The amount of solution to be introduced at one time, from 30 cc to 500 cc, depends upon the purpose of the procedure and the condition of the patient's bladder. Continuous or intermittent bladder irrigation, utilizing closed gravity drainage system, is the preferred method of bladder irrigation. NOTE: Except for the use of catheter plugs, no urologic procedure is more hazardous from the standpoint of producing urinary tract infection than is hand irrigation with a syringe. Syringe irrigation is not done unless absolutely necessary to relieve catheter obstruction, and then only with strict aseptic precautions. 2. PURPOSE: Bladder irrigation is the process of introducing a stream of solution into the bladder and draining it off by natural or artificial means. It serves the following purposes: removes blood clots or other solid material; prevents accumulation of blood in the bladder; determines proper placement of the catheter; measures bladder capacity or maintains bladder muscle tone; and applies medication to the lining of the bladder. 3. EQUIPMENT: A. Obtain from Central Supply: 1. Disposable irrigation tray containing: a. Drainage tray graduated to 1200 cc b. Irrigating syringe, 50 cc with tip guard c. Solution container graduated to 500 cc with cover d. Antiseptic towelette B. Obtain from Pharmacy solution as ordered 4. PROCEDURE: NUSRING ACTION A. WCSH hands before and after procedure. B. Explain the procedure to the patient. Provide privacy. C. Place the patient on his back with his knees flexed and legs relaxed to the
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RATIONALE-PRECAUTIONS A. To prevent cross contamination B. Reduce patient anxiety and elicit cooperation. Maintain patient dignity. C. Drape to provide privacy, warmth and protection.
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side. D. Open irrigation set and save the bag for disposal of contaminated items. E. Put on sterile gloves. F. Remove syringe and solution container from drainage tray. Handle the syringe by the plunger and place the barrel and tip in the drainage tray. G. Fill the 50 cc container with the prescribed amount of solution. H. Remove protective guard from syringe tip and place tip of syringe in the solution container. I. Remove underpad, open and place beneath the patient, absorbent side up. J. Place drainage tray conveniently for catheter drainage. Thoroughly cleanse the catheter and drainage tube connection with alcohol sponge, and disconnect, keeping both ends sterile. Place the catheter in the drainage tray, using the slot end of the tray to hold the catheter. Insert the end of the drainage tube connection into the sterile cover sheath provided, and secure to bed. K. Allow urine to drain, fill syringe, slowly inject solution into bladder and allow to return to gravity flow. L. If the catheter appears to be obstructed, insert the tip of the empty syringe into the catheter and attempt to release the obstruction by pulling gently on the plunger. If resistance is met, DC and go to step M. M. If obstruction is not relieved by aspiration, fill the syringe with 30 cc to 50 cc of solution and with moderate force, inject into the bladder. N. If obstruction persists, gentle to and fro manipulation of the catheter may encourage drainage to start. Deflation of the balloon may help this maneuver, but use care not to let the catheter come out. If this is not successful, call the physician at once. O. Before the gravity drainage set is reconnected, clean the end of the catheter and the drainage tube with an alcohol sponge. P. Replace the bed covers and leave the

D. Avoid contaminating the inside of the solution container, the inside of the drainage tray and the barrel of the syringe. E. Maintain sterile technique. F. Since the barrel of the syringe may enter the irrigating solution during filling it must be kept sterile. G. Do not use the solution container lid that comes with some sets.

I. Keep bed linen dry and prevent unnecessary discomfort to the patient. J. Maintain sterility and prevent urinary tract infection.

K. Return to gravity flow prevents injury to delicate tissues. L. Blood clots, mucous and bits of tissue may cause obstruction of the catheter. Vigorous aspiration can cause tissue damage. M. When clots or other material are obtained upon aspiration, allow the catheter to drain by gravity. Then repeat syringe irrigation until the bladder has been emptied of all clots and all drainage returns clear. N. Do not use force as this can cause damage to bladder tissues.

O. Prevent introduction of pathogenic organisms. P. Provide patient care.

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patient comfortable. Q. Measure return urinary output. Calculate by subtracting the amount of irrigant used from the total return. Record individual amounts of the I & O worksheet (AT 2893). R. Discard irrigation set per ICM III. C

Q. To record in I & O work sheet with 24 hour total on Daily Care Flow Sheet. R. Be aware of contraband and contaminated items.

5. RECORDING: In the Interdisciplinary Notes record the procedure, time, appearance of Drainage (blood clots, etc.) and the patient's reaction or any complications the procedure. Intake-Output Record - Record urinary output every eight (8) hours, total every 24 hours, record on Daily Care Flow Sheet (MH 5504). Document any patient teaching on Patient/family Health Education Record. 6. INFECTION CONTROL: Adherence to aseptic technique during irrigation is vital to the patient's safety and progress. The threat of infection is very great in urinary tract techniques. Instilling a foreign matter into the bladder, in this case the irrigation fluid, has inherent dangers of introducing infectious organisms at the same time. Meticulous hand wCSHing is essential before and after irrigating the bladder. If the sterility of the irrigation equipment cannot be guaranteed, use new equipment.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatments POLICY NUMBER: 432 Effective Date: August 31, 2006 SUBJECT: NASOGASTRIC TUBE INSERTION Cancellation: This procedure cancels procedure Number 328, dated 04/10/00, same subject. 1. GENERAL: Following a physician's written order, a Registered Nurse who has received instruction in Nasogastric tube insertion, may insert plain gastric tubes into the stomach through the nose or the mouth. Nasogastric tubes are used to assess gastrointestinal function, detect complications, treat problems, administer medications and decompress the stomach and duodenum. For these purposes the stomach is intubated with either a single lumen or double lumen sump tube. The sizes most frequently used for adults are 16 to 18 French. Marker rings are located at 18, 22, 26, and 30-inch points. Nasogastric tubes commonly used for feeding are #18 French. Because of the small diameter, feeding tubes may curl during insertion, making it necessary to use a guide. This procedure is to be done by Unit 1 Registered Nurses unless insertion is accomplished by the physician. Insertion may be done by a Unit 1 Registered Nurse on the patient's home unit. The lining of the GI tract is delicate and insertion of the tube may traumatize the lining and allow an entrance for pathogens into the system. For this reason, it is essential to insert the tube gently and to avoid using force if resistance is met during insertion. Careful hand wasing is essential before and after insertion and irrigation of the nasogastric tube, and before and after administration of tube feeding. 2. PURPOSE: To determine site, freshness and amount of gastrointestinal bleeding. To test aspirate for frank blood (guiac) or acidity. To administer antacids and other medications.

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To lavage the stomach. To administer gastric feeding.

3. EQUIPMENT: A. Nasogastric tube B. Water-soluble lubricant C. 50-60 ml. irrigating syringe D. Emesis basin E. Hypoallergenic tape F. Glass of water if not contraindicated G. Stethoscope H. Towel I. Flashlight J. Clamp or catheter plug K. Suction source L. Disposable gloves M. Specimen container (if needed) 4. PREPARATION OF EQUIPMENT: A. Have proper size tube available. B. Wash hands. C. Examine the tube to make sure it is free of defects, such as rough or sharp edges. D. Check patency by running water through the tube. 5. PREPARATION FOR INSERTION: NURSING ACTION A. Explain the procedure to the patient and show him the tube. B. Provide privacy C. WCSH hands D. Remove dental appliance and inspect oral cavity. E. Position the patient using one of the following: F. Sitting position - make sure he does not lean forward. RATIONALE-PRECAUTIONS A. The patient can cooperate more fully. B. The patient will be more comfortable. C. To reduce the incidence of nosocomial infections. D. Assure clear airway in the case of vomiting.

F. This decreases the gag reflex and makes swallowing easier. When leaning forward the tube tends to enter the trachea.

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G. Left lateral position if patient is unable sit up. H. Drape the patient with a towel or Chux. I. Put on gloves.

J. Measure length of the tube to be passed.

K. Extend the distal end of the tube to the bridge of the nose to the earlobe to the xiphoid process. L. Indicate this length on the tube by placing tape at that point on the tube. M. Lubricate the tube about 6-8 inches with water-soluble lubricant. N. Determine which nostril is more patent. Choose the nostril with the most airflow. O. Ask the patient if he has ever had nasal surgery or trauma or a deviated septum Inspect nostrils with a light. P. Occlude one nostril at a time to determine which has best airflow. Q. Have the patient hold an emesis basin.

G. This facilitates passage of the tube into the cardia of the stomach. H. Avoids soiling of patient clothing/linen. I. Avoid contamination of the tube and of hands by gastric content in the event of emesis. J. If the tube is in the esophagus, the patient may belch. If the tube is placed too far into the stomach, it may cause gastric erosion and hemorrhage. K. This measurement is the length needed to reach the stomach. L. To aid proper tube placement. M. This lessens irritation of the mucosa. N. To aid in a smooth, non-traumatic nasogastric tube placement.

Q. Possible emesis due to gag reflex when tube passes into posterior nasopharynx.

6. INSERTION OF THE NASOGASTRIC TUBE: NURSING ACTION A. Have patient lift head, then pass lubricated tube gently into the posterior nasopharynx. B. If resistance is met, rotate the tube slowly, aiming downward and toward the ear on the same side. If obstruction appears to prevent tube passage, do not use force but remove tube and try the other nostril. C. When the tube reaches the posterior pharynx, the patient may gag allow him a few moments to rest. D. Advance the tube firmly and steadily while RATIONALE-PRECAUTIONS A. Passage of the tube is facilitated by following the natural contours of the body. B. Avoid pressure on the tube which may cause bleeding from pressure.

C. The gag reflex is triggered by the presence of the tube. D. Swallowing facilitates passage of

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the patient is swallowing. (He may swallow water from a glass or straw if not contraindicated.) E. Have the patient flex his head on his chest as he takes sips of water, pass tube until tape mark is reached. (If patient is allowed water.)

the tube and minimizes gagging. Water lubricates the tube. E. This opens the esophagus and facilitates closing of the trachea. Swallowing facilitates passing of the tube.

NOTE: Withdraw tube immediately if a change in respiratory status is noted. I.e., coughing, cyanosis, unable to speak, this indicates placement in the bronchus. 7. TEST TUBE FOR PLACEMENT USING TWO OR MORE OF THE FOLLOWING TECHNIQUES: NURSING ACTION A. Place a 50-60 ml.-irrigating syringe on the end of the tube. B. Obtain gastric content by aspirating with the 50-ml. syringe. RATIONALE-PRECAUTIONS A. Allows for aspiration after insertion. B. Ascertain tube's location in the stomach. Return aspirated contents to the stomach if not needed for specimen. C. If tube is properly placed a rush of air should be heard. Repeated instillation may be required to assure tube's location. D. Bubbling indicates tube is in the bronchus, and immediate withdrawal is necessary. (Note - The absence of bubbling does not confirm placement by itself.) E. Tube is radiopaque. Placement may be verified.

C. Auscultate with stethoscope over gastric area while 15 ml. of air is inserted into the tube. D. Place end of tube in glass of water to check for bubbling.

E. Obtain an order for chest X-ray from a physician if necessary. 8. SECURING OF NASOGASTRIC TUBE: NURSING ACTION A. Anchor tube with hypoallergenic tape. Using 2 inches of tape, split lengthwise half way, attach un-split end of tape to nose and cross split ends around tubing. B. Connect the tube to suction or feeding as ordered by physician.

RATIONALE-PRECAUTIONS A. To hold tube in place. To prevent tubing from rubbing on patient's nasal mucosa causing erosion.

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9. DOCUMENTATION: For tube insertion, record the date, time, tube type and size, site of insertion, area of placement, and confirmation of proper placement in the patient' chart (IDN's). Also record the type and rate of feeding. Patient's tolerance of the procedure should be noted. Record amount of feeding on the Treatment Record (MH 5751). Total daily amount of feeding to be documented on the Daily Care Flow Sheet. 10. RELATED CARE: A. Head of patient's bed is to be elevated to at least 30 degrees to prevent gastroesophageal reflux. B. Maintain patency of tube by irrigating & repositioning as necessary. May rotate tube to prevent tube adherence to gastric mucosa and erosion. C. Observe drainage for change in amount, color, consistency and odor. D. Keep records of amount of intake and output on the Daily Care Flow Sheet. E. Monitor for electrolyte imbalance. F. Weigh patient daily or as ordered by physician. Monitor nutritional status and hydration. G. Continuous monitoring of tube feeding regimen is necessary to determine its effectiveness: 1. Assess tube placement, patient position and flow rate. 2. Observe patient's ability to tolerate formula, i.e., feeling of fullness, bloating, urticaria, nausea and vomiting, diarrhea or constipation. 3. Check laboratory findings. 4. Check clinical responses as noted in laboratory: BUN, Hgb, Hct, and serum protein. 5. Assess patient's hydration, color, and mucus membranes. 6. Offer mouth, lip, and nasal cleansing and lubrication every 2 to 4 hours PRN. 7. Assess bowel sounds prior to each feeding. 8. N.G. tube will be changed every 7 days unless contraindicated. Documentation of N.G. tube change in IDN's and on cardex. 11. COMPLICATIONS: A. Aspiration B. Electrolyte imbalance C. Hyperventilation D. Bradycardia E. Nasal mucosa erosion F. Tape burns on nose and face G. Trauma to gastric mucosa H. Reflux esophagitis

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12. CONTRA-INDICATIONS TO TUBE FEEDING: Absent bowel sounds and suspected intestinal obstruction.

13. REMOVAL OF NASOGASTRIC TUBING: NURSING ACTION A. Place towel across patient's chest and inform him that tube is to be withdrawn. B. WCSH hands and put on gloves. C. Rotate tubing and inject 10 ml of saline before clamping tubing. D. Instruct the patient to take a deep breathe and exhale slowly. E. Withdraw tubing slowly and cover it with a towel as it emerges. F. Discard N.G. tube per ICM III-C G. Provide oral and nasal care. H. Remove gloves and wash hands. I. Document in IDN's the date time, and patient's reaction to tube removal. Also document the mouth and nasal care given. RATIONALE-PRECAUTIONS A. No doubt patient will be happy. Prevent soiling of patient's clothing/linen. B. Prevent cross-infection. C. Ensure tube mobility. Tube is clamped to prevent drainage. D. This will relax the pharynx and aid in tube withdrawal. E. Covering the tube may decrease momentary nausea and may prevent vomiting. F. Universal body substance precautions. G. Mouthwash and nasal lubricant will aid patient's comfort and hygiene. H. To prevent the incidence of nosocomial infections.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatments POLICY NUMBER: 433 Effective Date: August 31, 2006 SUBJECT: GASTRIC LAVAGE 1. GENERAL: Gastric lavage is the aspiration of the stomach contents and washing out of the stomach by means of a gastric tube. This procedure is to be performed by a Registered Nurse on Unit 1. 2. PURPOSE: A. To remove unabsorbed poison after poison ingestion. B. To diagnose gastric hemorrhage and for the arrest of hemorrhage. C. To cleanse the stomach before endoscopic procedures. D. To remove liquids or small particles of material from the stomach. 3. NURSING ALERT - Gastric lavage may be dangerous: A. After the ingestion of acids, alkalis, hydrocarbons, or petroleum distillates. B. After the ingestion of strong corrosive agents. C. In the presence of convulsions. 4. EQUIPMENT: A. Obtain Gastric Lavage Kit with the following contents: 1. Irrigation solution bag 2. Tubing with stepped "T" universal connector 3. Drainage bag with hanger 4. 60 ml piston syringe 5. Specimen container B. Additional Equipment: 1. Water soluble lubricant Tap water or appropriate antidote as ordered (milk, saline solution, sodium bicarbonate solution, fruit juice, activated charcoal): 3. Gloves 4. Plastic bags 5. Any large lumen nasogastric tube with a radio opaque stripe 6. PPE (gown,Mask, Goggles)

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5. PROCEDURE: NURSING ACTION A. Wash hands and put on gloves. B. Remove dental appliances and inspect oral cavity for loose teeth. C. Measure length of the tube to be passed: C. If the tube is in the esophagus, the patient may belch. If the tube is place too far into the stomach, it may cause gastric erosion and hemorrhage. D. This measurement is the length needed to reach the stomach. E. To aid proper tube placement. RATIONALE-PRECAUTIONS A. To prevent cross contamination.

D. Extend the distal end of the tube to the bridge of the nose to the earlobe to the xiphoid process. E. . Indicate this length on the tube by placing tape at that point on the tube. F. Lubricate the tube with watersoluble lubricant. G. Place the patient in a high fowlers position with the head neck, and trunk forming a straight line. H. Pass the tube via the nasal (or oral) route while keeping the head in a neutral position. Pass the tube to the adhesive marking or about 50 cm (20 inches). I. Test for tube placement using 2 or more of the following techniques: J. Obtain gastric contents by aspirating with a 50 cc syringe. K. Auscultate with stethoscope over gastric area while 30 cc of air is inserted into the tube. L. . Obtain physician's order for chest x-ray to confirm placement. M. Aspirate the stomach contents with syringe attached to the tube before instilling water or antidote, then clamp tube. Save 30-60 ml of the specimen for analysis.(If

G. This position prevents fluid from running into the trachea and keeps reflux vomitus from being aspirated. H. The depth of insertion of the tube will vary with the height of the patient. If the tube enters the larynx instead of the esophagus the patient will experience coughing and dyspnea.

K. If tube is properly placed, you will here the sound of air entering the stomach.

M. Aspiration is carried out to remove the stomach contents.

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ordered by M.D.) N. Clamp and fill irrigation solution bag with ordered irrigant (approx. 3000 ml). Then hang bag above the level of the head. N. This will create a gravity flow of irrigant to the patient.

O. Fill the tubing from irrigation solution bag O. This removes air out of the tubing to T connector by opening snap clamp preventing the air from entering the located between bag and T. Close clamp patients stomach. when tube is full. P. Clamp and place drainage bag below the level of the stomach. Q. Attach T universal connector to the stomach tube and release clamp to start flow of lavage solution into gastric tube. Volume of fluid placed in the stomach should be small, around 250 ml. R. Clamp inflow tube and unclamp the outflow tube to allow irrigant to flow out. Measure the outflow amount to make sure that it equals at least the amount of irrigant. S. Save samples of first 2 washings (if ordered by M.D). T. Repeat lavage procedure until the returns are relatively clear. U. At the completion of lavage: P. Having the bag below the stomach creates siphon allowing the fluid to drain in to bag. Q. Overfilling of the stomach may cause regurgitation and aspiration or force the stomach contents through the pylorus.

R. This prevents accidental stomach distention and vomiting.

S. Keep first washing isolated from other washings for possible analysis.

V. Stomach may be left empty.

W. Antidote may be instilled in tube and allowed to remain in stomach. X. Cathartic may be put down tube. Y. Pinch off tube during removal or maintain suction while tube is being withdrawn. Z. Give the patient a cathartic if prescribed. X. To speed elimination of the poison through gastrointestinal tract. Y. Pinching off the tube prevents aspiration and the initiation of the gag reflex. Keeping the patients head lower than the body also gives this protection. Z. A cathartic may be given if the poison has no corrosive action on the bowel. The cathartic will help remove unabsorbed N.P.P No. 433

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material from the intestine. A1. Discard all disposable waste per ICM III -C. 6. RECORDING: A. Medication Record (MH 5750) - If medication or antidote was given, record the name of the drug, dosage and time it was given, per MHDS. B. Daily Care Flow Sheet (MH 5504) - Record amount of solution used and the amount of return flow. C. In Interdisciplinary Notes, record time, kind and amount of solution used in the procedure, who performed the procedure, any specimen collected and sent to the laboratory, a description of the return flow and the reaction or response by the patient. If an antidote was given, record the drug and who administered it. D. Document any patient education on Patient/Family Health Education Record. 7. INFECTION CONTROL: A. Thorough hand washing is essential for the staff member and the patient before and after the procedure. B. All dressings and disposable items to be discarded per ICM III C. C. The GI tract is not a sterile passageway. The natural enzymes and acids in the stomach and esophagus are usually sufficient to kill any problem micro-organisms. The lining of the GI tract is delicate; however an insertion of the tube may traumatize the lining and allow an entrance for pathogens into the system. For this reason, it is essential to insert the tube gently and to avoid using force if resistance is met during insertion. A1.To prevent cross contamination.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatments POLICY NUMBER: 438 Effective Date: August 31, 2006 SUBJECT: ADAPTIVE DEVICES 1. PURPOSE: To provide guidelines for Registered Nurses (RNs), LVNs, and staff to utilize adaptive devices for individuals 2. POLICY: This policy applies to skin care and all adaptive devices. The MD shall write an order for adaptive devices and state the reason for and duration. 3. PROCEDURE: Adaptive devices will require a physicians order, an assessment by the RN documenting the need for further evaluation by the physician for the need of adaptive devices. 4. GENERAL: 1. Evaluation of the individual as his condition changes and modifying treatment goals consistent with these changes. 2. Increasing or maintaining an individuals capability for independence through the use of adaptive devices to assist with self-care skills, and daily living tasks. 3. Enhancing of individuals physical, emotional and social well being through the use of adaptive devices. Equipment necessary to enable patients to increase their functional capacity shall be provided. This shall include, but not be limited to: 1. Supportive slings, supportive and/or assistive hand splints and materials from which to fabricate these and other assistive devices. 2. Adaptive devices to aid in the performance of daily living skills such as eating, dressing, grooming, writing, with instructions for their use.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatment and Procedures POLICY NUMBER: 439 Effective Date: June 20, 2007 SUBJECT: WHEELCHAIRS/WALKERS 1. PURPOSE: To provide translocation with safety and comfort. To provide mobility for individuals learning to become independent in activities of daily living. To promote or maintain independence, strengthening, endurance and overall mobility. 2. EQUIPMENT: 1. Wheelchair or Walker 2. Identified Postural Supports 3. ALERTS: 1. ALWAYS USE PROPER BODY MECHANICS TO PROTECT SELF AND INVIDUALS. 2. PROTECT Individuals hands and feet from injury. 3. Current Falls and risk assessment required. 4. PERFORMED BY: ALL STAFF

5. GENERAL INFORMATION: 1. Wheelchairs: Consider the wheelchair as an extension of the individuals body. Tell Individual before moving. 2. Steps: Check record for specific postural alignment support plans. Order would be to follow these plans. In addition: a. Individuals with leg or foot injuries have specific orders for wheelchair use.

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b. Sedated individuals need orders for wheelchair postural supports if used. Obtain assistance if needed or if unfamiliar with individual.

3. Explain purpose and procedure to the individual and bring personal wheelchair to bedside, lock breaks. 4. Adjust movable parts: Footrests/posts/positioning straps. 5. Assist individual: into wheelchair if able to bear weight. Place hands under axilla, help him to stand facing you and gently lower individual into wheelchair. If non-ambulatory, lift safely and position in wheelchair securing seat belt. Obtain assistance or use mechanical lift if needed or if unfamiliar with individual. 6. Cover: with blanket as necessary, to provide warmth, comfort and modesty. Use proper supports as identified. 7. Breaks: Ensure locking breaks on wheelchair for uneven ground when not attending to provide safety and when indicated in postural support plan. 8. Permit: Individual to remain in wheelchair, according to physicians orders. Reposition every 2 hours (if unable to position self) and PRN unless order to do otherwise. 9. Return: Chair to designated area when not in use. Battery powered chairs must be plugged in when not in use or as designated in ventilated room.

WALKERS: ALERTS: Always make sure the individual has appropriate footwear and the walker is in good repair. STEPS: 1. Check record for specific postural/mobility plans. Follow outlined plan. 2. Explain purpose and procedure to individual( if not independent in walker use) and provide assistance as outlined in plan. 3. Adjust support straps as needed for comfort and safety if applicable.

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4. If walker is in disrepair contact the department of person whose name appears on the postural/mobility plan. 5. If individual has a change in function and the walker does not seem to be appropriate notify the physician and the department or person whose name appears on the postural mobility plan. 6. Monitor individual for symptoms of fatigue such as increased respirations, diaphoresis, unsteadiness, verbal complaint or confusion. If any of these symptoms occur, assist the individual to the closest chair and notify the physician. FAILURE TO DO SO MAY COMPRAMISE THE INDIVIDUALS SAFETY. 7. Return walker to designated area when not in use.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatments POLICY NUMBER: 461 Effective Date: August 31, 2006

SUBJECT: TUBE FEEDING (GASTOSTOMY, ENTEROSTOMY) 1. GENERAL: Following a physician's written order a Registered Nurse or Psychiatric Technician who has been trained may administer gastrostomy/enterostomys/jejunostomy tube feeding. This procedure is indicated for patients who are unable to take foods orally or by nasogastric tube due to dysphagia, oral or esophageal obstruction, or trauma, or patients who have undergone gastrointestinal surgery that prohibits normal ingestion of food, or if patients have a chronic condition where nutrition needs cannot be met orally. Specific formulas are prepared commercially and are obtained from the pharmacy. The physician prescribes the caloric value, the volume, and the frequency of fluids to be given in a 24 hour period or at prescribed intervals. Recommendation from the Clinical Dietitian is essential in assessing the patient's nutritional status and developing the nutrition therapy plan. 2. PURPOSE: To provide a means of nutritional support when the oral route is inaccessible. 3. EQUIPMENT: A. Formula ordered by physician B. Tube feeding bag with tubing and flow regulator clamp C. I.V. standard D. Disposable Gloves E. Towel or disposable chuxs F. Water as ordered H. Emesis basin I. Bulb or asepto syringe J. Graduated container as needed K. Catheter plug and drainage tube protector 4. PREPARATION OF FEEDING FORMULA: A. After obtaining from the pharmacy , the unopened cans of formula may be stored and are to be administered at room temperature. Hot formulas may coagulate formula proteins and clog tubing. Heat may change the chemical composition of the formula. It may burn or irritate gastric mucosa. Chilling the formula is avoided because it increases viscosity of the liquid which may clog the tube. Cold formula may also cause vasoconstriction which reduces the flow of gastric digestive secretions which may cause cramping, nausea, vomiting and distention. B. WCSH hands, to avoid cross contamination. -1N.P.P No. 461

C. Pour the appropriate amount of formula into the feeding bag with the flow regulator clamp closed. Squeeze the drip chamber and fill half way. Remove the cap from the distal end of the tubing. Open the flow regulator clamp and run the formula through the length of the tubing. Then clamp the tubing and replace the cap on the distal end of the tubing. All air in tubing is removed so that it does not enter the patient and cause distention and discomfort. Hook feeding bag on I.V. standard 5. PROCEDURE:

6. SPECIAL CONSIDERATIONS: NURSING ACTION A. When ready to administer, shake the can well immediately before opening. Once opened, dispense the prescribed volume and discard any unused formula. B. During continuous feeding, assess the patient often for abdominal distention. C. If diarrhea occurs, notify the physician so that the underlying cause can be determined and corrected, e.g., altering the prescribed medications, changing the formula and/or administration rate/volume, switching to a fiber containing formula, administering antidiarrheal medication, or correcting a low serum albumin. Also ensure that proper infection control and equipment practices are being followed. D. If constipation occurs, notify the physician so that the underlying cause can be determined and corrected, e.g., altering the formula, adding fluids, ordering a bulk forming laxative, increasing patient activity, or changing a medication. E. Assess hydration and increase fluid intake as necessary if fluids are not contraindicated. F. Drugs may be administered through the feeding tube, except for enteric coated tablets. Crush tablets or open and dilute capsules in water prior to administering. Flush the tubing with water after administering medication. (obtain liquid medication when possible). G. Monitor blood glucose to assess glucose tolerance. Monitor serum electrolytes and other blood studies as ordered by the physician. 7. DOCUMENTATION: RATIONALE-PRECAUTIONS A. Agitation corrects separation which could alter the content of the planned feeding and potentially clog to tube. Immediate use and discard ensures the formula is not a vehicle for microbial contamination/growth. B. Distention may cause nausea and vomiting. C. Diarrhea is the most common complication. Common causes are: too high infusion rate or volume, lack of fiber, altered gastrointestinal flora (e.g., due to medications or contamination), hypoalbuminemia, or hyperosmolar solutions (Isotonic formulas are best tolerated.)

D. Irregular bowel movements can result from the low fiber content of the formula, inadequate fluids, medication, or lack of activity. The feeding should be stopped and evaluated if an obstruction is suspected. E. Dehydration may cause constipation. F. Avoid need for discomfort of I.M. injections.

G. To determine response nutritional support.

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A. On the treatment record, record the time, amount and type of formula given and the amount of water given. B. On the IDN's record the patient's reactions and tolerance to the procedure. C. Total the amount of feeding and fluid given on the Daily Care Flow sheet for the 8 hour shift. 8. REFERENCE: Nutrition Care Manual Section 302, tube feeding and Liquid Supplements.

NURSING ACTION A. Check the physician's order against the treatment card. B. Wash hands and prepare equipment. C. Approach and identify the patient, explain the procedure and provide privacy. D. Place the patient in high Fowler's or sitting position unless contraindicated. E. Place a towel or chux on the patient's lap. F. Put on disposable gloves. G. Pinch off the patient's gastrostomy/enterostomy/jejunostomy tube below clamp or plug. Remove clamp or plug. H. Remove cap from the distal end of the tubing to the feeding bag. Connect the feeding tube to the patient's "ostomy" tube. Recheck for secure fit. I. Adjust flow regulator clamp to the desired rate. Administer feeding slowly. J. After administering the correct amount of feeding flush the tubing by adding 100 ccs of water to the feeding bag or by asepto/bulb syringe directly into the "ostomy" tube. K. Shut off the flow regulator clamp and disconnect tubing while pinching off the "ostomy" tube. Recap and clamp tubings. L. Leave the patient in semi or high Fowler's position or sitting position for at least 30 minutes. M. Rinse all re-usable equipment with warm water. N. Discard disposable equipment per

RATIONALE-PRECAUTIONS A. For accuracy in administering the correct type, route, and amount of feeding to the right patient, at the right time. B. To avoid cross contamination. C. To gain patient confidence and lesson anxiety and embarrassment. D. To make the patient comfortable and aid digestion. E. To protect patient's gown or clothing from becoming soiled. F. To protect staff from accidental gastric fluid contact. G. To Avoid leakage from tube.

H. To avoid accidental separation of tubes during feeding. I. To prevent sudden distention which can cause nausea, vomiting, cramps or diarrhea. J. To prevent the tube from clogging and to lessen the chance of bacterial formation.

K. To prevent leakage from the "ostomy" tube. L. To aid in digestion, prevent aspiration. M. To prevent bacterial formation. N. To prevent the spread of infections. -3N.P.P No. 461

ICM III-C O. Discard gloves and wash hands. P. Change feeding equipment every 72 hours. (Label feeding equipment with date and time issued, and date and time to be replace.) O. To prevent nosocomial infections. P. To prevent bacterial formation.

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Section 5 Medications

State of California

Coalinga State Hospital

MEDICATION RELATED EVENT

Instructions: Complete page 1 (front) and FAX to Pharmacy and NOD. After US/Program
Management has completed Plan on page 2 (back) deliver to NOD. After NOD has completed Plan section deliver to Pharmacy for final processing. Pharmacy is to receive completed form no later than 3 days after MRE. PROGRAM:_______ UNIT: _____________________________________DATE: ______________ Date/Time Event Occurred: ___________________Date/Time of Discovery: __________________ Date/Time/Type of Order: _________________________________ Written Verbal Phone Staff/Title Reporting Event:_________________________________________________________ TYPE OF EVENT (check one that best describes the event) Transcription Prescribing/MD Orders Procedural Documentation Dispensing/Pharmacy Accidental Count Discrepancy CONTRIBUTING FACTORS (check all appropriate boxes) 1. Transcription Not transcribed Transcribed incorrectly Transcribed late Incomplete transcription 2. Documentation Med given/not charted Incorrect documentation 3. Dispensing Event Did not send med Sent wrong med Sent wrong dose Incorrect labeling Empty packet Torn med packet Sent wrong amount Incorrect form No label 5. Procedural Incorrect procedure Lack of procedural knowledge Med omitted/not given Wrong Individual Wrong time Wrong dose Wrong form Wrong route 6. Accidental Spilled Medication Fell in sink/trash/floor Mixed accidentally Crushed accidentally 7. Count discrepancy Meds not counted when delivered Missing medication Overage

4. Prescribing 8. Wasted Controlled Med Unclear/confusing order Individual refused Illegible writing PRN not needed after it was prepared Incomplete order Overage Incorrect order No MD signature 9. Other (specify) Non formulary ____________________________________________ BRIEF DESCRIPTION OF THE EVENT (by person discovering event)

_________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________
CSH # pending (new 2/06) NOT TO BE FILED IN INDIVIDUAL RECORD Page 1 of 2

State of California

Coalinga State Hospital

NOTIFICATION

DATE/TIME

Shift Lead/US NOD Physician Pharmacy PLAN TO PREVENT RECURRENCE OF MRE: US/Program Management: ____________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ NOD:_____________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Pharmacy:_________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ EVENT REVIEWED BY
NOD: Pharmacy: DATE/TIME

Send Completed Form To Pharmacy No Later Than 3 Days After MRE

CSH #pending (new 2/06) Page 2 of 2 NOT TO BE FILED IN INDIVIDUAL RECORD

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 500 Effective Date: June 21, 2007 This Policy replaces NPP 500 dated August 31, 2006 SUBJECT: ADMINISTRATION OF MEDICATION AND TREATMENTS - GENERAL RULES 1. GENERAL: Only a licensed physician, dentist or podiatrist is authorized to order medications. A Nurse Practitioner, working under Standardized Procedures, may order medications in accordance with written protocols. Only a physician or a pharmacist may dispense medication. Medications are administered by a hospital certified licensed nursing staff, except as follows: 1. A Psychiatric Technician Student may administer medications under the direct supervision of the Nurse Instructor. 2. Individuals may carry nitroglycerine as ordered by a physician. 3. As part of discharge readiness treatment activities, selected Individuals may be allowed, with WR Team approval, to self-administer medications under nursing staff supervision (see Section IV of this procedure). 4. Long-term care diabetic Individuals may draw and/or administer their own insulin after it has been determined they have the knowledge, ability, and the mental faculties to do this responsibly. Before this can commence, the Wellness and Recovery (WR) Team and physician must review the Individual. If approved, a Physician's Order must be obtained. A PT/LVN/RN, certified to administer medications, must directly supervise the Individual and assure that he does not compromise his or other's safety and that all other policies and procedures of medication administration are followed (see NP 513 and NP 523). A physicians order is required before any medication may be administered. 1. Name of medication - as listed in the Hospital Formulary 2. Form oral solid unless otherwise specified. 3. Dose - using metric system. 4. Route oral unless otherwise specified. 5. Frequency four times daily, etc. 6. Duration - x 45 days, x 5 doses, etc. 7. All PRN orders require a minimum number of hours between doses. 8. Psychotropic/neuroleptic PRN orders require a minimum number of hours between doses and may not exceed more than two doses per 24 hour period.
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A 24-hour period is defined as 0001 to 2400. Each unit has a distinct lock for the medication cabinets/cart. Medication room keys are to be kept by the designated med person or the designated relief (i.e. on their person in a secure manner). Medication keys are to be on the unit at all times. The only exception is on the Residential Recovery Units (RRU) which have only one nursing staff member assigned per shift. When these employees are required to go off the unit for necessary errands (e.g. Central Supply, Pharmacy,) the medication keys are to stay with the employee. All other policies and procedures about medications and medication room security and accountability will remain in force on the RRUs. Each time the medication keys change hands all control drugs (including control drugs to be returned to the pharmacy to be wasted) must be counted and accounted for and noted in the unit daybook (change of shift is noted, when signed on the Controlled Drug Count Signature Record).The locksmith must be called if the medication cabinets/carts cannot be opened. The assigned Med Person is responsible for the ordering and stocking of medications and is expected to anticipate the needs of the unit particularly for afterhours, weekends, and holidays. This includes any medical equipment needed e.g. syringes, med cups, lancets and test strips for blood sugar testing, etc. 2. PURPOSE: Medications are administered to aid the body in overcoming an illness, to relieve and to prevent symptoms, and to aid in diagnosis. Use of the following medication practices protects the safety of the Individual as we as the employee assigned to give medications, and provides for the security of the drugs by preventing unauthorized access. 3. EQUIPMENT: Varies according to route of administration (e.g. Oral, Parenteral, Eye, etc.). 4. PROCEDURE: It is the responsibility of the person transcribing an order to ensure that the required information is clearly stated and legibly written. Any confusion or concern over the meaning or appropriateness of any order is to be discussed with the ordering clinician, if possible, or the covering physician (i.e. MOC, PMOC). To clarify the order, have the physician rewrite the order or issue a telephone order prior to administering the medication or treatment (also see NP 514). Orders to prescribe over guidelines shall not be written or administered until a completed consultation is present in the Individuals chart. It is the responsibility of
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the person transcribing and/or administering an order over hospital guidelines to assure that a consultation is completed and in the chart. All medication orders are to be correctly and completely transcribed to the Medication Administration Record (MAR) and diet orders, daily care flow sheets, lab slip, etc. are to be processed prior to signing off, or "noting" the order. The nursing staff's signature under the order indicates that all transcriptions, processing, notifications, etc. has been completed (also see NP 514). It is the responsibility of each person administering medication to: 1. Review all charts at beginning of each shift to ensure that all orders are noted. 2. Clarify any orders that are improperly written, unclear, or appear to be inappropriate for the Individual at this time. During regular hours of operation, the staff is to contact the physician directly. After hours, weekends, and holidays staff are to contact the NOD. 3. Assess the Individual, prior to administering any medication, for signs and symptoms of possible untoward reactions, including but not limited to: -Allergic reactions -Neuroleptic Malignant Syndrome -Note: If a Individual is suspected of having NMS and if muscle stiffness is present and does not respond to a dose of medication designed to relieve muscle stiffness associated with EPS; do not continue to give additional medication for EPS - report symptoms to the physician. -Atropine overload. Be aware of required VS associated with giving certain medications/treatments (e.g. antihypertensives, beta blockers, antibiotics, etc.). Staff is responsible to assure that the Individual reports to the medication room in a timely manner in order to receive his medications. If necessary, staff will look for the Individual. Recording medication as refused occurs if the Individual has indicated he does not/will not take the prescribed medication. Failure of a Individual to report to the med room does not constitute refusal. Doses shall be administered within one hour of the prescribed time (posted in the Med Room) unless otherwise indicated by the prescriber (as noted in the physicians order) or other circumstances occur which require the med to be given at a later time e.g. if Individual is NPO for lab or medical procedure. Ensure that the expiration date has not been exceeded. Ensure any multidose vial used is dated and initialed when first opened and used within allowable time period (30 DAYS).

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Only one employee who is currently certified by the hospital to administer medications is to be assigned the primary responsibility to prepare, administer and chart medications at any given time. The Unit Supervisor/designee may assign a 2nd medication certified nursing staff to assist in the preparation, administration, and documentation of ordered treatments, as necessary. No person may administer medications/treatments prepared by someone else. The person administering medication/treatment must have: 1. Knowledge of the medication/treatment, including the usual dose, route of administration, the expected side effects and any special precautions or contraindications. 2. Knowledge of the Individual, including his identity, diagnosis, disease process and any allergies. 3. The assigned medication person is to have no other assignments that would interfere with the safe preparation, administration, and documentation of medications for that shift. 4. Medicine cabinets/carts are to be kept locked, except while medications are being prepared. Allow sufficient time to follow proper preparation procedures prior to administering medications. At no time are medications to be left unattended unless locked in medication cart. 5. Do not transfer medications from one bottle/box to another. Do not write on any medication label or bottle, with the exception of dating multidose vials as these actions are considered "dispensing". If a label on a container is difficult to read or comes off, return the container to the Pharmacy for relabeling. Do not interchange medication droppers. Do not use medications, dispensed and labeled for an Individual, for any other Individual. 6. After normal Pharmacy operating hours if a unit finds it does not have a control medication or non-control medication available for a Individual and that medication is not available in the night locker, the unit is to contact NOD. Prior to contacting NOD, the unit shall ascertain if another Individual on the unit, or if necessary neighboring units, has the needed medication in stock. NOD will authorize the unit to use this available medication after consulting with the On-Call Pharmacist. Only NOD is authorized to physically transfer the medication from one unit to another. The event will be recorded in the NOD 24-hour report. The event will be recorded in the unit(s) logbook. The unit(s) will contact Pharmacy when it opens for regular operation (also see NP 516). 7. Internal and External products are to be stored on separate shelves in the medication cabinet.

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8. Whenever the Pharmacy fills an order for "Individual carried" Nitroglycerine sublingual tablets, the Individual and the Unit Supervisor will be given an individual written authorization according to the Pharmacy Formulary and Policy Manual (Section II Number10). NURSING A C T I O N A. Concentrate entire attention on the preparation of medication and avoid all distractions. RATIONAL-PRECAUTIONS A. To reduce possibility of medication errors, administration of routine medications should not be interrupted to administer a non-acute PRN. B. An order could be incorrectly transcribed or not noted resulting in the order being omitted or incorrectly given.

B. Check all current copies of physician's orders before administering medications. Compare corresponding medication administration record; check the Individual's name, drug, dose, route, frequency and stop date (see III D above). C. Assemble necessary equipment.

C. Organization and planning saves time and effort and minimizes confusion and the possibility of error. D. To avoid spreading pathogenic organisms. E. Medication is not set up in advance (double pouring or pre-pouring). This ensures the right medication goes to the right Individual by the right route.

D. Perform hand hygiene. E. Oral medications and external treatment meds are set up (opened) when the Individual is present. Read the name of the Individual and the medication from the MAR (no double pouring or pre-pouring). Note: treatments are never administered in the med room; use of the Exam Room is recommended. F. Compare name of drug and dose with medication administration record, checking it three times. G. If the Individual has several solid medications they may, with due consideration for Individual safety, be put in the same medication cup. H. Do not mix any liquid medications together.
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F. Continual alertness, purposeful action, and repeated checking enhance concentration and prevent errors.

H. Certain liquid meds, when mixed together, may form a precipitate.

N.P.P. No. 500

I. Keep MAR(s), which identifies the Individual and the medication(s) visible at time of administration. J. Ambulatory Individuals come to the Medication Room for their medications at regularly scheduled med. times. Meds may be carried to the Individual when necessary, e.g. illness requiring bed rest or for privacy for an I.M. medication.

I. Identifying the Individual and medication is essential to assuring that the right drug will be given to the right Individual. J. Actual time for routine medications (once daily, twice daily, etc.) may differ from unit to unit, allowing sufficient time for correct preparation and procedures to be followed. Standardized times for the unit are posted in the Med Room.

5. PREPARATION: For the procedure to identify and report adverse drug reactions see Pharmacy Formulary and Policy Manual Section II Number 24. STAT and NOW orders take precedence over routine orders and should be carried out immediately. 6. ADMINISTRATION: ACTION A. It is the responsibility of the med person to make a positive identification of each Individual prior to administering meds/treatment. Use picture ID cards for this purpose. If necessary have a second staff member present to help with Individual identification. B. Make appropriate observations and assessments of the Individual for any contraindications to administering the medication. If an allergic reaction, Neuroleptic Malignant Syndrome or other adverse reaction is suspected withhold the medication, provide needed care, and immediately notify M.D., NOD, and supervisor. C. Read MAR to identify medications and Individual then give them their medication. RATIONAL-PRECAUTIONS A. Proper identification is essential to prevent errors in administering a drug. Illness and unfamiliar surroundings often cause a Individual to be confused. Same or similar sounding names, similar appearance or new Individual may cause the med-person to confuse one Individual for another. B. Prevention of adverse drug reactions is the best line of defense. Careful observation is necessary to provide prompt and timely action to prevent serious/life threatening outcomes. Withholding medication is often the most important step.

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D. Remain with the Individual until medication is swallowed. Check Individual's mouth, if necessary. E. Chart the medications immediately after Individual has swallowed them. Chart treatments promptly after administration.

D. To assure Individual is actually taking his meds and receiving properly prescribed treatment. E. For ready indication that medication has been administered.

PRN Orders: PRN medication orders not written in accordance with hospital policy will be immediately brought to the physicians attention (after hours MOC or PMOC) for correction (see III A above). PRN Medication orders not written in accordance with Hospital policy, procedure, and protocol will not be noted or given until the order is correctly written as noted in the following procedures. The Pharmacy and Therapeutics Committee (PTC) on an individual case-by-case basis may permit exception to these rules. PTC approval for exceptions will be written on Consultation Forms and filed in the Consultations section of the Individual's chart. In an emergency, PRN doses for psychotropic medications having greater frequency than 2X/24 hr may be given as written without a completed consult, with the understanding that the consult process will be followed in a timely manner, and that the total daily dose will not exceed the accepted upper limits for that medication. PRN orders will clearly specify parameters for administration based on observable conditions and behavior. PRN pain orders should refer to the specific pain syndrome, e.g., low back pain, cephalgia, and migrating arthralgia secondary to rheumatoid arthritis. PRN epigastric distress, GI upset, dyspepsia. PRN fever should be written as PRN temperature greater than N (N=number) degrees. PRN hypoglycemia should be written as PRN blood glucose less than nn (mg/dl). PRN insomnia orders: current hospital Psychotropic Medication Guidelines limit. PRN insomnia orders to a maximum of 14 days per month. Staff must document the Individual's sleep patterns in the IDN's.

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PRN EPS (extrapyramidal symptoms) should not be written. PRN drooling, tremor, rigidity, or other signs/symptoms of EPS for that Individual should be written in the order. PRN BID, TID, QID etc. Orders must conform to the Approved Acceptable and Unacceptable Abbreviations List (see AD 591). Orders must have a time frequency to indicate the spacing of doses. Orders should not be written PRN BID. The orders must be written: PRN q 12 hours or another specific frequency of administration. The maximum number of doses permitted in a 24-hour period must also be stated. PRN PO/IM should not be written. The circumstances in which IM, as opposed to PO, medications are given need to be specified e.g., "Lorazepam 2 mg PO PRN agitation per protocol (give lorazepam 2 mg IM if PO dose refused) q 2 hr NTE 2 doses/24 hr X 45 days." PRN hallucinations should not be written. If hallucinations are a symptom of agitation, they can be added to a given Individual's agitation protocol as a behavioral symptom, assessed in the same context as the other behavioral and physiological signs and symptoms. PRN anxiety medication may be ordered. The phrase "at Individual's request" may be added to the order. Neuroleptic and Sedative PRN's: Orders shall not be written to authorize more than two doses within 24 hours. Subsequent to an acute phase of illness, administration of any neuroleptic or sedative medication more than 20 doses PRN in one month (per State guidelines) requires review of the regular medication and dosage by the attending psychiatrist. PRN agitation orders must be written per protocol. A generic protocol applicable to all Individuals follows below. This can be modified by the WR Team for a given Individual. PRN medication protocol for agitation Agitation is defined as any three items from the Physiological and Behavioral (nonassaultive, non-threatening lists), with at least one behavioral item, or any one item from the Behavioral (threatening, assaultive) list. The specific items observed needs to be documented on the MAR. IDNs may be utilized to document more detailed observation if required.

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PRN medication protocol for agitation THREE ITEMS FROM THESE TWO LISTS (At least one being behavioral) Consistent with the Pharmacy Policy Manual (Number II Section 8), time frames shall be established and implemented limiting the duration of new drug orders in the absence of a prescribers specific indication of duration of therapy. The prescriber shall be contacted for new orders prior to the termination time established by the policy. For purposes of filling, dispensing, and administering medications, if an order is written without a specific duration of therapy, the following automatic stop dates shall apply: 1. Antineoplastic Agents 24 hours 2. DEA Schedule II Drugs 48 hours 1. Injectable Anticoagulants Seven (7) days 2. DEA Schedule III V Drugs Seven (7) days 3. Antibiotics/Anti-Infectives Seven (7) days 4. Oral Anticoagulants Seven (7) days 5. Corticosteroids Seven (7) days 6. All other classes of drugs 45 days If the automatic stop date falls on a holiday, this date shall be extended to the next regular working day, unless otherwise specified by the prescriber. 3. Medication orders are to be recorded on the Physicians Order form. The orders are to be signed and dated by the physician, dentist, podiatrist or Nurse Practitioner. 4. Under urgent or emergency circumstances a phone order may be taken by a registered pharmacist or licensed nursing staff. The ordering clinician is to sign the phone or verbal order within 48 hours or the next business day. 5. There are no "standing" medication orders. 7. SELF ADMINISTRATION PROCEDURE: The Individual must be approved by the units WR Team with a current physicians order to self-administer their medications. A Wellness and Recovery Care Plan will also be written for the self-administration of their mediations.

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The Pharmacy will prepare all medications in their respective containers, labeled for that individual. Medications will be stored in the unit medication room in a locked cabinet when not in use. The licensed nursing staff will assure that the Individual does not compromise his or other's safety and that all other policies and procedures related to medication, medication administration, and infection control procedures are followed, e.g. proper handling and disposal of syringes. Licensed nursing staff assigned to the medication room will be responsible for the direct supervision of the Individuals set up and self-administration of their medication. Nursing staff will chart the medications immediately after the Individual has swallowed/injected them. See NP 523 for detailed information about self-administration. 8. RECORDING/DOCUMENTATION: Forms used: Medication Administration Record (MAR). Diabetic Record. Immunization Record.

A. Medication Administration Record (MAR) page 1. 1. Ensure month and year is entered in the appropriate boxes (computerized form should be preprinted). 2. Enter any allergies in the appropriate space at the bottom of the form. If no known allergies, write none known. 3. Spaces bounded horizontally by dark lines are each to be used for one medication/treatment. 4. In the columns on the left side of the form, ensure the following are entered: a. date and time of order b. medication/treatment ordered, dosage, route if other than oral and frequency of administration c. stop date d. in the # box, write the problem number which corresponds to that which appears on the Physicians Orders. e. hrs time of adm column: i. using one row for each hour (to be given), record the hour when the medication/treatment is to be administered. ii. if medications/treatments require more than four administrations in a 24hr. period, use additional rows in the next available space. If all four blocks are not needed, leave the remaining blocks blank. Enter the next medication/treatment in the next available space, below the dark horizontal line. 5. Recording medications/treatments as given: a. Initial the appropriate date/hour box.
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b. The employee who administers the medication/treatment must sign with their signature (first initial and last name), title and identifying initials in the space at the bottom of page 2 of the form. c. to record site of injection, use site codes printed on the reverse side of the form. Enter site code in date/time box next to/below initials. d. review/assure that pulse and/or blood pressure readings are recorded and taken in conjunction with the medication/treatment. 6. Starting a medication/treatment not at the beginning of the month: a. enter identifying information on the left side of the form (following above procedures). b. draw an arrow from the beginning of the month (day 1) to the date before the date on which the medication/treatment is to begin (e.g. if the medication/treatment starts on the 7th of the month, draw the arrow from the 1st to the 6th). c. write START over the line drawn for the arrow. d. bracket-in the start time box of the medication/treatment on the appropriate day. e. bracket-in the stop date/time (if available on current MAR) of any medication/treatment that stops prior to 45 days in the same manner. 7. Recording refused/omitted medications/treatments: a. refusal - the appropriate box for that medication/treatment (time and date) will be circled and an R will be placed inside the circle. Additional pertinent, information is to be noted on the reverse side of the form (e.g. Individual says I dont need it anymore). An IDN may be written to capture more pertinent information if needed or required (e.g. Individual says I hate you and will never take meds if you are in the med room). Failure of a Individual to report to the medication room is not grounds for refusal. If necessary, staff will track down the Individual. b. omission if a medication/treatment is not given as ordered, the appropriate box for that medication/treatment (time and date) will be circled and an O will be placed inside the circle. A justification must be written on the reverse side of the form (e.g. unacceptable VS). An ID Note may be written to capture more pertinent information. c. refusals/omissions will be brought to the attention of the Medical Clinic physician, psychiatrist, or MOC/PMOC. B. PRN/STAT Documentation on MAR: 1. enter date and time. 2. enter appropriate problem number (must match physicians order). 3. enter the medication, dosage, strength, and route/site. 4. enter the reason for giving the medication/treatment (must match the reason stated in the physicians order and if for pain you must indicate the numerical value of the pain reported from pain scale, 0-10). 5. initial the entry. 6. record the results/effectiveness of the medication/treatment within 1 hour after administration (if for pain you must indicate the new, numerical value of pain relief reported from pain scale, 0-10). If the shift ends, prior to the review of relief (less

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than an hour since administration) the off-going med person must report this to the on-coming med person to assure completion of this portion of the MAR. 7. Enter initials, then signature (first initial and last name) and title in the space at the bottom of the form to verify the initials on any part of the MAR. 8. PRN, STAT, NOW doses of medication/treatments will be documented in chronological order of administration on the back of the MAR the PRN order is written on (MH 5764). The PRN medication record (CSH-047) should only be used as a continuation page, if the back of the MAR the PRN order is written on is full. 9. PRN will also be initialed on front of medication record as well to see patterns of medication usage. C. Exception to documentation on the MAR. 1. all insulin administration is documented on the Diabetic Record . 2. tuberculin skin testing (TST)/immunizations are documented on the Immunization Record. D. Discontinuing Medications/Treatments on the MAR. 1. discontinuing a medication/treatment prior to stop date: a. place a diagonal line inside the boxes that indicate the start/stop time and name of medication dosage, etc. Place initials and date on the diagonal line. 2. discontinuing a medication/treatment at the stop date: a. complete steps as in D.1-a then draw a diagonal line through the remainder of the empty date/time boxes on the form and write DC, initials and date on the diagonal line. 3. information written on the diagonal lines may go above or below the line depending on space available. 9. AFTER CARE OF INDIVIDUALS AND EQUIPMENT: ACTION RATIONAL-PRECAUTIONS A. Report any unusual circumstances A. The physician needs to be involving medications (e.g. toxic signs, informed in a timely manner to refusal of Individual to take insure continuity of care. medications, etc.) to the Medical Clinic physician, psychiatrist, or MOC/PMOC. Discuss in shift change. B. Prepare for next use. B. Clean medication cart after each use and other equipment used as needed with hospital approved cleaner. Return equipment to proper location.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 501 Effective Date: August 31, 2006 SUBJECT: ADMINISTRATION OF ORAL MEDICATIONS 1. GENERAL: (Also see: Administration of Medication and Treatments: General Rules - N.P. 500) Oral medications should be as palatable as possible. For liquid medication, measure the dose exactly using the proper measuring device e.g., oral/liquid dispenser, medicine dropper, or graduated medicine cup. Do not put medications back in the container after they have been poured. Oral medications are given according to each Units posted medication times unless a physicians order states differently. The person administering medication shall have knowledge of the medication, including drug and food interactions, the usual dose, route of administration, the expected side effects, and any special precautions or contraindications. Oral medications are contraindicated for Individuals who experience nausea and vomiting, are unable to take medications by mouth because of a disease condition, or are unconscious. Always check the expiration date on the label or container of the medication to be administered. Check storage requirements as some medications need to be refrigerated. 2. PURPOSE: Medications are administered orally to produce local effect on the alimentary canal or systemic effect after absorption into the blood stream. 3. EQUIPMENT/SUPPLIES: A. Disposable paper cups. B. Medication (as ordered by physician). C. Oral/liquid dispenser (if needed).

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4. PROCEDURE: A. Preparation

NURSING ACTION A. Perform hand hygiene. B. Check label with Medication Administration Record. C. Solid preparations (when pt. is present): For solid floor stock, pour correct amount of medication into the container lid then into the medicine cup. For unit dose, open unit dose medication packet and place in medicine cup. D. Liquid preparations (when pt. is present): E. Shake mixtures or suspensions before pouring (follow instructions on bottle). A medication with an unexpected precipitate or a change of color is not to be used. F. Do not mix liquid medications together. G. When liquid medication is poured from the bottle, pour from the side of the bottle opposite the label. H. Set the medicine cup so that the mark of the prescribed amount is at eye level. I. When setting up medications that require the use of a dropper, the bottom of the meniscus is the point to measure. J. Wipe rim of bottle with a paper towel and replace cap.

RATIONALE - PRECAUTIONS

B. Assure correct medication. C. Do not handle pills or capsules by hand. Prevent contamination of medicine. Medication packets are not opened until Individual is present.

E. Some mixtures require rolling between hands while other should be shaken well. A medication that does not appear normal is to be returned to the Pharmacy. F. They may cause an undesirable interaction such as a precipitate. G. This prevents the label from becoming obscured. H. To get an accurate measurement.

I. The meniscus is the bottom of curve created by drawing up or pouring liquid into a container. J. To prevent medication buildup on rim and cap. Make certain towel is clean.

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B. Administration NURSING ACTION A. Solid preparations: provide the Individual with water unless other fluids are ordered. RATIONALE - PRECAUTIONS A. Fluid reduces the friction between the medication and mucous membrane, thus allowing the medication to go down quickly. Fluids help to dissolve solid drugs. B. If a medication, such as cough syrup, is given for its effect on the mucous membrane of the mouth or upper respiratory tract, it is not to be diluted or followed by water. C. Precipitation can occur with medications in a suspension when given with fluids other than water. If needed, check with pharmacist. D. Advise him against chewing or swallowing the medication and against drinking until completely dissolved. E. It is difficult to determine the exact amount of medication absorbed.

B. Liquid preparations: May give additional fluid with medications unless contraindicated.

C. Use water to mix with medication in a suspension e.g. phenytoin, hydroxyzine. D. Sub-lingual medication is placed under the Individual's tongue to dissolve. E. If Individual vomits soon after administration of medication attempt to identify the medication and notify physician. Do not re-administer medication unless ordered to do so by a physician. C. Variations

1. Drugs such as iron and acids may discolor the teeth or damage the enamel. Give these medications with a straw or dilute well and then give with a straw. 2. Individuals may object to the taste of certain medications. Disguise or mask taste by allowing the Individual to suck on a small piece of ice, by serving with fruit juice, food, or by pouring over crushed ice and serving with straw. 3. Medications may be crushed only with a physician's order. Capsules are never crushed. 4. All medications that are refused by the Individual or are otherwise contaminated are placed in the Pharmacy return baggie for disposition by the Pharmacy. It is the responsibility of the Pharmacy to dispose/waste medications. Staff is not to flush medication down the sink or toilet (per EPA rules).

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5. RECORDING: Document medications administered immediately after administration and before administering medication to the next Individual. Medication omitted or refused are charted on the Medication Administration Record (MAR) by using the appropriate code (O or R) which is then circled. Record explanation for omission or refusal on back of MAR; chart more detailed information in the ID Notes (also see NP 500).

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 502 Effective Date: August 31, 2006 SUBJECT: TOPICAL APPLICATIONS 1. GENERAL: The physician determines and orders the specific treatment to be applied to an area. Nursing staff will observe for open lesions, rashes, or areas of erythema and skin breakdown, and observe for local changes in the skin occurring during use of the prescribed drug. Treatments performed by staff should be in the exam/treatment room. 2. PURPOSE: A. To treat infection B. To reduce inflammation C. To produce anesthesia D. To relieve discomfort 3. EQUIPMENT: A. Obtain from Central Supply: 1. Tongue blades (Sterile as needed) 2. 4 x 4 gauze to cleanse area (Sterile gauze if skin area is broken) 3. 4 x 4 sterile gauze, if dressing is ordered. 4. Paper tape 5. Disposable gloves 6. Disposable gown, if danger of contact is anticipated. B. Obtain from the Pharmacy: 1. Medications as prescribed 4. PROCEDURE: Application of topical NURSING ACTION A. Perform hand hygiene. B. Gather necessary supplies. C. Check medication against orders. RATIONALE-PRECAUTIONS A. To maintain a clean procedure B. Expedites procedure and minimizes Individual anxiety. C. Ascertain correctness of E. To protect sensitive skin F. To treat infestation G. To lubricate

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medication and concentration. D. Squeeze medication from tube, pour lotion, or using a tongue blade take ointment/cream out of jar and place into waxed med cup. E. Explain the procedure and prepare the Individual. Provide for privacy as required. Have the Individual remove necessary clothing and assume a position, which is suitable for treatment. F. Don disposable gloves. G. Unless otherwise indicated, the skin is cleansed of the old application before a new one is applied. If an excoriated area is being treated, sterile gauze and a light touch is recommended for cleansing. H. Spread a small, smooth, thin quantity of medication evenly over skin surface following direction of follicle growth. I. If there are infected areas and medication is to be applied directly to the lesions; use a separate tongue blade as applicator for each area. J. Apply dressing if ordered. K. Discard any used gauze, tongue blades, med cup, and gloves into clear plastic bag and place in contraband trash. L. Perform hand hygiene. M. Observe for signs of adverse skin reaction, e.g., increased redness, irritation or itching. If present, cleanse area of residual medication, discontinue treatment, notify physician and write a descriIndividualive I.D. Note. Topical Specifics. A. Lotions may need to be shaken thoroughly before application. Look for
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D. Minimizes cross-contamination

E. Adequate explanation facilitates both Individual understanding and cooperation.

F. Prevention of cross-contamination. G. Removal of old medication aids in the effectiveness of the new application. Gentle cleansing diminishes disruIndividualion of the new cell growth. Dry thoroughly. H. Do not use excessive friction. Gently massage in medication if instructed to do so. I. To prevent spreading the infection from one area to another.

J. Dressing ensures the medication does not rub off. K. Prevent cross contamination and infection.

L. To maintain hygienic safety. M. Assess progress of treatment. Prevent continuation of adverse effects.

A. If they do not mix well within a reasonable amount of time, obtain a

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separation of contents. B. Permit lotion to dry thoroughly before being covered with dressing or clothing. C. Adrenocorticosteroid agents are to be applied using gloved fingertips or sterile tongue depressor. Use a small amount and rub in thoroughly.

new supply. B. To allow for absorIndividualion of medication and to protect Individuals clothing. C. Medication is most effective when using only a thin layer. When used as a long-term treatment, reduces the risk of a systemic reaction to absorbed steroids. Avoid contact with eyes and perform hand hygiene.

5. SELF ADMINISTRATION Individuals may apply their own topical medications at staff discretion and under staff supervision. Nursing staff will instruct Individual on proper application of topical medications and will observe Individual applying topical medication. Documentation of Individual teaching will address teaching done, the level of the Individuals understanding, and compliance with established nursing and infection control procedures. 6. RECORDING A. Document any Individual education in the ID Notes. B. Document medication/treatment per N.P. 500. C. The Individuals response to treatment should be addressed at least monthly in the RN Monthly Summary. State if the areas have shown improvement or not and describe the Individuals level of cooperation. Document if treatment was discontinued or changed by the physician, reason why, e.g. healed, not responding to treatment, etc.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 503 Effective Date: August 31, 2006 SUBJECT: SUPPOSITORIES 1. GENERAL: Any Registered Nurse, Licensed Psychiatric Technician, or Licensed Vocational Nurse may insert suppositories, by the order of a physician. 2. PURPOSE: Suppositories are used to: A. Lubricate B. As a vehicle for medication C. As a fecal softener D. Laxative 3. EQUIPMENT: A. Obtain from Central Supply: 1. Disposable gloves 2. Tissue wipes 3. Bed pan (if necessary) B. Obtain from the Pharmacy: 1. Water soluble lubricant 2. Medication (as ordered by physician)

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4. PROCEDURE NURSING ACTION A. Explain procedure and necessity of medication to the Individual. B. Screen bed or close door and have Individual remove appropriate articles of clothing. C. Have Individual lie on left side in Sims position; draw right knee halfway up to chest. D. Perform hand hygiene. Put on gloves. Remove protective wrapper if present and lubricate the tip of the suppository with a small amount of water-soluble lubricant. E. Ask the Individual to breathe through his mouth while the suppository is being inserted. F. Spread the Individual's buttocks and gently insert the suppository beyond the internal sphincter (2") using the gloved hand. G. After insertion, encourage the Individual to retain suppository for at least fifteen (15) minutes, staying on his left side. H. Have the bedpan available for elimination if Individual is bedfast or bathroom is distant. RATIONALE - PRECAUTIONS A. Minimizes anxiety and embarrassment. B. To provide privacy. C. Position enhances visibility of the anus and relaxes sphincter. D. To protect the hands/fingers and reduce friction.

E. To allow for additional relaxation of the rectal sphincter. F. To ensure retention of suppository and effectiveness of treatment. G. Instruct the Individual that the urge to expel the suppository will go away shortly when the suppository melts. H. Provide for comfort and minimize embarrassment. Results are usually obtained within 15 to 30 minutes, but it could be as long as an hour.

I. Remove and dispose gloves and perform hand hygiene. 5. SELF-ADMINISTRATION OF SUPPOSITORY Individuals may be allowed to self-insert suppositories based on nursing approval and after appropriate instruction. Nursing staff will consider the mental status of the Individual to determine his ability to insert his own suppository. Documentation of Individual teaching will address teaching done and level of Individuals understanding and compliance with established nursing and infection control procedures. 6. RECORDING A. Wellness and RecoveryDocument any Individual education in the ID Notes. B. Document medication per N.P. 500.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 504 Effective Date: May 29, 2007

SUBJECT: ADMINISTRATION OF PARENTERAL MEDICATIONS 1. GENERAL: A. The administration of parenteral medications can be hazardous. Special precautions are required to minimize the risk to the Individual and to the employee. It is mandatory to use safety syringes when the size or type needed is available through Central Supply. Strict aseptic techniques must be used to avoid infection. Accurate dosage and proper site for injection are essential to avoid injury to tissues and severe or permanent nerve damage. Maximum amounts to be injected in any single site are: 1. Subcutaneous route, one (1) cc; 2. Intramuscular route two (2) cc's in the deltoid and 3. Three (3) cc's in the thigh or buttocks. Note: All injectable dosages of insulin or anticoagulant medications must be checked by two (2) licensed nursing personnel. Check the Medication Administration Record (MAR), the physician's order, the label on the vial (for name, strength, dosage and expiration date), and the prepared syringe (for amount). B. Blood pressure and pulse will be taken prior to the administration of scheduled IM psychotropic medications. If a Individual is hypotensive, the physician will be notified and medication withheld. After administering anti-psychotic IM medication, staff will encourage the Individual to remain recumbent for at least 20 minutes after the IM injection is given. The Individual is to remain under close observation for any side effects from the medication for at least 15 minutes after the injection. Thirty minutes after the IM injection (excluding deconoates) BP, pulse, and respirations should be taken and recorded by staff. 2. PURPOSE: A. To provide more rapid and complete absorption. B. To prevent destruction of medication by digestive secretions. C. To provide an alternate route of medication administration.

3.

EQUIPMENT:

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A. Obtain from Central Supply: 1. Alcohol swabs. 2. Sterile, disposable safety syringes and needles. 3. Puncture resistant container (Sharpstainer). 4. Clean, disposable gloves. 5. Filter needle, regular needle, and separate syringe for use with glass ampule. B. Obtain from Pharmacy: 1. Medication (as prescribed).

4.

PROCEDURE: PREPARATION

NURSING ACTION A. Check physician's order against Medication Administration Record (MAR). Check Individual's chart for allergies or any contraindications.

RATIONALE-PRECAUTIONS A. To prevent medication errors. Physician's orders, MAR, and medication container must all correspond. Each nursing service staff is to be familiar with every drug he or she administers. If any doubts about any drug consult Pharmacy, physician, RN, or drug information books. B. Medications provided in multi-dose vials are to be dated and initialed upon opening by nursing staff. Such medications are to be used for no more than 30 days after the container is opened.

B. When using a rubber-capped vial (single or multiple dose):

C. Remove the soft metal cap (if present) to reveal the rubber stopper. D. Cleanse the rubber cap with an alcohol swab. E. If applicable, attach the needle to the syringe and remove the needle cover. F. Pull the plunger back to the mark, which corresponds to the amount of solution to be given; insert the needle into the rubber cap and inject the air into the vial. G. Draw out the correct amount of
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D. Using friction when cleansing removes contaminants. E. Do not touch any of the metal on the needle. Handle by the outside cover. F. An accurate amount of air must be injected to ensure correct dosage and ease in withdrawal of fluid.

G. Air present in the fluid will alter the

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solution, being careful to expel all air bubbles from the syringe before removing the needle. H. When a narcotic is ordered, assess respiration rate before giving narcotic. I. If respiration rate is below 12, hold the narcotic and notify the physician. J. When using a single dose ampule: K. Before preparing to open the ampule, make certain all medication is in the main body of the ampule and not in the stem or tip. Snap or shake ampule several times as necessary. L. Hold ampule in one hand and break off stem with the other. M. Using the syringe selected for injection and a filter needle, insert needle into the solution without touching the sides of the ampule and draw up the solution. N. After the ordered amount of medication is in the syringe, using aseptic technique, remove filter needle and replace it with the appropriately sized injection needle. Dispose of filter needle in sharps disposal container. O. When using a medication that must be reconstituted, refer to the medication package insert for instructions. P. If injection will be given away from the Med. Room, take a sharpstainer to the area. Q. Do not give drugs that have changed consistency, color or odor.

amount of medication being given.

H. Most narcotics depress respiratory rate. Respiratory rate below 12 is considered a contraindication.

K. Medication in the stem of the ampule will be lost when the ampule is opened, resulting in an incorrect dosage.

L. Use gauze to hold the ampule firmly and to protect the fingers while breaking off stem. M. The filter needle removes particulate matter from the medication as it is drawn up. Be careful not to touch the edge of the glass with the needle to minimize all chances of contamination. N. When the filter needle is used to draw up medication it must not be used for injection, as the retained particles would be released with the medication.

O. Make certain that the entire insert is read for complete instruction before beginning reconstituting.

Q. Changes in medication may mean instability, chemical changes, or precipitation.

B.

SELECTING THE SITE

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NURSING ACTION A. Determine the site to be used. Factors to be considered are: B. Frequency of injections.

RATIONALE-PRECAUTIONS

B. When the Individual is receiving frequent injections, alternate the site to prevent irritation and permit absorption. C. Some medications are absorbed better in certain areas than in others. D. A sore or inflamed muscle may trigger severe referred pain. E. Select a site that does not feel tender to the Individual and where tissue does not contract to become tense and firm. If the Individual is obese, be sure IM injections go into the muscle, not fatty tissue. Use longer needles or give injection in the arm or thigh, rather than buttocks.

C. Amount and type of medication. D. Condition of site. E. Palpate the muscle prior to injection.

C. ADMINISTRATION NURSING ACTION A. Perform hand hygiene. B. Put on gloves. B. To prevent transmission of communicable diseases (standard/transmission based precautions). C. Injection into tense tissue causes pain. Good visualization is essential for safe administration of the medication. RATIONALE-PRECAUTIONS

C. Help Individual to a comfortable position and expose the site for injection. For injection in the gluteus medius, position the Individual face down. A "toe-in" position relaxes the muscles. D. Cleanse the skin with an alcohol swab using a firm circular motion while moving out from the center of the area with each stroke. E. Subcutaneous Injections:
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D. Pathogens present on the skin can be introduced into the tissues by the needle. Friction aids in cleansing the skin. Contamination occurs when a soiled object is rubbed over a clean surface.

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F. Gently stretch the skin taut at the site of injection. G. Insert the needle quickly at a 45 to 90 angle. H. Intramuscular Injections: I. Press tissue around injection site down firmly, holding the skin taut between the thumb and first two fingers. I. Compression of subcutaneous tissue helps assure that the needle will enter the muscle and helps seal the needle track when tissues are allowed to return to normal. J. Quick insertion minimizes pain. Medication needs to be deposited in the muscle tissue. K. Discomfort is caused when solution is injected into compressed tissues due to increased pressure against nerve fibers. L. Medications injected into the blood stream are absorbed immediately and the intrinsic properties of some medications make intravenous administration dangerous. M. Rapid injection of solution creates a sudden increase in pressure on the nerve fibers resulting in pain. N. Blood mixed with the medication is not to be injected into the Individual. G. Quick insertion of the needle reduces pain. Angle depends on skin turgor and the amount of fatty tissue present.

J. Insert the needle quickly at a 90 angle. K. When the needle is in place, release the tissue to return to normal. L. Pull back slightly on plunger to determine if needle is in a blood vessel.

M. If no blood appears, inject the medication slowly. N. If blood appears, withdraw the needle, redraw medication with a new syringe and needle and select a new site. O. Withdraw the needle quickly. P. If a safety syringe is not used, after completing the injection, hold the syringe with the needle pointing away. Q. If using a safety syringe, automated needle retraction occurs only when the barrel is emptied and the plunger is fully depressed. R. Rub the injection site gently with a new alcohol swab unless massage or
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O. Slow removal of the needle pulls the tissue and may cause discomfort. P. To avoid accidental puncture with the contaminated needle, do not recap the needle. Q. The needle automatically retracts into the syringe preventing exposure to the contaminated needle and rendering the syringe non-reusable. R. Massaging aids in the diffusion and absorption of the medication.
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rubbing is contraindicated. S. If injection site bleeds, use direct pressure and cover with a Band-Aid. D. VARIATIONS NURSING ACTION A. Needle size and the angle at which the needle is to be inserted vary with the size of injection and the age, weight and general condition of the Individual. RATIONALE-PRECAUTIONS A. Intradermal injections: 1 cc tuberculin syringe with short bevel, 25 to 27 gauge, 3/8 to 1/2" needle. Subcutaneous injections: are commonly given with a 1 to 3 cc syringe using a 25 to 27 gauge, 5/8 inch, 3/8 inch, or 1/2 inch needle. A tuberculin syringe graduated in 0.01 cc may also be used. An Insulin syringe graduated in 100 units is specifically used for administration of insulin. Intramuscular injections: are commonly given with a 1 to 5 cc syringe with small gauge needle and length appropriate for muscle site; e.g.: deltoid muscle 22 to 25 gauge, 5/8 to 1" needle; needle sizes for the vastus lateralis, ventrogluteal, and gluteus medius vary from 18 to 22 gauge, needle lengths vary from 1 to 1 1/2". For drugs of an oily nature, a 20 gauge is used. B. Medications that are given by the ZTrack method (e.g. iron, dextran) require the tissue be pulled taut in one direction only prior to injection. C. Massage is not applied to an area when a medication is irritating to tissues or when it would increase the chances of tissue damage. D. When the medication for IM injection is more than 3 cc's and two syringes must be used, it is recommended that the injection be given in 2 different sites e.g. left and right glutens. B. Z-Tract method of injection prevents the medication from seeping back and staining surface tissue. S. Instruct Individual to leave Band-Aid on until bleeding has stopped.

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5. RECORDING: A. Chart IM and non-insulin subcutaneous medication administered along with site code on the MAR per N.P. 500. B. Chart subcutaneous injected insulin on the Diabetic Medication Administration Record. C. Intradermal TB Skin Tests are recorded on the Immunization Record.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 505 Effective Date: August 31, 2006

SUBJECT: ADMINISTRATION OF NOSE DROPS OR NASAL SPRAY 1. GENERAL Administer nasal medication after oral medications are administered. Nasal spray or nose drops are ordered for Individuals. Preparations containing oil are not given indiscriminately by this route since they may be aspirated. 2. PURPOSE Nasal medication is administered for local effect: vasoconstriction, antiseptic, or antihistaminic. 3. EQUIPMENT A. Facial tissue B. Medication (as ordered by physician specifically for the Individual). 4. PROCEDURE

NURSING ACTION A. Perform hand hygiene before and after each procedure. B. Read label carefully for contents, expiration date, Individuals name, instructions.

RATIONALE-PRECAUTIONS A. Avoid contamination. B. Assure Individual safety.

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C. Instillation of Drops: NURSING ACTION A. Position Individual in a sitting position with head tilted back or position Individual in the supine position with head hyper extended with a pillow. B. Draw up medication dropper until it is approximately 1/4 full, holding the tip down. C. Gently raise tip of nose and instill ordered number of drops into each nostril. Do not insert dropper into nostril, or touch tip to skin. D. Ask the Individual to remain in this position for approximately three to five (3-5) minutes. E. Place tissue within reach of the Individual and help him adjust to a comfortable position. Instruct him not to blow his nose. RATIONALE-PRECAUTIONS A. For ease of inserting drops Allows the drops to flow with gravitational pull.

B. Fluid concealed inside rubber squeeze tip will give an inaccurate measure. C. Prevent contamination of tip, which is placed back into solution.

D. Gravity will aid drops in reaching mucus membranes. E. Medication will be more effective.

D. Nasal spray: NURSING ACTION A. Position Individual in a sitting position. B. Insert tip of spray container gently into Individual's nostril. C. Holding center of container with thumb and forefinger, squeeze container once or twice. D. Have Individual sniff mildly with each spray. RATIONALE-PRECAUTIONS

B. Avoid pushing too hard for Individual safety and comfort.

D. Pulls medication farther into nostril. Delivers medication to frontal sinuses.

5. AFTER-CARE OF INDIVIDUAL AND EQUIPMENT: NURSING ACTION A. Write date container opened on label.
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RATIONALE-PRECAUTIONS A. Avoids use of ineffective medication.

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B. Leave facial tissue within reach of Individual, but caution him against blowing his nose. C. Replace cap, dispose of dropper, if disposable, and return medication to proper place. 6. RECORDING

B. For greater medication effectiveness. C. Nose drops and sprays are used by one Individual only.

Note medication as administered on the Medication Administration Record per N.P. 500. Record any unusual reactions in the IDN's and notify physician if indicated.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 506 Effective Date: August 31, 2006 SUBJECT: ADMINISTRATION OF HAND-HELD INHALANT MEDICATIONS 1. GENERAL: Inhalers are dispensed only for Individuals, and will be labeled by the Pharmacy for the Individual. Spacers shall be labeled with the Individuals name and shall be used for that Individual only. Knowledge of the specific medication being used as well as the apparatus used to deliver it is essential in order to produce the most beneficial results. 2. PURPOSE: Hand-held inhalers deliver topical medication to the respiratory tract. Bronchodilation and mucolysis are common goals of treatment. Absorption in the lungs is rapid and produces local effects. 3. MEDICATION & EQUIPMENT: A. Metered-dose nebulizer as ordered. B. Spacer (Spacer is not needed if the inhaler has a built in spacer). 1) Spacers will be labeled with Individuals name by Pharmacy staff. 2) If Individual is transferred to another unit, spacer will be transferred with the Individual to the new unit. C. Peak flow meter if ordered. D. Drinking water to gargle. 4. PROCEDURE: A. Administration of Hand Held inhaler (Open mouth technique). NURSING ACTION A. Hold the nebulizer with the mouthpiece at the bottom. B. Shake the container vigorously. RATIONALE-PRECAUTIONS A. Medication canister is designed for delivery in this position. B. Ensures adequate mixing to deliver correct dose.
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C. Instruct the Individual to position mouthpiece one to two inches from his lips. (Use two fingers as a measure.)

C. This allows the large medicine particles to drop out of the mist before the rest of the medication enters the mouth. This reduces adverse effects. D. This draws the full dose of the medication into the lowest portions of the lungs.

D. Instruct the Individual to open his mouth widely and breathe out naturally. Then have the Individual breathe in slowly through his mouth as the med person/Individual depresses the medication canister down to release the medicine. Continue slowly breathing in for three to five seconds. E. Instruct the Individual to hold his breath for the count of ten.

E. Allows the medication to reach the alveoli. Breathing out too quickly simply exhales the medication back into the room. F. Keeps the distal bronchioles open and increases absorption of medication. G. The first puff of quick relief medication opens the bronchioles so that the second puff is delivered more efficiently. Quick relief medications are Beta2agonists e.g. albuterol and ipratropium bromide. Controller medications are inhaled steroids, e.g. nedocromil, cromolyn, and long-acting beta2-agonists e.g. salmeterol. H. Removes irritating and distasteful medication from the mouth and back of the throat. Glucocorticoid inhalers can increase the risk of thrush if the Individual does not gargle and rinse. I. Prevents accumulation of residue. Note: Do not wash cromolyn inhalers with water as this will cake the medication (which is a powder), and renders the inhaler inoperable.

F. Instruct the Individual to exhale slowly through pursed lips. G. If two puffs of the medication are ordered, wait at least 30 seconds before administering the second puff of controller medication or pretreating before exercise. Wait 2 to 5 minutes between puffs of a quick relief medication while having asthma symptoms and between the quick relief medication and any other inhaled medication.

H. Have the Individual gargle and rinse with water after receiving the medication. This is very important when using glucocorticoid inhalers. I. Remove cromolyn inhaler and rinse the mouthpiece with warm water.

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B. Administration of a hand held inhaler using a Spacer. Note: Use of a spacer helps get the medication to the Individuals lungs instead of his mouth and holds the medication so that the Individual may inhale at his own pace. Spacers are dispensed by the Pharmacy with all glucocorticoid inhalers and upon physicians order with other inhalers. NURSING ACTION A. Remove mouthpiece cap and insert the nebulizer into the spacer. B. Shake vigorously. C. Have the Individual exhale completely and place his lips tightly around the mouthpiece. D. Spray one puff of medication into the chamber. E. Instruct the Individual to breathe in slowly and fully through the mouth, taking three to five seconds to inhale. F. Instruct the Individual to hold his breath for the count of ten. G. If two puffs of the medication are ordered, wait at least 30 seconds before administering the second puff of controller medication or pretreating before exercise. Wait 2 to 5 minutes between puffs of a quick relief medication while having asthma symptoms and between the quick relief medication and any other inhaled medication. E. A whistle will sound if the Individual is inhaling too rapidly. F. Allows the medication to reach the alveoli. G. The first puff of quick relief medication opens the bronchioles so that the second puff is delivered more efficiently. Quick relief medications are Beta2agonists, e.g. albuterol and ipratropium bromide. Controller medications are inhaled steroids, e.g. nedocromil, cromolyn, and long-acting beta2-agonists, e.g. salmeterol. H. Clean entire apparatus once each week according to package instructions. C. Ensures maximum inspiration of medication. RATIONALE-PRECAUTIONS

H. Wipe mouthpiece clean between each use and replace cap.

C. Use of the Peak Flow Meter: NURSING ACTION RATIONALE-PRECAUTIONS

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A. Insert the mouthpiece into the end of the flow meter. Cardboard disposable mouthpieces are to be used once and then thrown away. B. Set the arrow to "zero".

A. Disposable cardboard mouthpieces are used to decrease risk of infection. B. The instrument is for single Individual use only. It must be recalibrated each time. C. The indicator arrow must be clear to move freely. D. This measures the peak expiratory flow. It is used to determine need for and effectiveness of inhalant treatment. E. The physician will order when and how frequently to take peak flow readings. F. Peak flow results must be consistently documented for ease of retrieval of information.

C. Hold the flow meter so that the slot is away from the Individual's hand. D. Have the Individual take a deep breath, make a tight seal around the mouthpiece with his lips, then blow into the flow meter as hard and as fast as he can with a short, sharp burst of breath (like blowing out a candle). E. Have him do this three times. Reset the arrow to zero between each breath, and note the highest reading on the scale. F. When the measurement accompanies routine inhalant medication, record peak flow results on the MAR in the next available box below the space in which the medication order was transcribed. G. When the measurement accompanies PRN inhaler medication order, record peak flow results on the same line on the PRN record as the dose given. H. If the Individual has a peak flow order with no medication order, record peak flow results on the MAR as in #6 above.IndividualIndividual

5.

RECORDING: -Record medication and peak flow on MAR as directed above. -Document all Individual teaching in the ID Notes.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 507 Effective Date: August 31, 2006 SUBJECT: INSTILLATION OF EYE MEDICATION 1. GENERAL: Eye medications are ordered for Individuals only and come packaged in individual containers. The flexible type container permits the medication to be squeezed out drop by drop. Do not interchange eyedropper between different medications or use one Individual's eye medication for another Individual. Commercially prepared eye drops are sterile and the applicator tip should be treated in the same manner as sterile instruments. To maintain sterility, do not touch the applicator tip to the Individual's skin, eye, eyelashes, or with the fingers. Do not use solutions in which there has been a change in color or formation of sediment showing decomposition. 2. PURPOSE: In this procedure, medication is administered to eye for local effect. A. To treat infection B. To reduce inflammation C. To aid in diagnosis D. To provide anesthetic E. To relieve discomfort F. To decrease intraocular pressure G. To provide vasoconstriction (relieve congestion, itching and irritation) H. To provide moisture 3. EQUIPMENT: A. Facial tissues. B. Medication (ordered specifically for the Individual). 4. PROCEDURE: A. INSTILLATION OF EYE DROPS:

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NURSING ACTION A. Perform Hand Hygiene Protocol before and after procedure. B. Explain procedure to the Individual. C. If secretions are present, cleanse prior to administering the eye medication. D. Use thumb or forefinger to pull down on the skin overlying the cheekbone just beneath the eye. E. Hold the dropper close to the eye, but avoid touching the eyelids, lashes or eyeball. Drop desired amount of medication into the conjunctival pocket. Release the lid. F. If more than one drop or if two different medications are to be administered, wait five (5) minutes before instilling additional drops/medication. G. Ask the Individual to close eyes gently, and then blink once or twice. H. Ask the Individual to refrain from rubbing his eye. I. Observe Individual for any side effects or adverse reaction to medication. J. After drop instillation, have Individual apply pressure at bridge of nose at inner canthus using tissue and thumb and forefinger.

RATIONALE-PRECAUTIONS A. Avoid contamination. B. To elicit his cooperation and reduce anxiety. C. If not removed, debris on eyelid may wash into eye. D. This pulls the lower lid away from the eye and exposes the conjunctival pocket in which the drop is placed. E. The conjunctiva is less sensitive than the cornea and the Individual is more comfortable when the drops are not placed directly on the cornea. Placing drops directly on cornea will stimulate blinking. F. A waiting period between drops allows absorption of medication, prevents medication from running out of eye, and prevents medication interaction. G. Blinking of the lids will evenly distribute the medication upon the eye surface. H. Prevents medication from running out of the eye. I. If Individual develops an adverse reaction, notify physician at once. J. This is called punctal occlusion and will help prevent the medication from draining through the nasal lacrimal duct to the nose and entering the systemic circulation. This helps to decrease the possibility of side effects, especially when potentially toxic or irritating drops is used. K. To prevent contamination.

K. Once medication is opened it is not sterile. Be careful not to touch any part of the applicator to eye.

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B. APPLICATION OF OINTMENT TO EYE: NURSING ACTION A. Pull lower lid downward and ask Individual to look up. B. Squeeze small amount of ointment onto sterile gauze. C. Apply a thin layer of ointment into the lower conjunctiva. To break off ointment from tube, turn tube sharply in opposite direction. D. Do not touch applicator to eyelid. E. Release lower lid and ask Individual to close eyes for 30 seconds to distribute ointment. RATIONALE-PRECAUTIONS A. For ease of application. B. To get rid of dry plug at end of tube. C. To prevent contamination of tip or injury to eye, avoid touching eye or lid with tube. D. To prevent contamination of applicator. E. After a few moments, moving eye with closed lids will distribute ointment around eye. Keeping the eye closed helps to liquefy the ointment. F. Instruct Individual not to rub eyes. H. If Individual develops an adverse reaction, notify physician at once.

F. Gently wipe off any excess ointment with tissue. H. Observe Individual for side effects or adverse reaction.

5. RECORDING: Document medication on Medication Administration Record per N.P. 500.

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N.P.P No. 507

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 508 Effective Date: August 31, 2006 SUBJECT: INSTILLATION OF EAR MEDICATION 1. GENERAL: Administer ear medications after oral medications are administered. Ear medication is ordered and specifically labeled for the Individual. It is not to be used for any other Individual. Note: Some conditions may prohibit instillation of certain medication into the ear canal; e.g. perforated eardrum or medications containing hydrocortisone if Individual has viral or fungal infections. 2. PURPOSE: A To treat infection, inflammation and pain of the middle and external ear. B Produce local anesthesia to facilitate removal of cerumen or a foreign body. C To soften impacted cerumen. 3. EQUIPMENT: A. Labeled medication as prescribed for specific Individual B. Cotton balls C. Disposable gloves 4. PROCEDURE: NURSING ACTION A. Gather necessary supplies. RATIONALE-PRECAUTIONS A. Expedites procedure & minimize pt. anxiety B. To maintain a clean procedure. C. Delicate ear membranes can be easily damaged by incorrect administration of otic drops. When a cold solution is placed into the ear the Individual may become dizzy. D. Safety check, prevent cross contamination.
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B. Perform hand hygiene and don gloves. C. Read label carefully to determine the correct temperature for instillation. To warm otic drops safely, allow standing at room temperature, or rolling bottle between hands for several minutes. D. Check name of Individual on label.
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E. Check expiration date on container. F. Explain the procedure to the Individual. G. If any drainage on external ear, clean outer ear with a moistened cotton ball. H. Tilt the Individual's head toward his shoulder with the affected ear upward or position Individual in the recumbent position on unaffected side. I. Gently pull the auricle upward and backwards. J. Without touching the dropper to the ear, instill the ordered number of drops into the affected ear. Direct the drops to fall against the side of the ear canal not against eardrum. K. Have the Individual maintain the position of his head for at least five 5 minutes after instillation of ear drops or allow Individual to lie on his side for 5-10 minutes. L. Cleanse external area around ear gently with moistened cotton ball.

E. To ensure potency. F. To gain his cooperation and alleviate his anxiety. G. Drainage can interfere with the effectiveness of the medication. H. Allows for better visibility and aids in medication administration. Gravity helps distribute the medication. I. Straightens the external auditory canal in adults. Promotes delivery of medication into ear canal. J. Prevent dropper from becoming contaminated and to ensure continued sterility of drops. To avoid Individual discomfort. K. To prevent medication from running back out before it is effective. This may be easiest if Individual sits down or lies down. L. Discard cotton balls in trash container (clear plastic bag) for prevention of infection and cross contamination.

N. If ordered; repeat the procedure to other ear after 5-10 minutes. 0. Perform hand hygiene. 5. RECORDING A. Note medication as administered on the Medication Record per N.P. 500 B. Record any unusual reaction/drainage in the ID Notes and notify Physician. C. Document any Individual education in the ID Notes.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 509 Effective Date: August 31, 2006 SUBJECT: NURSING PROTOCOL FOR ADMINISTRATION OF PROPRANOLOL 1. GENERAL: Propranolol is administered at Coalinga State Hospital for: cardiac indications, calming effects, anti-agitation, anti-akathesia, headaches, essential tremor, pheochromocytoma, and neuroleptic side effects. 2. PURPOSE: The following nursing actions will be taken to assure that every measure of safety is provided for the Individual. 3. PROCEDURE: A. Initial Administration: NURSING ACTION A. Before initial administration of propranolol, nursing staff must assure that the Individual has been assessed and evaluated for contraindicating conditions by the attending physician. RATIONALE PRECAUTIONS A. Heart blockage greater than first degree, bronchial asthma, congestive heart failure without coexisting tachyarrythmia and diabetes mellitus, allergic rhinitis, sinus bradycardia, right ventricular failure secondary to pulmonary hypertension cardiogenic shock. B. Hypotension or reduced coronary output is contra-indicated in the use of propranolol.

B. The nursing staff will check pulse and standing blood pressure before and 2 hours after first dose and then before subsequent doses until stabilization is achieved. C. Until dose stabilization is achieved, blood pressure and pulse will be monitored daily or more frequently, as indicated. The physician will be notified and dose held when the pulse rate is below 55, the systolic blood
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C. Possible adverse reactions: CV bradycardia, hypotension, congestive heart failure, and peripheral vascular disease, CNS fatigue, lethargy, and agranulocytosis.

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pressure is below 90 mm Hg, or the diastolic pressure is below 50 mm Hg. D. Do not crush sustained release propranolol. D. This would result in rapid absorption of the medication and onset of hypotension.

B. Determination of Dose Stabilization: 1. Nursing staff will refer Individuals to the physician when vital signs are consistently within normal limits. 2. The physician, if it is determined that the Individual is stable on propranolol, will write an order for blood pressure and pulse to be monitored no less than weekly. C. After Dose Stabilization is Achieved: NURSING ACTION A. Blood pressure and pulse rate will be monitored weekly and as indicated. B. In the event the Individual refuses doses of propranolol, the nursing staff will notify the attending physician or after hours notify NOD who will notify the MOC. C. Nursing staff will observe Individuals receiving propranolol for signs of: unusual bruising and/or bleeding, nausea, vomiting, diarrhea, constipation, respiratory distress, rash or eye problems, ataxia, pulse < 55 or B/P < 90/50. Hold dose and notify the physician if any of the above is found. D. Individuals receiving propranolol will be assessed daily and any unusual behavior or complaint will be drawn to the attention of the physician or MOC immediately. E. Nursing staff will be familiar with the implications and drug interactions relevant to Individuals receiving propranolol. F. Propranolol concentrate may be given with juice, applesauce, or pudding. E. Drug interactions may range from uncomfortable to life threatening. F. Makes the concentrate more palatable as propranolol concentrate is bitter if taken by itself.
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RATIONALE - PRECAUTIONS

B. Due to the dangers of sudden discontinuance of this medication e.g. exacerbation of angina and myocardial infarction. C. Possible side effects of propranolol which can be dangerous to the Individual.

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D. Recording 1. Record med administration on MAR per NP 500. 2. Record vital signs on the Vital Signs Record. 3. Record any teaching in the ID Notes.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 510 Effective Date: August 31, 2006 SUBJECT: CARE OF THE INDIVIDUAL RECEIVING CLOZAPINE

1. GENERAL: Clozapine is indicated for the severely ill schizophrenic Individual who has not responded to other neuroleptic medication or who is experiencing intolerable side effects from current medication. During the stabilization, period Individuals will be titrated up from an initial low dose. Because of potentially severe blood dyscrasias, Pharmacy will only distribute unit dose supplies based on mandatory weekly or biweekly white blood counts (WBCs). Due to the effect of clozapine on the GI tract, special consideration must be given when assessing the Individual for potential or actual constipation. A Individual may be constipated or have a partial impaction with no symptoms, or subtle symptoms. Nursing is required to assess any change in Individual status that may indicate constipation or formation of an impaction. The following changes in a Individuals status can indicate the beginning of an impaction: changes in mental status (e.g. confusion, delirium); an increase in the Individuals presenting psychiatric or psychotic symptoms; physical changes such as bloating, discomfort or pain in the abdomen or rectum. If changes are found upon assessment, the change in status must be referred to the physician immediately. Though some Individuals on clozapine have had no difficulty with constipation, each Individual will be monitored by eliminative subsystem each shift. 2. PURPOSE: To assure that clozapine is administered safely and in a manner that minimizes risk from potential untoward reactions. 3. PROCEDURE: A. Pre-Treatment Baseline: NURSING ACTION A. All Individuals on clozapine will have a Wellness and Recovery Plan as long as they are on the medication and must
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RATIONALE-PRECAUTIONS A. Individual will be evaluated and educated regarding diet, fluid intake, exercise and other related factors
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agree to follow the plan. B. Obtain a physician's order for baseline lab work.

associated with clozapine with special emphasis on constipation. B. Ongoing monitoring of the Individual for potential adverse reactions requires adequate baseline information to interpret changes. C. Pharmacy will not dispense the medication until it has received verification that baseline work-up is complete.

C. The physician will receive a start-up packet from pharmacy containing all the necessary paperwork. The following baseline data is completed or current by: -Lab Within 30 days: WBC Within previous year: - Serum creatinine - Electrolytes - Liver function panel - Total protein - Albumin - Urinalysis -30 days prior to starting, a complete physical assessment including: - abdominal and rectal exam - KUB -EKG - Within previous year D. Complete set of Vital signs twice daily for 3 days. E. Observation and documentation of bowel habits two weeks prior to initiation of clozapine.

E. If constipation is present or part of the Individual's history, the problem must be resolved/treated before clozapine therapy is instituted. F. Nutrition Services has a vital role in nutritional intake and prevention of constipation

F. Prior to initiating clozapine, a referral will be sent to Nutrition Services

B. Obtaining the Medication: A. The initial dose of medication will not be distributed until the pretreatment procedures and forms are completed and the clozapine registry has been contacted and an authorization number has been received. Physicians orders must
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also be sent to the pharmacy. B. To obtain subsequent doses of the medication, bring a copy of the physician's orders. C. Return to the Pharmacy any pills left over after the dosing period. D. If new orders are written and/or the current, on-hand supply is insufficient, bring the remaining doses back to Pharmacy with the most current orders and new medication will be dispensed. E. If the Individual refuses a dose and/or a dose needs to be wasted, notify Pharmacy so that additional doses can be dispensed. F. If Pharmacy is closed and it is necessary to obtain doses of the medication, call NOD. C. Monitoring White Blood Counts: A. Obtain a physician's order for weekly WBCs with differential for the first 6 months or weekly or bi-weekly WBC's with differential after the first 6 months (weekly or bi-weekly will be determined by the physician after the first 6 months of treatment). Monthly KUB times three months and then quarterly thereafter. B. Write "WCB with DIFF. for Clozapine" in the box labeled "test requested" on the lab slip any time a CBC is ordered on a clozapine Individual.Individual C. Schedule the Individual to have a CBC drawn weekly. A. Agranulocytosis may occur and is a potential severe adverse reaction.

C. All doses must be accounted for.

F. To assure there is no interruption of the Individuals treatment.

B. Laboratory personnel must be notified on the lab slip that the Individual is being monitored for clozapine in order to process the results. C. To avoid duplicate or unnecessary needle punctures. The lab can obtain all the needed samples with a single puncture. D. The lab is closed on all state holidays and the interval between CBCs must never be more than seven (7) days. E. If the WBC reveals a significant drop in cell count, even if WBC count is still in
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D. If the routine lab day falls on a holiday; an extra lab draw must be scheduled. E. If the WBC falls below 3500, labs will be drawn twice weekly. Vital signs will be
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taken daily.

F. If the WBC drops below 3000, Clozapine will be stopped. If WBC drops below 2000, the Individual will be admitted to the Infirmary Unit for reverse isolation

normal range, or WBC tests reveal three or more consecutive drops in WBC cell counts the Individual needs closer monitoring for potential infection. F. To reduce and prevent infection in a Individual whose WBC may be low.

D. Ongoing Nursing Care of the Individual on Clozapine: 1. Vital Signs: A. One hour after the first dose then twice daily for 21 days after the first dose. A. Monitoring vital signs when initiating clozapine is important since side effect such as hypotension, tachycardia, and fever may occur. Special consideration needs to be given to Individuals who may also be on a benzodiazepine due to possible respiratory collapse or hypotension. B. These are frequently the first signs of dropping WBC.

B. Report fever or sore throat to attending physician immediately. 3. Lab work: A. Monitor weekly or bi-weekly WBC with differential. Assist the Individual to keep weekly or bi-weekly appointments. Liver function panels are required every six (6) months. Serum creatinine levels are done at the 3rd and 6th months, then every 6 months thereafter. B. Reinforce with the Individual the importance of general infection control measures (hand hygiene, not sharing cups, etc.). C. Educate Individual regarding fluid intake (if medical condition permits) to a minimum of 2000 cc per 24 hours (four ounces of prune juice may be ordered to be given with medications up to three times a day) along with adequate fiber, exercise, and use of stool softener (if ordered). Encourage Individual to
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A. Agranulocytosis may occur in Individuals receiving clozapine. Liver and kidney function must also be monitored.

B. To prevent infection in a Individual whose WBC may be low.

C. To prevent constipation, a frequent and possible life threatening side effect. Some Individuals who may not be able to monitor hydration effectively themselves may need further assistance such as an extra cup of water or juice at meal and medication times.
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increase fluid intake further during warm weather. D. Monitor oral intake. Baseline data will include intake at meals and medication times or any other time decided by staff/Individual (e.g. snack time). E. Encourage 15-30 minutes of exercise (e.g. walking) at least three times a week. If the Individual is not capable, refer to rehabilitation therapist for alternative activities. F. If the Individual becomes constipated during clozapine treatment, observe stool and immediately report results to the physician. If the Individual does not have a bowel movement within 48 hours, refer Individual to the physician. G. Continue to encourage fluid intake and supplemental liquid dietary fiber, e.g., prune juice and/or a fiber enhanced supplement. The Registered Dietician and physician treat additional modifications in fiber on an individual basis. H. If the Individual has a fecal impaction unit staff will notify a physician immediately for evaluation and intervention(s). I. Educate the Individual for possible side effects of sedation and/or dizziness. Benign hyperthermia (5% of Individuals) usually occurs early in the treatment and may be as high as 104 degrees. As with any other fever, an infectious process should be ruled out. Tachycardia has been observed in about 25% of Individuals who experience an average increase of 10 - 15 beats per minute. It is dose dependent. J. A towel may be placed on the Individual's pillow at night for increased
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D. To provide consistency in accomplishing adequate fluid intake. To assure that the Individual is drinking fluids. E. To prevent constipation.

F. It is estimated that up to 60% of Individuals receiving clozapine will become constipated.

H. If the Individual has a fecal impaction this may be a medical emergency.

J. Hypersalivation is a known side effect and is typically worse during sleep.

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salivation. K. The Individual may cough at night due to hypersalivation. If excessive coughing occurs this should be brought to the attention of the physician and documented by the staff in the Individuals chart. E. Managing Identified Adverse Reactions: 1. Seizures: A. Maintain the Individual's safety.Observe the course of the seizure and record. Hold the medication and report to the psychiatrist. 2. Hypotension: A. Teach the Individual to sit on the edge of the bed several minutes before rising, then to rise slowly to a standing position. B. Have the Individual report any symptoms of dizziness, lightheadedness, or difficulty breathing.

(affecting approximately 31% of Individuals). K. If the Individual coughs often at night he may develop respiratory problems due to aspirating small amounts of saliva.

A. Seizures increase in likelihood as the dose increases.

A. Orthostatic hypotension can be a side effect and can be particularly severe during initial dose adjustment. B. Individuals with pre-existing cardiac conditions are at highest risk. Individuals receiving benzodiazepines are also at risk.

F. Continuity of Care when Individuals are transferred from One Unit to Another: A. The transferring unit will notify the receiving unit of impending transfer in sufficient time to allow the receiving unit to coordinate lab draw times. B. The transferring unit will return any remaining doses to Pharmacy. C. The receiving unit will obtain medication as described in above Section II B. G. Continuity of Care after Discharge from the Hospital: A. If the Individual is going to court or is being discharged, complete the Nursing
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A. Weekly or bi-weekly blood-draw schedules must not be interrupted as Pharmacy will not dispense medication without a current WBC (no older than seven (7) days).

A. The Nursing Discharge Summary is an essential tool to assure that the continuity
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Discharge Summary and include pertinent aftercare information (e.g. last 3 WBC dates and results). B. If Individual was recently taken off clozapine (within the last two weeks), record this information on the Nursing Discharge Summary. WBCs need to continue to be drawn for three weeks after Clozapine is discontinued

of Clozapine treatment and supportive care is not interrupted.

B. To prevent an atropine overload, at the receiving facility, the dose and discontinued date of Clozapine is required. To continue to monitor the Individual for side effects till the medication is no longer in his system.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 511 Effective Date: August 31, 2006 SUBJECT: CARE OF THE INDIVIDUAL RECEIVING OLANZAPINE 1. GENERAL Olanzapine is indicated for the severely ill schizophrenic Individual who has not responded to other neuroleptic medication or who is experiencing intolerable side effects from current medication. During the stabilization period Individuals will be titrated up from an initial low dose. 2. PURPOSE To assure that Olanzapine is administered safely and in a manner that minimizes risk from potential untoward reactions. 3. PROCEDURE A. Pre-Treatment Baseline: 1. Medication Review Committee consult approval for the use of Olanzapine must be obtained prior to the use of Olanzapine. 2. Complete vital signs must be taken within the past week. 3. LFTs and CBC with platelets performed within the last 90 days. 4. ECG within the previous year. B. Post Treatment Laboratory and Testing Screens: 1. Bowel care monitoring and recording daily for 30 days. 2. LFTs and CBC with platelets monthly for first 3 months. 3. Complete vital signs every week. 4. Body weight monthly. C. Additional information concerning dosing guidelines: 1. Olanzapine may be administered on a once daily schedule without regard to meals at a starting dose of 5 mg with a target dose of 10 mg after 7 days. 2. Dose increases should be limited to 5 mg per week. 3. Administration of Olanzapine once daily leads to steady-state concentrations in about one week. 4. Olanzapine tablets are available in 5 mg, 7.5 mg, and 10 mg strengths. 5. Tablets should not be crushed or split due to drug instability when exposed to moisture. 6. The maximum dose of Olanzapine is 20 mg per day. The safety of Olanzapine doses greater than 20 mg per day has not been evaluated. -1N. P.P No. 511

4. RECORDING Recording administration on the Medication Administration Record.

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N. P.P No. 511

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 512 Effective Date: August 31, 2006 SUBJECT: OXYGEN (O2) THERAPY 1. GENERAL CONSIDERATIONS A. Individuals on continuous oxygen therapy shall have access to all non-smoking Individual areas within the hospital (shall not be denied based solely on Individuals use of oxygen). B. Oxygen (O2) is an odorless, tasteless, colorless, transparent gas that is slightly heavier than air. C. There is always a danger of fire where oxygen is being used. D. Avoid using oils or grease around oxygen connections. E. Eliminate antiseptic tinctures, alcohol, and oil/petroleum products (e.g. petroleum jelly) in the immediate oxygen environment. F. Do not permit any electrical devices (radios, heating pads, electric razors) in or near an oxygen tent. G. Keep the oxygen cylinders secured in an upright position and away from heat. H. Oxygen can be administered from an oxygen tank or oxygen concentrator. Oxygen supplied to the Individual from a tank is controlled by using a pressure regulator that shows the amount of oxygen left in the tank and a flow meter that regulates oxygen in liters per minute. An oxygen concentrator has a flow meter only. I. Oxygen is given to relieve hypoxemia or hypoxia. J. Continuous oxygen therapy shall be administered upon the order of a physician. 2. TRAINING All nursing service personnel assigned to areas where oxygen is located will be formally trained in its use and function within 30 days of assignment. After the initial training, return demonstration will be required bi-annually (every 2 years).

3. ASSESSMENT -Suspect need for oxygen when Individuals predisposed to impaired gas exchange have: 1. Tachypnea 2. Tachycardia or arrhythmias.
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3. A change in level of consciousness. -Early use of oxygen therapy may prevent development of: 1. Cyanosis - occurs as a late sign. 2. Labored respirations - indicates severe respiratory distress. 3. Myocardial stress - increase in heart rate and stroke volume (cardiac output) is the primary mechanism for compensation for hypoxemia or hypoxia. -The use of the pulse oximeter is the easiest and least invasive method of monitoring/assessing Individual response to oxygen therapy. -Individual safety shall be considered. 1. Individual safety will be addressed in the nursing care plan. 2. Licensed personnel knowledgeable of oxygen policies and procedures will directly supervise Individual when oxygen therapy occurs away from the infirmary unit. 4. NURSING INTERVENTIONS A. Select the appropriate form of oxygen therapy after obtaining oxygen saturation via the pulse oximeter and assessing the Individual's current oxygenation status and acid-base balance. Choices are: 1. Low concentration - appropriate for Individuals prone to retain carbon dioxide (chronic obstructive pulmonary disease, drug overdose). Such Individuals may be dependent on hypoxemia (hypoxic drive) to maintain respiration. If hypoxemia is suddenly reversed, hypoxic drive may be lost. Respiratory arrest may then occur. 2. High concentration - appropriate in Individuals not predisposed to carbon dioxide retention. B. Monitor response to therapy by pulse oximeter evaluations. C. Increase or decrease the fraction of inspired oxygen (FIO2) concentration, as appropriate, to correct pulse oximeter to Individual norms. Note: Oxygen toxicity should always be of concern in the Individual receiving inspired concentration over 6 L/min. (60%) for longer than 24 hours. 5. EVALUATION A. Monitor Individuals response to oxygen therapy by using pulse oximeter (by attaining desired oxygen concentration) and by the decreased work of breathing. B. Check Individual for hypoxia; i.e., decreased LOC, increase heart rate, arrhythmias, restlessness, perspiration, diaphoresis, use of accessory muscles, yawning or flared nostrils and cyanosis. C. Observe Individuals skin integrity to prevent skin breakdown on pressure points from oxygen delivery system. 6. EQUIPMENT A. Oxygen source (tank or oxygen concentrator) B. Pressure regulator/flow meter
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C. Humidifier bottle & sterile water D. Oxygen delivery system (cannula, mask) E. Pulse Oximeter F. Sterile distilled water G. "Oxygen IN USE" signs H. Oxygen may be administered by nasal cannula or various types of face masks. It may also be administered via endotracheal or tracheal tube, T-piece, or hyperinflation bag (ambu bag). I. Paper bag, hospital wash basin to store disposable equipment between treatments. 7. PROCEDURE NURSING ACTIONS A. Assess the Individual's respiratory rate and level of consciousness (LOC). RATIONALE/PRECAUTIONS A. Oxygen by nasal cannula administration is often used for Individuals prone to CO2 retention. Oxygen may depress the hypoxic drive of these Individuals (evidenced by a decreased respiratory rate, altered mental status, and further PaCO2 elevation). B. To inform Individuals & hospital personnel in the area of oxygen use. C. Individual teaching & elicit cooperation. Teaching to include the hazards: & hospital regulation regarding oxygen in use. D. Make sure the humidifier is filled to the appropriate mark with sterile water. E. Attach the connecting tube from the cannula/mask to the humidifier outlet. E. When using nasal cannula, if Individual complains of dryness inside nose apply a water- soluble lubricant like K-Y jelly. F. Approximate oxygen concentrations delivered by nasal cannula are: 1 liter = 24% 2 liters = 28%
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B. Post "OXYGEN IN USE signs on the Individual's door and in view of Individual and visitors. C. Show the nasal cannula/mask to the Individual and explain the procedure.

F. Set the flow rate at prescribed liters/minute.

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3 liters = 32% 4 liters = 36% 5 liters = 40% G. Place the tips of the cannula in the Individual nose or place the mask over the Individual's nose and mouth and under the chin. Adjust straps. H. Adjust flow to prescribed rate. Note: because a nasal cannula is a low flow system (Individuals tidal volume supplies part of the inspired gas), oxygen concentration will vary, depending on the Individuals respiratory rate and tidal volume.

Note: Individuals who require low, constant concentrations of oxygen and whose breathing pattern varies greatly may need to use a venturi mask, particularly if they are carbon dioxide retainers. 8. GENERAL CONSIDERATIONS/INFECTION CONTROL A. Do not use extension cords (oxygen concentrator). B. Oxygen concentrator filter: Remove the filter of the (oxygen concentrator) weekly, place in clear plastic bag, send to Central Supply with requisition for cleaning and re-issue. (Do not clean filters on the unit). C. Wipe tubing and nasal cannula/mask with a clean cloth or gauze sponge moistened with water only. Wipe tubing first and nasal prongs/mask last. D. Check humidifier water level every 4 hours, if low, discard remaining water. Rinse out bottle with sterile water and discard. Fill bottle with sterile water to appropriate line marked on bottle. E. Change all disposable items every 48 hours including humidifier bottle, cannula/mask with tubing should be changed every 72 hours. At same time wipe oxygen concentrator (if used) with a clean cloth or gauze sponge moistened with water only. Between use, disposable items will be stored in a paper bag labeled with Individuals name and date in indelible ink. Paper bag will be placed in a clean hospital wash basin labeled with Individuals name F. If you experience any problems with equipment, complete a work order request and take it to Central Supply. G. Do not use alcohol or oil based products around oxygen dispensing equipment. 9. DOCUMENTATION
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A. Document Individuals oxygen administration and reaction/outcome on medication administration record per N.P. 500. Additional notes may be placed in an Wellness and Recovery note. B. Document any Individual teaching on the Health Education Record. 10. GENERAL SAFETY 1. Smoking is not allowed by the Individual when receiving oxygen therapy or within 15 feet of user and/or his oxygen delivery system. 2. Post Oxygen in Use signs on the entryways to area(s) of oxygen use. 3. No sources of open flame including candles shall be permitted in area where oxygen is being used. 4. Know the location of the nearest fire extinguisher. 5. If a fire occurs in the area, turn off oxygen immediately and remove user and deliver system from the area. 6. Do not run oxygen tubing under clothing, bedding, furniture or carpets. 7. Oxygen tanks must be kept upright & secured to either an oxygen hand truck, the wall or in a wheelchair attachment. 8. Make sure oxygen delivery system is turned off when not in use. 9. Visitors to the Individual and/or area of oxygen use shall be notified of the hazard of oxygen use (Oxygen in Use sign).

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 513 Effective Date: June 20, 2007 SUBJECT: ADMINISTRATION OF INSULIN This cancels NP 513 dated 3/1/07 1. PURPOSE: To provide nursing staff with guidelines for the safe and appropriate administration of insulin. 2. AUTHORITY: Title 22, division 6, 80092.8, Lippincott, W& W, Lippincott Manual of Nursing Practice eighth edition. 3. POLICY: Insulin therapy involves the subcutaneous injection of immediate, short, intermediate, or long acting insulin(s) at various times to achieve desired effect and the monitoring of glucose levels prior to the administration of insulin. Insulin is given by licensed nursing staff after the proper type(s) of insulin and dosage has been verified by a second licensed nursing staff. The second licensed staff is still required for Individuals who have been approved and assessed to self administer their own insulin (see NP 523). 4. EQUIPMENT: 1. Diabetic Record (MH563) and Continuation (MH5633A) 2. Prescribed vial(s) of insulin 3. Insulin syringe and needle 4. Alcohol swabs 5. Gloves 6. Sharps container 7. Personal Protective Equipment as needed 8. Glucometer, test strips, and lancets 5. METHOD: A. PREPARING MEDICATION:

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NURSING ACTION A. Check Diabetic Medication Record and select prescribed insulin(s). Check glucose level prior to administration of insulin as per physician order.

RATIONALE-PRECAUTIONS A. An open bottle of insulin currently in use can be kept at room temperature, out of direct sunlight. Check vial for expiration date and date vial was opened. Monitoring glucose level prior to administration of insulin for hypoglycemic levels. B. The licensed staff member verifying the dosage shall observe the insulin being drawn from the vial in order to verify the accuracy of the type of insulin and dosage. After verifying accuracy initial below the diagonal line on the Diabetic Medication Record. The staff member who draws-up the insulin initials above the diagonal line. For insulin being self administered the licensed staff member shall observe the insulin being drawn from the vial in order to verify accuracy of type and dose of insulin. After verifying accuracy initial the date and time on the Diabetic Medication Record C. The rolling action mixes the insulin. Never shake the bottle as this causes air bubbles, which could distort the dosage. D. Removes dust and grease but does not sterilize. E. To prevent buildup of negative pressure in the vial when aspirating medication, air must first be injected into the vial. F. Tap side of syringe barrel carefully to dislodge any air bubbles as accumulation of air displaces medication and causes dosage errors.

B. Verify type and dosage of insulin with another licensed staff member. The second licensed staff member is not required for Individuals who have been approved and assessed to self administer their own insulin (see NP 575).

C. Gently roll insulin vial between palms of hands to thoroughly mix.

D. Cleanse the rubber stopper on vial with an alcohol swab. E. Inject air into the vial equal to the amount of insulin you are giving.

F. Withdraw plunger to required dosage being careful to expel any air bubbles before removing needle from the vial.

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1. ADMINISTRATION OF INSULIN: NURSING ACTION A. Perform hand hygiene RATIONALE-PRECAUTIONS A. To Maintain proper hygiene. B. Ensures correct Individual receives the correct medication. Individual teaching assists with minimizing anxiety and gaining cooperation. C. Prevents possible exposure to blood. D. Check injection log on Diabetic Medication Record. Rotate site to prevent induration of tissue. E. Friction aids in cleansing the skin. Pathogens present on the skin can be introduced into the tissues by the needle. F. Angle depends on the skin turgor and the amount of subcutaneous fat present.

B. Identify Individual (see NP 500) and explain procedure.

C. D.

Put on disposable gloves. Select site for injection.

E. Cleanse the skin using a firm circular motion while moving out from the center of selected site. F. Gently stretch the skin taut at the site of injection. Insert the needle quickly and firmly at a 45 to 90o angle. G. When the needle is in place, release skin tension.

G. Quick firm insertion minimizes discomfort. Tight skin is easier to penetrate then loose skin H. The injection should be completed in 3 to 5 seconds. Avoid moving the syringe. I. This prevents painful pulling of the skin as the needle is withdrawn. Do not massage the site. J. Proper disposal of glass and needle prevents accidental injury. K. Controls transmission of infection L. To maintain proper hygiene

H. Depress the plunger, injecting the prescribed dose of insulin. I. Gently withdraw the needle if not a safety syringe. If a safety syringe is used, continue to depress the plunger until the needle retracts into the syringe. J. Properly dispose of syringe in designated Sharps container. K. Discard all disposable items into designated container. L. Perform hand hygiene. C. MIXING OF TWO INSULINS:

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NURSING ACTION A. Inject air into the NPH vial equal to the amount of NPH insulin to be given. Remove needle without withdrawing insulin.

RATIONALE-PRECAUTIONS A. It is very important to withdraw Regular insulin (which is a clear solution) first and then withdraw NPH insulin (which is a cloudy solution) so as not to contaminate the Regular insulin vial. B. Always remember: Clear to Cloudy.

B. Inject air into the Regular insulin vial equal to the amount of Regular insulin to be given. Then, with needle still in vial, withdraw prescribed units of Regular insulin. C. Using same syringe, insert needle into NPH vial. Do not inject anything. Invert vial and withdraw prescribed units of NPH insulin. D. Administer the two insulins immediately after mixing.

C. Be careful not to extract more than prescribed amount. Do Not push on plunger.

D. NPH insulin will slow down the action of the Regular insulin if mixed over a period of time. Do not allow insulin mixture to stand because unpredictable physical changes may occur.

D. DOCUMENTATION: The following information shall be recorded in the Individuals Diabetic Medication Record: -The drug name, dose, time, and route of administration. -The site where the injection was given (injection sites shall be rotated and recorded). -The name, initial and title of the licensed staff administering the medication. -The licensed staff member administering medication shall initial on the Diabetic Medication Record above the diagonal line and the licensed staff member verifying medication shall initial below the diagonal line in the box corresponding to the date and time the medication is given. -Individual fingerstick blood glucose testing shall be recorded on the back of the Diabetic Medication Record. -Any adverse reaction experienced by the Individual will be recorded in the ID Notes along with assessment findings and interventions. The MD (MOC via NOD after hours) will be contacted. -If the insulin is withheld or if the Individual refuses the insulin, circle the time it should have been given on the Diabetic Medication Administration Record. Document the reason it was not given or the reason it was refused in the Wellness and Recovery Notes, and notify the physician.

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6. COMPETENCY/TRAINING: Nursing Administration will assure all staff assigned medication room duties is trained and competent in the use of the facilitys blood glucose monitor. 7. GENERAL INFORMATION: Insulin injections shall be administered immediately after a syringe is filled. For those Individuals on a diabetic diet as ordered by a physician, dietary intake shall be monitored and documented on the Daily Care Flow Sheet. All orders pertaining to diabetic medication and diabetic care must be re-transcribed by hand onto the Diabetic Medication Record. The Diabetic Medication Record shall be used to document the administration of Diabetic medication. The vial of insulin must be initialed and dated when first opened. The vial may be used for 30 days after opening. The opened vial may be refrigerated or kept at room temperature (less than 86o F). Return to Pharmacy when it expires. Insulin therapy involves the following insulin preparations: TYPE IMMEDIATE ACTING Lispro, aspart SHORT ACTING Regular, semilente INTERMEDIATE-ACTING NPH, lente LONG- ACTING Ultralente insulin glargine MIXED Regular 30%, NPH 70% Regular 50%, NPH 50% Lispro 25%, NPH 75% Aspart 30%, NPH 70% ONSET HRS 0.25 hour PEAK ACTION 1-2 hour DURATION 4 hours

0.5-1 hour

2-4 hours

6-8 hour

1-3 hours

6-12 hours

16-24 hours

4-6 hours 1 hour

8-10 hours none

24-28 hours 24 + hours

0.5 hour 0.5 hour 0.25 hour 0.25 hour

2-12 hour 3-5 hours 0.5-1.5 hours 1-4 hours

24 hour 24 hours 24 hours 24 hours

8. PRECAUTIONS: A. Short-acting insulins are to be given 20 to 30 minutes before meals and Intermediate insulins are usually given once daily before breakfast or in divided doses before breakfast and the evening meal.

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B. Give insulin and food on time. Delaying a meal or HS snack may cause an insulin shock, particularly when regular insulin is used. C. Ignorance, neglect of therapy, undercurrent disease, or infection adversely affects the diabetic Individual. Know the signs and symptoms of hypoglycemic reaction (insulin shock), which is clinically more critical and can be fatal, and hyperglycemic reaction (diabetic ketoacidosis) so that prompt medical attention can be provided. If a Individual has symptoms of Hypoglycemic Reaction (insulin shock), check Individuals blood sugar level and take vital signs. Give glucose if Individual has a physicians order for it and meets conditions of the order for administration. Notify physician (MOC via the NOD after hours) of symptoms, vital signs, and interventions by staff. F. The following are signs and symptoms of hypoglycemic reaction (insulin shock) and hyperglycemic reaction (diabetic ketoacidosis):

HYPOGLYCEMIC REACTION (insulin shock) -Onset is sudden. -Headache, lightheadedness, weakness -Nervousness, apprehension, anxiety -Tremor -Excess perspiration; cold, clammy skin -Hunger, -Dizziness, faintness, -Tachycardia -Slurred speech -Pallor, -Dilated pupils, double vision -Memory lapse, confusion -Seizures -Blood sugar level < 60 mg/dL

HYPERGLYCEMIC REACTION (diabetic ketoacidosis) -Extreme thirst -Polyuria -Fruity breath odor -Kussmaul breathing (deep, rapid, labored, distressing, dyspnea) -Rapid thready pulse -Dry mucous membranes, poor skin turgor -Blood sugar level > 250 mg/dL -Headache, -Nausea, vomiting, abdominal pain, -Dim vision

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 514 Effective Date: August 31, 2006 SUBJECT: NOTING PHYSICIAN'S ORDERS 1. GENERAL: When physicians orders have been noted it signifies that the orders have been: 1) transcribed onto the Medication Administration Record (MAR); 2) appropriate forms have been completed and/or processed; 3) new or revised modified diet orders have been faxed to the diet office; 4) labs, etc have been appropriately processed; 5) any needed equipment has been ordered (usually from pharmacy or central supply). Physician's orders returned to the unit from the Medical Clinic or written on the unit are noted as soon as possible but no more than one hour after they have been received by nursing staff. Physician's orders must be written and noted accurately, legibly, and in a manner, which minimizes the possibility of a medication error. Any order or set (series) not written in accordance with hospital policy, procedure, and protocol will not be noted until corrected. IndividualsDuring regular operating hours, unit staff are to contact the prescriber directly to have the orders corrected. After hours, weekends, and holidays unit staff are to contact the NOD. Unless otherwise indicated by the physicians order (e.g. stat orders), the time of first administration of a new medication(s) is the next scheduled HS dose. Medications ordered for pain, nausea/vomiting or diarrhea and antibiotics must have the first dose administered with two (2) hours from the time the order was written. MOC or PMOC orders written after normal hours of pharmacy operation may be administered without prior pharmacy approval. Pharmacy will review these MOC and PMOC orders when the pharmacy opens during regular business hours. At the beginning of each shift, all Individual clinical records are to be reviewed to ensure that all orders are noted and medication related orders have been faxed to the Pharmacy. The person assigned to medications on the P.M. shift will check the unit daybook as soon as he/she comes on duty to note charts checked out to the clinic. When these charts are returned to the unit, they should be checked for new orders and the orders noted as soon as possible. -1N.P.P No. 514

2. PURPOSE To standardize the noting of physicians orders and to ensure the timely delivery of physician orders to the Pharmacy to allow pharmacist review of each order prior to the first dose being given. The goal of the process is to minimize risk to the Individual, prevent drug-food interaction, drug-drug interaction, as well as to assure non-pharmacy orders are processed in a proper and timely manner. 3. EQUIPMENT -Physicians Orders -Medication Administration Records (MAR)

-Other forms as needed -Fax and Telephone/Verbal Order stamps

4. TELEPHONE/VERBAL ORDERS: A. Telephone orders shall be accepted only by staff legally authorized to dispense or administer medication. The person receiving the order shall write it directly on the Physicians Order form, read it back to the prescriber for verification, indicate that it is a telephone order of the prescriber, sign the order and indicate time and date of order, and place the Telephone/Verbal Order signature stamp on the appropriate area of the order where the prescriber will later sign the order. B. The use of telephone orders should be limited to urgent situations when the prescriber is not readily available to be present. The prescriber must sign, date, and time the telephone order within 48 hours or the next business day. C. Verbal orders are given by a physician in the physical presence of the staff legally authorized to dispense or administer medication. Verbal orders are given when the physician needs to give an order but is unable to write it down at that time (e.g. is called away to an emergency). The prescriber is to sign the order prior to the end of the prescribers shift. If necessary, nursing staff will contact the prescriber prior to the end of the prescribers shift to have the order signed. If the order remains unsigned after hours, nursing staff will contact the NOD and section E below will be followed for MOC/PMOC review. D. Each night all unit records will be audited for unsigned verbal and telephone orders. E. Any telephone order that remains unsigned after 48 hours or the next business day will be invalid. During business hours, unit staff will contact the prescriber prior to the expiration. If after hours, the MOC or PMOC (as appropriate) will be notified. The physician will review the Individuals status and will either discontinue the order or rewrite a new order with corresponding progress note. 5. ORDERS TO WITHHOLD OR TO WITHDRAW LIFE-SUSTAINING SUPPORT (DO NOT RESUSCITATE) -2N.P.P No. 514

The above order will not be implemented until after review and approval by the Medical Director and Executive Director. 6. MEDICAL CLINIC AND UNIT RESPONSIBILITIES A. After receiving a medication related order(s) medical clinic nursing staff (if order originates in the Medical Clinic) or unit nursing staff (if order originates on the unit or through NOD) will immediately FAX the physicians order(s) to the Pharmacy at the appropriate designated FAX number for review and approval by a Pharmacist. Physicians Orders do not need to be noted prior to faxing to the Pharmacy. Failure to fax the orders first can delay the ability of the Pharmacy to process and dispense the medication in a timely manner. B. Orders addressing modified diets and dietitian referrals are also immediately faxed to the Diet Office. This does not need to include renewals for regular diets. C. After order has been faxed, Medical Clinic or unit staff (as appropriate in A above) will utilize the fax stamp and date and initial to indicate that the order has been faxed to the Pharmacy and/or Diet OfficeIndividual. D. The order(s) will then be noted, insuring completeness and correctness. Note: Unit staff is responsible to note orders. There will be instances in which the Medical Clinic staff will actually do the processing e.g. referrals to outside provider, ordered labs where the blood or other body fluid was obtained and processed through the Clinical Lab, etc. The Medical Clinic staff will write an ID Note indicating this was done. Unit staff noting the order will use this as a reference to assure the Physicians Order was completed. E. Medications will not be administered until approval is received from the Pharmacy indicating that a pharmacist has reviewed and approved the order. Exceptions: 1. The Monthly Medication Review is a compilation of all orders approved since the previous review. If no changes are made to any medication on the review, further Pharmacy approval is not required to continue administration of medications, however the newly signed orders must still be faxed to the Pharmacy. 2. MOC or PMOC orders written after normal hours of pharmacy operation may be administered without prior pharmacy approval. Pharmacy will review the MOC and PMOC orders when the pharmacy opens during regular business hours. 3. STAT or Now orders. F. In the event that an order is not approved a pharmacist will contact the physician and telephone the Unit with instructions/new orders. G. Unit nursing staff will maintain all Pharmacy approval notices/ faxes in the med room until the Individuals next monthly medication review. H. Changes to medications on the review require prior approval before administration of the first dose 7. PROCEDURE:

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NURSING ACTION A. If a medication order is unclear, it will be clarified/rewritten immediately. No order will be noted if part of the order is lined out unless it is initialed by the prescriber. During regular operating hours, staff are to contact the prescriber directly to have the orders corrected. After hours, weekends, and holidays staff are to contact the NOD. B. Carry out all STAT orders. Write after each order given or done and the time on the order. Also enter medication given on medication record on PRN-STAT notes of the Medication Administration Record. C. Appropriate nursing staff (see V. A. above) shall fax physician orders to the Pharmacy, with the physicians order clearly identifiable. D. Orders addressing modified diets, including periodic renewals, and dietitian referrals are also faxed to the Diet Office. E. A specific notation of action taken will be included and initialed for certain orders (e.g., if lab work is ordered, a notation by that order may read done with initials, or if a consult is ordered a notation may read completed or sent and initialed). If the action is to transcribe an ordered medication to the MAR, a check mark at the end of the ordered medication is sufficient. F. A licensed nursing employee will note the physicians orders, which denotes that the order(s) have been carried out and orders for medications/treatments have been transcribed exactly as written onto the MAR. Transcribed orders must be noted by license nursing staff with date, time, signature and title directly below the physicians orders verifying correctness. -4-

RATIONALE/PRECAUTIONS A. To ensure that orders and documentation is legible, complete, understood by staff, and conforms to accepted practices and requirements of legal documentation.

B. STAT orders take priority over all others and need to be carried out as soon as possible.

C. Allows for a systematic prompt mechanism for Pharmacy to review the orders and for entry into Individual profiles. D. Assures the Individual will receive the appropriate diet.

E. To communicate that these particular orders have been completed, appropriate forms filled out, and/or processed.

F. Orders are noted only after they have been properly transcribed onto the MAR and/or any other procedure, protocol, etc. has been completed with the appropriate notation placed on the order.

N.P.P No. 514

G. To discontinue a medication or treatment prior to originally scheduled stop date: 1. Place a diagonal line inside the brackets, which indicate the stop time of the medication on the MAR. 2. Place initials and date on that diagonal line. 3. Draw a diagonal line through the entire medication order. H. For medication or treatments ordered daily (or more often), transcribe the order to the MAR: 1. In choosing the time that medication is to be given consider individual drugs, as some are to be given with food and others on an empty stomach. The physician should specify when the medication is to be given. Specific times for daily, twice daily, etc., should be posted on the unit. 2. Transcribe medication/treatment orders to Individuals MAR entering medication dosage, interval, route of administration, and form. 3. For re-ordered monthly medication or treatments without changes it is not necessary to re-write the entire order onto another MAR. It is acceptable to change the start and stop dates by lining out the old dates and writing in the new dates. The new start date must conform to the date the order was renewed. The new stop date must be recalculated from the new start date (usually 45 days). I. All orders written in the past 24 hours (since the last NOC audit) are audited by the NOC shift in conjunction with the MARs. At the end of the section audited the auditor dates and signs in red. It is the responsibility of the Unit Supervisor to assure correctable errors are properly -5-

G. Properly discontinuing an entry on the MAR will help prevent charting errors.

H. Assists in assuring that all policies and procedures have been followed correctly.

N.P.P No. 514

corrected and to assure any additional required paperwork has been completed e.g. Medication Related Event form, Special Incident Report, etc. 8. COMPUTERIZED MEDICATION ORDERS NURSING ACTION A. When a unit receives the computerized physicians orders assigned staff will assure that these orders are current and correct by comparing them with all current orders in the Clinical Record. The person verifying that the orders are indeed correct will write Transcribed by then sign and date. This will be done directly below the last order on each page of the corrected Physicians Orders. B. Medication Administration Records (MAR) are printed approximately 3 days prior to the 1st of the month. Assigned staff will check the newly received computerized MAR of each Individual against the current physicians orders in the Clinical Record by the 1st of each month. Upon completion of this review (and corrections made if needed) the person verifying that the MAR is indeed correct will initial the upper right hand corner of each MAR. C. The Monthly Medication Review is a compilation of all orders approved since the previous review. If no changes are made to any medication on the review, further Pharmacy approval is not required to continue administration of medications. However, the order must still be faxed to the Pharmacy. Changes to medications on the review require prior approval from the Pharmacy before administration of the first dose. RATIONALE/PRECAUTIONS A. This will assure that all the current physicians orders have been printed correctly and that all recent orders were included on the printouts.

B. This will assure that all the current physicians orders have been printed correctly on the MAR and that all recent orders were included on the printout.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 515 Effective Date: August 31, 2006 SUBJECT: CONTROL DRUGS (Scheduled Drugs) 1. GENERAL: Controlled substances are pharmaceuticals whose use and distribution are controlled by the Federal Government due to the possible abuse potential for the product, or whose use is regulated internally by the specific institution to prevent employee misuse. All scheduled drugs are to have accountability; however, any drug may become a control drug if the P&T Committee Recommends such need for accountability. 2. ACCOUNTABILITY: All control drugs are kept in a double locked system: room has a lock and the cabinet/mediation cart in the Medication Room. Exception: Controlled agents requiring refrigeration will be stored in the Medication Room refrigerator in locked container. There shall only be one set of keys for the medicine cabinet and the control drug boxes. This set of keys will be kept by the assigned (RN/PT/LVN) med person at all times. Medication cabinet keys are to be accounted for at the beginning of each shift. The person assigned to medication on the on-coming shift is responsible for counting control drugs with the person assigned to medications who is going off duty. Both check the actual number of tablets, capsules, vials, etc., against the number listed on the control sheet. Any discrepancy in the count should be reported immediately to the Unit Supervisor and shift lead. Discrepancies will be reconciled for before off-going personnel leave. When the count is completed and all medications are accounted for, both off-going and on-coming nursing staff will sign the Controlled Drug Signature Record. Signatures on this record verify that all procedures pertaining to proper control drug count have been followed and accounted for. The completed controlled drug Signature Record is to be returned to the Pharmacy at the end of every month. Control drugs are recorded in the logbook whenever they are picked up from the Pharmacy, or returned to the Pharmacy. This entry will include drug name, strength, quantity, control number, time received on unit or sent to pharmacy, employee's first and last name, and discipline. An entry will be made in the Day Book identifies whenever med keys change hands at times other than the change of shift. Each time the medication keys change hands, all controlled drugs must be counted and accounted for. 3. MISSING CONTROLLED SUBSTANCES:
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A. If at any time any control drug(s) is (are) found to be missing, the Pharmacy must be notified at the earliest possible time. B. The unit will complete a Special Incident Report and notify the NOD. C. The unit supervisor and shift lead shall be notified immediately. 4. DISPOSAL OF UNUSABLE CONTROLLED DRUGS: A. The employee finding or noting the unusable controlled substance is to inform the Unit Supervisor and shift lead as soon as possible. B. Upon determining that a dose must be wasted, the staff member responsible for medications, noting such a need, shall circle the respective number on the Control Drug Accountability Sheet corresponding to the dose to be wasted. All wasted drugs are to be returned to the pharmacy for proper disposal of the drug. C. On the back of the same Accountability Sheet, write the following information: 1. Dose number, reason for wasting, method of wasting (i.e. returned to pharmacy unless there are other circumstances where med cannot be recovered such as spilled liquid med), signature of person wasting dose and a second signature of person witnessing the dose being wasted (at least one of the two signatures must be a Registered Nurse or Unit Supervisor/designee). Wasted control drug must be returned to the pharmacy for proper disposal per pharmacy guidelines. 5. OBTAINING CONTROLLED DRUGS DURING NORMAL PHARMACY HOURS: A unit may obtain drugs from the Pharmacy only during the normal working hours of the Pharmacy Department, except in the case of an emergency. Pharmacy hours are listed in the Pharmacy Policy Manual. During non-normal Pharmacy hours, a Pharmacist is also available by pager. (Contact NOD or the Communication Center for assistance). Controlled drugs must be ordered on the Controlled Drug Requisition Form. The Pharmacy will issue, with each controlled drug, a Controlled Drug Accountability Sheet. Unit personnel will complete this form as indicated. Neither controlled drugs nor Controlled Drug Accountability Sheets may remain on the unit for longer than 60 days from the date of issue. After 60 days or when the sheet is completed or the order discontinued, the Controlled Drug and/or Accountability Sheet are to be returned to the Pharmacy. 6. OBTAINING CONTROLLED DRUGS DURING EMERGENCIES: A. Emergencies shall be defined as: (1) those times when the Pharmacists are not available because the Pharmacy is closed; (2) when a doctor orders "stat" medication or it is a new MOC/PMOC order and the unit does not have the controlled drug in stock; (3) those times when a unit has depleted its supply of required medication and the medication order has not been discontinued.
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B. During an emergency, a unit may obtain controlled drugs by contacting NOD for assistance to procure the drug from the NOC locker, to coordinate transferring control drugs from one unit to another, or to call in the On-Call Pharmacist. 7. TRANSFERRING CONTROLLED SUBSTANCES WITHIN THE HOSPITAL: Controlled drugs are issued to a unit (not a Individual) by the Pharmacy. During emergencies (as defined above) NOD will coordinate the transfer of control drugs from one unit to another after consulting with the On-Call Pharmacist. Only the NOD is authorized to physically move a control drug from one unit to another. These instances shall be recorded in the NOD 24-hour report. Both the sending and receiving units shall record the event in their respective logbooks. When pharmacy is open for regular operations, both units shall report the transfer event to the pharmacy. 8. RETURNING DISCONTINUED/UNUSED, TRANSFERRED/DISCHARGED INDIVIDUALS' OR EXPIRED CONTROLLED DRUGS TO THE PHARMACY: All units will return Controlled Drugs and/or Accountability Sheets to the Pharmacy when: A. The doctor discontinues the order and no other Individual on the unit is receiving the medication(s). B. The Individual is discharged or transferred and no other Individual on the unit is receiving the medication(s). C. The controlled drug has reached its labeled expiration date. D. When control drugs reach 60th day of issue to the unit. 9. DOCUMENTATION ERRORS: Any documentation error on the Controlled Drug Check Sheet shall be brought to the Pharmacy Departments attention. This shall be done as soon as is possible after discovery of such an error. The Pharmacy shall re-issue any such drug and accountability sheet after proper processing procedures are completed. 10. Handling of Specialized Dosage Forms: Specialized dosage forms include, but are not limited to novel delivery systems such as transdermal patches. Follow the same policy for ordering controlled drugs (See Section I & IV), however only a one-week supply of transdermal patches may be ordered. A. Unit Staff will document receipt of and subsequent placement on Individual of each dosage using MAR and Controlled Drug Accountability Sheet.
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B. Staff will physically inspect each Individual on every shift during the period of therapy to ensure patch is in place and unadulterated. C. Upon completion of therapy of each dosage unit the removed patch will be placed into a plastic bag provided by the Pharmacy. The Pharmacy will inspect each returned patch for potential adulteration and destroy in compliance with State and Federal Laws.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 516 Effective Date: July 26, 2007 This policy replaces NPP# 516 dated Febuary 28,, 2007 SUBJECT: MEDICATION RELATED EVENTS 1. GENERAL: Each person making, observing or recognizing a medication related event is to file a Medication Related Event Report. A Special Incident Report (SIR) is completed if the event has a potential or actual adverse impact to the individual. 2. PURPOSE: A. To protect the health/safety of the individual. B. To prevent recurring Medication Related Events. C. To ensure accountability for medication doses. D. To assure that each employee's practice in the administration of medication is competent. E. To assist in the gathering of data regarding Medication Related Events for analysis. F. To provide a basis for system improvement/corrective action based on objective data. 3. DEFINITION: A. A Medication Related Event is any breakdown in the medication usage process resulting in a preventable event that may cause or lead to inappropriate use or Individual harm, while the medication is in the control of the health care professional. B. Such events may be related, but not limited to, professional practice, health care products, procedures and systems including: prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring or use. C. Medication Related Events generally will fall into the following categories: Prescribing Error: An error of prescribing occurs when there is an incorrect selection of drug, drug dose, dosage form, quantity, and route, and concentration, rate of administration or instruction for use of a drug product ordered by a physician or other legitimate prescriber. Errors may also occur when unclear or incomplete orders are written
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and nursing staff does not bring these to the attention of the prescriber for correction or clarification. Dispensing Error: An error of dispensing occurs when the incorrect drug, drug dose, concentration, dosage form, or labeling is formulated and delivered to the unit. Administration/Procedural Error: An error of administration occurs when there is an omission of the medication or incorrect selection and administration of a drug, drug dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product as ordered by a physician or other legitimate prescriber. These errors usually occur when one or more of the 5 Rights of medication administration are not followed: Right Individual, Right Med, Right Time, Right Dose, and Right Form. Transcription/Documentation Error: These are errors in which the transcription of an order to the Medication Administration Record (or other appropriate form) is omitted, incorrect, or incomplete. These errors also involve medication(s) which have been correctly administered but incorrectly charted as given e.g. charting is omitted, charted as given for wrong day and/or time, or wrong medication is charted as given. Drug Accountability Errors: These errors generally do not involve the individual. These errors involve control drugs (incorrect count, wasting, control drug not signed as given, etc.) and regular medication (missing medication, receiving more or less medication than was recorded as delivered, receiving/administering expired medication, contaminated medication such as falling into sink or on floor, etc.). 4. PROCEDURES FOR REPORTING MEDICATION RELATED EVENTS: A. If a Medication Related Event does not reach the individual: 1. The person discovering the error will initiate the Medication Related Event form and correct the error if possible. The shift lead/US will be notified of the discovery. a. Staff will complete page 1 of the Medication Related Event form. And fax to pharmacy and NOD. The original Medication Related Event form will then be stamped with the units FAX stamp to indicate this was completed. b. After US/Program Management has completed the plan on page 2 deliver to the NOD to complete section on page two. c. After NOD has completed the plan section the MRE is taken to pharmacy for final processing.

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d. Pharmacy is to receive the completed form no later than 3 days after MRE. 2. Depending on the circumstances of this type of event, a Special Incident Report (SIR) is completed if the event has a potential adverse impact to the Individual. Staff will utilize AD 830 (Special Incident Reports) to determine if an SIR needs to be completed. B. If a Medication Related Event does reach the individual: 1. The first order of priority will be to assess the individual and provide any needed interventions that do not require an order from a physician. 2. The NOD will be notified by phone or page immediately regardless of the condition of the individual. 3. The MD (MOC/PMOC after hours via the NOD) will be contacted regardless of the condition of the individual. 4. Staff will follow any direction and/or orders received from the MD or MOC/PMOC. 5. In addition to completing the Medication Related Event form, a Special Incident Report (SIR) shall be completed if there is an adverse effect to the individual. The shift lead, NOD, and Pharmacy will also be notified as described in A above. 5. DOCUMENTATION: In addition to completing the Medication Related Event form and Special Incident Report (SIR) as described above, assessment findings and care/interventions rendered shall be documented in the ID Notes. Other findings shall also be recorded on the appropriate form(s) e.g. vital signs shall be recorded on the Vital Signs Record. 6. TRACKING/MONITORING: Central Nursing Services (CNS) Administration will review and monitor information and data received about Medication Related Events. CNS Administration will coordinate with Pharmacy and other departments and committees to resolve identified problems and trends.

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N.P.P No. 516

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 517 Effective Date: July 26, 2007 This policy replaces NPP 517 dated May 8, 2007 SUBJECT: MEDICATION ADMINISTRATION ORIENTATION/COMPETENCY VALIDATION 1. GENERAL: Only licensed nursing service staff that has successfully demonstrated their competency in medication administration may give medications without supervision at Coalinga State Hospital. 2. MEDICATION ADMINISTRATION COMPETENCY VALIDATION: A. All licensed nursing services staff that may be required to administer medications at Coalinga State Hospital shall be oriented to the med room and successfully complete the Medication Administration Practicum. The Orientation/Competency validation process will minimally include: 1) Review of nursing procedures regarding medication administration. 2) Assessment of the employee's knowledge of medications and medication procedures including noting physicians orders. 3) Supervision of an employee's demonstrated proficiency in administering medications. The Orientation/Certification Process will also extend to those employees demonstrating a need for retraining. B. The nursing educator will forward the exam to the HSS. (See 3A.) C. The HSS/designee will perform the clinical validation (which includes on site observation and supervision of employee administering medication with procedural review of oral, injectable and topical medications and instillations [including actions and side effects]). If the employee passed the clinical certification review, then the employee is able to administer medications without supervision. The HSS will assure that the Training Department, receives all necessary/required paperwork so a record of competency/validation is maintained. D. Medication Administration competencies are to be completed quarterly. The Unit Supervisor or designee is responsible for two of the four competencies (the first and third quarters) and the HSS will complete the alternating quarterly competencies (the second and forth quarters). The initial staff competency validation is to be completed by the HSS. -1N.P.P No. 517

3. COMPETENCY REVALIDATION: A. Annually, all licensed nursing service staff, with the exception of Health Services Specialists, who are required to administer medications shall be required to attend an updated class on medication administration taught by a designated instructor from the Training Department and pass a written and/or a proficiency examination (examination is on a pass/fail basis). B. If the employee fails to pass the written Med-Cert. Test the Training Center notifies the Unit Supervisor/designee and the HSS/designee, and then processes the Med Certification failure notice. C. The Unit Supervisor will notify the HSS of anyone who requires clinical validation/revalidation for any other reason prior to assigning him/her to administer medications. The HSS will make recommendations for necessary actions, e.g. recertification, clinical certification, clinical supervision, etc. 4. MINIMUM STANDARDS: Minimum standards relating to medication administration include: A. Knowledge of Coalinga State Hospital Nursing Policies and Procedures as described in the Nursing Policy and Procedure Manual and knowledge of the Pharmacy Formulary and Policy Manual; B. Knowledge of medication administered including action of medication, beneficial effect and adverse effects of medication; C. Proficiency in administering oral, injectable, topical, ophthalmic, otic and nasal medications; D. Knowledge of the Individual, including proper identification, allergies, and history. 5. CORRECTIVE RETRAINING: Corrective retraining will be done at the request of the Program Director/designee and may include: A. Same as described above. B. Pharmacology review. C. Or any designated part of the certification training process based on the nature of the need.

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Unit Supervisor or designee Medication Pass Confirmation of Competency

Employee Name: __________________________ Title: ______ ________ I.D. #: _________ Birth Month: _________ Date Observed: ________Time: ________ Program: __________ Unit: _________

Medication Administration: 1. Identifies patients using two forms of identification. Yes_____ No______ 2. Leaves Medication in its original Package until given to the Individual. Yes_____ No______ 3. Uses a 3 Check Process to Medication Preparation: Yes_____ No______ a. Checked when medication is selected against MAR. b. Checked after med wrapper opened and placed in medication cup. c. Checked empty wrapper / packaging against MAR before administration. 4. There is a second staff member standing by the med pass line actively assisting in the proper identification of the individual in the medication line. Yes_____ No______ 5. The employee confirms that the individual swallowed all medications. Yes_____ No______ 6 No more then five individuals are in the Medication Line at a time. Yes_____ No______ 7. Medication related teaching done in a professional manner as needed to the individual Yes_____ No______ NA_______ 8. Employee safely and accurately administered medications according to the 7 Rights including; monitoring of laboratory findings, V/S, documentation, and pain assessment. Sufficient fluid for the medications was administered. Yes______ No_____

Employee: _____________________________________________ Signature US or designee Evaluator: _________________________________________ Printed Name US or designee Evaluator: __________________________________________ Signature Note: Send Original to Central Nursing Services and Copy to Nursing Coordinator.

Note: Send Original to Central Nursing Services and Copy to Nursing Coordinator.

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HSS MEDICATION ADMINISTRATION COMPETENCY Employee Name: _________________________Title:______________Birth Month:__________ ID# ________________________ Date Observed:___________ Time:____________ Program/Unit:___________ Not Met

INDICATORS Knowledge Base:

1. Verbalizes generic and trade names of medications administered. 2. Describes therapeutic effects, usual doses, and routes of medications administered. 3. Differentiates expected side effects from adverse reactions. 4. Explains "sliding scale" for regular insulin. 5. Verbalizes symptoms and appropriate interventions of hypo/hyperglycemia. 6. States rationale of unapproved abbreviation list and location. 7. Verbalizes proper procedure for wasting and disposal of medication.

Met

N/A

Administration (Per Hospital Policy):

8. Applies principles of asepsis to medication administration. 9. Prepares medications no more than 1 hour before administration. 10. Identifies Individual by name and photograph to ensure correct identification. 11. Checks for allergies. 12. Measures, interprets & records B.P. & pulse before administering cardiac & antihypertensive medication. Withholds medication as indicated. 13. Opens/pours medication in front of Individual. 14. Correctly administers crushed and liquid medications. 15. Checks medication with MTR 3 times. 16. Educates the Individual regarding medications. 17. Assesses Individual before administering PRN/Stat medication. 18. Administers: correct medication (including controlled medication) correct dose to correct individual by correct route at correct time/date 19. Ensures that the Individual swallowed all medications. 20. Applies proper technique with use of safety syringes. 21. Ensures Individual's privacy and confidentiality. 22. Properly administers eye/ear drops, inhalers/spray.

Documentation (Per Hospital Policy): -4N.P.P No. 517

23. Documents and signs out controlled medications correctly. 24. Documents meds given on MTR immediately after administering. 25. Documents on MTR when medication is not taken and notifies physician. 26. Documents reasons for administering PRN/Stat medication. 27. Documents effects of PRN/Stat medication within one hour. 28. Documents telephone order, read back, noting, and transcribing orders. 29. Documents Involuntary and/or Emergency Medication administration for PRN/Stat.

Environmental:
30. 31. 32. 33. 34. Keeps medication room and cart locked when not in use. Keeps medication room and cart clean and tidy. Properly stores items in clearly marked areas of medication cart. Keeps medication keys under constant surveillance. Does not leave medication unattended.

Employee Signature HSS Evaluator (Print Name):

HSS Evaluator (Signature): Note: Send original to Central Nursing Services and Copy to Nursing Coordinator.

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N.P.P No. 517

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 518 Effective Date: March 7, 2007 SUBJECT: PROCEDURES AND CERTIFICATION 1. GENERAL: Intravenous procedures that require Coalinga State Hospital approved training and certification are: 1. Venipuncture Procedure 2. Intravenous Administration of Fluids 3. Administration of Admixture Intravenous Solutions 4. Heparin Lock-insertion of Male Adaptor plug (Heparin Lock) for Intermittent Infusion therapy 5. Withdrawal of Blood for Laboratory Tests 2. RESPONSIBILITY: Currently licensed Registered Nurses who have a current Coalinga State Hospital approved certification of proficiency are authorized to perform the above enumerated intravenous procedures. 3. OBJECTIVE: To protect the Individual, Physician, Registered Nurse, and the hospital in the area of performance of Standardized Procedure Functions as defined in Section 2725 of the California Business and Professions Code (Nurse Practice Act). 4. CRITERIA: Coalinga State Hospital Administration, Physicians, and Registered Nurses acknowledge the legal rights of Registered Nurses to start and administer fluids intravenously providing the following criteria are met: 1. The Registered Nurse has had specialized instructions and training with concomitant certification of proficiency by Coalinga State Hospital in the specific intravenous procedure they are performing. 2. The Registered Nurse performs the technique upon the order of a licensed physician. 3. The physician's order is for a specific Individual.

5. CERTIFICATION:

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The Registered Nurse will attend Intravenous Procedures classes consisting of theory and practice, which will lead to development of proficiency in these procedures. Initial certification will include: 1. Completion of required course in theory and practice. 2. Return demonstration on simulated arm. 3. One supervised I.V. start under the supervision of certified RN or MD. Annual re-certification will include: 1. Completion of required course in theory & practice. 2. Return demonstration on simulated arm. VENIPUNCTURE PROCEDURE This procedure is performed by Coalinga State Hospital I.V. Certified Registered Nurses only upon direct order of a Physician. 1. PURPOSE Intravenous infusion is the introduction of fluid/electrolyte and/or medication directly into a vein. It is used to hydrate tissue, give nourishment, restore volume, and administer medication. 2. EQUIPMENT A. B. C. D. E. I.V. tray Prescribed I.V. Solution I.V. Standard I.V. tubing. Disposable gloves

3. PROCEDURE NURSING ACTION A. Perform hand hygiene RATIONALE-PRECAUTIONS A. Good medical asepsis will help prevent contamination during I.V. procedure. B. Organization helps to expedite the procedure. C. To elicit Individual cooperation and reduce apprehension. D. To prevent contamination of hands by blood.

B. Assemble equipment C. Approach and identify Individual. Explain the procedure and rational for venipuncture. D. Put on disposable gloves.

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E. Select I.V. site as distal as feasible. Do not hesitate to examine both arms carefully, or to switch from one arm to the other before attempting a venipuncture.

E. Veins below an infiltrated or phlebetic site may not be usable if they lead into the network of the affected vein. The anatomy of superficial veins in the human arm is quite variable from arm to arm in the same person. In obese people veins may be palpable but not visible. F. To ensure proper distention of the vein. The best tourniquet is a short length of flexible flat rubber; it is less painful and holds tighter than tubing.

F. Apply tourniquet above selected site in a slip knot. The correct way to apply a tourniquet is to pull the loop toward you. Thus both ends are up and out of the field and the tourniquet can be loosened with one easy motion.

Note: If you have difficulty palpating the distal veins, wrap a blood pressure cuff below the antecubital fossa and inflate it to just below your client's systolic (usually below 100 mm Hg). Deflate the cuff after palpating the veins. If you plan to use the cuff instead of a tourniquet to dilate the veins, deflate it to 40 mm Hg after having dilated the veins. G. Ask Individual to open and close his hand repeatedly, then to relax entire extremity. H. Cleanse skin with an antimicrobial skin preparation such as alcohol I. Inserting Protective I.V. Catheter Precautions: To avoid catheter damage or loss during intermittent therapy, use only a Jelco Intermittent Injection Cap and a 1" or shorter hypodermic needle. A maximum 21 Gauge (preferably a 25 Gauge) needle is recommended. 1. Select site. Palpate the vein to ascertain that there is no pulse. 2. Prepare venipuncture site as per hospital routine and apply tourniquet. Remove the sheath. 3. Visually inspect catheter for imperfections. Do not break the catheter tip needle seal by rotating the catheter around the needle. 4. Hold the device by the ribbed needle housing with thumb and fingers on opposite sides. Bevel and push-off tabs should be in the up position. 5. Using a 25-30 degree angle, insert needle into skin and vein. During insertion, hold ribbed needle housing; do not hold by catheter hub or needle guard. A flashback of blood into the flash chamber will confirm vein entry. Release tourniquet or blood pressure cuff. 6. Slightly advance the catheter and needle together to assure full catheter entry into
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G. To facilitate visibility and palpation of the vein. H. To rid skin of as much contaminating bacteria as possible.

vein lumen. 7. Holding the device stable, place your finger on the primary push-off tab and thread the catheter into the vein until the desired length has been inserted. As you thread the catheter, the needle guard begins to cover the needle. Do not reinsert needle into catheter at any time. The needle could cut the catheter, resulting in catheter embolus. 8. Using your finger to stabilize the device at the push-off tab, retract the ribbed needle housing until it securely and irreversibly locks into place. Listen for the "click" which tells you the needle is locked. Remove the tourniquet. 9. Apply digital pressure to the vessel just above the tip of the catheter. Holding the hub securely with one hand, remove the needle guard with the other hand by twisting slightly and pulling it out of the catheter hub. 10. Without touching the open end of the hub (fluid pathway), securely connect tubing adapter. 11. Secure catheter and apply dressing per hospital routine.

Inserting a winged-tip needle butterfly needle: 1. Select a winged-tip needle (a 20 to 22 gauge needle is adequate for an adult). (Winged tip needles are used in short term therapy with adults and elderly Individuals who have small fragile veins.) 2. Carefully affix end of IV administration tubing to end of winged-tip needle. Remove sterile cover from needle. Run fluid through needle. 3. Hold needle by its wings. 4. Anchor vein by placing your thumb below the Individual's vein and gently stretching the skin by pulling down distally. 5. With bevel of needle up, enter Individual's skin at an angle. You may use either of these methods: a. Enter skin at an angle either next to or along side the vein. Flatten angle once needle is under skin and enter vein from the side. b. Enter skin and vein in one smooth motion from above. You will feel a gentle "pop" or release as the needle enters the vein. Observe for flashback of blood in needle tubing. (This method requires experience and judgment, since it is easy to put the needle through the vein.) 6. Advance needle carefully up the course of the vein 7. Release tourniquet or blood pressure cuff.

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8. Open clamp on IV tubing and observe drip chamber. (Fluid should flow easily, and there should be no sudden swelling around IV site.) 9. Reduce flow rate to keep open until you have taped the needle and tubing in place. 10. Cover site with sterile two-by-two inch strips or transparent semi-permeable adhesive dressing. 11. Tape winged-tip needle and tubing to Individual's skin. 12. Set drip rate on I.V. controller according to physicians orders. 13. Document according to hospital policy.

Inserting an Over-The-Needle Catheter Angiocatheter: NURSING ACTION A. Remove needle cover carefully just prior to insertion. Inspect both needle and catheter. B. Turn bevel of needle up and insert needle and catheter together as one unit into Individual's skin-either along side or above the vein. C. Insert catheter and needle into vein. Advance unit into lumen, making sure that both are inside vein. Observe for back flow of blood in plastic hub of needle. D. As soon as catheter is fully in place, release tourniquet. E. Hold needle hub and gently advance plastic catheter over needle and up vein to desired length. F. DO NOT attempt to replace needle inside of catheter if the venipuncture is not successful. G. Place small, sterile gauze sponge under hub of over-the-needle unit. H. Gently withdraw needle from inside catheter with one hand, placing your fingertip firmly above catheter tip to occlude vein and prevent sudden bleeding. I. Connect hub to IV administration set.
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RATIONALE-PRECAUTIONS A. Barbs or rough edges can occur even with new needle bevels. B. Bevel needle in the "UP" position assists with needle insertion.

C. This indicates you are in the vein.

D. This method prevents inadvertent puncture of vein.

F. This action may shear off a piece of the catheter.

J. Open clamp on set briefly and observe drip chamber. Fluid should flow rapidly without obstruction, and there should not be any sudden swelling at the I.V. site. K. Reduce flow and proceed with taping. L. Cover with sterile dressing or transparent semipermeable adhesive dressing. Date and initial site dressing.. M. Tape tubing to Individual, using two strips of tape. N. Set drip rate on I.V. controller according to physician's orders. O. Document according to Hospital Policy. 4. SITE OBSERVATION & PRECAUTIONS NURSING ACTION A. Observe site. If needle has not entered vein correctly, the area at the needle site will begin to bulge and become discolored by a collection of blood and fluid in the subcutaneous space. If this occurs, close the clamp on the tubing. Remove the needle quickly and apply firm. external pressure over the area with a dry sterile sponge. Re-attempt above the first site or if necessary in the opposite arm. B. If venipuncture is unsuccessful after 2-3 attempts, request assistance from another certified R.N. and notify the physician. C. Apply arm board if venipuncture site is near a joint or if additional support is needed. Do not apply constrictive tape above the I.V. insertion site. D. Assist the Individual to a comfortable position. E. Check the I.V. frequently for infiltration, inflammation, and proper rate of flow (air vent open, no kinks in tubing, proper operation of I.V. Controller). INSERTING A MALE ADAPTOR PLUG (HEPARIN LOCK/SALINE LOCK)
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RATIONALE-PRECAUTIONS A. Assure a successful venipuncture was made.

C. Immobilize the area as necessary to prevent the needle from being dislodged.

This procedure is performed by Coalinga State Hospital I.V. Certified Registered Nurses only upon direct order of the Physician. 1. DEFINITION: An intermittent infusion set (heparin lock/saline lock) is an indwelling reservoir in the vein for intermittent infusion therapy when continuous infusion therapy is not indicated. Periodic injections of heparin into the device keep the needle or catheter patent. 2. EQUIPMENT A. Male Adaptor Plug B. Antimicrobial prep. of povidone-iodine C. Tape and gauze D. Heparin solution/saline solution as ordered by physician E. Syringe for heparin/saline solution. F. Two (2) 3 cc safety syringes for normal saline G. Disposable gloves 3. PREPARATION OF EQUIPMENT AND INDIVIDUAL When continuous infusion therapy has been discontinued/not indicated and there is a need for intermittent infusion therapy for a Individual who has an indwelling overthe needle catheter, a male adaptor plug may be inserted into the catheter to convert it to a heparin lock/saline lock. NURSING ACTIONS A. Check the physician's order. RATIONALE - PRECAUTIONS A. To determine proper authority to initiate heparin lock/saline lock, and medication. B. Maintain medical asepsis during procedure. C. Organization helps to expedite procedure. D. Medical asepsis.

B. Perform hand hygiene. C. Assemble equipment. D. Perform hand hygiene and put on gloves. E. Prime the Male Adaptor Plug with normal saline. F. Close the roller clamp on the infusion set to stop the infusion, and aseptically remove the protective cap from the Male Adaptor Plug. Detach the I.V. tubing, and insert primed Male Adaptor Plug into the catheter hub. G. When initiating a heparin lock/saline lock when there is not an existing I.V. site, follow Section III. K.
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this procedure under "inserting an over-the-needle-catheter". After the venipuncture, advancement of the catheter into vein, and withdrawal of the needle, connect the primed Male Adaptor Plug into the catheter hub. H. Apply a fresh dressing being certain to keep the injection port outside the air-occlusive tape for quick access. I. Flush Male Adaptor Plug and catheter with prescribed amount of heparin/saline solution. 4. INTERMITTENT INFUSION THERAPY NURSING ACTIONS A. Equipment 1. Three 2 cc safety syringes with 25/1 needles 2. 1 Bottle of Normal saline for injection 3. Antimicrobial skin preparation (i.e. povidone-iodine) 4. Heparin solution (unless using normal saline) B. Three separate safety syringes 1. FILL 2 - 3 cc safety syringes filled with 2 ml of normal saline with a 25X1 needle 2. FILL one syringe of prescribed heparin solution, unless using saline. C. Swab the injection port with an antimicrobial skin preparation such as povidone-iodine. D. Insert the syringe containing normal saline and aspirate for blood return to
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H. Medical asepsis and access to injection port.

RATIONALE - PRECAUTIONS

B. To insure patency or catheter and to flush male adaptor plug.

C. Medical asepsis.

D. Ensure patency of catheter.

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ensure that the catheter is in the vein. E. Inject 2 ml of normal saline and remove syringe. F. Attach prescribed intermittent I.V. infusion through Male Adaptor Plug port and infuse at prescribed rate. Observe for adverse reactions to the medication. G. Remove intermittent infusion and flush with 2 ml of normal saline (2nd syringe of normal saline). H. Inject the prescribed amount of heparin solution into the Male Adaptor Plug, unless using a saline lock. I. Unless another peripheral insertion site cannot be found, the heparin lock/saline lock should be changed every 72 hours. E. Flush heparin from catheter. F. Intermittent infusion initiated and observe for reaction.

G. Remove medication, prepare for heparin lock (unless making it a saline lock). H. Ensure patency of next intermittent infusion. I. Prevent undue trauma to veins.

COALINGA STATE HOSPITAL

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DEPARTMENT OF EDUCATION AND TRAINING I.V. CERTIFICATION RECORD

This is to certify that __________________________________, R.N, License # ___________ has completed the required course in I.V. Venipuncture Procedure including theory and practice __________________________Instructor Date________________

This Registered Nurse has been directly supervised in performing the following Venipuncture Procedures. Any of the following may be used: Protective I.V. Catheter I.V. Intracatheter I.V. Butterfly Needle I.V. Angiocatheter Return Demonstration: (Performed on simulated arm) _______________________ Instructor Date __________

Written evidence of the above education, examination and demonstration shall be documented upon successful initial training (Certification). Recertification will occur annually to include: 1) completion of required course in theory and practice, and 2) Return demonstration on simulated arm. Certification Records and a reference list of certified Registered Nurses will be maintained by the Training Office, Coordinator of Nursing Services, and the Central Nursing Office. Recertifications: _______________________ Instructor _______________________ Instructor _______________________ Instructor _______________________ Instructor

Date: __________ Date: __________ Date: __________ Date: __________

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N.P.P No. 518

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 519 Effective Date: August 31, 2006 SUBJECT: INTRAVENOUS SOLUTIONS AND ADMIXTURE I.V.SOLUTIONS 1. DEFINITION: Intravenous infusion is the introduction of fluid/electrolytes and/or medication directly into a vein. It is used to hydrate tissue, give nourishment, restore blood volume, or administer medication. 2. POLICY AND GENERAL INSTRUCTIONS: Only Registered Nurses who have a current Coalinga State Hospital approved I.V. Certification of Proficiency are authorized to perform "Intravenous Procedures". Upon a physician's written order a specially trained Coalinga State Hospital Certified Registered Nurse may start any I.V. except blood or blood products from the blood bank. 3. EQUIPMENT: A. Intravenous solution B. Intravenous tubing C. I.V. needle or over-the needle catheter D. Tourniquet E. Arm board F. Tape and gauze G. I.V. standard H. iodine swab I. Antibacterial ointment as ordered by physician J. I. V. label K. Gloves

4. PREPARATION OF EQUIPMENT AND INDIVIDUAL NURSING ACTION A. Check the physician's order.
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RATIONALE - PRECAUTIONS A. To determine what will be given and the rate of flow.
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B. Perform hand hygiene.

B. Good medical asepsis will help prevent contamination during I.V. procedure. C. Organization helps to expedite the procedure. D. To ensure that the correct solution is used and to avoid introduction of contaminated material into the body.

C. Assemble equipment. D. Check the label and clarity of the solution.

E. Remove cap or plastic sheath cover from plastic I.V. bags. F. Pharmacy will add medication to Intravenous Solution bottles (Admixture) and label bottle with name of medication amount, and expiration date. G. Listen for vacuum sound when removing rubber seal; attach tubing to bottle. H. Attach Butterfly Needle to end of tubing (if Butterfly Needle is to be used instead of over-the-needle catheter. I. Run solution through tubing to clear air. Clamp tubing. J. Take equipment to bedside. Identify the Individual by checking his picture or rand card. K. Explain venipuncture procedure and the purpose of the I.V. to the Individual. L. Help the Individual to a comfortable position with the arm well supported. Find a comfortable position for yourself where you will have good access to the arm. I. To prevent forming air emboli in Individual, when I.V. is started. J. To ensure that the I.V. is given to the intended Individual. K. To relieve anxiety and elicit cooperation by increasing his confidence in you. F. To identify contents of Admixture Solution

G. A vacuum sound is heard when the rubber seal is removed from a sterile bottle unless the seal has been perforated by adding medication.

5. NURSING CARE DURING INTRAVENOUS ADMINISTRATION: NURSING ACTION A. Explain function and process of Intravenous Administration.
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RATIONALE - PRECAUTIONS A. To allay fears/anxiety and elicit Individual cooperation.

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B. After I.V. is started, adjust rate of flow as ordered by physician. Label bottle for time, date started and flow rate. C. Check I.V. site frequently, observe connection between needle and tubing for back up blood.

B. To maintain proper hydration and avoid over-loading the circulatory system. C. To look for infiltration, edema, pain, redness, infection and blockage of flow, or first stage phlebitis. Back flow of venous blood in connector when I.V. bottle is lowered indicates needle is patent.

D. I.V. site care. The I.V. site must be covered with a sterile dressing or a transparent covering such as op-site designed for this purpose. I.V. site should be changed every 72 hours. E. Observe Individual for possible side effects from any medications added. F. Change I.V. bottle and tubing every 24 hours. Label tubing and bottle with start and DC date. 6. DISCONTINUING OF I.V: NURSING ACTION A. Check physician's orders. RATIONALE - PRECAUTIONS A. To ensure that the I.V. is being discontinued on the proper date and time. B. Standard Universal Precautions C. To stop fluid being administered. E. Adverse medication reaction may occur. F. To reduce risk of on site bacterial growth in I.V. equipment with concomitant infection to Individual.

B. Perform hand hygiene and put on gloves. C. To discontinue I.V, close the tubing clamp. D. Carefully remove the I.V. site tape and dressing. E. Remove I.V. device and apply pressure until bleeding stops, then apply band-aid or dressing. F. Empty solution from I.V. container and discard empty bottle and I.V. tubing in the contaminated trash container. G. Discard contaminated I.V. needle or intracath in specially marked needle puncture resistant container from Central Supply.
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F. This equipment is considered contraband. G. Dirty needle can be potential source of disease and possible injury to others.

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H. Remove gloves, wash hands. 7. ADMINISTRATION OF ADMIXTURE I.V. SOLUTION It is be the policy Coalinga State Hospital that all admixture I.V. solutions will be prepared and labeled as outlined in the Pharmacy Formulary and Policy Manual Admixture labeling will record the type and dosage of medicine added, as well as the expiration date of the admixture.

8. EQUIPMENT A. Primary I.V. solution/tubing set/extension hook or I.V. controller B. Piggyback additive I.V. solution with secondary transfer tubing set C. Antimicrobial preparation of povidone-iodine D. Alcohol sponges 9. PROCEDURE Piggyback medications are administered through an established I.V. line via a secondary (piggyback) container. All I.V. procedures are performed by Coalinga State Hospital I.V. Certified Registered Nurses only upon direct order of the physician. NURSING ACTION A. Check physician's orders. B. Perform hand hygiene. C. Look at admixture solution holding it to a light, for clarity, integrity of container. D. Before administering the admixture solution, the R.N. must have a thorough knowledge of the admixture medication, its action dosage, and possible adverse side effects. RATIONALE-PRECAUTIONS A. To ensure that the Individual receives the proper type and dose of admixture solution. B. Hand hygiene helps to prevent cross contamination. C. To avoid use of contaminated solution. D. To be able to adequately assess the beneficial effects or adverse side effects the Individual may manifest.

Caution: Be sure medication is compatible with fluid being administered; when in doubt, the Registered Nurse is required to contact the Pharmacist (on call if after hours) for clearance on compatibility of the admixture solution to be infused with the primary I.V. solution being administered.

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Note:

During a life-threatening emergency the physician may administer or confirm the compatibility of the I.V. drug or admixture solution with the primary I.V. solution. E. Gravity will allow the piggyback solution to flow into the Individual, temporarily preempting the flow of the primary I.V. solution, until the piggyback solution is infused.

E. Lower the primary solution bottle. This is accomplished by placing an extension hook between the bottle and the primary I.V. standard. This effectively lowers the primary I.V. solution bottle to a lower level than the piggyback I.V. solution. F. In setting up the I.V. an aseptic technique is required. G. Remove the I.V. bag outlet cover. H. Close tubing clamp on the secondary transfer set. I. Squeeze the drip chamber and utilizing aseptic technique insert the spike into the I.V. bottle outlet. J. Invert secondary bottle and hang on I.V. standard. Squeeze and release drip chamber until chamber is half full of solution. K. Clear air from the secondary tubing by opening clamp and running solution through the tubing to eliminate air bubbles. Clamp tubing. Replace sterile protector. L. Cleanse uppermost injection site of primary I.V. tubing with antimicrobial preparation of povidone-iodine. Followed by cleansing with an alcohol sponge. M. Attach needless connector to site of primary I.V. solution tubing at uppermost injection port. Then connect secondary tubing to needless connector. N. Open the secondary tubing clamp full and adjust the flow of the piggyback additive solution with the lower clamp of the primary I.V. tubing. (Caution: flow must not be controlled by clamp on the secondary set).
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F. To prevent contamination. G. Be alert that cover was tight fitting and utilize aseptic technique. H. This prevents fluid from flowing before proper connections are made. I. Use firm steady pressure to avoid slipping and contaminating equipment. J. This prevents air from collecting in tubing.

K. To prevent air emboli from entering the Individual.

L. To provide a contaminate free injection site.

M. Solution from the primary container will run into the piggyback tubing (clearing out any remaining air), when the secondary tubing clamp is opened. N. When the flow is properly adjusted by the lower clamp of primary I.V. tubing, the flow from the additive bottle will proceed until the bottle is exhausted; then the primary solution will automatically reinstitute flow.

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O. To Note: When the piggyback container empties, you can administer the residual medication in the tubing just above the upper injection port until the fluid level reaches the needle at the upper injection port. When you release the pressure on the tubing, solution from the primary container may move into the piggyback tubing, but the back-check valve will prevent it from entering the piggyback bottle. P. Label the piggyback's infusion tubing with the time and date. Q. If you will need to hang a secondary piggyback bottle, close the roller clamp on the primary set and lower the empty bottle below the drip chamber on the primary set. Open the slide clamp on the piggyback tubing and allow the primary solution to fill the piggyback tubing. Close the slide clamp on the piggyback tubing, remove the spike from the empty container, and aseptically insert it into the newly prepared piggyback container. Hang it on the I.V. pole, open the slide clamp, and adjust the flow rate with the roller clamp on the primary set. R. Attaching a piggyback solution to an I.V. controller with a primary solution: 1.) Spike secondary I.V. solution bag and hang on second hook on I.V. pole. 2.) Fill drip chamber half full and prime tubing. 3.) Pause controller and clamp primary tubing. 4.) Insert from secondary tubing into primary I.V. tubing at the uppermost injection site. 5.) Remove drip sensor from primary chamber and place on secondary drip chamber. 6.) Set controller at prescribed rate and
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O. This ensures Individual is receiving the dosage ordered.

P. Change I.V. tubing every 24 hours to prevent infection. Q. Refilling the secondary tubing in this manner prevents having to repuncture injection site and thus avoid possible introduction of contaminants at the injection site.

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press start. 7.) Observe drip chamber to determine if flow has begun. 8.) When piggyback container empties, alarm will sound. Pause controller and close clamp on secondary tubing. Place drip sensor back on primary chamber, set controller to prescribed rate for primary solution and press start. S. Observe for Individual's physiological and psychological reaction to administration of the admixture. Monitor vital signs as indicated. S. To determine the beneficial or adverse side effects the Individual is experiencing.

9. RECORDING/DOCUMENTATION OF I.V. THERAPY: A. I.D. Note: 1. Indicate problem number, date and time and the I.V. site. Record the I.V. device used, device size, rate of infusion, name of solution and amount. Record any type and amount of medication given to the Individual and how medicine was given (i.e. Piggyback or I.V. bottle). 2. If starting an I.V., record the amount and location of unsuccessful attempts to place the I.V. device. 3. Record pertinent observation about the I.V. site (edema, pain, redness, signs of infection) or signs of phlebitis. Record I.V. site care, tubing, bottle and I.V. device changes, as well as the Individual's reaction to the procedure. B. Medication Record: 1. Record the time administered, type and dosage of medication given I.V. C. Intake and Output Flowsheet Record the time I.V. started and discontinued, type and amount of solution, and type and dosage of medication added. At change of shift, record the amount of solution left in the bottle. All totals from the I&O worksheet should be placed on the Intake and Output Flowsheet at the end of each shift.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 520 Effective Date: August 31, 2006

SUBJECT: INSERTING A MALE ADAPTOR PLUG (HEPARIN LOCK/SALINE LOCK) 1. DEFINITION: An intermittent infusion set (heparin lock/saline lock) is an indwelling reservoir in the vein for intermittent infusion therapy when continuous infusion therapy is not indicated. Periodic injections of heparin into the device keep the needle or catheter patent. Note: This procedure is performed by Coalinga State Hospital I.V. Certified Registered Nurses only upon direct order of the Physician. 2. EQUIPMENT: A. Male Adaptor Plug B. Antimicrobial prep. of povidone-iodine C. Tape and gauze D. Heparin solution/saline solution as ordered by physician E. Syringe for heparin/saline solution. F. Two (2) 3 cc syringes for normal saline G. Disposable gloves 3. PREPARATION OF EQUIPMENT AND INDIVIDUAL: When continuous infusion therapy has been discontinued/not indicated and there is a need for intermittent infusion therapy for a Individual who has an indwelling overthe needle catheter, a male adaptor plug may be inserted into the catheter to convert it to a heparin lock/saline lock. NURSING ACTIONS A. Check the physician's order. RATIONALE - PRECAUTIONS A. To determine proper authority to initiate heparin lock/saline lock, and medication. B. Maintain medical asepsis during procedure. C. Organization helps to expedite procedure.
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B. Perform hand hygiene. C. Assemble equipment.

D. Perform hand hygiene and put on gloves. E. Prime the Male Adaptor Plug with normal saline. F. Close the roller clamp on the infusion set to stop the infusion, and aseptically remove the protective cap from the Male Adaptor Plug. Detach the I.V. tubing, and insert primed Male Adaptor Plug into the catheter hub. G. When initiating a heparin lock/saline lock when there is not an existing I.V. site, follow N.P. 570. After the venipuncture, advancement of the catheter into vein, and withdrawal of the needle, connect the primed Male Adaptor Plug into the catheter hub. H. Apply a fresh dressing being certain to keep the injection port outside the air-occlusive tape for quick access. I. Flush Male Adaptor Plug and catheter with prescribed amount of heparin/saline solution. 4. INTERMITTENT INFUSION THERAPY: NURSING ACTIONS A. Three separate syringes

Medical asepsis.

H. Medical asepsis and access to injection port.

RATIONALE - PRECAUTIONS A. To insure patency or catheter and to flush male adaptor plug.

B. 2 - 3 cc syringes filled with 2 ml of normal saline with a 25X1 needle C. One syringe of prescribed heparin solution, unless using saline. D. Swab the injection port with an antimicrobial skin preparation such as povidone-iodine. E. Insert the syringe containing normal saline and aspirate for blood return to
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D. Medical asepsis.

E. Ensure patency of catheter.

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ensure that the catheter is in the vein. F. Inject 2 ml of normal saline and remove syringe. G. Attach prescribed intermittent I.V. infusion through Male Adaptor Plug port and infuse at prescribed rate. Observe for adverse reactions to the medication. H. Remove intermittent infusion and flush with 2 ml of normal saline (2nd syringe of normal saline). I. Inject the prescribed amount of heparin solution into the Male Adaptor Plug, unless using a saline lock. J. Unless another peripheral insertion site cannot be found, the heparin lock/saline lock should be changed every 72 hours. F. Flush heparin from catheter.

G. Intermittent infusion initiated and observe for reaction.

H. Remove medication, prepare for heparin lock (unless making it a saline lock). I. Ensure patency of next intermittent infusion.

J. Prevent undue trauma to veins.

5. RECORDING/DOCUMENTATION Follow documentation as outlined in N.P. 571.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 521 Effective Date: August 31, 2006 SUBJECT: INTRAVENOUS BLOOD WITHDRAWAL BY REGISTERED NURSES 1. PURPOSE: To obtain blood samples for clinical laboratory testing. 2. RESPONSIBILITY: Registered Nurses who have a current Coalinga State Hospital approved Certification of Proficiency for blood withdrawal by venipuncture are authorized to perform this procedure upon order of physician. Certification of Proficiency is obtained after successfully completing the approved CSH Certification for Intravenous Blood Withdrawal Training. A copy of the certificate, which indicates successful completion, can be found at the end of the procedure. 3. EQUIPMENT: A. Disposable gloves B. Tourniquet C. Syringe 10 cc. and 21X1 needle or vacutainer and adapter with 21X1 multiple sample needle. D. Vacutainer Tubes (refer to CSH Laboratory Manual for type(s) of tube(s). E. Proper laboratory slips, correctly, legibly and completely filled out. F. Alcohol sponges. G. Clean dry cotton balls H. Paper tape. 4. PROCEDURE: NURSING ACTION A. Inform Individual of what you are going to do. Check for any blood precautions. B. Perform hand hygiene. Wear exam gloves while you perform procedure.
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RATIONALE/PRECAUTIONS A. To obtain cooperation; it will lessen fear and resistance. B. Prevent self/Individual contamination during procedure.
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C. Select site for venipuncture. Inspect both arms to find and use the best vein.

D. Assemble syringe and needle/vacutainer.

C. Ante-cubital fossa is usually best site. Be sure Individual is comfortable and well supported, either sitting or lying down. D. syringe is preferable for fragile, collapsible veins. If using an adapter, assemble necessary tubes in an accessible location. It is also a good idea to have spare tubes in case a tube with no vacuum is encountered. Note: A tube may be introduced onto the needle inside the adapter, but only up to the line on the adapter; going further will penetrate the stopper and destroy the vacuum. E. Use light to moderate pressure to distend veins enough to permit visualization or palpation.

E. Lightly apply tourniquet half way between shoulder and elbow. Do not leave on for more than 2 min. F. Lightly palpate vein with fingertip. Keep the arm flat and extended. Use a support (e.g. book or Individual's other fist) under the elbow if necessary. G. Prepare the puncture site by rubbing vigorously in a 2-3 inch radius with 70% isopropyl alcohol. Allow alcohol to dry slightly or wipe away with a sterile cotton ball. H. Remove needle guard. Turn needle so that bevel is facing upward. I. Anchor skin and vein below puncture site with free thumb. J. Align syringe/adapter with vein and puncture skin and vein with a smooth, gentle motion.

G. Disinfect puncture site.

I. Prevent vein from rolling or sliding away from needle. J. Be careful not to go all the way through the vein. When using a syringe, blood will appear in the neck of the syringe when the vein is entered If, after 3 attempts, you are unable to obtain an adequate specimen, notify a physician for assistance.

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K. If using a syringe, withdraw the plunger smoothly. If using an adapter, brace the adapter with your holding hand and push the vacutainer tube onto the vacutainer needle with your free hand. Fill additional tubes as needed. L. When sufficient blood has been collected, remove the tourniquet. Withdraw the syringe/adapter and needle from the puncture site. Place a clean, dry cotton ball over the puncture site and apply pressure for at least one minute.

K. Pulling too hard on a syringe plunger will hemolyze the blood. Be careful not to move the needle when pushing or pulling Vacutainer tubes on and off.

L. It is a good idea to remove the vacutainer tube from the adapter needle before withdrawing the needle from the vein; otherwise several drops of blood are likely to drip out of the needle. Applying pressure to puncture site with an alcohol soaked cotton ball actually lengthens the clotting process. Inadequate pressure will lead to bleeding and/or bruising and/or hematoma.

M. If using syringe, puncture the top(s) of the required tube(s) with the needle and allow the tubes to fill via vacuum. N. Dispose of needle using established hospital procedures - do not recap, bend, or cut needles. O. For all tubes other than red, or red/gray top tubes, gently invert 8-10 times to mix the blood and the anticoagulant. P. Before releasing Individual, inspect puncture site; if indicated, apply clean, dry cotton ball and tape in place. Q. Label specimen tubes with Individual's full name, CSH number, Unit number, date, and initials of person who drew blood. N. Prevent self-contamination with Individual's blood

O. Vigorous mixing or shaking will hemolyze the blood.

P. Prevent delayed bleeding.

Q. Proper identification of specimen.

Note: If after 3 attempts you are unable to obtain a blood specimen, notify physician for assistance.

5. CHARTING IN WELLNESS AND RECOVERY NOTES

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A. Chart problem number, blood drawn and site drawn from, test ordered, time, date and when sent to the Laboratory. B. Chart Individuals response to the procedure. C. Sign name and title of employee completing note. 6. SENDING OUT BLOOD FOR REFERENCE LABORATORY TESTING OUT BLOOD FOR REFERENCE LAB TESTING A. If the lab test is not going to be performed in-house, arrange for transportation of the specimen to the proper Laboratory by the approved courier service, CSH Transportation, or CSH Protective Services. Transportation should occur as soon as possible. B. Fill out two forms legibly: one CSH laboratory requisition and one contract lab Miscellaneous Laboratory requisition. -All copies of contract lab forms are sent to the contract lab. -The CSH laboratory requisition, with the contract labs requisition copy attached, is to be sent to the CSH Clinical Laboratory. Make sure that the date and time of collection, the reference laboratory used, the procedure(s) requested, and the phlebotomist's name are all specified.

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COALINGA STATE HOSPITAL CERTIFICATION RECORD FOR DRAWING OF BLOOD BY REGISTERED NURSES FOR TEST PURPOSES

This is to certify that ___________________________________, R.N., License # ___________________ has completed the required course in intravenous blood withdrawal. The Registered Nurse has been directly supervised in performing the following withdrawing of blood: Either of the following may be used: 1. Vacutainer 2. Syringe

Instructor 1. _________________________________ Date ______________________ 2. _________________________________ Date ______________________ 3. _________________________________ Date ______________________ 4. _________________________________ Date ______________________ 5. _________________________________ Date ______________________ Note: Instructor may require that the individual needs more than the five (5) minimum required for Certification. Written evidence of the above education, examination and clinical demonstration shall be documented upon successful initial training (i.e. Certification), and thereafter on an annual basis (i.e. Recertification). The Training Center, Coordinator of Nursing Services, the Supervising Registered Nurse of the Infirmary Unit, and the Central Nursing Office will maintain a reference list of certified Registered Nurses.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 522 Effective Date: August 31, 2006 SUBJECT: IMMUNIZATIONS 1. GENERAL: The immunizations most often ordered at this facility are Tetanus/Diphtheria (Td), Influenza, and Measles/Rubella single-antigen vaccine and combination vaccines (MR). Annual influenza vaccinations will be coordinated by CSH Public Health Services to assure Centers for Disease Control and Prevention guidelines, policies, procedures, and protocols are maintained. 2. PURPOSE: To ensure quality Individual care by providing Individuals and staff protection from tetanus, diphtheria, influenza, measles, rubella, and/or other preventable diseases. 3. RESPONSIBILITY: A. Routine immunization will be administered by licensed nursing staff from Central Medical Services following a written order from a physician. Other immunizations may be performed by licensed nursing staff on the unit when special circumstances require large numbers of Individuals to be immunized. B. The Public Health Physician will make the final decision on advisability of immunization appropriateness, including screening for contraindication. C. The Public Health Nurse will assist licensed nursing staff from Central Medical Services and on the treatment units by providing immunization information and inservice training as needed. D. Following the mandated requirement of the National Vaccine Injury Act (NVIA), Vaccine Information Statements (VIS) must be provided to all Individuals prior to administration of vaccine against communicable diseases applicable to our facility. 1. Individuals receiving any of the vaccines stated in the NVIA shall be given VIS information. 2. A corresponding IDN stating that the information was given (and Individual's response to instruction) is to be written. 3. VIS will be available in Spanish, English, and in additional languages if needed.

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4. PROCEDURE A. The need for immunization will be determined: 1. On the Individual's admission to Coalinga State Hospital; 2. At the time of his annual physical examination or; 3. At the discretion of the treating physician, as indicated due to injury and/or potential exposure. B. An H.S.S./designee will review: 1. The Individual's records and; 2. Interview the Individual indicated to determine his need for immunization. C. When it is determined immunization is needed: 1. A written order will be obtained from the attending physician. 2. Individuals determined to need an immunization who are on the Admission Unit will receive the appropriate immunization by a licensed nursing staff of that unit. All other Individuals determined to need immunization (e.g. at the time of the Annual Physical Exam) will be referred to the Central Medical Clinic. 3. Individuals determined to need an immunization after an injury will have this done by an R.N. in the Urgent Care Room. 4. Immunization may be given under other circumstances e.g. when an outbreak is identified and/or suspected. Specific procedures and protocols for these instances will be issued at that time. D. Safety precautions regarding side effects or adverse reactions: 1. Each Individual will have his V/S taken and recorded once prior to administration and once 24 hours after dose given. 2. Each Individual will be closely observed for at least 20 minutes following the immunization for side effects or adverse reaction. Individuals who require an escort to the Central Medical Clinic will be accompanied by a staff member who will remain with the Individual during this observation period. 3. During the observation period, emergency equipment and drugs will be available in the area where the vaccination was administered. E. Reporting of adverse reactions (or suspected adverse reaction) following immunization: 1. Adverse reactions that must be reported are: anaphylaxis; encephalopathy; shock, collapse, hypotonic, or hyporesponsive episodes; seizures; any complications or sequelae (including death); and/or any event listed on the vaccine manufacturer's package insert. 2. Staff shall immediately report adverse reactions or suspected adverse reaction to the attending physician, Pharmacy, and N.O.D. if after hours. The Public Health Office shall be notified within the next working day.

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3. The Public Health Office will report adverse reactions to the Pharmacy; local county, state, and/or federal health departments; and/or Centers for Disease Control. 4. Any unused vaccine from a multidose vial producing adverse reaction will be quarantined (under appropriate manufacturer's storage recommendations) and returned to the Pharmacy. 5. DOCUMENTATION A. The date, dosage, route, site, manufacturer and lot number of the vaccine, and name and title of the person administering the vaccine will be documented on the Immunization Record. B. An IDN will be written if the Individual has any actual or suspected adverse response(s). C. All written and/or verbal education received by the Individual will be recorded in the IDNs.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 523 Effective Date: August 31, 2006 SUBJECT: SELF-ADMINISTRATION OF MEDICATION 1. PURPOSE: This policy shall set forth the guidelines and parameters for the self-administration of medication(s). 2. AUTHORITY: Title 22; Pharmacy Policy and Procedure Manual. 3. POLICY: A. No Individual may self-medicate except as a part of a Wellness and Recovery Plan. B. Individuals residing on ACUTE units may not self-administer medications or treatments. (Title 22, Section 71233). Individuals residing on ICF units are allowed to self-administer sublingual medication and insulin. (Title 22, Section 73365.) C. Individuals who self-administer medication(s) must have a current order for selfadministration by a physician. D. No medication may be given without a current order from a licensed physician, dentist, podiatrist, licensed nurse practitioner, or other person authorized to give such order. E. The Medication Room person shall be familiar with the nursing considerations, methods of application, Individuals teaching, adverse effects, any food/drug interactions, and contraindications for the specific medication. F. The Medication Room person shall know the potential and systemic effects of the medication. G. Nursing staff shall instruct the Individual how to properly administer the medication. Each Individuals competency shall be assured by return demonstration, ability to verbalize what has been taught, or other appropriate means prior to self-administering medication. H. All Individual teaching shall be documented in the Wellness and Recovery Notes (IDN). When the self administration of insulin is involved, the RN will utilize Attachment A RN ASSESSMENT OF INDIVIDUAL FOR SELF ADMINISTRATION OF INSULIN and Attachment B INDIVIDUAL COMPETENCY FOR SELF ADMINISTRATION OF INSULIN. I. A PT/LVN/RN, certified to administer medications, must directly supervise the Individual and assure that he does not compromise his or other's safety and that all other policies and procedures of medication administration are followed.

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4. METHOD A. ASSESSMENT: 1. Once approved by the WR Team to self-administer medication, determine the Individuals emotional readiness and physical capability to effectively selfmedicate. 2. Assess each Individuals learning abilities and teaching needs. 3. Assess Individuals knowledge about the etiology and pathology of the illness for which they may self-administer. 4. Assess Individuals knowledge of expected action of the medication, signs/symptoms, possible side effects, and possible adverse reactions. 5. Assess Individuals history of drug use: prescription, non-prescription, and illicit/illegal. 6. Determine physical ability to administer medication by assessing fine grasp, hand strength, reach, and coordination. 7. Continuous on-going re-assessment of the Individuals capability to selfadminister shall be done on an as-needed basis and as determined by the WR Team. B. GOALS / EXPECTED OUTCOME: 1. The Individual is able to describe the expected action, purpose, side effects, possible adverse reaction(s), appropriate dosage, and schedule of medication. 2. The Individual is able to take, administer, or use medication without assistance on prescribed schedule. 3. The Individual is able to state when to notify physician and nursing staff about medication problems. 4. The Individual is able to demonstrate preparing prescribed medication dose. C. IMPLEMENTATION/INTERVENTION: NURSING ACTION A. Assess if Individual is able to read, understand and follow written instructions by asking Individual to read a teaching pamphlet and explain what was read. B. Assess Individuals learning readiness and abilities. C. Assess Individuals knowledge regarding drug therapy: name of drug(s), how to administer, purpose or action, daily doses and times taken, side effects to expect, and what to do if problems occur. KEY POINTS A. Learning is inhibited if Individual is illiterate, has difficulty with written instructions, has a language barrier, or diminished visual acuity. B. Presence of significant illness, frailty, or the suggestion of or presence of confusion will impact the teaching plan. C. Reveals Individuals level of understanding and need for instruction.

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D. Assess Individuals sensory function including sight, hearing, touch, and physical coordination, including ability to self-administer injections.

E. Assess Individuals belief in need for drug therapy. Consider cultural values, religious beliefs, and personal experiences with medications, and values about drugs. F. Prepare the environment for a teaching session: a. Select a room that is well lit. b. Provide comfortable seating. c. Control sources of noise and distractions. G. Prepare teaching materials: a. Materials should be printed in large bold letters if needed. b. Illustrations of safety guidelines should be provided if available. c. Written schedules or individualized instruction sheets are helpful. H. Be sure Individuals who wear glasses or hearing aids do so during the teaching session. Ensure availability of interpreter if necessary.

D. Individuals sensory impairments create the need for specific types of teaching strategies so that the nurse can be sure Individual has the capacity to see the medication, open prescription bottles, and read labels. E. Many factors influence a persons willingness to follow drug regimen.

F. Room environment should be designed to minimize existing sensory alterations. A comfortable environment free of distractions promotes attention.

G. Teaching materials should be designed to meet each Individuals learning needs and capacity to learn.

I. Present information clearly and concisely: a. Face learner. b. Use short sentences and speak in slow, low-pitched voice. c. Provide descriptions in terms the Individual can understand. J. Provide frequent pauses so that Individuals can ask questions and express understanding of content. K. Provide frequent short teaching sessions. Learning about multiple medication regimens will require several teaching sessions. L. Ask Individual to explain

H. Use of glasses or hearing aids increases a Individuals sensory perception and likelihood of understanding the content. Hearing instructions in ones native language greatly facilitates understanding. I. Individuals with hearing loss or visual problems will be able to see staffs expressions and hear voice more clearly. Prevents confusion of terminology.

J. Increases Individuals participation in the learning process. Ongoing feedback assures staff that the Individual is acquiring information. K. Improves Individuals attention and retention of information discussed.

L. Feedback measures Individuals -3N.P.P No. 523

information about the drug: purpose, actions, maximum frequency, side effects, and interactions, foods to avoid. M. Have Individual prepare dose for the prescribed medication. N. Ask Individual about any questions.

cognitive learning.

M. Indicate Individuals understanding of dosages and schedules. N. Offers opportunity for clarification and minimizes any remaining confusion or misunderstanding.

D. EVALUATION: 1. After administration of any medication, the Individual should be observed for desired results, any side effects, or untoward reactions. Keep the physician and the WR Team appraised of the results. 2. Report any abnormalities. 3. As needed, update unit staff of the treatment progress or lack of progress at the Change of Shift Report. 4. Periodically evaluate Individuals level of understanding and learning retention. Learning needs to be reinforced. E. DOCUMENTATION: 1. Observe, report, and record the desired therapeutic effects, precautions taken, and any untoward reactions of the medication administered in the ID Notes. 2. Document instruction provided, learning outcomes achieved, and the Individuals response to teaching and learning outcomes in the ID notes. The RN will utilize attachments A and B if Individual is to self administer insulin. 3. Staff will chart the Individual self-administered medication in the Medication Administration Record (MAR) or Diabetic Record per NP 500 and NP 562.

RN ASSESSMENT OF INDIVIDUAL FOR SELF ADMINISTRATION OF INSULIN YES NO

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1. Individual is approved by Wellness and Recovery Team for self administration of insulin. 2. Individual is able to read, understand and follow written instructions 3. Individual is assessed for learning readiness and abilities and teaching needs 4. Individual is knowledgeable regarding drug therapy: name of drug, purpose or action, daily doses, side effects and what to do if problems occur. 5. Individual is assessed for sensory functions including sight, hearing, physical coordination and ability to selfadminister injections. 6. Individual is assessed about etiology and pathology of diabetes. 7. Individual teaching done and documented in IDN (including causes, symptoms, treatment, prevention of hypoglycemia and hyperglycemia etc.) Comments: RN Signature ____________________________________Date ____________ Attachment A NP 575 Addressograph

CSH # pending (new 3/06)

INDIVIDUAL COMPETENCY FOR SELF ADMINISTRATION OF INSULIN Satisfactory Needs Improvement -5N.P.P No. 523

1. Performs proper hand hygiene. 2. Roll insulin vial between palms of hands. 3. Cleanse the rubber stopper on vial with an alcohol swab. 4. Demonstrates correct method of holding syringe. 5. Inject air into the vial equal to the amount of insulin dose. 6. Verbalizes understanding of Cloudy-ClearClear-Cloudy (proper mixing of insulin). 7. Able to select site and verbalizes understanding of rotating the site. 8. Able to demonstrate preparing prescribed medication dose and return demonstration. 9. Demonstrate correct technique of administering injection. 10. Demonstrate correct method of disposing of syringe and lancet in sharps container. 11. Able to verbalize when to notify staff if any problem occurs. COMMENTS:

RN Signature _______________________________Date _________________ Attachment B NP 575 Addressograph

CSH # pending (new 3/06)

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 524 Effective Date: July 26, 2007 This policy replaces NPP # 524 dated August 31, 2006 SUBJECT: 24 HOUR AUDIT (TRANSCRIPTION REVIEW OF CHARTS & MARS FOR PHYSICIAN ORDERS) 1. PURPOSE: The Transcription Review is meant to serve as checks and balances system to ensure the early detection of errors and omission of orders. This safeguard measure is accomplished by conducting a review of all charts as a part of Shift duties. 2. POLICY: 1. ALL CHARTS on the unit shall be checked each night for newly written physician orders. 2. The Unit Supervisor is responsible for ensuring the entire night audit procedure is completed nightly and corrections are made daily. 3. The staff member who discovers a medication error will notify the unit Shift Lead and initiate a Special Incident Report. The unit Shift Lead is responsible for ensuring that the appropriate action and notification is taken as clinically indicated (refer to Special Incident and Medication Errors). 4. Night shift personnel shall utilize the 24 Hour Shift Audit form and continuation page when conducting the audit review of the charts. 5. The Unit Supervisor and Nursing Coordinator reviews the 24 Hour Shift Audit form and continuation page daily and follow-up as needed. 6. The following documents shall be reviewed for errors in transcription, omission of initials, and/or lack of pertinent documentation: Physicians Orders Medication & Treatment Record Diagnostic MTR for Lab Specimens and Consults and Radiology Medication Diabetic Record Clozapine Medication Record Supplement and Daily Care Flow Sheets IDNs (nursing services and physician) Observation Record ( Q 15 Minute Observation Log) Behavioral Restraint Record -1N.P.P No. 524

 Nursing Care Plans Miscellaneous Lab Slip Request forms 7. Nursing staff shall review all charts on the unit for new and renewed orders from the previous day. All errors of transcription shall be immediately brought to the attention of the Shift Lead and NOD for follow-up action as needed. The unit physician and/or the Medical Officer of the Day (MOD) shall be notified of any INDIVIDUAL INVOLVED medication errors. 8. For Individual Involved and Individual Uninvolved medication errors a Special Incident Report shall immediately be initiated by the staff person who finds the error. Notify the physician/MOD and follow the physicians order as directed. (Refer to NPPM #516 Medication Related Events). 9. When an improperly transcribed order results in a medication error, initiate an SIR. The staff person who finds the error shall take the appropriate steps to remedy the error (e.g. Note and transcribe the physicians order that had not been transcribed; obtain physician clarification for an unclear order, etc). 10. When preparing the Medication and Treatment Record the Nursing staff shall also be responsible for comparing the pre-printed MAR with the Physicians Monthly orders. These shall be compared with the current physician orders and the Medication Treatment Record. All variances shall be brought to the attention of the unit physician for correction as needed. 3. GENERAL INFORMATION: Medications and treatments are ordered by a physician or other licensed clinician who is legally authorized to write orders. The maximum period for a written order is 45 days. The REVIEW DATE for computer generated medication renewals will be assigned by the Pharmacy. Medication errors have a potential to occur as a result of accidental oversight during the transcription phase. As a result of this, several safeguard measures are in place to assist with prevention of these errors. When an order is initially written, the Med Person is responsible for noting and transcribing the order. As a further safeguard to prevent medication errors to the Individual, night shift nursing personnel are responsible for reviewing all the charts of the unit to recheck and confirm the accuracy of the transcription against the physicians orders.

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4. PROCEDURE: Nightly chart review for new orders:

NURSING ACTION A. The Medication Room person adds to the Med Room Communication Log the names of all Individuals for whom new orders were written by the physician within the past twenty-four hours. B. The employee reviews all unit charts for new or renewed medication orders from the previous twenty-four hours. Confirm accuracy of the transcription. Notify Shift Lead of any transcription discrepancy for follow-up action as needed. C. The employee indicates that the order was reviewed by drawing a red line down the left hand side (i.e. in the date/time/ problem # column) and then across the physicians order sheet. Write in black ink 24 Hour Check: sign full legal signature and title, followed by date & time of review.
Date Time Prob #

KEY POINTS A. The Med Room Communication Log serves as a vehicle for maintaining continuity of care between the Med Room staff of all three shifts and serves to alert the staff of new orders. B. The employee utilizes the 24 Hour Shift Record when conducting the nightly audit. The nightly review of all charts for new orders serves as a safeguard measure to prevent medication errors to the Individual.

C. Sign below the red line. This red 24Hour line is a mark of assurance to other Med Room staff that the transcribed order is complete, accurate, and, safe.

PHYSICIAN'S ORDERS AND MEDICATION

6-16-06 1300 1 Haldol 10 mg P.O. Q.I.D. x 45 days ----------- ---------------------------------------------------------- Dr. Henry John M.D. ----------------------------------------------Noted: Jane Smith PT 6-16-02 @ 1310 hrs 24 hr Check: David C. Moon PT 6-17-02 @ 0115 hrs -------------------------------

D. All errors (transcribing, omission of initials, lack of documentation in IDNs, or on the MAR, Diagnostic MTR [lab, consults, and radiology], Diabetic Record, etc.) are to be entered on the audit form. E. The Shift Lead will submit the copy of

D. All transcription corrections are to be made immediately by the person who identifies the error and recorded as corrected in the last column. E. Unit Supervisor will review and -3N.P.P No. 524

the 24 Hour Shift Audit to the Unit Supervisor every morning.

take appropriate follow-up action as needed based on the findings of the audit.

F. The US will give a copy to any staff involved so that corrections can be made or development of any plans of action as needed. G. A copy is given to the Nursing Coordinator every morning.

F. The US retains the original copy while the errors are being corrected

G. The Unit Supervisor will appraise the NC of plans of action initiated based on the audit findings. The Unit Supervisor will retain the original copy.

NURSING ACTION A. The Medication Room person, in conjunction with the unit physician and RN/Case Manager, maintains a written schedule of medication reviews for the unit population. B. The Medication Room person identifies in the Med Room Communication Log the names of Individuals whose medications are due for renewal. A calendar board is also utilized to identify those Individuals up for Med Review renewals.

KEY POINTS A. The Review Date for computer generated medication order renewals will be assigned by the Pharmacy.

B. All units will receive pre-printed Physician Orders and MARs prior to the assigned expiration date of Monthly Orders. Utilizing the Med Room Communication Log and a calendar board assists with alerting the night shift staff to prepare physician order sheets and I.D. Notes.

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Section 6 Diagnostic Procedures

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 600 Effective Date: August 31, 2006 SUBJECT: CLINIC PROCEDURES 1. PURPOSE: To provide guidelines for care and treatment that may not be available on the Individual's assigned unit. 2. POLICY: Nursing personnel shall be responsible for sending consultations ordered by a physician to the appropriate clinic in a timely fashion and for ensuring the Individual is taken for his/her appointment at the scheduled time. All Individuals shall shower, have clean clothing, and brush their teeth prior to clinic appointment. 3. GENERAL INFORMATION: The following clinics are available to Individuals at Coalinga State Hospital: Audio logy GI Clinic Neurology Physical Therapy Surgery Dental Occupational Therapy Pulmonary Function TB X-Ray EEG/EKG Infectious Disease Optometry Podiatry EMG Internal Medicine* Physical Medicine Speech

* Serology, Dermatology, and Endocrine Clinic is included within the Internal Medicine Clinic For services not available at Coalinga, arrangements are made with clinics or hospitals in the community through the Medical Director.

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4. PROCEDURE: NURSING ACTION A. Addressograph the appropriate Consultation Referral and Report Form. B. Ensure consult is complete with all necessary information. B. Physician will complete consult. Must include name of clinic for treatment or recommendation, urgent or standard reason for consult (include pertinent history, physical finding, diagnostic reports) C. Clinic will schedule appointment with the unit at a time that is convenient to both. KEY POINTS

C. Send consult to appropriate clinic. If emergency, consult clinic or clinic physician by phone. D. Ensure that the Individual is neat and clean E. Explain to the Individual where they are going and why. F. Escort Individual to the clinic at appointed time with the Individual's chart, cost accounting slip , and addressograph plate (if requested). For emergency appointments take consult and addressograph plate. G. Call clinic in advance if unable to keep scheduled appointment time.

D. Special attention may be needed for particular clinics. E. To allay fears and gain Individual's cooperation. F. DO NOT be late for appointment, as it affects other Individuals, personnel, disrupts the clinic schedule, and the Individuals continuity of care.

G. Every effort should be made to keep the scheduled appointment as rescheduling delays Individual treatment. Be sure to notify clinic when Individual is transferred, discharged, refusing to go, or if Individual will be late. Notify receiving unit of pending appointments when Individual is transferred. H. Upon returning to unit, staff escort shall give the chart to the Med. Room Nurse or Shift Lead to insure treatment orders, need for follow-up appointment(s), and transcription of clinic physician orders is accomplished.

H. Check chart for orders by clinic physician before leaving clinic.

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I. Document in ID Note all appointment procedures performed and findings noted. Document if appointment is not kept and reason. J. Provide the Consult Report findings to the Unit and Med-Surg. Physicians for review and follow-up.

I. Maintain continuity of care and treatment.

J. Follow procedure as outlined in NPPM Diagnostic MTR: Consult and Radiology.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 601 Effective Date: August 31, 2006 SUBJECT: LABORATORY PROCEDURES 1. PURPOSE: This policy will provide guidelines for the appropriate process and procedure(s) to be used for laboratory specimen collection. 2. POLICY: 1. A physician's order is required before obtaining any laboratory specimen. Physician order must specify date to be obtained, except random urine drug screens for those individuals with an open problem and current treatment plan for substance abuse. 2. All laboratory specimens shall be placed, stored, and transported in fluid impermeable sealed plastic bags that have a biohazardous symbol on them. Lab slips should be placed in a compartment separate from the specimen(s). 3. GENERAL INFORMATION: In all procedures where it can be reasonably anticipated exposure to blood or other potentially infectious material may result, personal protective equipment and engineering controls shall be used. A. Engineering controls are those that isolate or remove the blood borne pathogen hazard from the workplace (e.g., sharps containers.) B. Personal protective equipment consists of special clothing or equipment worn by an employee for protection against a hazard. General work clothing (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment. C. If refrigeration is indicated, laboratory specimens shall be stored in a specially designated refrigerator in which no food or drugs are kept. D. For Drug Abuse Screening, urine is the specimen of choice. E. Registered Nurses who have demonstrated proficiency in venipuncture technique may obtain blood specimens.

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F. Blood specimens may also be obtained at the specimen collection station by the contractors phlebotomist(s) during normal working hours, Monday through Friday. G. All urine specimens will be collected by the Mid-Stream Clean Catch process, except for the collection of 24-Hour urine specimens.

4. PROCEDURE: NURSING ACTION A. Check for Physicians orders. KEY POINTS A. Determine if individual is to be N.P.O. for test. B. Be sure stamp is legible on all copies. C. Include physician's name, unit, date, diagnosis (related to reason for obtaining specimen), and name of person obtaining specimen.

B. Addressograph appropriate lab slip. C. Fill out form completely.

D. Check appropriate box for required D. Include essential information. test and write in source of specimen. Such things as STAT or CALLBACK must be included on the request or it will be handled as a routine. Verify test with doctors orders. E. Hand hygiene before and after procedure. E. Use appropriate protective equipment and engineering controls if it is reasonably anticipated exposure to blood or other potentially infectious material may result. G. Each specimen must be labeled separately. Use two (2) forms of identifying each individual before collecting specimen(s). H. All surfaces shall be decontaminated after completion of procedure if contamination occurs.

F. Collect specimens and label with individual's name, CSH number, test required, physician's name, and any other pertinent information. H. When collecting urine specimens, be sure the cap fits the container snugly to reduce spillage.

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I. Place all specimens in leak-proof plastic bag provided by the contractor's specimen collection station at Coalinga. J. Any specimens obtained after early morning pick-up, must be delivered to the specimen collection site by the unit staff. K. Document in chart and on the MAR.

I. Place specimen in lab specimen Refrigerator in the program for early morning pick-up.

J. If there is any delay in delivery of the specimen, place in specimen refrigerator. DO NOT LEAVE ON COUNTER. K. Type of specimen, time, date, and name of person, obtaining specimen and test requested.

5. AFTER HOURS PROCEDURE:

NURSING ACTION A. Contact NOD/ACNS when Physician's Order is written.

KEY POINTS A. NOD/ACNS will expedite delivery to contracting laboratory.

B. Addressograph appropriate lab slip B. Mark STAT or CALL BACK on lab and fill out completely. slip. The lab slip is to accompany the specimen. C. Collect specimen in usual manner C. Place specimen(s) in refrigerator, and deliver to Central Sally Port for sign log sheet, and call ACNS pick-up by contracting laboratory. Office at ext. D. Document in chart. D. Type of specimen, time, date, and name of person obtaining specimen and test requested.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 602 Effective Date: August 31, 2006 SUBJECT: RADIOLOGY PROCEDURES 1. PURPOSE: To provide guidelines for completing x-ray examinations on individuals housed at C.S.H. 2. POLICY: A physicians order, including a signed X-Ray Request and Report form (CSHxxxx), is required for all routine and special diagnostic x-ray procedures. 3. METHOD: For emergency services after hours, weekends, and holidays, the MOD will refer Individuals to the appropriate contract hospital as needed. For special diagnostic procedures, procedure Instruction sheets and pre-printed Physicians Orders sheets shall be utilized by nursing staff to direct staff on specific care required to prepare the Individual for the special x-ray procedure. 1. CSH Radiology will provide instruction sheets for procedures performed at CSH Radiology. 2. Instruction sheets for procedures performed at the contract hospital will be provided by the contract hospital via the Medical Ancillary Services office at CSH.

4. PRECAUTIONS: 1. Pregnant staff must not escort Individuals to Radiology. 2. Female Individuals who are suspected of being pregnant must have their pregnancy status verified prior to the scheduling of the x-ray exam. 3. Pregnant Individuals will not be x-rayed unless it is an emergency situation and the physician authorizes such x-ray to be completed.

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5. PROCEDURE: NURSING ACTION A. Follow clinic procedures outlined in Nursing Policy and Procedure. B. For special diagnostic procedures at CSH, an instruction sheet and a preprinted Physicians Orders sheet will be faxed to the unit on the day the appointment is scheduled. C. The unit should obtain the medications called for in the prep sheet from the pharmacy. B. Special diagnostic procedures such as UGI, BE, etc. Require special preparation in advance of x-ray appointment. These procedures will be scheduled at Coalinga or at the contract hospital. C. Laxatives, opaque medication, etc. KEY POINTS

D. Ensure that the unit physician signs the D. Applies to special diagnostic pre-printed Physicians Orders sheet for procedures scheduled at Coalinga only. the preparation for the Individual. E. Notify Nutritional Services of any special dietary requirements. F. Ensure individual remains NPO when applicable. G. Assist Individual in Radiology as needed. H. Document in chart.

G. To gown, remove jewelry, etc.

H. Documentation should include: procedure done, reaction of Individual, etc.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 603 Effective Date: August 31, 2006 SUBJECT: CLEAN CATCH (MIDSTREAM) URINE COLLECTION 1. PURPOSE: This policy will provide guidelines for the procedure to be used to obtain a clean voided specimen for diagnostic purposes. 2. POLICY: 1. All laboratory orders are to be transcribed from the physicians order onto the DIAGNOTIC MTR: LAB Diagnostic MTR: Lab, Diagnostic MTR: Consult & Radiology). 2. Any licensed nursing employee may obtain a clean catch urine specimen for laboratory analysis when ordered by a physician. 3. Nursing personnel, having direct or the potential for contact with exposure to blood, body fluids, or other potentially infectious material of individuals, are expected to practice STANDARD PRECAUTIONS according to guidelines established by the CSH Infection Control Program. Personal Protective Equipment (PPE) and engineering controls shall be used as needed. 4. When a urine specimen needs to be collected, nursing staff are to use the Laminated Instruction Guide Series I: Clean Catch Urine Specimen Collection to instruct individual on how to collect a urine specimen by using the midstream (clean catch) process. 5. ALL urine specimens shall be collected by the clean catch process, including specimens for Urinalysis (UA) and Culture and Sensitivity (C&S). The only exception will be 24-Hour Urine collections. 3. GENERAL INFORMATION: To decrease contaminated specimens, the Infection Control Committee designated that urine specimens are to be collected by the midstream (clean catch) process. The instructions are to be used by nursing staff to instruct individuals on how to collect a urine specimen.

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1. Clean catch containers are obtained from Central Supply and have the contents of the package listed on the outside. They are sterile unless opened or damaged. 2. The instructions for use are on the inside of the package. 3. During business hours (Monday - Friday, 0800 - 1630) collected specimens are sent immediately to the designated specimen collection site refrigerator prior to the 0800 pick-up or to the main lab. If specimens have already been picked up from the Program specimen refrigerator. This should be done within thirty (30) minutes of collecting the specimen. 4. During non-business hours, weekends, and holidays, collected specimens are sent immediately to the specimen collection site refrigerator within 30 minutes for storage until next pick-up. If it is a STAT order, contact the NOD so that arrangements can be made through the ACNS office for the Contract Lab to pick up the specimen from the Central Sally Port refrigerator. Again, the specimen must be taken to the specimen collection site within 30 minutes of obtaining the specimen in order to decrease the chance of contamination from sitting at room temperature. 4. PRECAUTIONS: The fluid blood and moist body substances of all individuals shall be treated as thought they were contagious. Hand hygiene before and after procedure. Wear gloves and handle the specimen as if it were capable of transmitting disease. 5. EXPECTED OUTCOME: 1. Individual produces midstream urine specimen that is not contaminated with feces or toilet paper. 2. Non-contaminated urine specimen obtained and delivered to contract lab in timely manner. 6. EQUIPMENT: 1. 2. 3. 4. 5. 6. 7. 8. Laminated Instruction Guide (Series I: Clean Catch Urine Specimen Collection) Clean catch container. Antiseptic solution. Appropriate waste receptacle. Plastic sealable specimen transport bag for lab specimen. Gloves. Other personal protective equipment as appropriate. Completed laboratory requisition form Miscellaneous Lab slip.

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7. PROCEDURE: NURSING ACTION A. Check physicians orders. B. Hand hygiene KEY POINTS A. To prevent error. B. To prevent infection or contamination of specimen. C. This is recorded on Miscellaneous Lab slip. Contract Lab requires that the source of the specimen and physicians diagnosis or suspected diagnosis needs to be identified on the lab slip, including the name of the ordering physician.

C. Label specimen container and lab slip while hands are clean. Label specimen container with date and time of collection, individuals name, CSH number, and unit location. Include on lab slip individuals name, CSH number, unit, test requested, nature and source of specimen, date and time of collection, name of the ordering physician, and physicians diagnosis or suspected diagnosis. D. Identify individual by photo ID and explain procedure to the individual. Assess and evaluate individuals understanding of purpose and ability to cooperate. E. Have individual wash his/her hands before, and after, procedure. F. Instruct the male individual to expose the glans and cleanse area around meatus. Wash area with mild antiseptic solution or liquid soap. Rinse area thoroughly to remove soap residue.

D. Use the Laminated Instruction Guide (Series I: Clean Catch Urine Specimen Collection) to instruct individual on how to collect a clean catch midstream urine sample. E. Reduces transmission of microorganisms. F. Observe technique of individual to verify compliance with technique. The urethral orifice is colonized by bacteria and must be cleaned thoroughly to prevent contamination of the urine. Antiseptic solution can inhibit bacterial growth in a urine culture. G. Having the individual begin to urinate in a bedpan, urinal, or toilet and then stop urinating washes the urine out of the distal urethra, reducing the risk of collecting organisms at the urethral orifice.

G. Allow initial flow to escape.

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H. Collect the midstream urine specimen. Avoid collecting the last few drops of urine. I. Instruct the individual to wash hands.

H. Assist individual as needed using gloves. Remove gloves and wash hands upon completion of procedure. I. Reduces transmission of microorganisms. J. Outside of bag should not be touched by the hand contaminated by specimen prior to hand washing. Make sure that the lid is properly screwed onto the cup to prevent leakage and spills. K. Send specimen in specimen transport bag immediately to the designated specimen collection site. The specimen must be refrigerated immediately as the colony count increases after 30 minutes and contaminates may grow. L. Staff member who collected the specimen will record the exact date and time the specimen was collected on the lab slip, and the Diagnostic MAR: LAB . Its disposition will also be reflected in the ID notes. M. As the lab report arrives on the unit, the Med Room person and/or the Shift Lead is responsible for notifying the RN of its arrival. The RN is expected to promptly review all incoming lab results, then date and initial the Diagnostic MAR: LAB form. If the results of the lab(s) are out of therapeutic parameters, the RN shall notify the physician of these results and reflect this on the Diagnostic MAR: LAB form by checking the YES box, followed by identifying the same information in the IDN, including action taken.

J. Using a new single glove to handle the specimen, place it into a specimen transport bag using clean hand to handle the bag. Follow by thorough hand washing. K. Place completed lab slip in pouch of the specimen transport bag.

L. Document in IDN, lab slip, and on the individuals Diagnostic MAR: LAB. Document individual teaching on the Wellness and Recovery Individual and Family Health Education Record.

M. Immediate evaluating, sorting, and logging begin when the lab reports arrive on the unit. Promptly report unusual test results to physician.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 604 Effective Date: August 31, 2006

SUBJECT: COLLECTION OF 24-HOUR URINE SPECIMEN 1. PURPOSE: This policy will provide nursing staff with the appropriate guidelines for the collection of a urine specimen over a 24-hour period. 2. POLICY: Any licensed nursing employee may obtain a 24-hour urine specimen for laboratory analysis when ordered by a physician. 3. GENERAL INFORMATION: 1. Bottles for 24-hour urine specimen are obtained from the Laboratory Processing Station. Preservatives are added to each bottle after the collection process to preserve the integrity of the pH of the urine. Questions or concerns should be addressed to the Specimen Collection Station Staff. 2. Urine collected must be placed in a bucket of ice on the unit until taken to the lab refrigerator after completion. 3. Testing is usually done for, but not limited to, protein or creatinine clearance as determined by the physician. 4. EQUIPMENT: 1. 2. 3. 4. 3,000 ml bottle. Urinal or bedpan. Graduate measure. Three (3) lab slips, one for each bottle.

5. PRECAUTIONS: 1. Hand hygiene thoroughly after handling each specimen. 2. In all reasonably anticipated exposures to blood or other potentially infectious material, personal protective equipment and engineering controls shall be used. -1N.P.P No. 604

6. PROCEDURE: NURSING ACTION A. Check physician's order. B. Explain procedure to individual. KEY POINTS A. To prevent error. B. Emphasize that all urine must be collected during the 24-hour period. C. Be sure to use two forms of identification to identify correct individual. D. Follow collection instructions for 24- hour urine sample labeled on the plastic container.

C. Give individual urinal or bedpan.

D. Have individual void in early AM and discard urine. Begin 24-hour collection with next voiding. E. Instruct individual to wash hands after each voiding. F. Complete three (3) lab slips and label bottles. G. At the end of 24 hours, take the specimen bottle(s) and lab slip(s) to the lab or PROGRAM SPECIMEN REFRIGERATOR.

F. One for each bottle.

G. Keep the specimen container(s) refrigerated or in a bucket of ice until the entire specimen is collected. Return unused bottles to the lab.

7. DOCUMENTATION: Record in I.D. Notes A. time collection began, B. amount and color of urine C. time collection was completed D. health care teaching done (also document on the Wellness and Recovery Individual/Family Health Education Record, CSHxxxx Also record specimen collection on the Diagnostic MAR form.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 605 Effective Date: August 31, 2006 SUBJECT: OBTAINING STOOL SPECIMENS FOR LABORATORY ANALYSIS

1. PURPOSE: Laboratory examination and analysis of stool provides useful information about the nature of elimination. Stool specimens are collected to determine pathologic conditions such as tumors, hemorrhage, infection, and mal-absorption problems. These conditions can be detected by the presence of blood, bile, urobilinogen, fat, nitrogen content, ova, parasites, protozoa, and bacteria. Guidelines are provided to aid in specimen collection. 2. POLICY: 1. All laboratory orders are to be transcribed from the physicians order onto the DIAGNOSTIC MAR: LAB CSHxxxx(Diagnostic MAR: Lab, Diagnostic MTR: Consult & Radiology). 2. Pre-label the specimen container and lab slip. Using Miscellaneous Lab slip document Individuals name, CSHxxxx, unit, test requested, nature and source of specimen, collection date and time, name of the ordering physician, physicians diagnosis or suspected diagnosis. 3. Any licensed nursing employee may obtain a stool specimen for laboratory analysis when ordered by a physician. 4. Nursing personnel, having direct or the potential for contact with exposure to blood, body fluids, or other potentially infectious material of Individuals, are expected to practice STANDARD PRECAUTIONS according to guidelines established by the CSH Infection Control Program. Personal Protective Equipment (PPE) and engineering controls shall be used as needed.

3. GENERAL INFORMATION: 1. If more than one stool specimen is needed, allow one or two days between collection and number each stool specimen accordingly on lab slips.

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2. Place stool for culture in container with C&S preservative (available from lab) and keep at room temperature. Stool for O&P should always be placed into the specimen container with O&P fixative (available in lab), cap tightly and mix well. Specimens obtained for ova and parasites do not need to be refrigerated. Do Not send fresh stool for culture or O&P. 3. During business hours (Monday - Friday, 0800 - 1630) collected specimens are sent to the designated specimen collection site refrigerator prior to the 0800 pickup, and to the main lab if specimens have already been picked up. This should be done within (30) minutes of collecting the specimen. 4. During non-business hours, weekends, and holidays, contact the NOD so that arrangements can be made through the ACNS office for the Contract Lab to pick up the specimen from the Central Sally Port. (Do Not place stool specimen(s) in refrigerator.) 5. Do not obtain specimen from toilet. Do not use specimen that has been urinated on. Do Not have Individual pass the specimen directly into the vial. 4. STOOL FOR OVA AND PARASITE (O&P): 1. Collect specimens in a clean, waxed cardboard container or sterile screw-capped plastic vial that may have a spoon attached to the lid. Transfer to O&P fixative. Fill to line on vial, Do Not Overfill. Cap tightly and mix well. 2. Collect early in the disease and before antibiotic treatment if possible. Care must be taken to not contaminate the specimen with urine or any residual soap, detergent or disinfectant. Those portions of the stool that contain pus, blood or mucus are best. 3. Specimen should be brought to the lab ASAP. 4. Collect prior to radiology studies, i.e. Barium Sulfate - must wait 5 - 7 days. 5. Individual should not receive laxatives, mineral oil, magnesium, bismuth, and antidiarrheal meds, certain antibiotics for at least 48 hours prior to collection. 6. Stool must be free of water or urine. 7. Must use fixative kit. Place into O&P Stool Fixative vial ASAP - no more than 30 minutes if liquid or one hour otherwise. Once in kit, its good for an indefinite time. 8. No more than one specimen per day. 9. Never incubate or freeze. Room temperature only. 5. STOOL FOR WBC: Stool for WBC can also be done from Stool Preservative Kit vial if ordered with an O&P exam. Otherwise collect specimen in a clean, waxed cardboard container.

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6. STOOL FOR PINWORM: Obtain special pinworm collector from the Lab. Use for perirectal sample. 7. STOOL FOR OCCULT BLOOD: To reduce both false positive and false negative results the following guidelines should be observed. I. The individual to be tested should: 1. Be placed on a meat-free, high bulk diet two days prior to the test and continue through the test period 2. Avoid all blood-containing foods (meats) 3. Avoid foods rich in peroxidase-like substances (turnips, horseradish) 4. Be restricted, for 48 hours prior to the test, from some medications which may cause false positives: aspirin, iron preparations, Butazolidin, as well as drugs that may be associated with increased GI blood loss (steroids, colchicine, indomethacin). Discuss with physician. 5. Not take more than 500 mg of Vitamin C per day, as this may cause false negative results. 6. Not be tested if bleeding hemorrhoids are present or, for females, during menstrual periods. 7. Not be tested if diarrhea is present. II. The licensed nursing staff obtaining the stool specimen should: 1. Consult with the physician if any of the above (in I.) are applicable. Follow orders as directed. 2. Inform the dietician of the testing so any foods that may affect testing can be avoided. 3. Obtain and test three (3) consecutive stool specimens to increase probability of detection of occult blood. 4. Collect specimen in a clean, waxed cardboard container, or sterile, screwcapped plastic vial that may have a spoon attached to the lid. 8. STOOL CULTURE: Stool culture is for Shigella, Salmonella and Campylobacter. Any other bacterial pathogen needs to be indicated with the physicians order. Leave at room temperature and transport ASAP to lab for processing. Use C&S (culture and sensitivity)media as preservative. Specimen still needs to be processed promptly for best results. Shigella, in particular, is difficult to recover if delays occur. Shigella is delicate. They will not survive the drop in pH that occurs when the stool is refrigerated and therefore the specimen should be left at room temperature.

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9. PRECAUTIONS: Medical aseptic technique should be followed during collection of any stool specimen. Feces contain a variety of microorganisms that can easily be transmitted if specimens are handled incorrectly. 1. The fluid blood and moist body substances of all Individuals shall be treated as though they were infectious. Refer to Administrative Directive 3 Standard Precautions. 2. Hand Hygiene before and after procedure. Follow Biohazardous Waste Procedure for proper disposal. 3. The Solutions in the vials are poisonous. Keep out of reach of Individuals.

10. EQUIPMENT: 1. Sanopan stool collection pan (also called Pilgrims Hat); 2. Clean disposable gloves; 3. Waxed cardboard or plastic specimen bottle with lid, or sterile culture transport tube with swab for cultures (C&S collection, culture swabs are obtained from the Lab); 4. Other personal protective equipment as required; 5. Tongue blades (Use sterile tongue blades for cultures); 6. Toilet paper and bag; 7. Completed laboratory requisition form Miscellaneous Lab Slip 8. Stool Preservative Kit for ova and parasites; pinworm collectors (obtain from Lab). 9. Appropriate receptacle. See Biohazardous Waste Procedure. 11. ASSESSMENT: NURSING ACTION A. Determine purpose of stool specimen and correct method of obtaining and handling specimen. KEY POINTS A. Prevents collection of specimen at time when laboratory cannot test it. Consult with the CSH Laboratory or Contract Lab for any questions regarding collection procedures. B. Prevents invalid test results on stool specimen. Appraise the dietician of the testing so that dietary modifications can occur.

B. Determine if Individual should have dietary modifications or restrictions before test.

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C. Assess Individuals understanding of reason for collection of stool specimen.

C. Reveals Individuals ability and willingness to cooperate in collection of specimen. D. Allows for more effective planning.

D. Determine normal defecation pattern of Individual. E. Assess Individual for gastrointestinal dysfunction, such as abdominal pain, nausea, vomiting, excessive flatus, diarrhea.

E. May indicate specific physical problem.

12. PROCEDURE: NURSING ACTION A. Check physician's orders. B. Hand hygiene with soap and water. C. Identify Individual by photo ID and explain the procedure to Individual. Assess Individuals understanding of purpose and ability to cooperate. D. Assemble equipment needed. KEY POINTS A. To prevent error. B. Reduces spread of infection. C. Provides basis to determine need for health teaching and need for assistance. Individual teaching assists with gaining Individuals cooperation.

E. Label specimen container with date and time of collection, Individual name, CSH number, and unit location. Prelabel Lab slip to include date and time of collection, Individual name, CSH number, unit, test requested, nature and source of specimen, name of the ordering physician, physicians diagnosis or suspected diagnosis. F. Instruct Individual to void into toilet before defecating.

E. This is recorded on Miscellaneous Lab slip (MH 6075). Contract Lab requires that the source of the specimen, and physicians diagnosis or suspected diagnosis needs to be identified on the lab slip including the name of the ordering physician.

F. Feces should not be mixed with urine or toilet tissue. Urine inhibits fecal bacterial growth. Toilet tissue contains bismuth, which interferes with test results.

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G. Place collection pan on toilet. H. Put on disposable gloves and remove a small portion of feces (2 cm X 2 cm) from the bedpan with the tongue blade and place in C&S preservative specimen container. Fill to line. Do Not Overfill. Cap tightly and mix well. I. Ova and parasites: Use The spoon built into the vial cap and transfer small samples from areas that appear bloody, slimy, or watery. Continue adding samples until the liquid level in the vial reaches the red fill line. Avoid over or under filling. Mix specimen in the solution using the spoon provided. Recap the vial, making sure the lid is tight. Shake the vial until the contents are well mixed. J. Using a new single glove to handle specimen, place it into a specimen transport bag using the clean hand to handle the bag. Follow by thorough hand washing.

G. Collection pan must be clean. H. Follow appropriate hand hygiene protocols.

I. Specimen must be taken to specimen collection site.

J. Outside of bag should not be touched by the hand contaminated by specimen prior to handwashining.

K. Cleanse all equipment or dispose appropriately, in Biohazardous waste container. L. Leave area clean and neat. Use aerosol-deodorizing spray in area if necessary. M. Note character of stool while preparing specimen for lab. Document in IDN, lab slip, and on Individuals Diagnostic MAR LAB. Document Individual teaching on the Wellness and Recovery Individual and Family Health Education Record CSHxxxx N. Place completed lab slip in pouch of the specimen transport bag.

K. Refer to A.D. Biohazardous Waste procedure.

L. To provide for unit comfort and dispel odor.

M. Staff member who collected the specimen will record on the Lab slip and the Diagnostic MAR: LAB the exact date and time the specimen was collected. Its disposition will also be reflected in the ID notes.

N. Send specimen in specimen transport bag to designated specimen

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collection site within 30 minutes. O. Immediate evaluating, sorting, ands logging begins when the lab reports arrive on the unit. Promptly report significant test results to physician. Provide all lab results to the Med/Surg physician for review. O. As the lab report arrives on the unit, the Med Room person and/or Shift Lead is responsible for notifying the RN of its arrival. The RN is expected to promptly review all incoming lab results then date and initial the Diagnostic MAR: LAB. If the results of the lab are out of therapeutic parameters, the RN shall notify the physician off these results and reflect this on the Diagnostic MAR: LAB by checking the YES box, followed by identifying same action in the IDN including action taken.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 606 Effective Date: August 31, 2006 SUBJECT: DNA SPECIMEN PROCEDURE 1. PURPOSE: This Nursing policy will provide the appropriate policy and procedural guidelines to be followed to meet the statutory registration and DNA requirements for Sex, Arson, Narcotics and Serious Crime Offenders. 2. POLICY: 1. All individuals admitted to CSH who are required to register with the Department of Justice (DOJ) shall be pre-registered upon admission. Registration and preregistration includes all required documentation, such as DNA samples, photographs, and finger, thumb, and palm prints, if there is not yet an analysis of the required samples on file with the Sex and Arson Registration Unit of the DOJ. (See Registration/Notification Requirements Procedure Manual.) 2. Any individual admitted to the hospital from the California Department of Corrections (CDC) who meets the above requirements is expected to have preregistered while in the correctional facility. The CFL office will contact the Coalinga Unit Parole Agent regarding PC 2962 and PC 2964(a) parolees and CIW regarding PC 2684 prisoners to ascertain pre-registration status if no documentation is available on the Legal Status Summary or elsewhere. It will be necessary to preregister these individuals if no documentation can be located by CDC or DOJ. 3. All clients, upon discharge, parole, release, or on court visit (if not expected to return), shall be notified of the statutory requirements pertaining to the duty of certain offenders to register with the local law enforcement agency. (See Registration/Notification Requirements Procedure Manual, for General Advisory, and specific Sex, Arson and Narcotics forms to be used in addition to the General Advisory.) 3. PC 290 SEX OFFENDER REGISTRATION/NOTIFICATION REQUIREMENTS: Any individual who meets any of the following requirements shall be required to register for the rest of his or her life while a resident of California: -Convicted in this state or in any other state, federal or military court or found guilty in the guilt phase of a trial but not guilty by reason of insanity (NGI) in the sanity

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phase, since July 1, 1944, in violation of any one or more of the sex offenses listed in Section 3 of the Registration/Notification Requirements Procedure Manual. -Discharged, paroled or releases from any penal institution following commission or attempted commission of any of the sex offenses listed in Section 3 of the Registration/Notification Requirements Procedure Manual. -Determined to be a mentally disordered sex offender (MDSO) under Article 1 (commencing with Section 6300) of Chapter 2 of Part 2 of Division 6 of the Welfare and Institution Code (W&I Code). Prior to release, individuals convicted of sex offenses and attempted sex offenses shall be informed of the requirements to register with law enforcement upon release utilizing the DOJ Notification of Sex Offender Registration form (SS 8047 {goldenrod}).

4.

ARSON REGISTRATION REQUIREMENTS:

The hospital is required by PC 457.1 to notify any Individual convicted of arson or attempted arson in violation of section 451, subdivision (a) or (b), 451.5, 453, or 455 of his/her duty to register with the chief of police in the city where the person is residing and the sheriff of the county where the person is residing. This notification is to be done using the Notice of Arson Offender Registration Requirement, Form SS 8049 (see Section 5 of the Registration/Notification Requirements Procedure Manual). Upon discharge of any arson offender, the hospital is required by PC 11150 and PC 11151 to notify in writing the State Fire Marshal, all police departments, and the sheriff in the county in which the individual was convicted and, if known, the county in which he/she is to reside.

5. NARCOTICS REGISTRATION REQUIREMENTS: The hospital is required by Health & Safety Code (H&S) 11592 to inform individuals convicted of crimes described in H&S 11590 of the requirement that they register with law enforcement upon release. This notification is to be done using the Notice of Narcotic Offender Registration form SS 8048 (see Registration/Notification Requirements Procedure Manual).

6. PRE-REGISTRATION PROCEDURE: 1. Upon admission, Addressograph staff will review the admission documents, including the CLETS report included in the admission packet, to determine if the

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individual meets the criteria for sex, arson, or narcotics registration. They will also determine if the individual meets the criteria for a serious offense. 2. Upon determining that an individual meets the criteria for sex, arson, narcotics or listed serious crime(s), Addressograph staff will complete two index cards, listing qualifying offenses and whether PC 290, PC 296, or both apply. One card will be placed in the Addressograph rolodex for tracking purposes and one card will be sent to the CFL office to be added to the Master List. a. Addressograph staff will initiate the Green Flag (see Admissions or Program PC 290/PC 296 Manual by completing the top section and the qualifying offenses section and then providing the Flag to Admissions staff by placing it on the top of the Legal Section of the chart. b. If the new admit has a Green Flag in his/her old chart, Addressograph staff will place it in the new chart prior to providing the chart to Admissions staff. 3. Addressograph staff will also include form MH 7017 (see PC 290/PC 296 Manual) in the chart for use by the social worker for all individuals upon discharge, transfer to another state hospital, or release to court visit if it is likely the individual will not return. 4. Throughout the individuals stay at the hospital, Addressograph staff will notify the Program and CFL when a sex, arson, narcotics, or serious crime client is to be discharged, paroled, released to court visit (if not expected to return), or transferred to another state hospital.

5.

Designated unit staff will refer to the Green Flag to ensure that the required registration and DNA samples have been, or will be, obtained prior to discharge. Only DNA samples are required for serious crime offenses, not registration. Upon receiving a new chart with a Green Flag for an individual who meets the criteria listed in the Registration/Notification Requirements Procedure Manual, Section 3, Admissions staff will complete the pre-registration packet and the fingerprint cards with a photograph included (see Admissions PC 290/PC 296 Manual for specific forms). a. Individuals with serious crime offenses listed in A.D., Attachment D do not need to register.

6.

7. PC 296 DNA PROCEDURES FOR SEX AND/OR SERIOUS OFFENSES: 1. Any individual who is required to register under Section 290 (Sex Offenses), or PC 296 (Serious Crime Offenses), must provide two specimens of blood, a saliva sample, a photograph, and thumb and palm-prints for law enforcement identification purposes one time only, unless the samples provided are unusable or lost (see the Registration/Notification Requirements Procedure Manual). 2. Only a physician, registered nurse, licensed vocational nurse, technologist or clinical laboratory bio-analyst may withdraw blood specimens for the purpose of this law.

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3. If an individual refuses to provide the required samples and specimens, the individual will be advised, in writing by CSH staff, the DOJ, CDC, any law enforcement personnel, or officer of the court, that he/she is guilty of a misdemeanor. This is punishable as a separate offense by both a fine and imprisonment. In most cases, the individual will not be released until the requirement is met. If the individual refuses and he or she is required to be discharged to court visit, the Program will notify the court and Sheriff by phone and/or fax that the individual has refused to comply. 4. Admission Suite RNs will obtain DNA samples and complete the cards in the DNA Kit upon receiving the new chart for an individual who meets the criteria. Admission Suite staff will assist the RN with obtaining the thumbprint for the two blood samples, the palm print card (red border), and with the additional photograph that is placed in the DNA Kit. 5. The DNA Kit is to be mailed the same day the samples are obtained. If it is too late to mail that day, it is to be placed in a refrigerator and mailed the next business day. 6. The Green Flag completed by Admissions staff is to be replaced on top of the Legal Section of the chart. If the individual refuses to have DNA samples taken, Admissions staff is to note refusal, sign and date in red on the Green Flag, place the individuals name on a Refusal Log, then check weekly with the Program(s) regarding the refusal status. 7. The Admission units R.N. is to collect the DNA samples if the individual has refused in the Admission Suite. However, the individual must be returned to the Admission Suite for the finger, thumb, and palm prints, and the picture to be completed by Admissions staff, who will then remove the individuals name from the Refusal Log. 8. The Admission Suite staff will complete the top section of form SS 8047 (Goldenrod NCR paper) and send the form via hospital mail to the Program office for the unit where the individual is housed. 9. The form will be logged into the PC 290/PC 296 Notification Requirement Log and placed alphabetically in the accordion file folder titled PC290/PC 296. (The CFL office will supply both the Log and the accordion file folder.) 10. When an individual is to be transferred to another Program, the Program Director or designee will remove Form SS 8047, SS 8048, or SS 8049 from the file and send it to the Program accepting the individual, to be placed in that Programs accordion file and noted on the Programs Log. 11. When an individual is to be discharged, paroled, released, or transferred to another state hospital, the Program Director or designee will provide form SS 8047, SS 8048, or SS 8049 to the appropriate social worker for notification to the individual, completion of the form, and distribution as listed on the bottom of the form.

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12. All the notification duties required by the staff and the individual are on the appropriate form, with copies for review in the Program PC 290/PC 296 Manual, so they will not be listed in this policy. 13. If the individual has been committed as a sexually violent predator (SVP) according to W&I Code 6604, although a form SS 8047 must be completed, only after release is the individual required re-registering with the local law enforcement agency every 90 days. Failure to do so may be punishable by imprisonment in a state prison or in a county jail for up to one year.These individuals are also among those whose movements must be reported by the hospital to DOJ pursuant to W&I Code 5328.2 (see Program PC 290/PC 296 Manual, Movement Notification). 14. All individuals to be discharged from the hospital are to read, sign, and receive a copy of the Discharged Individual Advisory of PC 290 Registration (see Program PC 290/PC 296 Manual, form MH 7017). 15. Individuals to be discharged are to be informed by the social worker that this is a general advisory, the details of which may or may not apply to them. If they have any questions regarding the applicability of the sex offender registration law, they are advised to contact their local law enforcement agency and/or Department of Justice. 16. If the individual is incompetent, unwilling to sign, or unable to read, staff are to check the appropriate box on the form, then sign and date it, provide the individual with a copy and place the form in the chart. 17. After the individual has read and signed form MH 7017, it is to be given to the individual and a copy is to be placed in the chart. 18. The Program procedure for pre-registering and/or obtaining DNA samples for individuals who met any of the criteria and who were admitted between 07/08/03 and the beginning of the Addressograph/Admissions process, or who refused to provide DNA samples, is presented in the Program PC 290/PC 296 Manual. -Each program will be provided with a list of the names of individuals who require pre-registration and/or DNA samples. -It will be the responsibility of each Program to pre-register and collect DNA samples for the listed individuals who were admitted during this interim time. -Until all appropriate individuals, either new admissions or current individuals have been pre-registered, when a unit is notified that an individual is being discharged, the Green Flag in the chart is to be reviewed immediately. -Any individual requiring completion of pre-registration of Notification of Registration forms or DNA samples, shall have the DNA samples obtained and the individual shall be taken to Admissions for a photo, and finger, thumb and palm prints, including the thumbprints on the blood samples, after calling Admissions for an appointment.

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19. The Community Liaison Representative (CLR) or designee will be responsible for updating the policy and procedures as indicated. 8. GENERAL INFORMATION: 1) Standard Precautions shall be used at all times. Gloves must be worn at all times when doing venipuncture. Hand hygiene before and after procedure. 2) Follow all Precautions listed in Nursing Policy Collecting Blood Specimens by Venipuncture (Blood Drawing). 3) The blood and saliva specimens obtained are potential evidence that can be used in a court of law to either help clear or convict an individual of a future crime. Thus the Nurse who obtains the specimen shall see that the samples are collected strictly according to the instructions in the DNA Database Collection Kit. 4) Once the Nurse Seals the kit with a security seal, the kit may not be opened under any circumstances. If something is forgotten to be put in the box after it is sealed, the entire kit and samples must be destroyed and the specimens must be reobtained using a new kit. 9. EQUIPMENT: The DNA Data Base Collection Kit is obtained from the Program Office. Use only one kit per individual and do not mix other individuals blood or saliva sample when sealing the kit for mailing. The kit should contain the following: One security seal. One set of Instructions One California Dept. of Justice Invoice (Form BFS 200, NCR with 3 copies). One DEPARTMENT OF JUSTICE Cal-DNA Program specimen information card. One ink remover towelette Two pre-inked sheets for thumbprints. Two special Vacutainer tubes in a plastic protection sleeve and liquid absorbing sheet. Two special Saliva (Buccal) Sample swabs. One (white) coin envelope. 10. PROCEDURE: COLLECTION OF THE BLOOD SAMPLE:

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NURSING ACTION A. Verify the individuals identity before beginning. Use two forms of identification. B. Check Physicians orders and put on gloves before opening the DNA Kit. C. Use only the blood collection tubes provided. D. Using the two (2) blood tubes provided, draw the specimen from the individual. Draw the purple top tube first. Fill the tubes entirely (a minimum of 2ml is required for each tube). E. Write the individuals name and CII number on each tube. Also, write your initials and date specimen drawn on both tubes. F. Lightly ink the individuals right thumb and align the thumb vertically along the length of the tube. G. Press the individuals thumb on the designated area of the blood tube and gently roll the thumb slightly from side to side. H. Place the blood tubes into the plastic tube holders, stopper them, and then put the tubes into the plastic bags. Seal the bags. Leave the liquid absorbing sheets in the plastic bags as protection. I. Use the ink remover towelette to clean the ink from the individuals thumb.

KEY POINTS A. Work with only one individual at a time. This will limit the possibility of mixing-up samples or specimen information cards. B. Gloves are used to prevent any chance of DNA contamination. C. Extra blood tubes may be ordered if needed. D. Follow Nursing Policy on Collecting Blood Specimens by Venipuncture (Blood Drawing) on steps used for venipuncture. E. NOTE: This is a different procedure than a routine blood specimen. The individuals CII number, not the CSH number is placed on the label. F. Use the pre-inked sheets provided in the kit. G. The label on the tubes provided has a space indicated for thumb print.

H. The blood collection tubes in the kit are inside the plastic bags and plastic tube holders with the liquid absorbing sheets wrapped around the plastic tube holders. I. The ink will not come off with soap and water.

SPECIMEN INFORMATION CARD:

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NURSING ACTION A. Print legibly (or preferably type) all of the requested information on the Specimen Information Card. B. If information is unknown, leave that area of the card blank. C. Be sure that the CII number is complete: a letter (A, M, or H) followed by an eight-digit number. D. Sign the card where indicated and have the individual also sign where indicated. E. Lightly ink the individuals right thumb and gently roll the thumb across the designated area of the card.

KEY POINTS A. Illegible or incompletely filled out cards will delay processing of specimens. B. Do Not Write anything in the Date Received or CAL-DNA Specimen No. areas. C. NOTE: Do Not Use the individuals CSH number. The CII number is in the legal section of the chart.

E. If for any reason another digit besides the right thumb is used, indicate which digit was used.

F. Using the towelette provided, clean the ink from the individuals thumb, or other digit.

F. You may wish to wait until all thumb prints have been completed prior to cleaning the ink form the thumb.

COLLECTION OF THE SALIVA (BUCCAL) SAMPLE: NURSING ACTION A. Before starting, put on a new pair of examination gloves. Remove one of the two swabs from the sterile package. B. With the serrated edge of the swab, scrape the inside of the individuals cheek for 20-30 seconds. C. Eject the swab into the coin envelope by pressing down on the opposite end of the swab stick. D. Repeat the above procedure for the other side of the mouth with the second swab, ejecting it into the same envelope. E. Write the individuals name and CII number on the envelope, then date, initial, and seal the envelope. D. The swabs will air dry inside the envelope during storage. E. Ensure that the information is legible. KEY POINTS A. Do Not touch the tip of the swab. It should only come in contact with the individuals mouth. B. Slowly rotate the swab as you are scraping the cheek so that cells may be collected on the entire surface area of the swab.

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MAILING THE KIT: NURSING ACTION A. Place the blood tubes, coin envelope (with the buccal samples), and the CALDNA Specimen Information Card inside the cardboard box. Place the foam pad over the specimens. If a reimbursement form was completed, place the top two copies of the form in the box. Seal the box with the security seal. B. Mail the kit as soon as possible to the address printed on the kit. If unable to send the kit immediately, the sealed kit should be kept refrigerated (preferably at 4o C). DO NOT PLACE KITS IN THE FREEZER. KEY POINTS A. It is recommended to place the paperwork on top of the foam pad.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 608 Effective Date: August 31, 2006 SUBJECT: BLOOD GLUCOSE TESTING COMPETENCY VALIDATION 1. PURPOSE: To protect the Individual, physician, nursing staff and the hospital in the areas of specialized procedures. Only Licensed Nursing Staff who have a current Coalinga State Hospital approved Competency Validation of Proficiency in performing glucose monitoring are authorized to perform these procedures. See manufacturers guidelines. Exception: Psychiatric Technicians students under the direct supervision of a clinical nurse instructor.) 2. AUTHORITY: See manufacturers guidelines. 3. POLICY: The licensed nursing staff: A. Will be instructed in the performance of glucose monitoring. B. Will be familiar with all policies and procedures regarding monitor. C. Will have completed the above steps and then demonstrate competence before a trained observer. D. Will demonstrate competence before a trained observer every (2 years). 5. DOCUMENTATION OF COMPETENCY: Competency Validation records will be maintained by the employee's Unit Supervisor and a reference list will be forwarded to the NOD Office and the Coordinator of Nursing Services. 6. INDIVIDUAL TEACHING: As a part of discharge planning, diabetic Individuals nearing discharge, with team approval may be instructed in the techniques of blood glucose monitoring. Before this can commence, the Individual must be reviewed by the I.D. Team and physician. If approved, a physician's order must be obtained and a nursing care plan written. A PT/RN, trained to administer medications and trained to preform blood glucose monitoring, must directly supervise the Individual and assure that he does not compromise his or other's safety and that all other policies and procedures glucose monitoring .

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 609 Effective Date: August 31, 2006 SUBJECT: BLOOD GLUCOSE MONITORING 1. PURPOSE: To provide guidelines for accurately and rapidly obtaining a quantitative measure of a Individuals blood glucose. 2. POLICY: 1. A Test Strip Holder will be issued for each Individual requiring blood glucose monitoring labeled for use with that Individual only, and kept in the Treatment Room. 2. Quality control checks shall be performed each day of use. Quality control consists of cleaning the Meter, performing a Check Strip test, and High and Low Glucose Control Solution tests. Results of the quality control checks shall be recorded, dated, and signed on the Daily Quality Control Record. The Daily Quality Control Record shall be retained for two years. 3. Individual fingerstick blood glucose testing shall be recorded on the Medication Diabetic Record. Staff member will initial the appropriate box on the front of the Diabetic Record - Page 1 indicating the date and time of the testing (see Attachment B) and record the results on the reverse side of the Diabetic Record - Page 2. 4. To maintain quality control and the ability to correlate results, the serial number of the blood glucose test machine (located on the reverse side of the meter) is to be entered on the Diabetic Record - Page 2. If a different blood glucose test machine is used to conduct the fingerstick, the serial number of that machine is to be entered on the Diabetic Record. 5. For those machines not used on a daily basis, Quality Control Checks shall be performed at least monthly (on the first of each month) and documented on form. 6. Treatments shall not be performed in the medication room. 3. COMPETENCY/TRAINING:

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Prior to performing blood glucose testing, mandated annual competency training will be required of all level of care nursing staff. Documented evidence of completed training will be kept on file at Training Center. 4. GENERAL INFORMATION: 1. Excessive water loss (dehydration) upsets the bodys chemical balance, which can affect the blood in many ways. One very important effect is that the plasma portion of blood will be greatly reduced which makes the blood thicker. The blood may not penetrate the Test Spot properly. This may cause the Meter to give inaccurately low blood glucose results. The following are some factors, which could lead to dehydration: -Vomiting and diarrhea -Prescription drugs, e.g., diuretics -Sustained uncontrolled diabetes 2. Test Strips cannot be used beyond their printed expiration date. Containers must be dated and initialed when first opened, and must be used within four months after the date first opened. Never use a discolored strip. Keep containers capped when not in use. 3. Fingerstick blood glucose testing is used for definitive testing for use with sliding scale insulin coverage and for screening when a Individual is exhibiting signs/symptoms of hyperglycemia or hypoglycemia . 5. EQUIPMENT: 1. 2. 3. 4. 5. 6. 7. 8. Meter Check Strip Control Solutions (High, Low) Test Strips Sterile Lancets Gloves Sharpscontainer Alcohol (optional)

6. CHECK STRIP TEST PROCEDURE: The Check Strip is used to check that the Meter is operating properly. The Check strip should be used: At least once each day of use; After cleaning the Meter; Before adjusting Individual medication based on Meter results; If Meter has been dropped; Whenever results do not reflect how the Individual feels or

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When you suspect that the results are not accurate.

CAUTION: Individual blood glucose test results may be inaccurate if the Check Strip reading does not fall in the acceptable range. The acceptable range for the Check Strip is located on the reverse side of the Meter. CLEANING AND MAINTAINING THE CHECK STRIP: Follow manufactures guidelines/instructions for cleaning and maintainence. GLUCOSE CONTROL SOLUTION TEST: High and Low Glucose Control Solutions should be used to verify the System performance: At least once per day of meter use; If the cap has been left off the vial of Test Strips or if they have been exposed to excessive heat, humidity, or cold; If a test has been repeated and the blood glucose results are still lower or higher than expected (i.e., not consistent with Individual's symptoms).

7. PROCEDURE: NURSING ACTION A. Prepare Glucose Control Solution, High and Low. KEY POINTS A. Check the expiration date on vial label. Solution should be used within 90 days after the vial is first opened. When opening a new vial, date and initial the vial. Shake the vial vigorously with each use. B. Check expiration date on Test Strip vial. Do not use Test Strips from a vial after four months of first opening. When opening a new vial of Test Strips, date and initial the bottle. C. A CODE will appear on the display. Check and adjust the code number to assure it matches the code number of the vial of Test Strips being used.

B. Prepare test strips.

C. Press the ON/OFF button on the Meter.

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D. Insert Test Strip when INSERT STRIP appears on the display. E. Apply a drop of Glucose Control Solution when APPLY SAMPLE appears on the display. E.The Meter then counts down from 45 to 0 seconds.

8. TROUBLESHOOTING: If the machine falls out of range for the Test Strip or high/low glucose solution ranges conduct the following: Recheck Review technique Clean meter Check battery Try troubleshooting with the manual, and consulting with the NOD, before contacting Central Supply When contacting Central Supply provide as much information as possible regarding the nature of the problem, or, if necessary, take the Glucometer to Central Supply 9. BLOOD TESTING: IMPORTANT: Getting a good drop of blood is one of the most important steps in getting an accurate blood glucose result.

NURSING ACTION A. Check Physicians order. B. Choose a clean, dry work surface and gather together testing materials. C.Have Individual wash hands in warm soapy water, thoroughly dry and hold in dependent position. Optional use of alcohol.

KEY POINTS

C. Warm water stimulates the flow of blood to fingers, making it easier to obtain a sample for testing. If you use alcohol to clean the Individuals finger, make sure you let it dry before you perform a fingerstick.

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D. Press ON/OFF button, a CODE NUMBER will appear on the display for several seconds. (EXAMPLE) CODE 10 This will be followed by INSERT STRIP on the display.

D. Make sure that the code number on the Meter display matches the code number on the Test Strip package. If CODE matches proceed to Step 5.

E. If Code number does not match: Press the CODE button (C). A code number will reappear on the display for several seconds. With the code number on the display, press and release the code button again, and the number will advance by one. Continue pressing until the number on the display matches the code number on the test strip package. The Meter is now properly coded, and the test may proceed. The Meter will remember that code until the code is changed for a new package of Test Strips. F. When INSERT STRIP appears on the display, slide the Test Strip into the Holder, notched end first, Test Spot side up. G. WAIT will appear on the display for a few moments. Then, H. APPLY SAMPLE appears on the display, and remains for five minutes or until you apply blood to the Test Spot on the Test Strip.

10. OBTAINING A DROP OF BLOOD: NURSING ACTION A. Prick lateral side of fingertip. Obtain a large, hanging drop of blood. Let gravity help by having puncture facing downward. KEY POINTS A. Washing hands under warm water assists with increasing circulation to the area for obtaining a blood sample.

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B. The blood should form a rounded shiny drop that covers the test spot completely, and stays wet during the entire test. C. The Meter counts down from 45 to 0 seconds. D. Press the ON/OFF button to turn Meter off. E. Carefully drop lancet into Sharpstainer. Dispose of used test strip into regular trash container.

B. The meter will beep when it detects that a sample of blood has been applied to the test spot. C. There will be a series of beeps when the result is displayed. Be sure to wait for the beeps before you note the results.

F. Document.

E. Refer to A.D. Biohazardous & Sharps Waste. The test strip is not considered biohazardous waste and may be placed into a regular trash container. F. Document the Blood Sugar results on the edication Diabetic Record Page 2 (MH 5633).

MAINTENANCE/CLEANING: Follow manufactures guidelines/ instructions

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 610 Effective Date: August 31, 2006 SUBJECT: COLLECTING SPECIMENS: FECES, CULTURES AND URINE 1. PURPOSE: Collecting specimens aids in diagnosing the disease process and condition of the Individual. 2. POLICY: The collection of specimens is done by order of the physician or physician's assistant. Fill out the proper laboratory request correctly and completely. Send the correct amount of specimen and keep warm or refrigerated as appropriate. 3. EQUIPMENT A. Obtain the necessary equipment: 1. Disposable gloves 2. Bedpan and Toilet tissue 4. Specimen container with lid 5. Tongue blades 6. Laboratory slip a. Microbiology Sensitivity for cultures and sensitivities b. Parasitology and Stool for occult blood and ova/parasite requests 7. Plastic bag. 4. COLLECTING THE FECES: NURSING ACTION A. Obtain stool specimen container B. Wear disposable gloves C. Explain procedure to the Individual and have him void before the specimen is collected D. Remove the plastic container lid and label the lid with Individual's name and number. E. Explain the proper use of the specimen hat to the Individual. RATIONALE-PRECAUTIONS A. Stool specimen collection container (listed as hat in C/S catalog) B. As personal protective equipment C. To keep the specimen hat free of urine

D. Assure Proper identification of the specimen for the laboratory E. Place specimen hat on toilet making sure that the container fits into the holder and that the holder is under the toilet seat. Do not

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F. Retrieve covered specimen container (with the specimen) from the Individual. G. Remove gloves and do hand hygiene. H. Cover labeled specimen container securely and place in plastic bag separate from slip I. Unit staff will take specimen to lab J. Do not collect stool specimens for ova & parasites or cultures when the lab is closed. They must be taken to the lab within 2 hours.

replace lid on plastic specimen container until after the specimen is obtained. F. Discard the holder in the contraband trash

G. To prevent contamination. H. To assure adequate and timely handling of specimen and to prevent soiling of lab slip

J. To assure the quality and accurateness of results.

5. COLLECTION OF FECES FOR OCCULT BLOOD TESTING: A. Individual Preparation: It is preferred that the Individual be on a Special Diagnostic Diet for two days before and during the test period. 1. Foods to Avoid: Meat, turnips, horseradish and melons. 2. Drugs and Vitamins to Avoid: Vitamin C in excess of 250 mg. per day, aspirin anti-inflammatory drugs, and iron preparations. 3. Foods to Eat: Well-cooked meats, poultry and fish; bran cereal daily; cooked fruits and vegetables; peanuts and popcorn. B. Sample Collection: See section III for instructions. C. Hemoccult Card Preparation: For purposes of submitting stool sample to the laboratory, a Hemoccult card may be used, if desired. Hemoccult Cards are available through Central Supply. Place a small stool specimen (about the size of a match head) on one end of an applicator and smear thinly inside Box A. Obtain second sample from different part of stool. Apply thin smear inside Box B. Be sure to include any part of the stool specimen, which appears to have blood or mucus, or appear black and tarry. Close cover; label with Individual's name and number; and return slide to laboratory. Caution: Protect card from heat. 6. COLLECTION OF THROAT AND SPUTUM CULTURES: Mark the laboratory slip (Microbiology Sensitivity section) with source or site of material cultured in space marked "Specimen". Be sure the lab slip is marked with the date and time specimen was collected as well as any antibiotic prescribed for the Individual.

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A. Obtaining a Throat Culture: 1. Obtain sterile culturette. 2. Remove the culturette tube from package and mark the paper cover (in space provided) with the Individual's name, number, unit number and the time the culture was obtained. 3. Remove culturette from plastic tube (saving tube) carefully making sure swab end does not touch anything. Swab only area to be cultured; do not touch other areas with swab. Place culturette back in plastic tube touching the inside of the tube as little as possible. Squeeze end of tube containing culture medium preservative so that ampule hat shatters. 4. Insert plastic tube back in marked paper wrapper. 5. Take culture to Clinical Laboratory with laboratory request as soon as possible. Do not keep in the refrigerator. The culture may be kept un-refrigerated for no more than 72 hours. B. Collection of Sputum for Gram Stain and Culture: 1. Obtain a sterile container. 2. Submit 1 lab slip for smear, if ordered, and one (1) for culture. Note date and time collected on slip. 3. Method of obtaining: a. Instruct Individual to rinse his mouth with warm water first. b. Instruct Individual to take several deep breaths, exhale and clear his throat. c. Then cough vigorously and expectorate directly into sterile sputum container. Avoid contamination with saliva. d. Specimen should be properly labeled, bagged and taken to the lab immediately by unit staff. e. Do not put laboratory slip inside plastic bag with specimen. 4. Early morning specimens are preferable. 7. COLLECTION OF URINE: A. CULTURE: Obtain a sterile urine specimen container with lid from Central Supply. Submit container in a plastic laboratory specimen bag. 1. Mark the laboratory slip (Urinalysis/micro-biology Sensitivity) for requested lab work (See Clinical Laboratory Manual). Mark the date and time of specimen collection on the lab slip. 2. Wear disposable gloves. 3. Explain the procedure to the Individual. Ask him to wash genitalia and void a small amount of urine into urinal or toilet before using the container (cleancatch urine specimen). 4. Retain approximately 25-50 ml of urine in the specimen container. Cover container, mark Individual's name, number and unit number on side of container. Place in plastic laboratory specimen bag. Transport specimen to laboratory as soon as possible. Refrigerate in the clinical laboratory refrigerator if testing to be delayed (specimen may not be refrigerated for more than 24 hours). Do not put laboratory slip inside of plastic bag with specimen. 5. A routine urinalysis can be performed on the same sample, which is submitted for culture and sensitivity, provided that a Urinalysis lab slip is sent along with the lab slip (Mark the Microbiology section of the slip). A culture cannot be performed on a specimen submitted in a routine urinalysis container (must be a sterile container). B. Routine Urinalysis Specimen: Collect a minimum of 60 ml of urine into a non-sterile urine cup. First morning specimen is the most concentrated and is the preferred specimen when testing for protein and sediment. Deliver to lab within two hours of collection.

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C. Twenty-four (24) hour collection of urine: 1. Notify laboratory of the test ordered so that preservatives may be added to the container, if necessary. Some containers with additives may be available from the lab. Schedule the collection period so that it will finish on a regular weekday morning. 2. Obtain a 2 liter container from Central Supply, fill out label with Individual's name, number, unit and/or room number, date and time collection is started. Depending on the emotional and mental state of the Individual, the bottle will be kept in a designated storage area, sitting in an ice bucket or refrigerated until the end of the 24-hour period. 3. Explain the procedure to the Individual to obtain his cooperation. 4. The collection is started with an empty bladder. Have the Individual void and discard the amount voided. Note and record the time the collection is started. 5. Stress to the Individual that he is to void in a urinal and this is poured into the 2-liter container. Save all urine voided in the next 24 hours. 6. Have the Individual void at the end of the 24-hour period. Save this sample too. Tell him that the collection is finished. Remove sign from door. 7. Write dates and times of collection on lab slip. Label to indicate 24-hour collection sample. 8. Take specimen to laboratory immediately. 8. RECORDING: A. In the Wellness and Recovery Notes indicate specimen ordered and time obtained, any unusual characteristics of material, color, consistency, blood or mucus present, amount of specimen (if applicable) and time it was sent to the laboratory. B. Document any Individual teaching on the Wellness and Recovery Individual/Family Education Record .

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 611 Effective Date: August 31, 2006 SUBJECT: PULSE OXIMETRY 1. PURPOSE: This policy will provide nursing staff with appropriate guidelines and the procedure to be used when obtaining pulse oximetery readings as part of the nursing assessment process of a full set of vital signs. 2. POLICY: 1. Intermittent use by a Registered Nurse of the pulse oximeter to assess need for or to evaluate oxygen therapy does not require a physicians order. 2. Continuous pulse oximetry use or changes in therapy as a result of pulse oximetry readings, requires a physicians order. 3. The pulse oximeter shall be brought to the scene of all medical emergencies 3. COMPETENCY/TRAINING: The Unit Supervisor/designee shall ensure each of their nursing service staff receive pertinent orientation to all equipment used on the unit. 4. GENERAL INFORMATION: Pulse Oximetry is the noninvasive measurement of oxygen saturation (Sp02). All Nursing Services Staff may assist in obtaining pulse oximetry readings for the Registered Nurse or Physician. Indications for use of the pulse oximetry may be any of the following: -Evaluate oxygen therapy on an intermittent basis -Evaluate or monitor oxygen saturation in individuals who are hemodynamically unstable. -Evaluate oxygen saturation in individuals with sleep apnea or upper airway obstructions. -Monitor oxygen saturation in individuals where arterial puncture is difficult or contraindicated. -Use during a medical emergency. -1N.P.P No. 611

There are no contraindications to the use of Pulse Oximetry. Pulse Oximetry only reflects Saturated percent of oxygen (Sp02). It does not indicate changes in either ventilation or metabolic conditions. For this reason Pulse Oximetry should not be an alternative to an Arterial Blood Gas. A Pulse Oximeter is available on all Individual occupied units. 5. EQUIPMENT: 1. Oximeter 2. Welch Allyn Vital Signs Monitor with Pulse Oximeter 6. CARE/ CLEANING AND HANDLING OF THE OXIMETER: Follow manufactures instructions/ guidelines on care and handling of the oximeter. Central Supply serves as the resource for all questions regarding medical equipment used on the units. 7. PROCEDURE:

NURSING ACTION

KEY POINTS

A. Review chart for appropriate orders. A. Intermittent use by a Registered Nurse for assessment of individuals respiratory status does not require a physicians order. B. Collect appropriate equipment. B. Ensure all equipment is in working order. C. Always use two forms of identification. D. Explaining the procedure will help to elicit cooperation and allay apprehension.

C. Identify individual.

D. Explain procedure to individual.

E. Connect the cable to the Oximeter as shown. Do not use excessive force, unnecessary twisting, kinking when connecting or when using the probe.

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F. Place the probe on the individuals finger. Allow the cable to lay across the palm of the hand and parallel to the arm of the individual. G. To begin measuring the individuals SpO2 and pulse rate, press the ON key. When turned on, the Oximeter goes through this power-up sequence: The pulse strength bar segments light one at a time. The Oximeters software revision is momentarily displayed. The assigned Individual number for spot check printouts is momentarily displayed. H. Document individuals SpO2 and pulse rate. *Notify Physician/MOD and NOD of any abnormal readings immediately. H. Normal SpO2 reading is 92-100% Abnormal SpO2 reading less than 89%,

EQUIPMENT Welch Allyn Vital Signs Monitor with Pulse Oximeter Oximeter

FUNCTIONS Measures blood pressure, pulse, temperature, respiration and oxygen saturation Measures pulse and oxygen saturation

LOCATION

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 613 Effective Date: August 31, 2006 SUBJECT: HOLTER MONITOR REFERRALS 1. PURPOSE: Twenty-four hour Holter Monitoring service is available through the EEG-ECG Department. At this time there are two Holter recording units which may be used for up to (8) eight tests weekly. Routine service is 0900 to 1500, Monday through Thursday. 2. POLICY: There are instructions about the pain button and the Individual activity diary, which must be followed during the 24 hours of monitoring. for this reason, a licensed staff member must accompany the Individual for the application of the Holter Monitor. 3. METHOD: A physician with clinic privileges may order this testing on the consultation/referral & report form (mh 5722). this form is to be filled out in full, including the reason for testing and the Individual's age. A legible copy of the Individual's current medications must accompany this request. This form may be mailed or brought to the EEG-ECG Department in the Central Medial Service hallway. The Individual will not be able to bathe during the 24 hours of monitoring. Unit staff will need to make arrangements for the Individual to bathe prior to the application of the Holter Monitor. Dirt, skin oils and perspiration decrease the ability of the electrodes to adhere for 24 hours of testing. 4. DOCUMENTATION: A. The ECG Technician will write an I.D.N. re: Holter Monitor placement and instruction provided to the Individual. It will be noted also, that written instructions are in the Individual activity diary, which is provided for unit staff reference. B. The staff member escorting the Individual to his appointment will write an I.D.N. stating that the Holter recording device was applied and the Individual's response to this application. Document any health or treatment education provided to the Individual or his family using Part 2 of the Health Education Record, noting all appropriate codes. The documentation can either refer to a more detailed note or education plan, or specify a brief description of the educational session. An I.D.N. will be written if applicable. C. The Full Disclosure Analysis report is sent to the Central Medical Clinic physician, for evaluation and response, before going to the unit and/or requesting physician.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Diagnostic Procedures POLICY NUMBER: 615 Effective Date: August 31, 2006

SUBJECT: REFERRING INDIVIDUALS TO CENTRAL MEDICAL CLINIC 1. PURPOSE: The purpose is to facilitate the referral of Individuals from their unit/program to the Central Medical Clinic. 2. PROCEDURE: A. Day of the Appointment: 1. A clinic nurse will telephone the unit on the day of the Individual's appointment, giving the time of the appointment and the clinic for which he is scheduled. 2. The staff member receiving this call will: a. Note the appointment in unit specific assigned place(s), i.e. office calendar and/or appointment log. b. Attach copy 2 of the appointment card to Individuals chart. B. Inform the Individual of his appointment and if required transcribe the information on the Individual activity board or other notification area. Give 1st copy of appointment card to the Individual. d. The Unit will provide STAFF ESCORT for Clinic Appointments when Individual is: 1. Forgetful, unreliable, or regressed. 2. Has a PAS level 1 C. Examine the chart to ensure that it contains pertinent records and forms with an adequate space available for recording the clinic visit. (i.e. Physician's Order Sheets, Wellness and Recovery Notes, Physician's Progress Notes, Medication Record, Treatment Record, Vital Signs Record, Lab Reports, Seizure Record, etc.). D. Review the last Clinic Physician's Orders Sheet for laboratory tests, consultations, diagnostic procedures, etc., which need to be available at the time of the Individual's clinic appointment. If these items are not available, ascertain when they will be. Reschedule Individual's appointment if necessary.

E. The Unit Supervisor/designee will ensure that there is a tracking system in place on the units to account for all unit records off the unit, i.e. unit records sent to clinics. F. When transportation service is available (usually M-F, 0745 to 1500) the majority of charts for routine appointments will be picked up. When chart transportation service is not available, staff will need to deliver charts to the clinic. G. Ensure that the Individual arrives in the clinic 10 minutes prior to the scheduled appointment time. H. When the clinic staff is not present, charts may be left in the locked chart distribution locker by the laboratory. 3. RETURNING CHARTS TO THE UNIT : A. Clinic Staff 1. When the clinic physician is finished with the Individual's chart, the notes and orders will be checked for legibility, medications, treatments, consultations and return appointment orders. 2. Clinic Referral Form CSH xxxx will be completed by checking items 1-4 as appropriate. 3. Chart transportation service will deliver charts to Unit by 1500, when available. After 1500 and any time transportation service is not available, the clinic nurse will call when charts are ready for pick-up. 4. Clinic staff will FAX all new medication orders to the Pharmacy. For STAT or emergency orders. The unit will be called as soon as the chart is available for pick-up. 5. When chart transportation is not available, charts not picked up by 1130 or by 1630, will be placed in the chart distribution room next to the lablocker, located at... Unit staff should check there as part of their regular chart/lab pick-up routine. B. Unit Staff 1. Review physician's note and orders with the clinic nurse as necessary, paying particular attention to any medications or supplies, which must be obtained, before the order can be carried out. All requests for lab work, consultation, x-ray, EEG/ECG, etc., will be completed by the clinic staff and marked with the date of the Individual's next clinic appointment. The clinic staff will mark "ordered in clinic" next to the order for each request prepared. 1. On the unit, the medication person will be notified of new orders. 4. TRANSCRIBING CLINIC ORDERS: A. A designated unit staff member shall be responsible for noting and transcribing clinic orders. This includes posting follow-up appointment and initiating treatment or medication and checking that forms for any ordered tests or consultations are completed. B. Medication orders for pain, nausea/vomiting, diarrhea, and antibiotics must have the first dose administered within two (2) hours from the time the order is written. C. The Clinic Checklist on the front of the unit record will be removed after the orders have been noted and progress notes or consultation forms have been reviewed and initialed by the unit physician. To ensure review, the Individual will be added to the medical appointment log.

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 620 Effective Date: August 31, 2006 SUBJECT: COMPUTERIZED LABORATORY REQUISITIONS 1. PURPOSE: To assure ordered laboratory requisitions are entered correctly into the computerized clinical laboratory tracking system. 2. AUTHORITY: Coordinator of Nursing Services 3. POLICY: Only units piloted at present will be required to utilize the computerized clinical laboratory tracking system and will enter the required information in a timely and accurate manner. All other units will continue utilizing paper requisitions. 4. METHOD: A. General: The Orchard Harvest Laboratory Information System is designed to replace the paper laboratory requisition system. B. Accessing the System: 1. On your computer station, open Internet Explorer. This will take you to the CSH Intranet Home Page. 2. On the left side Home Page, under departments, go to the Medical link and click. On the Medical page click on the Orchard Software Login link. This will take you to the login page. 3. Your username will be (in lower case letters) your first initial and last name (as one word, not separated out). If this is your first time logging in, your default password is the same as your username. You will be prompted to change your password. Follow the instructions to change your password. 4. If your login is successful, the screen will say Welcome to Coalinga State Hospital Laboratory and you will now be able to enter the information.

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5. If you still have problems logging in, contact the person and number on the screen; do not contact the Information Technology (IT) Department. C. Entering Information: 1. From the Welcome screen, click on the Order Samples link on the left side of the screen. 2. Enter the following Individual information: a. Name b. Provider ordering the test c. Unit number d. Testing Location e. Test(s) ordered (Note: this will open to another screen where tests can be checked. Click Add Order Choices at the bottom of the page when done. Click on the Details button for more information about the test e.g. fasting/non-fasting, all tests performed in panels, etc.) f. Test priority (routine or STAT [see D4 below]) g. Diagnosis 3. The above information can be obtained via search or pull down screens to assist in entering the information. 4. Click on the Next button to take you to the Sample Information page. 5. On the Sample Information page, enter the following: a. Draw date and time b. Add comments if needed c. Delivery method choose paper d. Click on Save Order e. The Summary screen will appear. If the information is incorrect, click on the Edit or Delete buttons, as appropriate, and re-enter correct information. If the information is correct, click on Sign Out on the left side of the screen to leave the program. D. Other Information: 1. For specimens obtained after hours and sent to the contract lab, necessary testing and demographic information for the receiving lab can be printed from the Summary screen and sent with the properly labeled specimen. Retain a copy of the summary. 2. If a test is ordered on a recurring basis, that information can be entered by clicking on Save as Recurring and following the information on that page. 3. Utilize the help screen when needed. If problems persist, click on How do I get a user name and password? link on the sign-in screen.

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This will display the person and number to contact. Do not contact the IT department. 4. STAT labs ordered in the Central Medical Services (CMS) Clinic will be entered by nursing personnel of the clinic and Order Done or Completed will be written next to that order. If there is nothing else ordered, the order will also be noted by CMS nursing personnel. 5. If required information is not entered, the system will tell you what you need to do by displaying the error(s) in red letters at the top of the screen. E. Documentation: 1. Orders are to be noted only after all items relevant to the order have been processed by nursing staff. Noting an order indicates it has been processed. 2. Continue to track laboratory orders on your unit as before. Currently nursing personnel is restricted to entering only information into the system.

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Section 7 Emergency Procedures

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 700 Effective Date: June 8, 2007 SUBJECT: MEDICAL EMERGENCY 1. PURPOSE: To provide appropriate guidelines for the expected response of Coalinga State Hospital staff to medical emergencies. AUTHORITY: Coordinator of Nursing Services POLICY: A. All nursing staff will be trained and certified in first aid and CPR including use of an AED. A. All available clinical staff near a medical emergency shall immediately proceed there and offer all appropriate assistance within their skills and scope of practice. B. Medical emergencies are defined as conditions requiring immediate medical attention to prevent death, disability, and serious illness, prevent injury/complications, or to alleviate pain or suffering. 1. Life-threatening medical emergency examples are: cardiopulmonary arrest, severe hemorrhage, and uncontrolled seizures. 2. Non Life-threatening medical emergency examples are: suspected fractures, dislocations, or lacerations; respiratory difficulty; abdominal pain; other acute distress. These require immediate medical care, which hospital resources (physicians, nurses, drugs, suction, oxygen, first aid, etc.) should ordinarily be able to adequately handle. 3. The hospitals emergency number, 7119, will be called during medical emergencies in order to coordinate and expedite proper resources e.g. paging physicians and nurses, contacting ambulance and CDCR for transport, etc. METHOD: A. The staff person most qualified in emergency medical care by training and experience shall exercise medical/nursing control until relieved by a still more qualified person or until control has been yielded to ambulance personnel. B. An I.V. of Normal Saline or D5W at a rate of TKO (to keep vein open) may be started by RNs who are I.V. proficient prior to a physicians order

2.

3.

4.

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C.

D.

E.

F.

G.

H.

in life threatening emergencies. A physicians order must be obtained ASAP. Nursing staff may start oxygen therapy prior to a physicians order in emergency situations. Oxygen should be administered up to 6 liters per minute via nasal cannula, 6 to 10 liters per minute via facemask, and up to 15 liters per minute via Venturing mask. A physicians order must be obtained ASAP. Responsibilities of the Unit Supervisor (US) or Shift Lead (if US not present) for medical emergencies occurring on a unit: 1. The shift lead shall assure that adequate unit nursing staff have been assigned to the emergency care of the individual and shall make or direct another staff member to make any needed calls for additional assistance if there has been insufficient response to the emergency. 2. The shift lead shall assure that all necessary and appropriate equipment and supplies have been brought to the scene, e.g. emergency cart, emergency drug box, AED, vital signs equipment including pulse oximeter, blood glucose equipment, gurney, etc. Whether the emergency occurs on or off a unit, the goal of a medical emergency is to render immediate and necessary care in order to transport the individual to the Urgent Care Room (UCR). The UCR has trained staff and the necessary equipment to further assess and stabilize the victim of the medical emergency and if necessary ready the victim for transport via ambulance to another facility (e.g. Coalinga Regional Medical Center). ASSESSMENT: 1. Immediately assess the individual to determine the medical emergency status: Life-Threatening or Non Life-Threatening. 2. Clinical Indicators would include: patent airway vital signs level of consciousness presence of injury complaint of pain (location, severity, intensity) skin color/temperature OUTCOME CRITERIA: 1. To prevent death, disability, serious illness, injury or complications. 2. To alleviate pain or suffering 3. To provide the highest possible medical emergency care in efficient and safe manner. 4. To provide accurate documentation of all medical emergencies. IMPLEMENTATIONS AND INTERVENTIONS: NURSING ACTION KEY POINTS 1. Nursing staff must remain with the individual in all medical emergencies.

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2. The first responder is to direct other staff to obtain Emergency Cart, AED, emergency drug box, vital signs equipment with pulse oximeter, blood glucose equipment, and any other available equipment based on assessment findings. 3. The first person on the scene shall initiate appropriate treatment (e.g. CPR, AED).

2. Directing other staff to bring equipment allows you to remain with the patient and continue with the assessment.

3. Cardiac arrest is usually sudden and unexpected. Time is of the essence. Brain damage occurs in 4-6 minutes. 4. Always have someone call 4. The person calling will 7119 to assure others to be remain on the line to give exact involved in emergency care are location and relevant either on their way or have been information until the notified so they can prepare Communications Center hangs (e.g. UCR personnel). up. 5. Start an I.V. and oxygen. 5. A RN may start an I.V. of Oxygen up to 6 liters per minute Normal Saline or D5W at TKO via nasal cannula, 6 to 10 liters (To Keep Open) rate without a per minute via facemask, or up physician order in a lifeto 15 liters per minute via threatening emergency. A Venturi mask may be started in physicians order must be a life-threatening emergency. obtained ASAP.

6. When CSH physician has arrived on the scene, s/he will direct the Emergency. 7. Continue life saving measures until Individual is yielded to ambulance personnel. 8. If a transfer to a medical facility is indicated, CSH Transfer Form is filled out and sent with the individual. 7. If individual is to be transported by ambulance and an IV is in place, it must be Normal Saline, per their protocols. 8. This form may be completed and faxed after the individual has been transported in life threatening emergencies in order to assure arrival at the medical facility in a timely manner.

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DOCUMENTATION AND EVALUATION: 1. Document the events, assessment findings, and interventions in the I.D. Notes. 2. Documentation should include but is not limited to: a. Date and time of medical emergency b. Type of medical emergency c. Nursing interventions and patient response d. If appropriate, when resuscitation began e. Vital signs (including pain assessment) f. Time assistance arrived and who arrived, e.g. physician, HSS, RN, HPO, CDCR personnel, ambulance personnel, etc. g. Any medications/equipment used 3. Completion of a Special Incident Report. 4. Completion and forwarding of any paperwork needed to restock UCR equipment, supplies, and/or medication(s) used.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 701 Effective Date: August 31, 2006 SUBJECT: MANAGEMENT OF FOREIGN-BODY AIRWAY OBSTRUCTION (CHOKING VICTIM) 1. PURPOSE: To provide appropriate guidelines for the emergency care and treatment of the Individual with a foreign-body airway obstruction (choking victim). 2. POLICY: 1. All personnel who have been trained in AHA (American Heart Association) may administer abdominal thrusts. Certification shall be in conjunction with basic cardiopulmonary resuscitation training. All medical emergencies shall be responded to in a prompt and competent manner by all available nursing staff. The most qualified staff member is in charge (regardless of Civil Service Classification) until relieved by a still more qualified person or the paramedics. The Choking Assessment Form will be initiated bye the RN for all choking incidents.

2. 3.

4.

3. DEFINITION: Management of foreign-body airway obstruction is a part of basic life support that consists of recognizing respiratory arrest. It involves the use of abdominal thrusts which is a technique used for unblocking an obstructed airway by giving forceful thrusts to the abdomen. 4. COMPETENCY/TRAINING: All full contact and limited contact employees shall be trained in basic life support per and shall be renewed per hospital policy not exceeding two years. 5. ASSESSMENT: 1. Early recognition of airway obstruction is the key to successful outcome of the victim.

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2. It is important to distinguish this emergency from fainting, stroke, heart attack, epilepsy, drug overdose, or other conditions that can cause sudden respiratory failure but are treated differently. 3. Symptoms of choking: A. Occurs while person is eating and suddenly becomes quiet with a look of alarm on his or her face. B. The victim cannot speak or breathe and becomes cyanotic. C. The victim may have poor (inadequate) air exchange initially as indicated by a weak ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, and possible cyanosis. A partial obstruction with poor air exchange should be treated as if it were a complete airway obstruction. D. The victim collapses (falls forward, passes out.)

6. CONSCIOUS CHOKING ADULT:

Nursing Action A. Recognize the universal sign for choking. Ask the victim if he/she is choking and determine if the victim is able to speak or cough. B. Perform the abdominal thrust maneuver until the foreign body is expelled or the victim becomes unconscious. C. For victims who are in advanced stages of pregnancy or are obese, apply chest thrusts.

Key Points A. To perform chest thrusts, stand behind the victim and place your arms under the victims armpits to encircle the chest. Press with quick backward thrusts. B. Stand behind the victim and wrap your arms around the victims waist. Press fists into abdomen with quick inward and upward thrusts.

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7. OBSTRUCTED AIRWAY (IF VICTIM IS OR BECOMES UNCONSCIOUS): 1. Determine unconsciousness. Shake and shout. Activated EMS (Emergency Medical System) CALL 7119. 2. Open the airway utilizing the head tilt-chin lift method. NURSING ACTION A. Assess the victim for breathing. Look at the chest to rise, listen and feel for breathing for 5 to 10 seconds.

KEY POINTS

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B. Check for foreign body. Finger sweep only if object is visible and in reach.

C. Attempt rescue breathing open airway and give two (2) deep breaths. Utilize a breathing device. DO NOT USE MOUTH TO MOUTH. If breaths are unsuccessful, reposition the head and try again. D. Re-attempt ventilation. If unable to ventilate, repeat sequence until successful.

D. Alternate these maneuvers in rapid sequence: Ventilation

E. After successfully clearing the obstructed airway and providing adequate ventilation, obtain a complete set of vital signs (including pain assessment), and pulse oximetry reading. F. DOCUMENT. Complete all required documentation (e.g. S.I.R., Choking Assessment Form). F. The RN shall initiate the Choking Assessment Form for all choking incidents.

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ATTACHMENT: #1 CSH Post-Choking Assessment form

CROSS - REFERENCE: A.D. # Medical Emergency, NPPM # - Medical Emergency

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 702 Effective Date: August 31, 2006 SUBJECT: CARDIOPULMONARY RESUSCITATION (CPR) 1. PURPOSE: To provide nursing staff with current and appropriate guidelines for the provision of CPR, which will provide oxygenated blood to the brain until appropriate, definitive medical treatment can restore normal heart and breathing function. 2. POLICY: 1. CPR shall be taught using, American Heart Association (AHA) standards. 2. Length of certification shall be two years. 3. Gloves and barrier devices shall be utilized while performing CPR. 4. All medical emergencies shall be responded to in a prompt and competent manner by all available nursing staff. 5. The most qualified staff person is in charge regardless of Civil Service Classification until relieved by a still more qualified person or the paramedics. 6. All appropriate emergency medical equipment, supplies, and emergency drugs shall be brought to the scene of an emergency. 3. DEFINITION: Cardiopulmonary Resuscitation (CPR) - the attempt to restore spontaneous circulation using the techniques of compression and pulmonary ventilation.

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4. GENERAL INFORMATION: An emergency situation where CPR may prevent death includes: heart attacks, drowning, electrocution, suffocation, drug intoxication, trauma, or any situation where there is an absence of pulse and or respiration. UTILIZE THE FOUR LINKS TO THE CHAIN OF SURVIVAL: 1. Early access: Immediately call 7119 to activate the EMS (Emergency Medical System) for a Individual in need of CPR. If more than one staff member is present, one should be sent to call 7119. If only one staff member is present they should call 7119 before initiating CPR. 2. Early CPR: CPR is more effective when started immediately after the victims collapse. 3. Early defibrillation: Early defibrillation is the link in the chain of survival most likely to improve survival rates. Thus, no link in the chain of survival should delay defibrillation. 4. Early advanced care: Early ACLS provided by trained personnel at the scene is critical in the management of cardiac arrest. ACLS provides advanced ventilatory support, establishes intravenous access, administers drugs, controls arrhythmias, and stabilizes the victim for transport.

5. ASSESSMENT: 1. Assess for early warning signs of a cardiac arrest: -Chest discomfort not relieved by rest (lasting 10 minutes) or relieved by NTG. -Sweating, nausea, SOB, or a feeling of weakness. -Be alert that the discomfort may not be severe and the person may not have all of the symptoms. The person may be in denial. 2. If the Individual has collapsed or is found on the floor, assess the scene for hazards (e.g. fumes, smoke, etc) before approaching the victim to ensure your safety. -Check victim for responsiveness. -Call 7119 if no response. -Assess victim using ABCD (Airway-Breathing-Circulation-Defibrillation) rule: Airway must be cleared. Breath for the victim utilizing a breathing device if not breathing. -Assess for carotid pulse, if none begin chest compressions.

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3. Assess for presence of wounds or injuries that may require a modification in the usual method of performing CPR such as severe bleeding, trauma, and injuries to the mouth. 6. OUTCOME CRITERIA: To maintain adequate ventilation and circulation until more advanced life support arrives. 7. PRECAUTIONS: Personal protective equipment is to be used per Infection Control Policy. 8. COMPETENCY/TRAINING: Required per A.D. BARRIER DEVICES: Location, Advantages and Disadvantages Type of Device Pocket Mask

Location Grounds presence

Advantages Ease of use Increased tidal volume

Disadvantages Delivers approx. 16% oxygen content.

Bag Valve Mask (Ambu Bag)

Crash Cart

Delivers up to 100% oxygen with supplement oxygen of at least 10L/minute

Decreased tidal volume. Difficult to use.

9. EQUIPMENT: 1. 2. A. B. 3. 4. 1. 2. Gloves Breathing device Ambu bag is most effective in delivering a higher percentage of oxygen Pocket Mask Defibrillator Emergency Cart Oxygen cylinder with extension tubing Portable suction machine

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PROCEDURE CPR: NURSING ACTION A. When a victim appears unconscious determine unresponsiveness. Gently tap or shake the victim and shout, Are you okay? If no response immediately activate EMS (call 7119). B. The person who calls the EMS system should be prepared to give the following information: A. Location of the emergency (building, unit number, ect); B. The telephone number from which the call is made; C. What happened (e.g. heart attack, injury if known, or signs/symptoms observed); D. How many people need help; E. Condition of the victim F. What aid is being given; G. Any other information requested; H. Hang up only when told by the dispatcher. C. Position the victim in a supine position on a flat surface. If victim is face down, roll the victim as a unit (log roll). Support the head, and neck, avoid twisting the body. D. Open the airway using the Head-tilt Chin lift maneuver. KEY POINTS A. Time is of the essence. Brian damage can occur in 4-6 minutes.

B. CALL 7119

C. The head must be higher than the feet. Airway management and rescue breathing are more easily achieved in the supine position. D. This will move the tongue away from the back of the throat and open the airway. E. the side of you check should be positioned directly above the victims mouth with your eyes looking down the length of the body.

E. Check the victim for breathing: a. Look for chest to rise and fall; b. Listen for air escaping during exhalation; c. Feel for airflow

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F. If victim is not breathing you must breath for the victim. Utilize protective breathing device.

F.

Give two shallow breaths.

CPR PROCEDURE USING BAG-VALVE MASK DEVICE (Ambu type): NURSING ACTION A. The mask is applied to the Individuals face with the rescuers hand. The last two or three fingers are placed on the mandible while the remaining fingers are placed on the mask. B. You must maintain the head-tilt, keeping the anterior displacement of the mandible while finding the optimum mask fit. The bag is then compressed with the other hand or between the other hand and thigh, or by both hands of a second rescuer. Observe the rise and fall of the chest. Listen for any air leakage around the mask. KEY POINTS A. The Ambu bag is preferred due to the higher oxygen delivery, 21% oxygen and increased to 100% oxygen with supplemental oxygen at 10L/min.

B. You can connect Ambu device to oxygen with a small oxygen tank. Set at maximum flow rate at least, 10L. This assures an adequate oxygen supply in the reservoir.

NURSING ACTION A. Proceed with CPR ventilation using approved technique. B. If the airway is open and the chest rises, check the carotid pulse for 5-10 seconds maintaining the head-tilt chin-lift. If pulse is present, maintain an open airway and perform rescue breathing (one breath every 5 seconds).

KEY POINTS A. One rescuer CPR has a 2 to 30, ventilation compression ratio. B. The carotid artery is the most accessible and reliable location for checking the pulse in adults.

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TECHNIQUE FOR CHEST COMPRESSIONS, ADULT CPR, ONE RESCUER: NURSING ACTION A. If the victim is not already on a hard surface, place a cardiac backboard under the victims back. B. Begin chest compressions. Assure proper hand placement by sliding the middle and index fingers up the ribs to locate the landmark lower half of the sternum. Continue with compressions with the ratio of 30 compressions and 2 ventilations (30:2) at the rate of at least 100 compressions per minute. Compression depth 1 to 2 inches. C. Check pulse and breathing after one minute. If pulse less, continue CPR with 2 breaths, followed by 30 compressions. Check pulse every few minutes. D. Continue CPR until: -Victims pulse and respirations are restored. -Victim is turned over to certified advanced life support team. -Rescuer is exhausted. -Ordered to stop CPR by physician KEY POINTS A. Activate EMS (dial 7119).

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TECHNIQUE FOR CHEST COMPRESSIONS, ADULT CPR, 2 RESCUER NURSING ACTION A. The second rescuer should activate EMS (dial 7119). Give the following information: -Location of emergency (building, unit number, etc) -The telephone number from which the call is made -What happened (heart attack if known or signs/symptoms observed) -Condition of victim -What aid is being given -Any other information requested -Hang up only when told to by the dispatcher B. The first rescuer begins the ABCDs of CPR. Airway open airway and look, listen, and feel. Breathing Give two slow breaths. Circulation check for a carotid pulse. If no pulse, state no pulse start compressions. Defibrillation done by trained staff as soon as possible after appropriate equipment is on scene. C. The second rescuer commences external chest compressions at the rate of at least 100/minute, counting out loud one-and-two, three-and, four- and, fourand, five etc. D. Continue compression to ventilation ratio of 30:2. When the compressor becomes fatigued, the rescuer performing ventilations should exchange places. Stop CPR after the First minute to assess for pulse and breathing. Then repeat assessment every few minutes. KEY POINTS A. The operator will announce a Code Blue to alert the MOC, NOD, ACNS, and HSS.

B. The second rescuer assumes position at the chest in preparation to perform chest compressions.

C. One rescuer is at the victims side performing chest compressions while the other is at the head performing ventilations.

D. 30:2 is the new protocol per the American Heart Association for 1 or 2 person CPR.

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E. Continue CPR until: a. Victims respiration and pulse are restored b. Victim is turned over to ACLS trained staff c. Rescuers are exhausted d. Ordered to stop CPR by physician

TECHNIQUE FOR 3 PERSON CPR: A. Follow the same procedure as Two person CPR. B. Rescuer one performs ABCD and gives two initial breaths by squeezing on the bag valve mask device. The second rescuer performs chest compressions. The third rescuer maintains the head in the correct position and holds the bag valve mask securely on the victims face. B. The third rescuer does not change places.

10. EVALUATION: 1. While ventilations are being performed the chest should rise and air movement within -+the lungs should be auscultator. 2. While compressions are being performed a faint carotid pulse should be felt. 11. DOCUMENTATION: 1. Complete documentation should be done on both the Medical Emergency Flow Sheet CSH 7107 and the IDN note. 2. Complete Emergency Critique form. 12. CROSS REFERENCE: A.D. Medical Emergencies, A.D. Standard Precautions, NP&P Section 700 series, P&T Manual P&T Manual Emergency Medication Kits. NP&P #419 Oxygen Therapy, NP&P #610 Pulse Oximetry, NP&P #716 Monitor/Defibrillator -8N.P.P No. 702

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 703 Effective Date: August 31, 2006 SUBJECTS: SEIZURES 1. PURPOSE: To provide a reference on action steps to take when Individual exhibits seizure activity. 2. POLICY: 1. Nursing staff shall immediately evaluate the Individual to determine the medical emergency status (LIFE THREATENING call 7119; NON-LIFE THREATENING call 7119) and take appropriate action as outlined in NPPM #700 Medical Emergency. 2. All available physicians and nursing staff shall respond to all medical emergencies in a prompt and competent manner. 3. An I.V. of Normal Saline or D5W TKO (to keep vein open) may be started by RNs who are I.V. proficient prior to a physicians order in life threatening emergencies. A physicians order must be obtained ASAP thereafter. 4. Registered Nurses may give I.V. Push medication in the presence of the physician (see NPPM #547 Administration of Medication &Fluids by Intravenous Route). 5. A record shall be made of each seizure which the Individual exhibits or when the nursing staff has reason to believe that the Individual has experienced a seizure. 6. The Seizure Record form (MH 5601), shall be filled out immediately after the seizure and on the shift which the seizure occurred. 7. The Seizure Record shall be used to maintain a log of all seizures and to indicate the characteristics of each seizure. 8. The Shift Lead or designee shall assure that all necessary and appropriate medical emergency response equipment and supplies are brought to the scene which includes the Emergency Cart, emergency drug box, the AED,

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pulse oximeter, and an extra oxygen tank. (In an emergency, IV Start-Kit found in the Emergency Drug Box). 3. GENERAL INFORMATION: A seizure is the response to an abnormal electrical discharge in the brain. The term seizure describes various experiences and behaviors. Anything that irritates the brain can produce a seizure. Precisely what happens during a seizure depends on what part of the brain is affected by the abnormal electrical discharge. The discharge may involve a tiny area of the brain and lead only to the Individual noticing an odd smell or taste, or it may involve large areas and lead to a convulsion - jerking and spasms of muscles throughout the body. The Individual may also have brief attacks of altered consciousness; lose consciousness, muscle control, or bladder control; and become confused. A seizure usually lasts for 2 to 5 minutes. When it stops, the Individual may have a headache, sore muscles, unusual sensations, confusion, and profound fatigue (called a postictal state). The Individual usually cannot remember what happened during the seizure. Seizures usually progress through three phases. During the first phase, the preictal period, the Individual may undergo mood or behavioral changes. This phase may also precede the actual seizure by minutes or days. Some Individuals may experience an aura (a sensory warning) during this phase. Auras are most often described as a flash of light, a strange taste, an unusual odor, a sudden headache, dizziness, a strange feeling in the stomach (butterflies), or even an intense overwhelming feeling of fear. The clinical manifestations of the aura can often provide helpful clues to the seizures origin. Accurately charting a Individuals report of an aura can provide information to help the neurologist diagnose the seizures origin. The second phase, the ictal phase, refers to the actual seizure activity. A cry, resulting from the forceful expulsion of air from the throat, may introduce the seizure. A nurses presence during the ictal phase can be a tremendous benefit to both the Individual and the neurologist; the nurses accurate charting of the seizures onset and pattern can assist the neurologist in pinpointing the origin of the seizure. The final phase is the postictal phase, the often slow recovery period that immediately follows a seizure. This period widely varies among Individuals and depends on a variety of factors, such as type, duration, and intensity of the seizure. For example, absence seizures are generally not followed by any symptoms. Once the seizure ends, the Individual resumes activity just as if nothing happened. However, after most complex partial seizures, the Individual is somewhat confused and tired, and this typically lasts from minutes to hours. After tonic-clonic seizures, the Individual is often confused

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and exhausted. Most Individuals say they require several hours of sleep to fully recover. Other common complaints include headache, muscle soreness, fatigue, and a sore cheek or tongue if these were bitten during the seizure. During the postictal period Individuals may experience any of the preceding complaints or other impairments such as changes in vision or touch sensation, muscle weakness on one side of the body, or difficulties with language. Often the postictal symptoms can also help to identify the area from which a seizure originated. For example, weakness in the left arm or leg may follow a seizure that began in the motor area of the right hemisphere of the brain. 4. DEFINITIONS/SEIZURE TYPES: The classification system for seizures has changed over the past decade. The new system classifies seizures according to whether the abnormal discharges arise from abnormal neurons on both sides of the brain (generalized seizures) or just one part of the brain (partial seizures). Partial seizures may or may not be associated with impairment of consciousness, depending on their location and the involvement of other brain structures. Partial seizures are further broken down into simple partial and complex partial. Simple partial seizures do not involve any change in consciousness. Partial seizures that involve any alteration in consciousness are now called complex partial instead of temporal lobe or psychomotor. In contrast, generalized seizures affect both sides of the brain and cause an abrupt loss of consciousness at the onset of the seizure. These seizures may or may not be convulsive. (During a convulsive seizure, a Individual also exhibits shaking or violent, involuntary contractions of single or multiple groups of muscles). A variety of seizures are classified as generalized seizures; however, their new classifications may not be familiar. The term grand mal has been replaced by tonic if the body becomes stiff, clonic if the body jerks, and tonicclonic if the body stiffens and jerks. Seizures that cause a brief loss of awareness, staring, or blinking are not longer termed petit mal, but are called absence. Status epilepticus is generally defined as more than 30 minutes of continuous seizure activity or two or more seizures without recovery of baseline consciousness in between. Convulsive (tonic-clonic) STATUS EPILEPTICUS IS A MEDICAL EMERGENCY that is LIFE-THREATENING and may cause broken bones, cardiac arrhythmias, anoxia, permanent neurologic injury, or even death if treatment is delayed or ineffective. The most common cause is

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Individual noncompliance with medications (Refer NPPM #700 Medical Emergency.

5. CLASSIFYING SEIZURES: A QUICK REFERENCE GUIDE: PRIMARY GENERALIZED SEIZURE: may be convulsive or non-convulsive 1.1 ABSENCE PARTIAL SEIZURES: 1.7 Brief loss of consciousness (5 to 30 seconds) Blank stare or eye blinking No postictal period - person automatically returns to previous activity 1.2 MYOCLONIC SIMPLE PARTIAL

Short abrupt muscle contractions of arms, legs, or torso Possibility of muscle contractions strong enough to cause a fall. Individual may drop objects, spill beverages, or be propelled out of a chair Symmetrical, asymmetrical, synchronous, or asynchronous contractions Lasts seconds 1.3 CLONIC

May be preceded by an aura Consciousness maintained Motor symptoms: abnormal unilateral movement of arm, leg, or both Sensory symptoms: may sense abnormal sounds, smells, or body sensation Autonomic symptoms: changes in heart rate, respiratory rate, or both. Skin flushing or epigastric discomfort Psychic symptoms: Individual may report intense feeling of fear or deja vu. Lasts seconds to minutes 1.8 COMPLEX PARTIAL

Muscle contraction and relaxation; jerking movements Both sides of body involved May last several minutes 1.4 TONIC

Sudden stiffening movements of the body, arms, and legs Involves both sides of the body; flexion of arms and extension of legs Common during sleep

Possible progression to secondarily generalized tonic-clonic seizure Consciousness impaired, not lost Eyes may be wide open Possibility that Individual may be unable to respond to questions or commands or respond inaccurately or inappropriately Automatisms such as lip smacking or picking at clothes Possible bizarre behaviors: running, screaming, or disrobing Jumbled speech or repetitive phrases Possible posturing or jerking movements Lasts seconds to minutes Postictal confusion and amnesia common

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Usually lasts less than 20 seconds 1.5 TONIC-CLONIC

Loss of consciousness A cry caused by contraction of respiratory muscles forcing exhalation Body stiff - patent falls to the ground Tonic phase: eyes may roll up or to the side, Individual may bite tongue; symmetrical extension of extremities Clonic phase: jerking of head, face, arms, and legs. End of clonic phase: Person becomes flaccid Urinary, fecal incontinence Exhaustion and confusion; hours of sleep for recovery 1.6 ATONIC

Abrupt loss of muscle tone-Individual falls to ground Lasts seconds Postictal confusion

6. CAUSES OF SEIZURES: High fever: Heatstroke Infection Brain infections: AIDS Malaria Rabies Syphilis Tetanus Toxoplasmosis Viral encephalitis Metabolic disturbances: Hypoparathyroidism High levels of glucose or sodium in the blood Low levels of glucose, calcium, Destruction of brain tissue: Brain tumor Head injury Intracranial hemorrhage Stroke Other illnesses: Hypertensive encephalopathy Lupus erythematosus Exposure to toxic drugs or substances: Alcohol (large amounts) Amphetamines Cocaine overdose Withdrawal after heavy use: Alcohol Sleep aids

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magnesium, or sodium in the blood Kidney or liver failure

Tranquilizers

Adverse reactions to prescription drugs Insufficient oxygen to the brain Carbon monoxide poisoning Inadequate blood flow to the brain Near drowning Near suffocation Stroke

7. INTERVENTIONS: SEIZURE ACTIVITY: NURSING ACTION A. Protect airway patency. Protect Individual from injury. KEY POINTS A. Direct available staff to obtain Emergency Cart, emergency drug box, AED, pulse oximeter, and an extra oxygen tank.

B. Assess type and extent of seizure.

B. Refer to classifying seizures: a quick reference guide.

C. If possible, place Individual on his/her side to facilitate drainage of secretions. D. Have staff notify the physician and NOD/RN STAT. E. Perform a brief neurologic assessment once the postictal period has passed. D. Dial 7119" for medical assistance. Dial 7119" for paramedics.

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8. STATUS EPILEPTICUS:

NURSING ACTION A. Quickly assess the Individual to determine his/her status. Activate EMS (Emergency Medical System). Call 7119. B. Maintain an open airway and protect the Individual from injury. C. Have staff call for physician and RN STAT. D. Direct staff to bring the Emergency Cart, drug box, monitor/ defibrillator, pulse oximeter, and an extra oxygen tank to the scene. E. Set up suction, open emergency drug box, and set up for possible IV insertion and drug administration.

KEY POINTS A. Status Epilepticus is a LifeThreatening Medical Emergency requiring immediate medical attention

E. An RN may start an I.V. of Normal Saline or D5W TKO (to keep vein open) without a physician order in a life threatening emergency. RN may give I.V. PUSH medication in the presence of a physician. (In an emergency, IV supplies are found in the Emergency Drug Box).

F. Obtain physicians orders for: a) IV (fluid and rate); b) Arrange for medical transportation to outside medical facility. G. Prepare Individual for transport. Coalinga Transfer form. G. In medical emergencies, an Coalinga Transfer form shall accompany the Individual

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1.8.1 TIPS TO REMEMBER Keep in mind the following when caring for a Individual during a generalized tonicclonic seizure: Keep calm. Reassure others nearby. Clear the area around the Individual of anything dangerous. Loosen anything around the Individuals neck that may make breathing difficult. Place something soft under the Individuals head (e.g. a blanket). If possible, turn the Individual gently on his or her side to help keep the airway clear. (Some Individuals may produce copious amounts of secretions during a seizure. Others may vomit). Stay with the Individual until the seizure ends. Reassure the Individual as consciousness returns. Speak softly and calmly. Do not attempt to force anything into the Individuals mouth. Do not attempt to hold the Individual down or to restrain movement. Do not attempt CPR during a seizure. Wait until the seizure has stopped, then asses ABCs. 10. PREICTAL PERIOD: Begin by asking and identifying what happened before the seizure. 1. Precipitating Factors: Did the Individual have some type of emotional upset? Did anyone notice any unusual behavior or mood changes before the seizure? Did some type of environmental stimulus, e.g. unusual light, pattern, or noise, start seizure? Did the Individual miss medication? 2. Aura: Was the Individual aware that attack was coming? How? Did the Individual have any unusual taste, smell, or visual change before seizure occurred? 11. ICTAL PERIOD: (See Classifying Seizures: Quick Reference Guide to best describe observation)

1. Point of Origin: What motor movements were observed? Where did muscle movements originate? How did the seizure progress? Was one side of the body affected or both? For example, if the movement started in the face, did it spread to the arms or legs? -8N.P.P No. 703

 2. 3.

Did the Individual display automatisms, such as lip smacking? Duration? How long did it last? Did the Individual fall? Involvement: Was seizure type generalized or partial? Did position of body change? Were teeth clenched? Was there frothing? Did color change on face/lips? Deviation of Eyes: Did eyes move laterally, upward, or downward? Was any nystagmus noted? What were the size and reaction of the pupils?

4. Was Individual incontinent of feces or urine? 5. Respiratory Pattern: Was there any apnea; dyspnea? Was there any irregular breathing, stertor, snoring, etc.? 6. Loss of consciousness: How soon could the Individual be aroused to point of response? Was Individual sleepy or confused during or after attack? What was duration of unconsciousness?

POSTICTAL STATE: Find out what happened after the seizure: Was Individual able to move all extremities? Was any weakness noted? Did Individual have any complaint of discomfort or unusual sensation after episode? Did Individual have any changes or peculiarities of speech? Was Individual confused or combative? How long did confusion last? Did Individual have any other behavioral changes? Did Individual complain of a headache? Describe Individuals level of consciousness. Was he or she able to follow simple commands? Does the Individual recall anything that occurred during the seizure? How often has Individual had seizures? How long has it been since the last seizure? How long did this seizure last?

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 704 Effective Date: August 31, 2006 SUBJECT: EMERGENCY CARE OF BURNS (FIRST AID) 1. PURPOSE: To alleviate pain, prevent infection and replace fluid loss. 2. POLICY: Prompt medical care shall be provided for all types of burns. Nursing staff shall immediately evaluate the Individual to determine the medical emergency status (LIFE THREATENING call 7119; NON LIFE THREATENING call 7119) and take appropriate action as outlined in A.D. #10.25 and NPPM #700 Medical Emergency. 3. COMPETENCY/TRAINING: All Level of Care nursing staff is required to take First Aid training at time of hire and every three years thereafter as a part of Mandated Training. 4. DEFINITION: BURN - Tissue injury resulting from contact and/or exposure to any thermal, chemical, electrical, or radioactive agents. The effects vary according to the type, duration, and intensity of the agent and part of the body involved.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 705 Effective Date: August 31, 2006

SUBJECT: EMERGENCY CARE OF WOUNDS (FIRST AID) 1. PURPOSE: Proper wound care is necessary to promote an intact skin layer after healing. The integument system is the bodys first line of defense against invasion by infectious microorganisms. Wound healing involves a series of physiological processes. These processes can be affected by location, severity, and extent of the injury. The purpose of this policy is to identify the different kinds of wounds and the appropriate care for each while observing proper blood and body fluid precaution and preventing infection. 2. POLICY: 1. All Individuals shall receive prompt and appropriate care of their wounds along with teaching and guidance on how they can help in their care. 2. Nursing staff will check if the Individuals tetanus vaccination is current and will obtain a physicians order to give the Tetanus-Diphtheria Adult Toxoid if the vaccination is not current. (Refer to Infection Control Manual Immunization Protocols for the schedule of primary immunization for Tetanus - Diphtheria Adult Toxoid protocol). 3. PRECAUTIONS: 1. The fluid blood & moist body substances of all Individuals shall be treated as though they were contagious. Refer to universal precautions infection control 2. In all reasonably anticipated exposures to blood or other potentially infectious material, Personal Protective Equipment (PPE) and engineering controls shall be used. 4. DEFINITIONS: A wound is an injury to the tissues of the body causing disruption of the normal tissue pattern, such as an injury caused by a physical means. -1N.P.P No. 705

5. CLASSIFICATION OF WOUNDS: A) Contusion - Closed wound caused by a blow to body by blunt object; a bruise characterized by swelling, discoloration, and pain. B) Laceration - Made by an object which tears tissue, producing jagged irregular edges. C) Puncture - A wound in which a foreign object, usually pointed or sharp in nature, pierces the skin. D) Incised - A clean cut made by a sharp instrument, such as a knife. E) Abrasion - Superficial wound involving scraping or rubbing of skins surface. 6. GENERAL INFORMATION: A) Clean Wound: Wound containing no pathogenic organisms. This wound, like a surgical incision, is aseptically made and does not enter the alimentary, respiratory, or genito-urinary tract. There is low risk of infection. B) Clean-contaminated Wound: Wound made under aseptic conditions but involving a body cavity that normally harbors microorganisms, e.g. surgical wound entering the gastrointestinal, genito-urinary, respiratory tract, or oropharyngeal cavity under controlled conditions. There is a greater risk of infection than with clean wound. C) Contaminated Wound: Wound existing under conditions in which presence of microorganisms is likely. Open, traumatic, accidental wounds; surgical wound in which break in asepsis occurred. Tissues are often not healthy and show inflammation. There is a high risk of infection. D) Infected Wound: A wound or incision invaded by a pathogenic agent like a bacteria, virus, or fungi and under favorable conditions multiplies causing injurious effects. Any wound that does not properly heal and grows organisms. Wound presents signs of infection (inflammation, purulent drainage, skin separation)

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7. EQUIPMENT NEEDED: -Disposable gloves -Gown (if wound is infected and purulent) -Forceps -Dressing and materials (e.g. gauze, bandages) -Tape -Scissors -Red bag for infectious waste and bio-hazardous waste container 8. EXPECTED OUTCOMES: -Stop bleeding; -Protect from contamination and infection; -Prevent shock; -Wound begins to heal; dressing is clean and dry; wound is free of drainage and inflammation; -Skin integrity is maintained. 9. ASSESSMENT: -Establish history and circumstances of how the wound occurred including physical factors involved. -Ascertain the time the incident happened. -Determine history of allergies and of past tetanus immunization. -Inspect the wound by checking for depth of the wound; nerve, vessel, or tendon involvement; bone injury; foreign bodies; general extent of wound contamination; and odor. -Assess drainage from wound (amount, color) and consistency of drainage.

10. INTERVENTIONS/IMPLEMENTATION: Controlling bleeding: NURSING ACTIONS A. Put on gloves. B. Assess the injury. C. Have other staff notify physician and HSS. KEY POINTS A. Follow Standard Precautions. B. Determine type and extent of injury. C. Prompt intervention is vital to alleviating and treating the trauma. Red Bag should be brought to the site. Dial 7119 for Non-Life Threatening Medical

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Emergencies. D. Apply direct pressure using thick pad, towel, or your gloved hand and elevate affected part if it does not cause pain. D. Control bleeding by applying direct pressure. If a dressing becomes saturated with blood, add another layer of dressing. Continue to apply pressure. Elevation of the affected part aids in reducing the bleeding. E. Monitor Vital Signs including pain rating assessment. Be alert for signs and symptoms of shock. F. Refer to NPPM #715 Emergency Care of Hemorrhage.

E. If bleeding is not controlled by direct pressure, apply pressure to a pressure point. F. When bleeding is under control, gradually release pressure point; but maintain direct pressure on wound. G. Avoid the use of a tourniquet unless a limb has been completely severed. H. Assess for shock and treat when indicated.

G. Tourniquets are restricted to lifesaving measures only. H. Refer to NPPM #707 Shock.

Cleansing wounds: NURSING ACTION A. Hand hygiene KEY POINTS A. Reduces transmission of microorganisms. B. Explaining the procedure to the Individual assists with gaining the Individuals cooperation and allaying Individual anxiety. C. Maintain Standard Precautions. D. Specimen for culture is best obtained before the wound is cleaned.

B. Assemble supplies and materials needed. Explain the procedure to the Individual.

C. Put gloves on. D. If a specimen is needed for culture and sensitivity, swab infected area with maximum saturation of cotton-tipped culture swab and place it back into the culture tube.

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E. Cleanse small wound with mild soap and water. Rinse thoroughly with clean water.

F. Clean large or deep wounds only when ordered by physician. G. Surgical incisions are cleaned along the edge in small circular motion. Do not scrub back and forth across the incision line. H. Apply clean and dry dressing using only the amount of tape necessary to securely attach the dressing. I. Dispose of blood soaked contaminated materials and dressings in the biohazardous container.

E. Gentle cleansing of a wound removes contaminants that might serve as sources of infection. Most antiseptic agents are caustic to tissues and may impair tissue healing. F. Follow physicians order as prescribed. G. To prevent contamination and mechanical trauma to the incision.

H. Too much tape may cause irritation and trauma to the skin.

I. To prevent transmission of pathogenic organisms.

11. INDIVIDUAL TEACHING: Instruct Individual on wound care and explain why these steps are necessary. Instruct the Individual in the following: 1. To ask for pain medication if needed. 2. Report immediately to the nursing staff if any of the following signs occur: a. Redness or swelling; b. Increased warmth around the wound; c. Pus, unusual drainage, and/or foul odor from the wound; d. Presence of red streaks around the wound e. Fever above 100 Fahrenheit or chills. Discuss what activities the Individual is allowed to undertake while the wound ishealing. 4. Keep suture area clean. Avoid tub baths. 5. Never rub vigorously near the suture line and pat dry after shower. 6. Show the Individual how to support the incision when coughing.

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7. Avoid touching the incision or wound area (as well as drainage tubings if present) to prevent infection. 12. EVALUATION/DOCUMENTATION: Include the following in the documentation about the wound and the care given: 1. 2. 3. 4. 5. 6. Describe the type of wound, e.g. surgical, accidental or inflicted injury. Indicate location, size, condition of the wound and amount of drainage. Identify if Individual is experiencing any pain or discomfort. Describe the wound care provided. Individual teaching given and his or her understanding of these. Discuss and document the Individuals perceptions and feelings regarding the wound, especially if this may cause scaring or disfigurement after healing. 7. Monitor and report healing progress.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 706 Effective Date: August 31, 2006 SUBJECT: HEAT RELATED CONDITIONS 1. PURPOSE: The purpose of this policy is to assist nursing staff in differentiating the types of heat disorders and to provide immediate assessment and intervention to protect individuals and staff from injury during times of extreme weather or when unit temperatures are too hot due to malfunction of equipment. 2. POLICY: Nursing staff shall immediately evaluate the client or staff member to determine the medical emergency status (LIFE-THREATENING call 7119; NON LIFETHREATENING call 7119) and take appropriate action as outlined in A.D. #10.25 and NP&P #700 Medical Emergencies. An I.V. of Normal Saline or D 5W at TKO (to keep vein open) may be started by RNs who are I.V. proficient prior to a physicians order in life-threatening emergencies. A physicians order must be obtained as soon as possible thereafter. During summer months individual served health education should be provided on a continuous and ongoing basis during therapeutic community meetings and during 1:1counseling regarding methods to prevent heat related illnesses. 3. COMPETENCY/TRAINING: All Level of Care nursing staff is required to take First Aid training at time of hire and every three years thereafter as part of Mandated Training. 4. GENERAL INFORMATION: By sweating, breathing, shivering, and shifting the flow of blood between the skin and internal organs, the body can usually keep its temperature within a narrow range in hot or cold weather. However, overexposure to high temperatures can result in heat disorders such as heat cramps, heat exhaustion, and heat stroke. -1N.P.P No. 706

The risk of heat disorders is increased by high humidity, which decreases the cooling effect of sweating, by extreme weather conditions (as is typical in the San Bernardino County during the summer months), and by prolonged strenuous exertion, which increases the amount of heat produced by the muscles. People at risk for heat related illnesses are the elderly, the very obese, those who work or exercise outdoors, people with health problems, those who have had a heat related illness in the past, those with medical conditions that cause poor circulation and those who take certain medications such as antihistamines, antipsychotic drugs, and diuretics. Heat related illness in its early stages can be reversed. 5. TYPES OF HEAT RELATED CONDITIONS: Dehydration - is a decrease in the bodys water level below that required for adequate circulation. A common cause of dehydration is overexertion in hot conditions so that the body loses large amounts of fluid in perspiration while fluid intake is inadequate to replace the volume. 6. CLINICAL MANIFESTATIONS: The victim may appear weak, dizzy, profoundly exhausted. They can have difficulty thinking clearly. They may experience nausea and may be drenched in sweat. They can have dark urine with a strong odor. They may have cramps. Taking a pinch of skin from the back of the hand can indicate more severe dehydration. If the pinched fold stays up (the skin is no longer pliable) the victim is becoming dangerously dehydrated. 7. TREATMENT/FIRST AID: Careful attention to adequate intake of fluids and electrolytes and recognizing individual limitations is an important step in preventing dehydration. Drink at least one quart (or liter) of fluid each hour you are doing physical activity for continuous hydration. Re-hydrate victim with plain chilled water. Do not use sweetened or salted liquids. Severe dehydration will require medical intervention with I.V. fluids. Heat exhaustion - is a condition resulting from exposure to excessive heat in which excessive loss of fluids from heavy sweating leads to fatigue, low blood pressure, and sometimes collapse. Electrolytes are lost with the fluids, disturbing the circulation and the brains functioning. This condition may progress to heat stroke. 8. COMPETENCY/TRAINING: All Level of Care nursing staff are required to take CPR and First Aid training at time of hire and then CPR every two years and First Aid every three years thereafter as part of Mandated Training.

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9. DEFINITIONS: Shock - a state in which there is loss of effective circulating blood; inadequate organ and tissue perfusion ultimately resulting in cellular metabolic derangement. Shock is classified as: Cardiogenic shock - secondary to ventricular failure and inadequate blood volume. Anaphylactic shock - an acute often-explosive systemic reaction when a previously sensitized person again receives a sensitizing antigen. Electric shock - injury caused by an electric current passing through the body. Neurogenic shock - caused by neurologic insult from injury, disease, or drugs, which disrupt transmission of nerve impulses. Hypovolemic shock - results from inadequate intravascular volume. Septic shock - caused by bacterial infection

Example: Toxic shock syndrome - a syndrome characterized by high fever, vomiting, diarrhea, confusion & skin rash that may rapidly progress to severe & intractable shock. The exact cause is unknown. An infection with exotoxin-producing strains of Staphylococcus aureus has been linked with 3.

10. COMPETENCY/TRAINING: All Level of Care nursing staff is required to take CPR and First Aid training at time of hire and then CPR every two years and First Aid every three years thereafter as part of Mandated Training. Example: Toxic shock syndrome - a syndrome characterized by high fever, vomiting, diarrhea, confusion & skin rash that may rapidly progress to severe & intractable shock. The exact cause is unknown. An infection with exotoxin-producing strains of Staphylococcus aureus has been linked with hypotension, vertigo, headache, moderately elevated temperature (not above 100 F).

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11. ASSESSMENT FOR HEAT EXHAUSTION: Assess the individual for signs/symptoms of heat related illness: Heat exhaustion/Heat stroke. 12. EXPECTED OUTCOME: To prevent this syndrome from progressing to heat stroke.

13. INTERVENTION FOR HEAT EXHAUSTION: NURSING ACTION A. Place the individual in a recumbent position in a cool, well-ventilated area. KEY POINTS A. Lying flat or with head lower than the rest of the body and sipping cool, slightly salty beverages every few minutes assists with rapid recovery. B. Assess symptoms. Obtain STAT complete set of vital signs. C. The main treatment is replacing fluids (rehydration) and electrolytes. Sometimes, fluid replacement may need to be given intravenously. D. If blood pressure remains low and the pulse remains slow for more than an hour despite this treatment, another condition should be suspected. E. Document all client teaching on the Wellness and Recovery Individual/Family Health Education Record (CSH 7156).

B. Notify physician/MOD and RN.

C. Push fluids.

D. Monitor vital signs/neurological status at least every 15 minutes until stable.

E. Provide health teaching to high-risk individuals regarding activity level during periods of high heat (greater than 85 F).

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14. HEAT STROKE/SUNSTROKE: Is the most serious of the heat-related illnesses. The body generates more heat than it is able to dissipate. It is a LIFE THREATENING MEDICAL EMERGENCY and requires IMMEDIATE and AGGRESSIVE treatment. Call 7119. Heat stroke occurs when the bodys heat regulating mechanism fails. The body temperature rises so high that brain damage and death may result unless the body is cooled quickly. When the body generates more heat than it is able to dissipate, heat accumulates, the bodys core temperature rises, and potentially widespread physiologic dysfunction occurs. Without immediate intervention, permanent brain damage or death can happen. 15. TWO TYPES OF HEATSTROKE: Classical and Exertional: Classic heatstroke - occurs in individuals who do not sweat normally, either because of a disease or certain medications. The typical victim is an older adult who lives without air conditioning and has underlying health problems, such as heart disease or diabetes. This type can take 2 3 days to develop. Studies have shown that even a few hour of air conditioning each day can prevent the condition. Exertional heatstroke - happens quickly, often after only a few hours of exercise. The skin is able to sweat, but the body still overheats because of a combination of hot weather, extra activity, and dehydration. Exertional heatstroke victims are usually young, otherwise healthy people, such as runners and football players. Dehydration is usually the first warning sign.

SIGNS/SYMPTOMS: HOT, RED, and usually DRY skin not sweating Body temperature is VERY HIGH (more than 105.0oF) Rapid, weak pulse Rapid, shallow breathing Pulse racing over 160 BPM Pupils are very small Severe headaches Being argumentative/combative Vertigo Disorientation Delirium Coma

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Individual is usually unconscious

16. PRECAUTIONS: Rule out Neuroleptic Malignant Syndrome and Lithium Toxicity. Signs of heat exhaustion or heat stroke may overlap. Individuals taking Haldol, phenothiazines, and anticholinergics are at higher risk. 17. TREATMENT/FIRST AID: This is a medical emergency Rapid recognition of the signs and symptoms so rapid treatment can occur. Rapid treatment is critical since the longer the bodys core temperature is elevated the greater the risks of severe organ damage and death. Severe Medical Emergency get to a hospital immediately Get victim into a cool place Cool the victim as quickly as possible in any manner possible Place the victim into a bathtub of cool water, wrap in water soaked sheets Cold bath or sponging Cold packs on the neck, in the armpits and groin Remove clothing use fans and air conditioner, ice or cold packs Place victim in a cool lake or river (supporting their head to keep it above water) DO NOT GIVE FLUIDS (if unconscious, cant swallow) DO NOT APPLY RUBBING ALCOHOL DO NOT give salt tablets (if unconscious, cant swallow or chew) Treat for shock 18. INTERVENTIONS FOR HEAT STROKE: Key Points A. Refer to A.D and NP&P #700 Medical Emergency. Dial 7119 for paramedic assistance or dial 7111 for hospital staff assistance. B. An RN may start an I.V. of Normal Saline (or D5W) at TKO (to Keep Open) rate without a physician order in a lifethreatening emergency. A physicians order must be obtained ASAP thereafter.

Nursing Action A. Call physician/MOD immediately. Get victim out of the heat. Bring emergency medical equipment to the scene. Notify the RN. B. Start an I.V. Begin Intake and Output record.

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C. Loosen tight clothing. Apply cool, wet cloths (such as towels or sheets) to the skin.

C. Keep victim lying down and continue to cool the body by all available means, e.g. use of a fan. Apply cool packs especially to the wrists and ankles, groin, each armpit, and on the back of neck to cool the large blood vessels. Avoid shivering. Stop cooling when temperature reaches 102o F. D. The heart rate increases and may quickly reach 160 to 180 beats per minute. The individual may become disoriented and confused and can quickly loose consciousness or have convulsions. E. Reduces cutaneous vasoconstriction that may occur from rapid cooling. F. Nursing staff must remain with the individual in all medical emergencies. G. Continue life saving measures until client care is taken over by the paramedics.

D. Monitor vital signs and neurological status at least every 5 minutes or more often if clinically indicated.

E. Massage body and extremities to maintain circulation. F. Remain with the individual to allay fears and provide constant monitoring. G. Prepare for transport as soon as possible with paramedics/ambulance.

19. OTHER TYPES OF HEAT RELATED CONDITIONS: Heat cramps are severe muscle spasms resulting from heavy sweating during exertion in extreme heat. Heat cramps are caused by the excessive loss of fluids and electrolytes - including sodium, potassium, and magnesium - resulting from heavy sweating, as occurs during strenuous exertion. 20. CLINICAL MANIFESTATIONS: Heat cramps often begin suddenly in the hands, calves, or feet; they are often painful and disabling. The muscles become hard, tense, and difficult to relax. Muscular cramping may be evident in the large muscle groups (thighs/shoulders). The individual may also have nausea, pale, wet skin, temperature between 98-100 F, normal blood pressure. Onset is sudden.

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21. ASSESSMENT FOR HEAT CRAMPS: Assess individual for Heat Related Illness, refer to clinical manifestations. 22. EXPECTED OUTCOME: To prevent condition from progressing or worsening. 23. INTERVENTIONS FOR HEAT CRAMPS: NURSING ACTION A. Take individual to a cool area. B. Notify physician/MOD and RN. KEY POINTS A. Provide rest. B. Follow treatment as directed by the physician/MOD. C. Heat cramps can be prevented or treated by drinking beverages or eating foods containing salt. D. Lightly stretch the muscle and gently massage the area. E. Strenuous exertion in a very hot environment or a poorly ventilated space should be avoided, and appropriate clothing should be worn. Fluids and electrolytes lost through sweating can be replaced by consuming salted foods and beverages, such as salted tomato juice or cool bouillon. Many commercial drinks, such as Gatorade, include extra salt.

C. Replace fluid and salt loss by giving the individual sips of salted water as ordered by physician/MOD. D. Gently massage the cramping muscles. E. Provide health education for the individual to maintain proper nutrition with intake of fluids and salt during periods of high heat. Consult and collaborate with the dietician on effective health teaching specific to individual client needs.

HEAT FATIGUE is caused by depletion of water and salt due to sweating. 24. SIGNS/SYMPTOMS: Feeling of weakness and tiredness

25. TREATMENT: Get out of the sun and into the shade Replace fluids with cool water

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HEAT SYNCOPE - presents as an orthostatic syncope (lightheadedness, fainting) episode that usually occurs with prolonged standing or sudden rising from a sitting or lying position. Predisposing factors include exercise without a cool-down period, dehydration, and lack of acclimatization. Heat syncope can result from inadequate cardiac output and postural hypotension. 26. TREATMENT: Recovery is immediate once the victim falls to the ground. Place the victim in a supine position and replace any water deficit. The victim should not engage in vigorous activity at least the rest of that day.

27. EVALUATION: Document in ID notes: 1. Date and time condition occurred 2. Problem number (temporary condition) 3. Individual's signs and symptoms 4. Vital signs 5. Nursing implementations/interventions and disposition of individual 6. Individual response to treatment

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 707 Effective Date: August 31, 2006 SUBJECT: EMERGENCY CARE OF SHOCK 1. PURPOSE: To provide prompt assessment and interventions measures for the lifethreatening conditions of shock. 2. POLICY: 1.Nursing staff shall immediately evaluate the Individual to determine the medical emergency status (LIFE THREATENING call 7119; NON LIFE THREATENING call 7111) and take appropriate action as outlined in A.D. and NPPM #700 Medical Emergency. 2. All available physicians and nursing staff shall respond to all medical emergencies in a prompt and competent manner. 3. An I.V., preferably of Normal Saline TKO (to keep vein open) may be started by RNs who are I.V. proficient prior to a physicians order in life threatening emergencies. A physicians order must be obtained ASAP thereafter and include rate of infusion. (Refer to NPPM #547 Administration of Medication and Fluids by Intravenous Route). Use largest bore needle available that can be inserted. 4. Oxygen administration up to 6 liters per minute via nasal cannula, or 6 liters to 10 liters via facemask, may be given by a Registered Nurse to Individuals with no history of Chronic Obstructive Pulmonary Disease prior to a physicians order in emergency situations. A physicians order must be obtained immediately thereafter. 5. Oxygen administration up to 2 liters via nasal cannula may be given by a Registered Nurse to Individuals with a history of Chronic Obstructive Pulmonary Disease prior to a physicians order in emergency situations. A physicians order must be obtained immediately thereafter.

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3. COMPETENCY/TRAINING: All Level of Care nursing staff are required to take CPR and First Aid training at time of hire and then CPR every two years and First Aid every three years thereafter as part of Mandated Training. 4. DEFINITIONS: SHOCK - a state in which there is loss of effective circulating blood; inadequate organ and tissue perfusion ultimately resulting in cellular metabolic derangement. SHOCK IS CLASSIFIED AS: Cardiogenic shock - secondary to ventricular failure and inadequate blood volume. Anaphylactic shock - an acute often-explosive systemic reaction when a previously sensitized person again receives a sensitizing antigen. Electric shock - injury caused by an electric current passing through the body. Neurogenic shock - caused by neurologic insult from injury, disease, or drugs, which disrupt transmission of nerve impulses. Hypovolemic shock - results from inadequate intravascular volume. Septic shock - caused by bacterial infection Example: Toxic shock syndrome - a syndrome characterized by high fever, vomiting, diarrhea, confusion & skin rash that may rapidly progress to severe & intractable shock. The exact cause is unknown. An infection with exotoxinproducing strains of Staphylococcus aureus has been linked with this syndrome.

5. PRECAUTIONS: Nursing personnel, having direct or the potential for contact with exposure to blood, body fluids, or other potentially infectious material of Individuals, are expected to practice STANDARD PRECAUTIONS according to guidelines established by the CSH Infection Control Program. Personal protective equipment and engineering controls shall be used as needed.

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6. GENERAL INFORMATION: Shock is the common factor in a wide variety of disease processes that present as an IMMEDIATE THREAT TO LIFE. Shock is inadequate tissue perfusion as a result of failure of one or more of the following: 1) the heart pump failure; 2) blood volume; 3) arterial resistance vessels; and 4) the capacity of the venous beds. Any condition that significantly effects any of the above may precipitate a shock state. Shock is a LIFE-THREATENING condition in which blood pressure is too low to sustain life. Shock results when a low blood volume, an inadequate pumping action of the heart, or excessive relaxation (dilation) of the blood vessel walls (vasodilation) causes severe low blood pressure. This low blood pressure, which is much more severe and prolonged than in fainting (syncope), causes an inadequate blood supply to body cells. The cells can be quickly and irreversibly damaged and die. Low blood volume may result from severe bleeding, an excessive loss of body fluids, or inadequate fluid intake. Blood may be rapidly lost because of an accident or internal bleeding, such as that caused by an ulcer in the stomach or intestine, a ruptured blood vessel, or a ruptured ectopic pregnancy. An excessive loss of other body fluids can occur with major burns, inflammation of the pancreas, perforation of the intestinal wall, severe diarrhea, kidney disease, or excessive use of diuretics that increase the output of urine. An inadequate pumping action of the heart also can result in less than normal amounts of blood pumped out with every heartbeat. The inadequate pumping action may result from a heart attack, pulmonary embolism, failure of a heart valve, or an irregular heartbeat. Excessive dilation of the blood vessel walls may result from a head injury, liver failure, poisoning, overdoses of certain drugs, or severe bacterial infection. 7. STAGES OF SHOCK/SIGNS & SYMPTOMS: STAGE I
Early or Compensatory Stage:
* Restlessness, irritability, apprehension;

STAGE II Intermediate or Progressive Stage:

* Listlessness, apathy, confusion, * Slowed speech;

STAGE III
Late or Decompensatory Stage:
* Confusion, incoherence, slurred speech; possibly

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* Slightly increased heart rate; * Normal blood pressure/slightly elevated systolic pressure or slightly decreased diastolic pressure; * Mild orthostatic blood pressure changes; * Normal/slightly decreased urine output; * Pale & cool skin in hypovolemic shock; warm flushed skin (in septic, anaphylactic, and neurogenic shock); * Slightly increased respiratory rate; * Slightly decreased body temperature (fever in septic shock).

* Tachycardia; * Weak & thready pulse; * Decreased blood pressure; * Narrowed pulse pressure (widened in septic shock); * Moderate to severe orthostatic blood pressure changes (25-50 mm Hg); * Oliguria; * Cold, clammy skin; * Tachypnea.

unconsciousness; * Depressed or absent reflexes; * Dilated pupils slow to react; * Slowed, irregular, thready pulse; * Decreased blood pressure with diastolic pressure reaching zero; oliguria/anuria; * Cold, clammy, cyanotic skin; * Slow, shallow, irregular respirations; * Severely depressed body temperature.

8. PRIMARY ASSESSMENT AND INTERVENTIONS:

Rapid recognition and prompt intervention are essential to increase the chance of survival, because a downward spiral of physiologic responses will occur if shock is not treated. 1. The initial priorities in the assessment are the same for all types of shock. -Is the airway open? Assess airway patency. -Is the Individual breathing? Assess the quality of the Individuals respirations. -Is there a circulation problem? Assess the circulatory status, pulse, blood pressure, capillary refill. 2. Initiate immediate interventions as indicated. -Resuscitate as necessary. -Administer oxygen to augment oxygen-carrying capacity of arterial blood. -Start cardiac monitoring. -Start I.V. -Control hemorrhage.

9. SUBSEQUENT ASSESSMENT AND INTERVENTION:

Once stabilized, continue assessment for causes: -identify precipitating factors that may have led to shock -identify type of shock Assessing a Individual in shock is a two-track process.

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Your assessment must be rapid to start intervening immediately in order to: a. Correct the underlying cause; b. Reverse the physiologic shock cycle. 10. EXPECTED OUTCOME: 1. To restore tissue perfusion & reduce peripheral vasoconstriction. 2. Provide immediate care to prevent death, disability, serious illness, injury, or complications. 11. IMPLEMENTATION/INTERVENTIONS: NURSING ACTION 1. Immediately assess the Individuals airway, breathing, and circulation. Initiate appropriate action (CPR, stop hemorrhage, etc.) KEY POINTS 1. Have another staff call for physician and additional staff. Dial 7119 for paramedic assistance or dial 7119 for hospital staff assistance.

2. Have additional staff bring emergency medical equipment to the scene (Emergency Cart, Emergency Drug Box, Monitor/Defibrillator.

2. Refer to NPPM #700 Medical Emergency. Phone numbers and locations of nearest emergency medical equipment are on red signs in nursing offices, treatment/medication rooms, and other locations. Start Medical Emergency Flow Sheet. 3. A physicians order must be obtained ASAP after the I.V. is started. Ask physician regarding rate of infusion. Shock usually requires rapid rate. Use largest bore needle available that can be inserted. (Refer to NPPM #547 Administration of Medication and Fluids by Intravenous Route (Heparin Lock and IV Administration).

3. An I.V., preferably of Normal Saline TKO (to keep vein open) may be started by RNs who are I.V. proficient prior to a physicians order in life-threatening emergencies.

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4. Keep Individual lying down flat, with feet slightly raised to increase venous return.

4. Administer oxygen as needed. The RN, prior to a physicians order in emergency situations, may give oxygen administration. A physicians order must be obtained immediately thereafter. Refer to NPPM #419 Oxygen Therapy.

5. Keep Individual warm but do not overheat. Continually reassure Individual and provide support.

5. Prepare Individual for transport to Acute Care Medical facility.

12. EVALUATION AND DOCUMENTATION: Documentation/charting should include the following: a. Time & date; b. Problem number; c. Initial Individual assessment and progress of symptoms; d. All nursing interventions and effectiveness of interventions; e. Vital signs; f. Time that assistance arrived, if paramedic assistance called; g. Disposition of Individual; h. Medical emergency critique/survey form. CROSS -REFERENCE: Medical Emergencies, Mandated Training; NPPM Section 700 Series, Standard Precautions, NPPM #547 Administration of Medication and Fluids by Intravenous Route (Heparin Lock and IV Administration), NPPM #309 Vital Signs, NPPM #419 Oxygen Therapy; First Aid Manual utilized for Mandated First Aid Training

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 708 Effective Date: August 31, 2006 SUBJECT: EMERGENCY TREATMENT OF HEAD INJURIES 1. PURPOSE: To provide guidelines for the assessment of the type/extent of head injury and for the initiation of appropriate emergency care and to prevent further injury. 2. POLICY : 1. Nursing staff shall immediately evaluate the individual to determine the medical emergency status (LIFE THREATENING call 7119; NON-LIFE THREATENING call 7119) and take appropriate action as outlined in NPPM #700 Medical Emergency). 2. Always suspect a neck injury when there is a serious head injury. Keep the neck and head still. Always apply an appropriately sized cervical collar prior to moving the individual. 3. PRECAUTIONS: Nursing personnel having direct or the potential for contact with exposure to blood, body fluids, or other potentially infectious material of individuals, are expected to practice STANDARD PRECAUTIONS according to the guidelines established by the CSH Infection Control Program. Personal protective equipment and engineering controls shall be used as needed Standard Precautions. 4. COMPETENCY TRAINING: All Level of Care nursing staff are required to take First Aid training at time of hire and every three years thereafter as part of Mandated Training. 5. GENERAL INFORMATION: Injuries to the head and spine can cause paralysis, speech or memory problems, or other disabling conditions. Injuries to the head and spine can damage bone and soft tissue including the brain and spinal cord. Since

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generally only x-rays can show the severity of a head or spine injury, always care for such an injury as if it were serious. Always consider the potential for spinal cord trauma/injury with any head injury. Exercise care when moving the victim's head and neck. Fracture of the cervical spine frequently accompanies a head injury. If at all possible, always apply a cervical collar before moving the victim. Special care must be taken when trying to stop any scalp bleeding where there is a suspected skull fracture. Bleeding from the scalp can be very heavy even when the injury is not too serious. Dont press too hard. Be extremely careful when applying pressure over the wound, so that bone chips from a possible fracture will not be pressed into the brain. An injury to the brain can cause bleeding inside the skull. The blood can build up and cause pressure that can cause more damage. The first and most important signal of brain injury is a change in the level of the victims consciousness. He or she may be dizzy or confused or may become unconscious. 6. SIGNALS OF HEAD AND SPINE INJURIES: Changes in consciousness Severe pain or pressure in the head, neck, or back Tingling or loss of sensation in the hands, fingers, feet, and toes Partial or complete loss of movement of any body part Unusual bumps or depressions on the head or over the spine Blood or other fluids in the ears or nose Heavy external bleeding of the head, neck, or back Seizures Impaired breathing or vision as a result of injury Nausea or vomiting. Persistent headache Loss of balance Bruising of the head, especially around the eyes and behind the ears.

GENERAL CARE FOR HEAD AND SPINE INJURIES: Minimize movement of the head and spine Maintain an open airway Check consciousness and breathing Control any external bleeding Keep the victim from getting chilled or overheated.

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7. ASSESSMENT: 1. FIRST PRIORITY: Assess Airway, Breathing, and Circulation. 2. SECOND PRIORITY: Activate EMS (Emergency Medical Response System). 3. DETERMINE CIRCUMSTANCES OF INJURY: ACCELERATION: occurs when the stationary head is struck by a moving object (baseball bat). DECELERATION: occurs when the head in motion strikes an immovable object (a fall to the pavement). INDIRECT INJURY: traumatic force transmitted from other parts of body CLOSED HEAD INJURY: a non-penetrating, blunt injury with no break in the skull or dura mater. Scalp bruises, lacerations, and skull depressions are examples. OPEN HEAD INJURY: a penetrating injury that breaks the integrity of the skull or the dura (covering). 4. DETERMINE TIME LAPSE SINCE INJURY. 5. DETERMINE PERIOD OF UNCONSCIOUSNESS. 6. DETERMINE BASELINE CONDITION: 7. ASSESS LEVEL OF RESPONSIVENESS/LEVEL OF CONSCIOUSNESS: Establishing the level of consciousness is most important. An alert individual is awake and remains so when not disturbed. A lethargic individual, when not disturbed, will fall asleep but can easily be awakened by voice or a nudge, and once awake will answer questions. A stuporous individual is asleep but can be awakened for a short period of time by a loud voice or vigorous shaking. Once awake the individual will answer some questions but rapidly falls asleep again. Orientation can be evaluated in alert, lethargic, or stuporous individuals. An individual who knows his or her name, location, and the year, month, date, and day is considered normally oriented. Any mistakes in these answers should be noted. Individuals who cannot be aroused to speak or follow commands are in some form of coma. In response to painful stimuli (pinching), the individual may pull away or attempt to push the pinching hand away. This purposeful activity in response to pain is the hallmark of semicoma. If, in response to pain, there is either no movement at all or stereotyped posturing of the extremities, then the individual is in coma.

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This posturing should be recognized, because it means severe brain malfunction, though not necessarily permanent damage. ASSESS PUPIL SIZE AND REACTIVITY: Once the level of consciousness has been established, the pupils should be checked. Pupils are normally equal in size or within 1 mm of each other. They briskly constrict when a bright light is directed at them. It should be realized that very small pupils (1 to 2 mm) do not react to light because they are already as small as they can become. Small pupils are always reactive. ASSESS RESPIRATIONS: Respirations should be carefully counted and rhythm noted. Normal regular respirations suggest that the brain stem is not severely damaged, whereas periodic respirations (hyperventilation alternating with apnea), continuous hyperventilation, or irregular breathing implies significant brain stem injury. Irregular respirations are of added concern because they may not be adequately delivering oxygen and removing carbon dioxide. ASSESS MOVEMENT: Movement or strength is evaluated by having the cooperative individual hold both arms steadily in front of him or her, followed by lifting one leg at a time off the bed. Difficulty with lifting or a downward drifting of an arm should be noted. Request the individual to grasp your hands and squeeze. Note the extent of this capability within both hands (e.g. severe weakness; mild weakness; normal power). Request the individual push their foot against your hand. Note this capability with both feet. ASSESS FULL SET OF VITAL SIGNS INCLUDING LEVEL OF PAIN: Identify if pulse is strong, weak, or absent. Be alert for signs and symptoms of increased intracranial pressure. Pain assessment is now required as a fifth vital sign and is to be assessed at the same time as other vital signs are taken (refer to NPPM #309 Vital Signs). HEAD EXAMINATION: The head should be examined carefully for lacerations and abrasions, which may be well hidden amid the hair. Blood issuing from the ears should be noted, and the skin over the mastoid examined for bruises. Traumatized individuals may have a cervical fracture but are unable to complain of neck pain. Do not roll the individuals head from side to side or to flex the neck. Immobilize movement of the head. ASSESS FOR SPINAL INJURY. ASSESS FOR OTHER INJURIES (fractures, etc.).

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8. IMPLEMENTATION AND INTERVENTION:

NURSING ACTION A. Maintain airway, breathing, and circulation. Utilize assisted mechanical ventilation, if necessary. Control hemorrhage, monitor vital signs, and apply first aid. B. DO NOT move the individual unless there is imminent danger (e.g., fire). Immobilize cervical area until spinal injury is ruled out. C. Remain with the individual and have another staff member activate EMS (Emergency Medical Response System) which includes notifying the physician and RN. D. Perform a neurological exam. Assess: -Orientation -Pulse strength -Level of Responsiveness -Pupil reaction and size -Take vital signs TPR & BP -Pain assessment -Evaluate motion and strength of the extremities

KEY POINTS A. Ensure adequate oxygenation to the brain. Hypoxia of the brain, which leads to increased intracranial pressure, is the most frequent cause of death following head injury. B. Protect the victim from any unnecessary movement because of the possibility of neck injury. Keep the head and neck still. C. Have the staff member dial 7119 for paramedic assistance or 7119 for in house hospital assistance.

D. Use Neurological Checklist CSH 7087 (see ATTACHMENT A) to record the neuro vital signs. It is essential that an initial neurologic examination be obtained to determine a baseline.

E. Keep NPO until evaluated by and orders received from physician.

E. DO NOT GIVE the victim any fluids, pain medications, medications, or cigarettes. These may mask important signs. F. Notify physician of any abnormal response, widening pulse pressure (normal pulse pressure is 40), projectile vomiting, bradycardia, slowing, deep respiration. If there is bleeding from an ear, it can mean that there is a skull fracture.

F. Continue monitoring vital signs/neuro checks as ordered by physician.

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G. Observe for signs and symptoms of intracranial pressure.

G. Symptoms of intracranial pressure may include: pupils unequal and sluggish or inactive, respirations variable, often slow or irregular, pulse variable, rapid initially and then slow, BP variable, reflexes frequently altered, often with incontinence and evidence of paralysis. There may be headaches with fluctuating drowsiness or mental changes. Coma, stertorous breathing, fixation of the pupils to light, and/or loss of consciousness almost always implies severe injury.

9. EVALUATION: Document in IDN all events of the emergency. -Description of individual's clinical status at time of emergency, during the emergency, and disposition of individual. -Use the "Nursing Neurological Checklist" CSH 7087 to document and record neuro checks/neuro vital signs. Include Pain Assessment. -Include all vital signs and neurological assessments. CROSS-REFERENCE: NPPM #700 Medical Emergency; Standard Precautions; NPPM #705 Emergency Care of Wounds; NPPM #715 Emergency Care of Hemorrhage; NPPM #309 Vital Signs; First Aid Manual utilized First Aid Training TTACHMENT: CSH 7087 NEUROLOGICAL CHECKLIST

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 709 Effective Date: August 31, 2006 SUBJECT: EMERGENCY CARE OF EYE INJURIES 1. PURPOSE: This policy will provide guidelines for the emergency treatment of eye injuries. Visual loss and eye pain are common symptoms of ocular emergencies. Prompt and immediate treatment is aimed at relieving pain and assuring visual function. 2. POLICY: 1. Nursing staff shall immediately evaluate the Individual to determine the medical emergency status (LIFE THREATENING call 7119; NON LIFE THREATENING call 7111) and take appropriate action as outlined NPPM #70 Medical Emergency. 2. DO NOT attempt to remove a penetrating object. 3. Do not cover a penetrating object with gauze. Use a metal eye shield to prevent further movement of the penetrating object. If the object is protruding, use a protective device, (e.g. a paper cup). Instruct Individual not to squeeze eye shut. 4. When a chemical exposure is suspected, immediate and copious irrigation is indicated. The nurse may irrigate the eye immediately while another staff member notifies the physician. If a foreign body is suspected, contact the physician immediately for evaluation and await further orders for irrigation and treatment. 5. Individuals with serious eye injuries should be transported to appropriate medial care lying down. 3. COMPETENCY TRAINING: All Level of Care nursing staff is required to take First Aid training at time of hire and every three years thereafter as part of Mandated Training.

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4. PRECAUTIONS: Nursing personnel, having direct or the potential for contact with exposure to blood, body fluids, or other potentially infectious material of Individuals, are expected to practice STANDARD PRECAUTIONS according to the guidelines established by the CSH Infection Control Program. Personal protective equipment and engineering controls shall be used as needed. Refer to A.D. #10.23 Standard Precautions. 5. IMPLEMENTATION AND INTERVENTION: CORNEAL FOREIGN BODIES, ABRASIONS & LACERATIONS: NURSING ACTION A. Keep individual form rubbing eye. B. Wash hands thoroughly. C. Assess eye for type of injury. D. Remain with the individual and have other staff notify physician and RN immediately. E. Place a dry sterile dressing over injured eye, then cover both eyes. F. Continually reassure and keep individual as quiet and calm as possible. KEY POINTS A. Explain the need to prevent additional injury. B. Refer to Nursing Policy #1214 Hand Hygiene. C. Also assess for extent of injury. D. If a foreign body is suspected, contact the physician immediately for evaluation and await further orders. E. Covering both eyes minimizes eye movement and helps prevent further injury. F. Refer to Nursing Policy #412 Irrigation of Eye, if physician orders treatment.

CONTUSION - BLACK EYE: NURSING ACTION KEY POINTS

A. Apply cold compresses intermittently for A. To ease pain and reduce swelling. 24 hours. B. Apply warm compresses after 24 hours. B. Warm compresses can help the body absorb the excess blood that has accumulated.

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PENETRATING INJURY TO EYE: NURSING ACTION A. Wash hands thoroughly. B. Assess the history of penetrating trauma and signs/symptoms; pain, bleeding, profuse lacrimation, decreased visual acuity, a visible corneal or sclera wound, possibly together with laceration of the lid. C. Remain with individual and have other staff notify physician and HSS STAT. KEY POINTS A. Refer to Nursing Policy #1214 Hand Hygiene. B. Remember to document your assessment.

C. HSS staff should be PAGED via the Coalinga Operator. DO NOT just leave a voice mail message on the HSS office phone. D. Manipulation may result in permanent blindness. E. Sudden loss of vision is a very frightening experience. Anxiety will be a prominent feature. F. If a metal shield is not available, or if it will not fit over the impaled object, improvise by use of a protective device, (e.g. use a paper cup).

D. DO NOT REMOVE impaled object. Do not manipulate the individuals eye. E. Reassure and keep individual as quiet and calm as possible. F. Use a metal eye shield over the eye if available while waiting for physician to arrive.

INJURY TO EYE LID: NURSING ACTION A. Notify physician and RN immediately.

A. If the skin around the eye or on the lid has been cut (lacerated), sutures may be needed. Prolonged exposure of the eye without a lid will cause blindness.

KEY POINTS

B. Apply gentle, direct pressure to control bleeding.

B. ONLY if there is no visible foreign body or penetrating object in the eye.

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CHEMICAL EXPOSURE/CHEMICAL BURN TO EYES EMERGENCY EYE IRRIGATION:

NURSING ACTION A. The nurse will immediately irrigate the eye(s) for suspected chemical exposure/chemical burn while another staff calls a Medical Emergency.

KEY POINTS A. Prompt action is necessary to diminish serious injury and pain. An ER/Eye-Face Wash (Sterile Isotonic Buffered Solution) for acid and alkali burns is located on all Janitor/Housekeeping carts. Normal Saline is also stored in the Emergency Cart that can be used for irrigation. There is also a small squeeze bottle for eye irrigation located in the First Aid Kit. B. The amount of solution needed to irrigate an eye depends on the contaminant. Major chemical burns need copious amounts. Use of I.V. tubing connected to a bag of Normal Saline solution ensures that enough solution is available for continuous irrigation of a chemical burn. C. Position individual to prevent solution from flowing over the nose into the other eye. Gravity aids the flow of solution away from the affected eye.

B. Flush area thoroughly. Repeat as necessary.

C. Assist individual into the supine position with his/her head turned to the affected side. Place a towel under the individuals head and have the individual hold another towel against the affected side to catch the excess solution. D. To perform copious irrigation, direct the stream at the inner canthus, so the Normal Saline or other solution flows across the cornea to the outer canthus. E. Periodically stop the flow and tell the individual to close his/her eye to move secretions from the upper to the lower conjunctival sac and to help dislodge any particles.

D. If the I.V. tubing is used with the I.V. bag of Normal Saline, open the control valve on the I.V. tubing to direct the flow across the cornea. E. Assess the individual for complaints of itching, burning, visual disturbances, sensitivity to light, and any pain, including location, duration, and intensity.

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EXPOSURE TO PEPPER SPRAY (OLEORESIN CAPSICUM): 6. GENERAL INFORMATION: Pepper Spray derives its name from the active ingredient Oleoresin Capsicum (OC) and is a natural substance made from various hot pepper plants. It is dispersed by strong propulsion with water. There are two effects from Pepper Spray: The individuals eyes will usually shut due to the intense burning. The active ingredient dilates the capillaries in the eyes causing blurred vision. It may take 30 to 45 minutes after exposure to open their eyes if a direct hit to the face occurs. The individual may also inhale the pepper spray, which attacks the respiratory system resulting in inflammation, intense burning, and uncontrollable coughing and gagging, often incapacitating the individual.

7. DECONTAMINATION PROCESS: NURSING ACTION A. Keep the individual calm. Explain the anticipated effects.

KEY POINTS A. Reassure individual that effect usually lasts 10 to 20 minutes.

B. Instruct affected individual to blow his or B. Clears sinus cavities of pepper spray. her nose. C. Flush eyes with fresh, cool water or saline solution. D. Use of fresh air or a fan is the most useful method of decontamination. C. Repeat as needed. See previous page (709.3) for procedural steps. D. Remove individual from the area where the Pepper Spray was used, if at all possible.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 710 Effective Date: August 31, 2006 SUBJECT: EMERGENCY CARE OF FRACTURES 1. PURPOSE: To provide guidelines for prompt assessment and intervention in the evaluation of a suspected fracture. 2. POLICY: Nursing staff shall immediately evaluate the Individual to determine the medical emergency status (LIFE THREATENING call 7119; NON-LIFE THREATENING call 7119) and take appropriate action as outlined in NPPM #700 Medical Emergencies. 3. COMPETENCY / TRAINING: All Level of Care nursing staff are required to take First Aid training at time of hire and every three (3) years thereafter as part of Training. 4. GENERAL INFORMATION: Fractures must be handled carefully to prevent further injury to tissues surrounding the site. Fractures may result from trauma or from pathologic disease. 5. DEFINITION: FRACTURE A fracture is a break in the continuity of a bone usually accompanied by injury to the surrounding tissues. Most fractures result from an injury, such as that caused by a fall or sports injury. A fracture occurs when the force against a bone is greater than the strength of the bone. The direction, speed, and power of the force affect the type and severity of the fracture, as do the age, resilience, and type of bone. 6. GENERAL CATEGORIES OF FRACTURES: There are over 150 fracture classifications.

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The 5 major categories are as follows: COMPLETE A fracture involving the entire cross section of the bone, and bone fragments are usually displaced. INCOMPLETE A fracture involving only a portion of the cross section of bone. One side breaks the other side usually just bends a.k.a. green-stick fracture. OPEN Bone extends through the skin (formerly called compound fracture). Open fractures are more likely to become infected than closed fractures. CLOSED Fracture does not break through skin (formerly called simple fracture). PATHOLOGIC Fracture occurs in diseased bone (such as cancer, osteoporosis) with no or only minimal trauma. 7. ASSESSMENT: Symptoms of fracture depend on site, severity, type of fracture, and amount of damage to other structures. 8. ASSESS FOR THE FOLLOWING: PAIN / DISCOMFORT: Sudden severe pain at the time of injury (may be localized to the area of tissue/skeletal damage and be resolved upon immobilization); absence of pain is suggestive of nerve damage Muscle spasms and/or cramping Utilize the Pain Scale for rating severity: LIMITED MOBILITY: Restricted / loss of function of affected part (may be immediate, owing to the fracture, or secondary, due to tissue swelling and/or pain. CIRCULATORY IMPAIRMENT :Hypertension (occasionally seen as a response to pain / anxiety). Hypotension (due to blood loss). Tachycardia (as a stress response, or resulting from hypovolemia).

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Pulse reduced or absent distal to local injury; delayed capillary refill, pallor of affected part Tissue swelling or hematoma mass at site of injury NEUROSENSORY LOSS: Loss of motion or sensation, muscle spasms Numbness or tingling sensation (paresthesia) Local deformities; abnormal angulation, shortening, rotation, crepitation (e.g. grating sound), muscle spasms Visible weakness or loss of function Agitation (may be related to pain / anxiety) 9. EXPECTED OUTCOME: 1. Relieve pain and prevent further injury 2. Prevent complications 3. Provide information about condition, prognosis, and treatment needs 10. PARTIAL LISTING OF POTENTIAL NURSING DIAGNOSES: Additional Injury, potential for: Falls Related to: Loss of skeletal integrity (fractures) Possibly evidenced by: any fracture that impairs mobility Comfort, Altered: Pain, Acute: Related to: Movement of bone fragments; Edema; Injury to the soft tissue; Stress, anxiety Possibly evidences by: Complaints of pain; Distraction; Self-focusing/ narrowed focus; Facial mask pain; Guarding, protective behavior; Alteration in muscle tone; Autonomic responses Gas Exchange, Impaired: Related to: Altered blood flow; blood/fat emboli; Alveolar-capillary membrane changes; Interstitial, pulmonary edema; Congestion Possibly evidenced by: Pulse oximetry < previous baseline or < 90; signs and symptoms of dyspnea or delayed capillary refill Mobility, Impaired Physical: Related to: Neuromuscular skeletal impairment; Pain/discomfort; Restrictive therapies (limb immobilization) Possibly evidenced by: Inability to purposefully move with the physical environment, imposed restriction; Reluctance to attempt movement; Limited range of motion; Decreased muscle strength/control

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11. PROCEDURE: NURSING ACTION A. Inspect the suspected fractured part. Cut away clothing if necessary. C. Assess for: Pain, Pulse, Pallor, and Paresthesia (distal to suspected fracture site), Paralysis (distal to suspected fracture site). KEY POINTS B. Look for angulation (bending), shortening, and/or rotation. C. Determine extent of trauma. Pain is usually the most obvious symptom. Absence or presence of the pulses distal to the injury should be noted and recorded. Paleness, mottled cyanosis, and coolness distal to the injury are indications of severe circulatory impairment and a physician is urgently needed. The neurologic status is evaluated by testing for numbness to pinprick distal to the injury. D. Determine if injury is Life Threatening or Non-Life Threatening and take appropriate action. E. To prevent further injury . DO NOT try to reduce or straighten the suspected fracture. F. Splints are available in the Crash Cart. Magazines, pillows, tree limbs, etc. may also be used to immobilize the injured site. G. The purpose of splinting is to prevent motion of fractured bone fragments thereby preventing further damage to local blood vessels, nerves and muscles. H. The signs of pain include increased heart rate and output, increased blood pressure, pupillary dilation, palmar sweating, hyperventilation, hypermotility, escape behavior and anxiety state. I. To decrease swelling. J. DO NOT attempt to cleanse wound or try pulling the bones back beneath the skin. K. Use pressure point when dressing

D. Have someone immediately notify the physician/MOD and RN. E. Handle the part gently and as little as possible. F. Apply splint before Individual is moved.

G. Immobilize the joint above and the joint below the suspected fracture, extending the splint well beyond the joints.

H. Investigate any complaint of pain or pressure.

I. Elevate extremity after splinting. J. In open fracture, cover wound with a dry, sterile dressing.

K. Control hemorrhage and treat for shock

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as needed. L. Transport Individual carefully and gently.

does no control bleeding. L. Obtain gurney, or wheelchair if needed to aid in transport. Determine if paramedics/ ambulance are needed. Injured area to be x-rayed and treated ASAP.

12. EVALUATION AND DOCUMENTATION: Documentation should reflect: 1. 2. 3. 4. 5. 6. 7. 8. Individuals initial reaction to the injury Circumstances surrounding and/or causing the injury Appearance and condition of the affected area Signs and symptoms of circulatory impairment and neurosensory loss, and precautions taken to avoid complications Local deformities, abnormal angulation, shortening, rotation, crepitation (grating sound) Notification of physician/RN and time Actions taken or initiated Disposition of Individual

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 711 Effective Date: August 31, 2006 SUBJECT: EMERGENCY CARE OF EPISTAXIS (NOSEBLEED) 1. PURPOSE: Guidelines for staff response to Individuals experiencing nosebleed. 2. POLICY: All Individuals will receive prompt care to stop the bleeding and will be taught epistaxis prevention measures and self care for immediate action for such occurrences. 3. DEFINITION: Epistaxis or nosebleed is bleeding or hemorrhage from the nose, which commonly originates in the anterior portion of the nasal cavity. This may also originate from turbinate or lateral nasal wall. 4. GENERAL INFORMATION: Medical management is needed when significant epistaxis occurs in which case the aim is to control bleeding and to correct the underlying problem. Typically, bleeding is from an anterior vessel. Bleeding from the posterior area, involving the large vessels, is frequently profuse and more difficult to control. Epistaxis can result from injury or disease such as: Trauma (e.g. direct blows); Hypertension or arteriosclerotic heart disease which can cause profuse, Prolonged, and dangerous bleeding; After a cold and blowing the nose too hard; Picking of nasal crusts Prolonged use of nasal sprays or drops; Prolonged use of nasal sprays or drops; After a period of strenuous activity; Exposure to high altitudes. Nasal ingestion of substances (e.g. cocaine sniffing)

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5. ASSESSMENT: Determine the amount and location of the bleeding (e.g. right or left nares). Take a set of Vital Signs (TPR, BP) and pain rating assessment. Note the Individuals color. Question the Individual to determine whether this is the first episode of bleeding. If nosebleeds have occurred before, determine their frequency and duration. Ask the Individual about any history of trauma to the nose, any recent oral or nasal surgery, allergies, hypertension, or blood disorders.

6. PRECAUTIONS: 1. In all reasonably anticipated exposures to blood and other potentially infectious material, personal protective equipment and engineering controls shall be used. 7. NURSING INTERVENTION: NURSING ACTION A. Put on gloves. B. Instruct Individual to breathe through mouth. Keep the Individual quiet and calm, and whenever possible, in a sitting position with head tilted slightly forward. C. Apply an ice bag to the back of the neck, under the upper lip, and bridge of nose. D. Apply manual pressure over the bleeding area by pressing the bleeding nostril toward the midline. E. Change the Individuals position gradually. KEY POINTS A. Maintain Standard Precautions. B. Monitor for signs of respiratory distress. Leaning forward during epistaxis diminishes chance of Individual swallowing blood. C. Ice pack assists with constricting the blood vessels involved in the epistaxis. D. Apply pressure for approximately 5-10 minutes or until bleeding is controlled. E. Do not place in the flat position (so blood is not swallowed).

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F. If bleeding persists longer than 10 minutes or estimated blood loss exceeds 30cc, notify physician. Monitor and record vital signs at 5-15 minute intervals as clinically indicated. 8. INDIVIDUAL TEACHING:

F. Observe if Individual is swallowing blood that may be dripping post nasally.

1. Instruct Individual to sit up and lean forward while compressing the soft part of the nose between the thumb and the index finger for 5 to 10 minutes. 2. Go to nursing staff and report the incident immediately. 3. Remind Individual not to pick nose and remove crusts. 4. Instruct Individual not to rub or blow the nose too hard. 5. Instruct the Individual on any other treatment or preventive measures ordered by the physician to prevent dryness. 9. DOCUMENTATION: Documentation should include: 1. Explanation of the causes 2. Estimation of the blood volume loss 3. Vital signs 4. Time the physician or MOD was notified and orders received 5. Teaching provided to the Individual and his response to these. Utilize the Wellness and Recovery Individual/Family Health Education Record (CSH 7156) to document this teaching.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 712 Effective Date: August 31, 2006 SUBJECT: EMERGENCY CARE OF POISONING 1. PURPOSE: To provide supportive care to maintain vital organ systems, identify the poison, prevent or minimize absorption of the poison, and monitor and treat for complications. 2. POLICY: 1. Anyone may call for information regarding poisonings, contents of products used in poisoning and/or identification of medications suspected of poisoning. 2. The following information should be AT HAND when calling the center: -Age and sex of Individual -Your name and phone # -Amount involved -Name or description of product -Any symptoms -Approximate time occurred -Doctors name

3. The Poison Control Center will provide instructions on what to do next. Do not follow the first aid suggestions on the product label, as these are often wrong. During normal duty hours, first check with the CSH Pharmacist. POISON CONTROL CENTER HEALTH PROFESSIONALS ONLY 1-800-411-8080

4. All available physicians and nursing staff shall respond to medical emergencies in a prompt and competent manner. 5. The nearest monitor/defibrillator, Emergency Crash Cart, and Emergency Drug Box shall be brought to the scene of all medical emergencies by the unit staff of the unit or building where the equipment is housed.

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6.

The Shift Lead/designee shall assure that all necessary emergency equipment are brought to the scene and that adequate staff have been assigned to deal with the emergency. Poison Control will offer advice as to how to treat a specific poisoning incident. Medication and treatment can only be given by order of the physician/MOD.

7.

3. DEFINITION: A poison is any substance, which when taken into the body by ingestion, inhalation, injection, absorption, etc., interferes with normal physiological function and represents dangerous and/or life threatening consequences to the Individual. 4. GENERAL INFORMATION: 1. 24 - hour Regional Poison Control Center: California Poison Control San Diego Division UC San Diego Medical Center 200 W. Arbor, San Diego 92103 - 8925 Health Professionals Only 1-800-411-8080 Public Hotline 1-800-876-4766 2. Virtually any substance can be poisonous if consumed in sufficient quantity. 3. Information concerning all potentially dangerous substances at CSH is kept on file at the Employee Clinic, the telephone operators office, and Health & Safety Office on Material Safety Data Sheets (MSDS). 4. Each unit has a MSDS for potentially dangerous substances normally kept on the unit. 5. Staff shall look for empty bottles and containers for suspected ingestion or inhalation. 6. Psychiatric evaluations may be done after the Individual is stabilized. 5. OUTCOME CRITERIA: 1. To remove or neutralize the poison without causing further damage to the body.

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6. IMPLEMENTATION AND INTERVENTIONS: Ingested poison: NURSING ACTION A. Maintain respiration and circulation. KEY POINTS A. Although poisoning can mimic other illnesses, the correct diagnosis can be established by the history, physical evaluation, routine and toxicologic evaluations, and clinical course. B. The physician or designee may contact Poison Control Center and obtain recommendations for emergency treatment.

B. Contact physician immediately for orders. Gather facts from victim or witnesses for the physician. Establish the following: Time, route, duration and circumstances (location, set of surrounding events, intent) of exposure; set of Vital Signs; the name and amount of each drug, chemical or ingredient involved; the time of onset, nature and severity of symptoms; the time and type of first aid measures provided; past pertinent medical and psychiatric history; and assessment for suicidality and psychiatric instability. C. Per order of physician: -Induce vomiting per Poison Control recommendation and by order of physician. -Dilute (corrosive) per Poison Control recommendation and by order of physician. -Prevent further absorption into the system per Poison Control recommendation and by order of physician. -Activated Charcoal Magnesium Citrate

C. DO NOT INDUCE VOMITING if victim is convulsing, semiconscious, or comatose or if Individual has taken a corrosive or hydrocarbon (kerosene, gasoline, paint thinner, lighter fluid), or if victim has no gag reflex. Emesis increases the likelihood of gastric perforation. -Give activated charcoal only after Individuals vomiting has subsided. Cathartics speed poisons elimination through the GI tract.

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Inhaled poison: NURSING ACTION KEY POINTS

A. Carry Individual to fresh air immediately. A. Remove from site of exposure. B. Start CPR as indicated. B. Refer to NPPM #702 Cardiopulmonary Resuscitation. Carbon Monoxide destroys oxygen carrying capacity of blood causing asphyxiation. C. Activate EMS (call 7119). The physician or designee may contact Poison Control Center and obtain recommendations for emergency treatment.

C. Contact physician immediately for orders. Gather facts from victim or witnesses for the physician. Establish the following: Time, route, duration and circumstances (location, set of surrounding events, intent) of exposure; set of Vital Signs; the name and amount of each drug, chemical or ingredient involved; the time of onset; nature and severity of symptoms; the time and type of first aid measures provided; past pertinent medical and psychiatric history; and assessment for suicidal and psychiatric instability. D. Per order of physician: Start oxygen as ordered. (In a Code Blue, O2 may be started pending physician order).

D. Refer to NPPM #419 Oxygen Therapy-Nasal Cannula/Face Mask. Symptoms of permanent central nervous system damage are: 1. Spastic paralysis 2. Visual disturbances

7. INJECTED POISONS (Stinging insects/Anaphylactic Shock): NURSING ACTION 1. Observe for anaphylactic shock. a. Severe fall in blood pressure. b. Difficult breathing c. Edema of face, lips d. Itching e. Bronchial constriction KEY POINTS 1. Refer to NPPM #713 Anaphylactic Reaction). Some people may have extreme sensitivity to Hymenoptera venom (Bees & Wasps). This constitutes an acute emergency, death may occur within 1 hour.

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2. Per order of physician a. Give epinephrine hydrochloride as directed.

2. Usual dose for epinephrine is 0.2cc 0.4cc Sub Q.

8. FOOD POISONING: NURSING ACTION A. Contact physician immediately for orders. KEY POINTS A. Food poisoning is a sudden explosive illness that occurs after ingestion of food or drink that contains bacteria, chemicals, and poisonous plants (e.g. poisonous mushrooms) or animals. B. Deaths from respiratory paralysis occur with botulism, some insecticides, fish poisoning, etc. C. Monitor vital signs on a continuing basis. Initiate Vital Signs Record (MH 5752).

B. Observe for signs of respiratory distress and notify physician if occurs. C. Per order of physician and advice from Poison Control: -Gastric Lavage (Tray on EB-11). -Prevent further absorption into the system. -Activated charcoal -Magnesium Citrate D. Report to Public Health.

D. Public Health Office shall be notified of any suspected food poisoning so that appropriate epidemiological investigation can be initiated and that follow-up preventative Public Health measures can be initiated.

9. SKIN CONTAMINATION POISONS: NURSING ACTION A. Immediately drench skin with water from shower, hose or faucet. B. Notify physician for orders. KEY POINTS A. Rapidity in washing is most important in reducing extent of injury. B. Refer to MSDS (Material Safety Data Sheet).

10. EVALUATION: -5N.P.P No. 712

Documentation should include the following: 1. Time & date; 2. Initial Individual assessment and progression of symptoms; 3. All nursing interventions and effectiveness of interventions; 4. Vital signs; 5. Time that assistance arrived, if paramedic assistance called; 6. Disposition of Individual.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 713 Effective Date: August 31, 2006

SUBJECT: ANAPHYLACTIC REACTION (SHOCK)

1. PURPOSE: To provide guidelines for the emergency treatment of an anaphylactic reaction. 2. POLICY: An I.V. of Normal Saline or D5W at a TKO (To Keep Vein Open) rate may be started by RNs who are I.V. proficient prior to receiving a physicians order in life threatening emergencies. A physicians order must be obtained ASAP thereafter. Oxygen administration of 2 to 6 liters per minute by nasal cannula, or 6 to 10 liters per minute via mask may be given by a Registered Nurse to Individuals with no history of Chronic Obstructive Pulmonary Disease (COPD) prior to receiving a physicians order in emergency situations. A physicians order must be obtained immediately thereafter (Refer to NPPM #419 Oxygen Therapy for additional information). 3. DEFINITION: Anaphylactic reaction a severe (and potentially fatal) systemic hypersensitivity reaction. 4. GENERAL INFORMATION: The condition may occur within seconds of exposure to the sensitizing agent; the more quickly the reaction occurs the more severe the shock is likely to be. It is always a life-threatening condition! Bronchospasms can develop and obstruct expiration. Individual can decompensate with cardiovascular collapse and shock. The single most common causative agent is Penicillin. Other agents which often cause anaphylactic reactions are serums (especially horse serum), vaccines, hormones, antibiotics, sulfonamides, local anesthetics, salicylates (e.g. aspirin), diagnostic chemicals such as iodine, foods (such as legumes, nuts, berries, seafoods, and eggs/egg products) and insect venoms.

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5. ASSESSMENT: Initial or early symptoms may include: Difficulty breathing and wheezing; warm, moist skin; apprehension; light-headedness; diffuse erythema or urticaria (hives); edema, especially around the eyes, lips, tongue, hands, feet, and genitalia; itching. Late symptoms may include: Severe dyspnea, stridor, air hunger; abdominal cramps; vomiting; diarrhea; incontinence; vaginal bleeding; difficulty speaking; high-pitched cough; laryngeal edema; hypotension with a narrowed pulse pressure; tachycardia. 6. OUTCOME CRITERIA: To maintain life, identify the allergen, and prevent further exposure to the sensitizing agent/allergen. 7. PRECAUTION: ALWAYS check the chart (or ask the Individual) for any allergies before administering any medication(s) or immunizations. 8. INTERVENTION: NURSING ACTION A. Notify physician immediately for emergency orders to be initiated (e.g. I.V. insertion, oxygen therapy). B. Prevent further exposure to the allergen if known. C. Maintain adequate ventilation continuously to maintain respiratory status and prepare for CPR. D. Have staff bring emergency equipment to the scene (Emergency Crash Cart, Emergency Drug Box, Monitor/Defibrillator, Pulse oximeter. KEY POINTS A. Have staff dial 7119 for paramedics.

B. To lessen the dose of allergen received. C. Be alert for signs of respiratory distress.

D. Signs are posted outside the units identifying where the emergency equipment is located as well as on the walls inside the units by the telephones.

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E. Administer medication as ordered by the physician.

E. Treatment may include injection of medications such as epinephrine, antihistamine (e.g. diphenhydramine), steroid (e.g. dexamethasone), etc. F. To increase the rate of absorption. G. Nursing staff is expected to exercise clinical judgment and take vital signs (Pulse, Respiratory Rate, B/P) and Pulse Oximetry reading as warranted by the Individuals condition. H. To lessen anxiety.

F. Massage IM or Sub-Q injection sites. G. Monitor Vital Signs.

H. Provide emotional support and inform Individual what is being done and why. I. A RN may start an I.V. of Normal Saline or D5W @ TKO rate, and oxygen. A physicians order must be obtained immediately thereafter. J. Have physician determine allergy status and document in chart.

I. Maintaining fluid intake, either I.V. or P.O., helps flush out the antigen. Normal Saline is the preferred I.V. solution.

J. To prevent further exposure risk.

K. Teach Individual to avoid allergen.

K. Document teaching (Refer to NPPM #x Individual and Family Teaching).

L. Document all events that occurred during this emergency. Include Individuals clinical assessment. 9. INDIVIDUAL TEACHING: Instruct the Individual as follows:

L. Note allergy in medical record appropriately.

For Individuals with known severe allergy to bee and other insect bites, they should avoid wearing bright colored clothes and perfumes or colognes, which will attract insects to them because these colors and perfumes/colognes look and/or smell like flowers. Teach the Individual to recognize early symptoms of sensitivity reactions. Teach the Individual to immediately notify staff of any discomfort such as itching, swelling, or shortness of breath.

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10. DOCUMENTATION: The following should be documented: 1. Accurate description of the Individuals symptoms, possible cause, and severity. 2. Complete vital signs, including pain scale, the 5th vital sign. 3. All nursing interventions done, including medications given, and their effectiveness or lack of effectiveness. 4. All Individual teaching provided and his ability to understand and comply with teaching. Document all Individual teaching on the Wellness and Recovery Individual/Family Health Education Record (CSH 7156).

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 714 Effective Date: June 8, 2007 SUBJECT: EMERGENCY MEDICAL EQUIPMENT 1. PURPOSE A. To have equipment and supplies readily available at the scene of a medical emergency within the security area of the hospital. B. To assure the person experiencing a medical emergency is transported to the UCR safely. C. To provide guidelines for managing the equipment and drugs used in medical emergencies. 2. AUTHORITY Nursing Administrator, Pharmacy and Therapeutics Committee 3. POLICY Nursing staff nearest to a medical emergency will respond to the event with necessary medical equipment including the Emergency Drug Box. Each unit will have access to an Automated External Defibrillator (AED), emergency drug box, oxygen, gurney, and suction. The assigned Nurse of the Day (NOD) will have access to an Emergency Response Vehicle (ERV) which has the above equipment (minus the emergency drug box) plus other medical supplies. The Emergency Response Vehicle has the ability to transport a victim to the Urgent Care Room (UCR). The UCR has the equipment and personnel necessary to stabilize and ready the patient for transport to an outside medical facility if this is needed. 4. METHOD A. The Unit Supervisor of each unit is responsible to assure all emergency equipment is maintained and operational. B. The Supervising Registered Nurse (SRN) of the medical unit is responsible for equipment on the unit and in the UCR. C. The SRN of the Central Medical Clinic is responsible for the emergency equipment in that area. D. The NOD is responsible for the equipment on the Emergency Response Vehicle.

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1. The NOD shall inspect the ERV no less than weekly and record such on the Emergency Response Vehicle Supplies form (attached). 2. The Assistant Coordinator of Nursing Services (ACNS) shall inspect the ERV supplies and the ERV Supplies form no less than monthly. E. After hours, NOD has access to Central Supply to restock any needed emergency supplies. F. All nursing staff will be current in CPR and First-Aid and deemed competent to use any medical equipment taught in those classes e.g. AED, ambu-bag. G. Only staff which have been trained and certified to use medical equipment shall do so.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 715 Effective Date: August 31, 2006 SUBJECT: EMERGENCY CARE OF HEMORRHAGE 1. PURPOSE: The management of hemorrhage can be a very serious, life-threatening, and panic-producing situation. Measures to stop the blood loss, immediate volume replacement, and the activation of the Emergency Medical Response (EMR) System are the primary focus. 2. POLICY: Nursing staff shall immediately evaluate the Individual to determine the medical emergency status (LIFE THREATENING call 7119; NON LIFE THREATENING call 7111) and take appropriate action. Nursing personnel, having direct or the potential for contact with exposure to blood, body fluids, or other potentially infectious material of Individuals are expected to practice STANDARD PRECAUTIONS according to guidelines established by the CSH Infection Control Program. Personal protective equipment and engineering controls shall be used during care of the Individual with hemorrhage and as needed. Refer to Standard Precautions.

3. COMPETENCY/TRAINING: All Level of Care nursing staff are required to take First Aid training at time of hire and every three years thereafter as part of Mandated Training. 4. DEFINITION: Hemorrhage is a loss of a large or copious amount of blood either externally or internally in a short period of time. 5. TYPES OF BLEEDING: Arterial bleeding - Are bright red and gushes forth in waves; related to heart rhythm; if vessel is very deep, flow will be steady.

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Venous bleeding - is dark red and flows smoothly. Capillary bleeding - is oozing of dark red blood; self-sealing controls this bleeding. 6. GENERAL INFORMATION: A pressure dressing is a temporary treatment for the control of excessive bleeding. The bleeding is usually sudden and not anticipated. It may be a lifethreatening occurrence related to accidental trauma, stabbing, suicide attempt, or other injury. The best way to stop external hemorrhage is direct pressure over the area of the wound. Most bleeding will stop within a few minutes when firm, direct pressure is applied for 5 to 15 minutes. If there is bleeding from a foot, hand, leg or arm, use gravity to help slow the flow of blood. Elevate the limb so that it is higher off the ground than the victims heart. If bleeding cannot be stopped by using direct pressure or by elevating the injured area, you may have to slow the supply of the blood using pressure points. Major arteries may be compressed against the bone to stop the blood flow. This can be accomplished by feeling for the victims pulse at the pressure point and pressing until no pulse is felt. However, because pressing these areas can completely stop the supply of blood, do so only in extreme emergencies. Alternate between using pressure points and direct pressure every couple of minutes until help arrives. An adult weighing 70 kg has a total volume of 5 liters of circulating blood. All nursing actions must be rapidly and effectively executed when excessive blood loss occurs. Once pressure has been applied, it must continue until definitive actions can be executed. INTERNAL BLEEDING: is to be suspected when the following warning signs are exhibited: coughing up or vomiting up blood or coffee ground material, passing blood in urine or stool, or passing black tarlike bowel movements. All require medical attention. Have the Individual lie on his or her back and elevate his feet. Have Individual breathe deeply. Keep Individual NPO and activate Medical Emergency. 7. EXPECTED OUTCOME: 1. Bleeding is controlled. 2. Fluid loss is minimal. 3. Individuals blood pressure and pulse remain within normal range.

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4. Circulation to distal parts is adequate. 8. ASSESSMENT: Bleeding may be evident or concealed. Clinical manifestations of blood loss may include: -Skin that feels cool or moist or looks pale or bluish -Rapid, thready, weak pulse -Rapid shallow breathing -Decreased blood pressure -Apprehension -Excessive thirst -Vomiting or coughing up blood -Tender, swollen, bruised, or hard areas of the body, such as the abdomen -Becoming confused, faint, drowsy, or unconscious 9. INTERVENTION: NURSING ACTION A. Phase i: immediate action first nursing staff on the scene: Quickly assess the Individual's airway, breathing and circulation. Activate Emergency Medical Response System. Locate external bleeding site. Apply direct pressure immediately. B. Direct additional staff to call for physician and the RN. Have someone bring the emergency equipment to the scene. C. Phase ii: applying pressure dressing second nursing staff on the scene: Quickly observe location of bleeding. Put on gloves, and gown if appropriate. Apply firm, manual pressure dressing over the wound or artery involved. KEY POINTS A. Rapidly cover bleeding area with many thicknesses of compresses. Use sterile cause pads or improvise if necessary by using a sanitary napkin(s), clean towels or handkerchief.

B. Dial "7119" for hospital medical assistance and "7119" for paramedic assistance. (Refer to NPPM #700 Medical Emergency). C. Personal protective equipment packets are available in the bottom drawer of the Emergency Cart and in the Red/White Emergency bag.

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D. Quickly assess Individuals pulse, blood pressure, skin color, anxiety/restlessness, changes in level of consciousness.

D. Findings of tachycardia, hypotension, diaphoresis, restlessness, and diminished urinary output indicate impending hypovolemic shock.

E. Elevate the injured part to control venous/capillary bleeding if a fracture is not suspected. Immobilize an injured extremity to control blood loss.

E. Raise the injured area above the level of the heart.

F. If bleeding is not controlled, apply pressure on the artery between the wound and heart. (pressure point).

F. A pressure point is a spot on the body where you can squeeze the nearby artery against the bone underneath. This can slow or stop the flow of blood to the wound.

G. An IV of Normal Saline or D5W TKO (to keep vein open) may be started by RNs who are I.V. proficient prior to a physicians order in Life Threatening emergencies. A physicians order for starting the IV must be obtained ASAP. H. Keep Individual warm. I. Monitor vital signs every 15 minutes or more frequent if Individual's condition deteriorates. J. Apply a tourniquet, ONLY as a last resort. If tourniquet is applied, do not loosen or remove unless ordered by physician. Mark time applied.

G. The IV needle should be the largest bore available. Rapid initiation of an IV is essential to help the body cope with the blood loss.

H. Reassure and comfort the victim. I. Be alert for signs and symptoms of shock. (Refer to NPPM #707 Shock). J. The decision to apply a tourniquet is to risk sacrifice of a limb to save a life.

10. EVALUATION AND DOCUMENTATION: Status of Individuals bleeding control, time bleeding was discovered, estimated blood loss, nursing interventions (including effectiveness of -4N.P.P No. 715

applied pressure dressing), apical and distal pulses, blood pressure, sensorium level, signs of restlessness. Document all events of the emergency. Include date, time, history of emergency, location of bleeding, describe type of blood vessel and approximate blood loss, arrival time of medical help, and time bleeding was control/stopped, disposition of Individual and condition of transfer. Provide information at the Change of Shift report. FUNCTIONS Monitoring Mode Semi-Automatic Defibrillation Adhesive Pads Used For Defibrillation Manual Defibrillation Synchronized Cardioversion External Pacing Variable Leads 3 Lead Monitoring Change in ECG size High and Low Rate Alarms Memory Card Memory Module and Tape Recorder 100 Joule Energy Setting in Manual Mode Additional Energy Settings in Manual Mode FIRST MEDIC ZOLL 1600 X X LIFE PAK 7 X

X X

X X X X X X X X X X X

X X X X X

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 716 Effective Date: March 3, 2007 SUBJECT: MONITOR/DEFIBRILLATOR 1. PURPOSE: This policy and procedure will provide staff with guidelines for the appropriate care and use of the AED

2. POLICY: All available nursing staff (RN, LVN, PT) shall respond immediately to any medical emergency and be prepared to cooperate in utilizing the equipment and medical skills necessary to provide immediate and appropriate nursing interventions. 2. An AED shall be brought to the scene of all medical emergencies. AEDs are currently available on all floors between housing units. The AEDs in the administration building are in the front hall and back hall by the training department and up stairs outside the executive suite. The AED shall be utilized in the following methods: In a medical emergency, (e.g. code blue), all BLS certified staff may use the AED appropriately as per the American Heart Association.

3. 4.

3. GENERAL INFORMATION/DEFINITIONS: The emergency cardiac care systems concept identifies early access to the EMS system, early CPR, early defibrillation, and early advanced cardiac care as the best approach to treatment of persons in cardiac arrest. The major determinant in successful resuscitation is time. The earlier defibrillation occurs, the better the prognosis. Emergency medical responders have only a few minutes after the collapse of a victim to reestablish a sustained perfusing rhythm. CPR can sustain an individual for a short period but cannot directly restore an organized rhythm. Restoration of an adequate perfusing rhythm requires defibrillation and advanced cardiac care, which must be administered within a few minutes of the initial arrest. Defibrillation is the therapeutic use of electric current delivered in large amounts over very brief periods of time. The defibrillation shock temporarily depolarizes (producing asystole on the monitor) an irregularly beating heart (e.g. ventricular fibrillation or

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pulseless ventricular tachycardia) and thus allows more coordinated contractile activity to resume. A defibrillator is an instrument that delivers an electrical shock to the heart. The AED incorporates a rhythm analysis system and require operator interventions including turning AED on to initiate rhythm analysis and pressing shock button to deliver the defibrillation. The AED recognizes ventricular fibrillation and ventricular tachycardia with a rate higher than 180 bpm as shockable rhythms. Ventricular fibrillation is a rhythm in which multiple areas of the ventricles display marked variation in depolarization and repolarization. The ventricles do not contract as a unit and there is no cardiac output. Ventricular fibrillation is the most frequent initial rhythm in sudden cardiac arrest. Only defibrillation provides definitive therapy. The chance of successful defibrillation diminishes rapidly over time (minutes). Pulseless ventricular tachycardia should be treated the same as ventricular fibrillation. 4. GENERAL INFORMATION FOR THE SEMI-AUTOMATIC ZOLL 1600 MONITOR/DEFIBRILLATORS: 1. The AED is employed by BLS certified trained personnel to revive victims of ventricular fibrillation, and pulseless ventricular tachycardia. 2. The Fire Department staff will validate and document monthly the operational status, and contents of supplies such as electrode pads, face masks, razor and gloves. This will include battery life, and any expiration dates on any of the equipment). 3. Training on the use of the AED will be done in New Employee Orientation and every two years after by the training department and affiliates. 4. Training on use of the AED will be offered to all staff through the training department. 5. All staff are responsible for notifying Fire Services immediately if a red X is noted in the bottom left corner indicating a LOW BATTERY: Battery should be removed and replaced with charged battery. 6. Practice may be done on units, using the simulator in the case of the AED. The NOD/RN may be contacted for mock codes 7. After any use of the AED, NOD/HSS must be informed. Battery and all used supplies must be replaced. 5. ASSESSMENT: 1. SUBJECTIVE: There may be history of coronary artery disease, cardiac dysrhythmia, drug overdose, or drug toxicity. 2. OBJECTIVE: A+B+C = Full Cardiac Arrest A. Unresponsiveness and B. Breathlessness and C. Pulselessness, D. Shock may be advised by the AED. 3. ASSESSMENT/DIAGNOSIS: Cardiac arrest with shockable rhythms (ventricular fibrillation and ventricular tachycardia with a rate over 180bpm). -2N.P.P No. 716

4. PLAN: All staff BLS certified and trained in the use of the AED will defibrillate shockable rhythms as indicated by the AED. 6. TREATMENT: A. Verify full cardiac arrests. B. CPR until AED is attached. C. Make sure all movement affecting the individual has ceased during analization and no one is touching the individual Im clear, youre clear, all clear before pushing the treatment button. D. Follow the American Heart Association Automated External Defibrillation (AED) treatment plan. 7. PHYSICIAN INTERVENTION: Turn over the resuscitation responsibility to full ACLS personnel directed by a physician/outside qualified rescuer or team after they have arrived and assessed the individual. 8. FOLLOW-UP: Continue to participate in the resuscitation efforts as directed by the team leader. Prepare to transfer the individual if so ordered. 9. EXPECTED OUTCOMES: The individuals chance of survival and pre-arrest functioning will be optimized. 10. PRECAUTIONS: 1. Never use in the presence of flammable agents. 2. Do not unnecessarily touch or move the individual when the defibrillator is attached and operating. Contact with the victim during analyzing may delay shock delivery.

3. STAY CLEAR OF VICTIM! Any contact with the victim during shock delivery may expose the operator to an electrical shock. Any contact with victim during analyze mode may result in inaccurate analysis. 4. Turn the device off to disarm and dump unwanted charge. 5. Remove any medication patches and residue prior to applying electrodes. Defibrillation through medication patches on the individuals skin may cause current to be redirected, burning the individual. -3N.P.P No. 716

6. Nitroglycerin paste or wet conditions can cause poor pad contact or electrical arcing between pads. Quickly wipe or dry skin before applying pads. 7. Avoid placing pads directly over implanted pacemakers or internal defibrillators. Safety and delivery of external defibrillation will not be affected but the implanted device will probably be permanently disabled. 11. COMPETENCY/TRAINING: All staff in the training departments category one and two and those required in category three will receive AED training as part of their new employee orientation and every two years thereafter. (Category one includes lic. staff and all staff in direct contact with the individuals served at CSH, Category two includes staff in CPS, radiology, work crew supervisors, ACNS, PD, PA and NCs, Category three receiving such training are the custodians supervising work crews. 12. EQUIPMENT: AED Emergency Drug Box (x 2) Emergency Response Vehicle

13. PROCEDURE FOR AED: NURSING ACTION 1. Set AED near the individual KEY POINTS 1. Does not require an order to use the AED 2. Follow verbal cues 3. Respect individuals privacy. 4. Ensure pads stick firmly and evenly to the skin of the chest. If needed there is a razor provided to shave hair from chest. The pads are adjustable to accommodate different size individuals.

2. Turn on the defibrillator 3. Remove clothing from the individuals chest. Wipe chest dry if it is damp. 4. Open AED pads and place on chest as diagramed. No contact with patient during analysis

5. If a shockable rhythm is detected, a

5. If this occurs, verify individuals

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voice will say PRESS Treatment button Ensure all assisting personal are standing clear of patient before pushing the treatment button 6. Resume CPR upon prompts

Position and that everyone is clear of the patient before pressing the button

6. To ensure adequate O2 and compressions.

14. DOCUMENTATION: A. Enter ID notes. B. Document in or give input for the Medical Emergency Flow Sheet (CSH #7107) and Medical Emergency/Code Blue Survey Questionnaire (CSH #109), PostEmergency Critique and Ideas questionnaire. These should be given to the NOD for delivery to the Chair of the Emergency Care Committee for review. 15. CROSS - REFERENCES: ADMINISTRATIVE DIRECTIVES: A.D. 10.25 Medical Emergencies NURSING POLICY & PROCEDURES: NP&P Manual - 700 Section (Emergency Procedures)

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 717 Effective Date: August 31, 2006 SUBJECT: NEUROLEPTIC MALIGNANT SYNDROME 1. PURPOSE: To provide nursing staff with appropriate guidelines and procedures for recognition of and treatment of Neuroleptic Malignant Syndrome (NMS). 2. POLICY: All individuals who exhibit Neuroleptic Malignant Syndrome symptoms shall receive individualized, appropriate treatment to alleviate those symptoms. 3. DEFINITION: Neuroleptic malignant syndrome (NMS) is a drug-induced disorder, characterized by disturbances in mental status, temperature regulation, and autonomic and extrapyramidal functions. It is a rare, but life-threatening disorder associated with the use of antipsychotic medications and other medications with similar pharmacologic properties. Fever, muscular rigidity, altered mental status, and autonomic dysfunction characterizes the syndrome. 4. GENDERAL INFORMATION: Although potent neuroleptics (e.g. haloperidol, fluphenazine) are more frequently associated with NMS, all antipsychotic agents, typical or atypical, may precipitate the syndrome [e.g. prochlorperazine (Compazine), promethazine (Phenergan), clozapine (Clozaril), risperidone (Risperdal). NMS has also been associated with non-neuroleptic agents that block central dopamine pathways [e.g. metoclopramide (Reglan), amoxapine (Ascendin), Lithium]. Often misdiagnosed, NMS is easily confused with other health problems; Malignant Hyperthermia; Heat Stroke; Lethal Cataonia; Hyperthermic Syndromes associated with other pharmacologic agent; viral encephalitis; structural brain lesions, and basal ganglia disorders with rigidity. NMS primarily occurs following the use of antipsychotic drugs, most commonly haloperidol and depot agents such as fluhenzine deconate

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(prolixin-D). However, other antipsychotic agents such as chloropromazine (thorazine), thiothixene, (navane), & thioridazine (melleril) have also been implicated as causative agents. NMS occurs in 0.5% to 1.5% of individuals using antipsychotic drugs. In some instances hot weather may trigger episodes of NMS, but it occurs throughout the seasons. Antipsychotics act primarily by blocking the neurotransmitter, dopamine, at specific receptor sites in the brain. It is hypothezied that this blockade can cause NMS. Dopamine is thought to play an important role in motor function, emotional reaction, and thought processes. The association of hyperthermia and hyperadrenegic function suggests involvement of hypothalamic dopaminergic tracts regulation temperature. It is reported that over half the cases of NMS involve the concomitant drug treatment with other than antipsychotics (e.g. lithium carbonate, tricylic antidepressants, antiparkinsonian, and benzodiazepines). Mortality/Morbidity: Due to increased awareness of this syndrome and efforts at prevention the incidenceis probably less now than in the past. The incidence of mortality, once reported at 20 to 30% is not estimated at 5 to 11.6%. Death usually results from respiratory failure, cardiovascular collapse, myoglobinuric renal failure, or arrhythmias. Morbidity from NMS includes rhabdomyolysis, pneumonia, renal failure, seizures, arrhythmias, and respiratory failure.

Sex: NMS has been reported to be more common in males (2:1 ration of males to females), most likely because of increased use of neuroleptics in males. Age: There is no age prediction for NMS. It may occur in individuals at any age that are receiving neuroleptics or other precipitation medications. 5. ASSESSMENT: ASSESMENT OF THE AIRWAY, BREATHING, AND CIRCULATION (ABCS) CLINICAL MANIFESTATIONS: NMS is more likely to develop following initiation of neuroleptic therapy or an increase in dose. The onset can be within hours, but on average, it is 4-12 days after beginning therapy.

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However, NMS can occur at anytime during neuroleptic use, even years after initiating therapy. Of those individuals who develop NMS, 90% of them will do so within 10 days. Some reports indicate that at anytime during drug use elevated blood pressure may precede the syndrome by a few days and can progress rapidly in 24 to 72 hours to the full-blown episode. CLASSIC SYMPTOMS: NMS is diagnosed by the development of muscle rigidity and elevated temperature following administration of antipsychotic medication. (Individual presents in a hypothalamic or adrenergic crisis with evidence of increased metabolic utilization) Severe muscle rigidity (lead pipe presentation as opposed to cogwheeling) Fever (100.5 to 107.5 F) 2.3.1.16 Altered consciousness; Change in mental status Restlessness Delirium Stupor Coma

2.3.1.16.1 Autonomic dysfunction Unstable, labile pulse & pressure; Hypotension or hypertension (75/50 to 180/130 mm/Hg) Tachycardia Profuse Diaphoresis Tachypnea (18 to 40 breaths/min) Incontinence

Masked faces (individuals may be agitated, psychotic, & delirious) 2.3.1.16.2 Autonomic manifestations Parllor Flushing Urinary retention; incontinence

2.3.1.16.2.1 Other motor disturbances Parkinsonian-like syndromes (tremors, akinesia, dyshpagia, drooling, bradykinesia) -3N.P.P No. 717

Tremor Sialorrhea (excessive flow of saliva) Dystonic reactions Chorea Occulogyric crisis Dyskinesias Seizures

2.3.1.16.2.2 Neurological symptoms Dysphasia Aphonia Hyporflexia Extensor plantar responses Akinetic mutism Dysarthria Ataxia Posturing

2.3.1.16.2.3 Laboratory findings Elevated creatinine phosphokinase- the muscle enzyme (CPK: 240 to 14,3000 U/L) Leukocytosis (elevated white blood count) Metabolic acidosis Elevated liver function tests Generalized EEG abnormalities

Different Diagnosis of Neuroleptic Malignant Syndrome

Symptom Hyperthermia Muscle Rigidity Diaphoresis Tachycardia Respirations Blood Pressure Acidosis Coagulopathy Myoglobinuria Mental Status Precipitant NMS Yes Yes Yes Yes Rapid Increased Yes Yes Yes Impaired Antipsychotics Malignant Hyperthermia Yes Yes Yes Yes Rapid Increased Yes Yes Yes Impaired Halothane -4Heatstroke Yes Not typical Not typical Yes Rapid Increased Yes Yes Yes Impaired Exposure or Lethal Catatonia Yes Yes Yes Yes N/A N/A ? ? ? Impaired ? N.P.P No. 717

Elevated CPK Elevated LFT Leukocytosis Onset Mortality Therapy

Yes Yes Yes Hrs-Days 10-20% Dantrolene, Dopaminergic Agnoists

Anectine ? Stress Yes N/A N/A Min-Hrs 30% Dantrolene

Exercise N/A N/A Yes Min-Hrs 20-50% ? Dantrolene N/A N/A N/A Days-Weeks 75-100% ECT, Corticosteroids

6. TREATMENT: Successful treatment requires prompt recognition, withdrawal of neuroleptic agent, exclusion of other medical conditions, aggressive supportive care, and administration of certain pharmacotherapies. It is essential to recognize signs of NMS early and discontinue antipsychotic medication when appropriate. Intensive medical nursing carae are important. Options vary, but dopamine agonsits (bromocriptine, amantadine), benzodiazepines, and dantrolene have been avocated as beneficial, particularly in sever cases. Immediate interventions include: immediate cessation of the antipsychotic & starting the individual on an anticholinergic medication such as diphenhydramine or benztropine. Supportive interventions include: IV hydration, cooling blankets, antipyretics, ice packs, evaporative cooling; if required-antipyretics & supplemental oxygen. A careful history should be taken before starting a new neuroleptic medication. Drug treatment which is recommended: Dantrolene- the drug of choice is peripheral skeletal muscle relaxant used to treat muscular rigidity. Dose ranging: IV 0.8 to 10mg/kg/day (exceeding 10mg/kg/day may lead to hepatic toxicity). Initial dose: 2 to 3 mg/kg/day over 10 to 15 min, P.O. range: 50 to 700 mg/kg/day given in divided doses of 100 to 200 mg. Parlodel (bromocriptine): given P.O., 2.5 mg to T.I.D. Meds which have been used with variable success are: Symmetrel (amantadine): P.O. 200 mg to 400 mg/day & Ativan (lorazepam): IV (2 mg) with repeated doses. Keep in mind that although individuals with NMS have recovered completely with conservative treatment alone, (cessation of antipsychotic & supportive measures), it is very difficult to assess the primary contribution to any given treatment when combined with all the conservative measures.

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7. IMPLEMENTAION AND INTERVENTION: NURSING ACTION A. Assess the individuals vital signs, including pain assessment, symptoms and precipitating history. B. Notify physician/MOD/NOD and RN immediately and report individuals status. C. Initiate emergency measures and supportive care (CPR, cooling measures, etc.). C. Hold next dose of antipsychotic medication until individual is examined by a physician. D. Continually monitor and document the individuals vital signs and symptoms. E. Continue supportive care. F. If Dantrolene is ordered, call pharmacy STAT. G. The individual must be monitored closely to rule out underlying infection. Adequate hydration must be maintained. 8. EVALUATION: Documentation should include: 1. All assessment data 2. the date, time, method of notification, and all findings that were relayed to the physician. 3. Arrival time of medical help 4. All interventions given 5. Clients response to treatment 6. Clients status and disposition at conclusion of interventions and follow up KEY POINTS A. Use the DIFFERENTIAL DIAGNOSIS TABLE as a guide.

C. If NMS is diagnosed, prepare to transfer individual to an acute medical facility where intensive monitoring and treatment is available. C. A physicians order is not required to hold a medication in an emergency. D. Use the Emergency Care Flow Sheet.

F. During off duty hours Dantrolene can be obtained form the night locker by the NOD.

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9. CLIENT EDUCATION: After an episode of NMS, the individual must be told that he/she is at risk for recurrence. The individual should report this reaction to all healthcare providers. CROSS REFERENCE: NP&P #700 Medical Emergency

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 718 Effective Date: March 7, 2007 SUBJECT: Oleoresin Capsicum (OC) or Pepper Spray Pre and Post care 1. PURPOSE: This policy establishes guidelines whenever Oleoresin Capsicum (OC) or pepper spray might be or has been utilized on individuals. California Department of Corrections and Rehabilitation (CDCR) correctional officers and Hospital Police Officers (HPO) are currently authorized to use this chemical at Coalinga State Hospital. 2. AUTHORITY: DMH Special Order 912.01, Executive Director and Coordinator of Nursing Services 3. POLICY: 1. GENERAL: A. Areas of exposure outside medical or other off hospital ground visits (e.g. court), nursing staff shall review the individuals medical record for any possible risk factors for the use of pepper spray (OC) e.g. known allergies to pepper spray, respiratory disorders such as asthma, COPD or other lung diseases. These risk factors will be communicated to the CDCR officer escorting the individual. B. During calls for HPO assistance calls/unit rounds: Time permitting, nursing staff will communicate to HPO any known risk factors of the individual for the use of pepper spray. C. Plant operations will be notified by nursing staff if use of pepper spray (OC) occurred within individual occupied unit and/or building for further hospital operations action (i.e. vent shutdown and any other necessary action). D. Nursing staff will notify physician and HSS if use of pepper spray (OC) has occurred. E. A Special Incident Report will be initiated and completed for all individuals exposed to OC.

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2. EFFECTS OF EXPOSURE TO PEPPER SPRAY (OLEORSIN CAPSICUM): Pepper Spray derives its name from the active ingredient Oleoresin Capsicum (OC) and is a natural substance made from various hot pepper plants. It is dispersed by strong propulsion with water. Unless the individual has a serious medical condition, effects of OC exposure should subside in 30 to 45 minutes even if no intervention occurs. There are two effects from OC: A. The individuals eyes will usually shut due to the intense burning. The active ingredient dilates the capillaries in the eyes causing blurred vision. It may take 30 to 45 minutes after exposure to open their eyes especially if a direct hit to the face occurs. B. The individual may also inhale the pepper spray, which affects the respiratory system resulting in inflammation, intense burning, and uncontrollable coughing and gagging, often incapacitating the individual. 3. DECONTAMINATION PROCEDURE: A. For OC exposure off hospital grounds: Watch Commander/dispatch will notify Assistant to Coordinator of Nursing (ACNS)/designee of circumstances where use of pepper spray (OC) was deemed necessary. ACNS will then notify nursing staff to plan for any needed follow up treatment when individual comes back to the unit. B. Decontamination Process shall be initiated by nursing staff if CDCR and/or HPO have not carried out the process. If CDCR and/or HPO have carried out a decontamination process, nursing staff shall provide follow up assessment of the eyes, skin, cardiac, and respiratory systems with appropriate interventions (if needed) and documentation. Staff will wear gloves at all times to prevent contamination to themselves. C. Nursing Staff Decontamination Procedure:

Nursing Action A. Reassure the individual and explain the anticipated effects of pepper spray. B. Instruct affected individual to blow his or her nose. C. Irrigate eyes with fresh, cool water at least 15 minutes, or until relieved. If

Key Points A. Effect usually lasts 30 to 45 minutes. B. Clears sinus cavities of pepper spray. C. When available, rinse affected areas with copious amounts of water or saline

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ingested, rinse mouth out with water. D. Use fresh air or fan is the most useful method of decontamination.

E. Assess for signs and symptoms of respiratory difficulties. F. If possible, remove contaminated clothing (use yellow bags with clear plastic liners to contain clothing), and shower individual.

solution. D. Remove individual from the area where the Pepper Spray was used, if at all possible. Do not apply creams, salves or lotions. E. Hyperventilation is usually caused by anxiety from the effects of the OC. F. Wear gloves to minimize risk of contamination and transfer of spray residual. Repeated contact with OC contaminated materials may result in contact dermatitis and late respiratory triggers.

6. EVALUATION: Documentation should include but not limited to the following: A. Date, time and problem B. Vital signs including sp02 and exposed area assessment C. Nursing actions taken pre and post exposure to pepper spray (OC) and individual response D. Other relative information

7. CROSS-REFERENCE: Administrative Directives for Medical Emergencies (342, 343) Nursing Policy and Procedure Manual: NP&P # 700 Medical Emergency, NP&P #408 Eye Irrigation, NP&P # 709 Emergency Care of Eye Injuries MSDS Manual First Defense Stream

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SECTION 8 INFECTION CONTROL

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 800 Effective Date: August 31, 2006

SUBJECT: INFECTION CONTROL PROGRAM 1. PURPOSE: The purpose of the Infection Control Policy is to outline the duties and responsibilities of nursing personnel for maintaining the CSH Infection Control Program. This program is based on State regulations, State and Federal Public Health standards and expectations, and the Centers for Disease Control guidelines. Each staff member is expected to know how to perform all procedures necessary for the prevention and/or containment of infection. Staff objectives for this program are: a) to provide optimum asepsis in Individual care, b) to provide an environment free of infections, c) to protect individuals served, personnel, and visitors against the risk of disease transmission, d) to participate effectively in infection control programs and surveillance monitoring activities as directed, requested, or required, e) to conduct and participate in planned, regular in-service training and education programs for Infection Control. 2. AUTHORITY: CDC, Title 22, CSH AD 508 3. POLICY: 1. Nursing personnel are to maintain appropriate work practices that are essential to the prevention, recognition, reporting, and management of the spread of disease or infection. 2. Nursing personnel are expected to participate in infection control programs as outlined in administrative directives, policies and procedures, and standards of practice. 3. Staff will assist with surveillance monitoring activities as directed, requested, or required.

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4. Nursing personnel will maintain ongoing Individual teaching and instruction of infection control measures based on the individual needs of the Individual and for the unit population. 5. Under the guidance and direction of the Unit Supervisor and in consultation with the RN/Case Manager, and/or Public Health Nurse, the Shift Leads of each shift will assist with insuring staff compliance of the CSH Infection Control Program. 6. In all matters of public health concern, guidance, or clarification the NOD and the Public Health Nurse are to be notified and regarded as the resource for nursing personnel. 7. The Public Health Nurse will plan, coordinate, administer, and implement the hospitals infection control program under the direction of the Public Health Officer. 8. Nursing personnel, having direct contact or the potential for contact with exposure to blood, body fluids, or other potentially infectious material of individuals served or staff, are expected to practice standard precautions according to guidelines established by the CSH Infection Control Program. 9. The fluid, blood, and moist body substances of all individuals served and staff shall be treated as though they were contagious. 10. Standard Precautions will be utilized for all individuals served. These precautions will also serve to guide the care of individuals served who are merely suspected of having such illnesses. 4. DEFINITIONS OF TERMS: Standard precautions - are practices that help to prevent the transmission of pathogens that might travel by means of blood or other body fluids and substances. Transmission-based precautions - are precautions taken for individuals served with certain or suspected highly contagious illnesses. It includes three sets of precautions based on three of the different ways diseases can spread: a) airborne (pathogens stay suspended in the air or dust becomes contaminated), b) by droplet (pathogens are sent into the air when an infected person coughs, sneezes, or talks), c) or by contact (pathogens are passed between a person and an object or another person).

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-Transmission-Based Precautions block the transmission routes through special precautions in the: -Placement of individuals served (e.g. separation or placing individuals served in rooms with other similarly infected individuals served); -Transport of individuals served (e.g. individual served wearing mask on escort to clinic); -Use of Personal Protective Equipment PPE (e.g. gloves, gowns, respirators, goggles); -Handling of Individual-care equipment. Airborne precautions - are required for individuals served known or suspected to be infected by airborne pathogens (e.g. measles, chickenpox, tuberculosis). Droplet precautions - are required for individual serves known or suspected to be infected by pathogens that travel in droplets, (e.g. scarlet fever, influenza, mumps, rubella, pertussis etc.). Contact precautions - are required for individuals served known or suspected to be infected by pathogens that travel by direct contact (e.g. impetigo, herpes simplex). 5. PERTINENT CATEGORIES INVOLVING NURSING PERSONNEL: 1. Health requirements of nursing personnel: 1.1 Medical examination of employees shall be done in accordance with hospital policy: 1.2 All employees shall have a pre-employment and annual health examination. 1.3 Follow-up skin testing of Tuberculin (PPD) negative employees shall be carried out once each year. 1.2 Employees who have a positive Tuberculin (PPD) Test shall be checked by chest x-ray only when clinically indicated and ordered by the physician. 2. Treatment of Personnel shall be done in accordance with hospital policy: 2.1 Employees who become ill on duty shall report to their supervisors. 2.2 Employees who have an infection that pose a hazard to individuals served or other personnel shall be cleared by a physician before being allowed to work.

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2.3 Prophylactic Therapy shall be provided for employees such as vaccines and immune globulins when indicated. 2.4 All level of care nursing employees are offered hepatitis B vaccine. 3. Protection measures for employees working on the unit: 3.1 Adequate hand washing facilities shall be available. 3.2 Periodic in-service training programs to update infection control procedures shall be provided. 3.3 Work area restrictions no food or drink shall be kept or consumed near biohazardous substances such as laboratory counters, in treatment rooms, or specimen storage areas (refrigerators).

6. SPECIAL PRECAUTIONS: The moist blood and body substances of all individuals served, staff, and visitors shall be treated as though they were contagious. In all reasonably anticipated exposures to blood or other potentially infectious material, protective barriers and engineering controls shall be used. Protective barriers (PPE - Personal Protective Equipment) such as gloves, masks, gowns, goggles, and caps are to be worn by an employee as the situation warrants for protection against a hazard. (General work clothes, e.g. uniforms, pants, shirts, or blouses are not intended to function as personal protective equipment protection against a hazard). Gloves shall be worn in all cases when touching the moist body substances, mucous membranes, or non-intact skin of other persons; for performing venipunctures, finger sticks, and other invasive procedures; for handling items or surfaces visibly soiled with blood or other moist body substances. Engineering controls are maintained in all locations of expected exposure and replaced on a regular schedule and as needed, e.g., sharps disposal containers, needle less Injection Systems, Safety Loc syringes, and BagValve-Mask devices, Laboratory Specimen bags. Transmission-Based (Isolation) Precautions shall be ordered by the attending physician in accordance with hospital policy. All employees shall adhere to these precautions.

7. HAND HYGIENE POLICY: Hand hygiene is the single most effective practice in preventing the spread of infections. Refer to nursing policy and procedure Hand Hygiene for specific details.

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8. EMPLOYEE EDUCATION PROGRAMS: Nursing personnel are to be oriented in the area of infection control (including Standard Precautions) at the time of hire, during Annual Infection Control Update, and at periodic In-service classes held as needed by the public health staff, Training Center, or their designees. Content to be covered includes information concerning the kinds and characteristics of organisms most likely to be of concern, source of these organisms, practice of aseptic techniques, hand Washing, isolation, special procedures for care of Individual with infectious disease, and the practice of cleaning, disinfecting, and sterilization procedures. The education program includes: Standard Precautions, Transmission-Based Precautions, infection control measures, practices and expectations, CALOSHA Blood Borne Pathogens Standard Exposure Control Plan including protective barriers and engineering controls, and the TB Exposure Control Plan.

9. NURSING ROLE AND RESPONSIBILITIES IN AN INFECTION CONTROL PROGRAM: Public Health Nurse's Role: 1. The Public Health Nurse II plans, coordinates, administers, and implements the hospital's infection control program under the direction of the Public Health Officer. General functions include the surveillance, reporting, prevention, and control of hospital infections. General Infection Control Responsibilities of Nursing Staff: 1. Takes responsibility for all nursing functions essential to the prevention, recognition, and management of infections. 2. Supports all hospital policies, practices, and procedures. 3. Attends to measures of medical asepsis, including hand Washing and isolation/precaution techniques. 4. Is alert to signs of infection and makes immediate reports. 5. Takes appropriate interim action upon signs of infectious disease potentially hazardous to others. Instructs individuals served in infection control procedures per hospital policy. 7. Serves as a basic source of information on infections. 8. Protects individuals served against exposure to infection.

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9. Instructs individuals served in matters of personal hygiene, aseptic techniques, etc. 10. Serves as a role model by practicing good personal hygiene. Sanitation: Responsibility of Nursing Services. 1. Waste or infective materials (e.g., secretions, excretions, body fluids, and tissues) shall be handled in accordance with Bio-hazardous Waste Nursing Policy and Procedure. 2. Infectious (contaminated) linen shall be handled in accordance with Nursing Policy and Procedure and Administrative Directive. 3. Cleaning of an Isolation Room shall be done in accordance with Nursing Policy and Procedure. 4. Terminal cleaning of a Individual unit shall be done in accordance with Nursing Policy and Procedure. 5. Each employee must clean up after oneself, wipe spills when they occur, and encourage others to do the same. 6. General cleaning of the units shall be done in accordance with the procedures outlined in the Coalinga State Hospital Housekeeping Manual and under the direction of a janitorial supervisor. 7. Unit refrigerators must be cleaned weekly by nursing staff: There shall be separate refrigerators designated for the following: -Food -Medications -Laboratory specimens These items identified shall not co-mingle in the same refrigerator: -All food items shall be dated on outside of container. -A thermometer is required in each refrigerator/freezer: -Temperature must be maintained between 36-46 F for drugs. -Temperature must be maintained below 40 F for food. -Temperature must be maintained at 0 to 10o F for frozen food items. -7.4 Temperatures shall be recorded daily on a Temperature Log for each refrigerator and/or freezer. Staff shall eat in designated areas only.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 801 Effective Date: May 29, 2007 SUBJECT: VERNACARE V2020 DISPOSAL UNIT/MACERATOR 1. PURPOSE: To provide instruction on the use of the Vernacare Human Waste Disposal System. To reduce staff exposure to human waste and improve compliance with the OSHA Blood borne Pathogens Standard. 2. POLICY: This policy will provide guidelines for the appropriate use and care of the Vernacare disposal unit. 1. Only biodegradable products and waste will be placed in the Vernacare Waste Disposal machine. a. Place no more than two (2) bedpans or urinals or emesis buckets at a time per cycle. b. Items such as plastics, disposable gloves, chux, and diapers will clog the machine. c. All Vernacare disposable items and autoclaved bedpan and fracture supports will be located in the Clean Utility Room. d. The Vernacare machines are located in the Soiled Utility Room. e. Keep the Soiled Utility Room user-friendly. The machine should be accessible and clear of equipment to prevent accidents. [One should not be clearing a pathway when ones gloved hands are soiled and carrying a container of body waste. 2. The Unit Supervisor/designee shall ensure that appropriate training in the use of the disposal unit per manufacturers guidelines and who to notify if unit not functioning properly, while the equipment is in use on their unit. If the Vernacare Waste Disposal Machine breaks down, call Plant Operations right away, so that the machine can be fixed as soon as possible. While the machine is out of service, human waste should be disosed of in other Soiled Utility Room where a second Vernacare Machine operates. If both machines are inoperable, then dispose in redlined biohazard trash receptacles. 3. GENERAL INFORMATION: a) The disposal unit macerates the recycled molded pulp paper human waste receptacles such as bedpans, urinals and emesis basins into tiny

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paper fragments and then flushes them safely into the sewer system where they biodegrade naturally. b) The unit is quiet, safe and virtually maintenance free. c) Vernacare meets all FDA, EPA, UL, and CSA requirements and satisfies all municipal sewage disposal standards. d) The risk of contamination and infection from improperly sanitized utensils is eliminated. 4. GENERAL PRECAUTIONS: 1) Staff should maintain proper infection control standards of universal precautions while handling the utensils. 2) The unit is to be used as per manufactures guidelines. 3) Never operate equipment if it has a damaged cord or plug, if it is not working properly 5. PROCEDURE: a. Individuals who need a bedpan should have a bedpan support (plastic and non-disposable), which is kept at the individuals bedside. A new, clean, disposable, paper bedpan liner or urinal should be provided as needed. The bedpan support should be wiped down with a germicidal solution after each use and may be reused by the same Individual until the Individual leaves or does not need it anymore. b. When the bedpan supports are no longer need by the particular individual, they are to be placed in a soiled item container located in the Soiled Utility Room. These items will be terminally cleaned and sterilized prior to being returned to the Vernacare bedpan supply shelves. c. The white bags should be used to cover the soiled Vernacare bedpan liners, commode bowls, and emesis basins during transport to the Soiled Utility Room. The bags are to cover and contain the human waste in the Vernacare receptacle to prevent splashing and spilling during transportation. The bags should be disposed of with the Vernacare receptacle and waste in the Vernacare Disposal Machine. d. To assist with I & Os, there is and will be a fluid measuring scale sitting on the back of the machine. It has a capacity of 2,000 ml (cc). Place the container on the scale. The scale reading the ml weight of the bedpan liner or urinal is the measurement. A chart is posted behind the scale, which includes the weight of each of the Vernacare items. e. When loading the Vernacare Waste Disposal Machine, prevent splashing and exposure by doing the following:

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1) Place the soiled item and contents carefully inside the machine. Use urinal cover to place into the machine (to eliminate splash). Always start the machine to prevent accumulation of waste. The cycle will be completed in 2 minutes. The machine pulverizes the paper products and contents. The macerated tiny pulp fragments are automatically flushed into the sewer system. When the cycle is completed, the disposal unit will be clean and ready for re-use. While the machine is operating, the lid will not open. When the lid is open the machine cannot be started. If the lid is closed and the machine will not start, or there is either the red or yellow light is illuminated and the machine will not operate, please call plant operations. The blue Rest Button will aid plant operations in getting the machine operational again.

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PROTOCOL: VERNACARE SYSTEM: NURSING ACTION A. The white bags should be used to cover the soiled Vernacare bedpan liners, commode bowls, and emesis basins during transport to the Soiled Utility Room. The bags should be disposed of with the Vernacare receptacle and waste in the Vernacare Disposal Machine. B. To assist with I & Os, there is and will be a fluid measuring scale sitting on the back of the machine. It has a capacity of 2,000 ml (cc). Place the container on the scale. The scale reading the ml weight of the bedpan liner or urinal is the measurement. C. When loading the Vernacare Waste Disposal Machine, prevent splashing and exposure by doing the following. Place the molded pulp paper items in the disposal i.e. bedpans, urinals, emesis basins, graduates, and bowls. D. Close the lid and press the start button. The unit disposes of the items and wastes cleanly and completely. E. Always start the machine to prevent accumulation of waste. The cycle will be completed in 2 minutes. The machine pulverizes the paper products and contents. The macerated tiny pulp fragments are automatically flushed into the sewer system. When the cycle is completed, the disposal unit will be clean and ready for re-use. F. While the machine is operating, the lid will not open. When the lid is open the machine cannot be started. If the lid is closed and the machine will not start, or there is both a red and/or yellow light illuminated and the machine will not operate, please call engineering. The blue Rest Button will aid Engineering in getting the machine operational again. -4N.P.P No. 801 KEY POINTS A. Only place molded paper items into the disposal to be macerated. The bags are to cover and contain the human waste in the Vernacare receptacle to prevent splashing and spilling during transportation.

B. A chart is posted behind the scale, which includes the weight of each of the Vernacare items.

C. Place the soiled item and contents carefully inside the machine. Use a urinal cover to eliminate the chance of splash.

D. Always close and lock the lid by pushing down on the lid and pulling the handle toward you. Once the lid is closed, push the Green Start button.

CLEANING AND DISINFECTING of the Vernacare System: NURSING ACTION A. Keep the outside of the unit clean. The outside of the machine should be wiped down daily with disinfectant by staff. B. Use an appropriate; Infection Control Committee approved disinfection solution. KEY POINTS A. Clean any spills as occur. Use universal precautions. B. Refer to Infection Control Policy for List of Approved Cleaning and Disinfecting Agents.

6. CARE OF THE SUPPORTS BETWEEN USES BY THE SAME INDIVIDUAL: Non-disposable items such as bedpans and urinal holders will be wiped with cloth or paper-towel soaked in disinfectant between uses. (Approved disinfectant is available from Environmental Management.) A container of disinfectant ready for use should be available in the Soiled Utility Room for this purpose. 7. TERMINAL CLEANING OF SUPPORTS: When the Individual no longer needs the non-disposable items, the dirty supports should be placed in the soiled item container located in the Soiled Utility Room. These items will be terminally cleaned and sterilized prior to being returned to the Vernacare supply shelves. 8. VERNACARE PRODUCTS: The following is a list of products that will be stocked by Central Supply. If you find that the quantity stocked is not sufficient or you run out of any, please advise Central Supply immediately. Central Supply has supply on hand. Consult the Vernacare Catalog for additional product information. -V20-001 Paper Bedpan Liner----------V20-040 Blue Bedpan Support -V20-005 Paper Fracture Liner---------V20-045 Blue Fracture Support -V20-015x Urinal-------------------------V30-020x Urinal Holders/Handles -V25-030 Portable Commode Chair Liner/13 Utility Basin -V25-010 Emesis Basin -V30-026 White Bags/BedpanCovers -V30-030 Urinal Cover

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 805 Effective Date: August 31, 2006 SUBJECT: ISOLATION AND PRECAUTIONS FOR INFECTIOUS/COMMUNICABLE DISEASE 1. PURPOSE: To provide Nursing Service staff with appropriate guidelines to prevent the spread of microorganisms among individuals, staff, and visitors. 2. AUTHORITY: Title 22, CDC 3. POLICY: 1. All nursing staff is responsible to assist in the prevention of the spread of infections and communicable diseases and shall report all such cases to the physician, Public Health Nurse, and NOD immediately. 2. The Unit Supervisor or designee is responsible for immediately notifying the Public Health Nurse (PHN) whenever Isolation or Precautions of any kind have been ordered by the physician for infectious or communicable diseases. 3. Individual served shall be transferred to the Isolation Suite located in infirmary unit only when this is necessary for infection control and has been approved by the designated physician in consultation with the Public Health Officer or his representative. 4. Guidelines published by the Centers for Disease Control and Prevention (CDC), will be used at Coalinga State Hospital. 5. In addition to Standard Precautions, TRANSMISSION BASED PRECAUTIONS will be utilized for individuals who have certain highly contagious illnesses. These precautions will also serve to guide the care of individuals who are merely suspected of having such illnesses.

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6. Nursing personnel will maintain ongoing individual client teaching and instruction of infection control measures based on the individual needs of the client and for the unit population. 4. DEFINITIONS: Isolation - Separation for the period of communicability of infected persons from others in such places and under such conditions as to prevent or limit the direct or indirect transmission of the infectious agent from those infected to those who are susceptible to infection or who may spread the agent to others. Precautions - Measures to be used by nursing staff when caring for individuals with any kind of infection. Types include: a. Standard Precautions b. Airborne Precautions c. Droplet Precautions d. Contact Precautions

5. GENERAL INFORMATION: Since it is impractical to develop a separate hospital nursing procedure for every condition that might occur, the CDC Guidelines are to be used when a separate nursing procedure is not available. The PHN is responsible for monitoring all individuals with infectious and/or contagious diseases. Upon request, the PHN is available to advise staff regarding appropriate precautions and care of individuals.

ATTACHMENT A - Types of Precautions: Contains information essential to understanding and properly using the different types of isolation or precautions. All nursing staff should review these recommendations frequently. ATTACHMENT B - Techniques for Isolation or Precautions: Contains information on the various types of PPE to be used at this facility. ATTACHMENT C - Table of Type & Duration of Precautions needed for Infections/Conditions with Legend defining the abbreviations.

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This attachment lists diseases or infectious conditions in alphabetical order. The table will give specific type of isolation or precautions to follow and the duration.

6. METHOD:

NURSING ACTION A. Look under disease/condition in Disease Specific Table ATTACHMENT C.

KEY POINTS A. In all matters of public health concern, guidance, or clarification, the Public Health Nurse II and the NOD are to be notified and regarded as the resource for nursing personnel. B. Use Disease Specific Table in Attachment C.

B. Determine type of isolation or precautions and duration recommended by CDC. C. Discuss with the physician when there is a need for a private room. D. Review type of precautions required.

C. To determine if treatment may be done on the individuals home unit. D. Follow specific procedures for handling contaminated articles, linens, etc. E. PHN will monitor all individuals with infectious/communicable diseases and is available upon request to advise staff. F. Consult with PHN II as needed.

E. Notify PHN immediately when the physician orders isolation or precautions.

F. Make a photocopy of the type of precautions required from ATTACHMENT A and place on the individuals door.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 810 Effective Date: August 31, 2006 SUBJECT: CLEANING OF ELECTRONIC MEDICAL EQUIPMENT USED ON THE UNITS 1. PURPOSE: To provide guidelines for the care, use, cleaning and maintenance of the different types of electronic medical equipment used on the units. Some of the types of electronic equipment includebut are not limited to the following: digital thermometers, Vital Signs Monitor, glucometer,, C-PAP machine, and the Oxygen Concentrator. 2. AUTHORITY: TITLE 22, CDC 3. POLICY: 1. Do not attempt to use any electronic medical equipment without a thorough working knowledge of how to handle, operate, and care for the machine(s). 2. Follow the Users Manual instructions for operating, testing and cleaning of the equipment. 3. Maintain Standard Precautions during use of all electronic medical equipment. 4. Central Supply serves as the resource for all questions regarding medical equipment used on the units. Consult with Central Supply when a new battery or other disposable, replacement parts are needed for the electronic unit. 5. Plastic disposable probe covers for the digital thermometers are specific to each unit and must always be used to cover the metal probe of the thermometer during use. Probe covers are available from Central Supply. 6. Dispose of used probe covers in appropriate designated waste receptacles.

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7. After trouble-shooting with the owners manual and consulting with the HSS, notify Central Supply of any malfunctioning equipment. In order to facilitate the repair/replacement of the malfunctioning equipment, staff should provide a description of the malfunction/problem (i.e. what is the equipment doing or not doing) when contacting Central Supply. 4. ELECTRONIC THERMOMETERS: Electronic thermometers are convenient to use, accurate, safe, and rapid in registering temperature (2 to 60 seconds). Their disposable covers save time and work and prevent contamination. They operate on the principle that heat offers resistance to a current in proportion to its temperature. This resistance is converted to a measurement that is displayed digitally. The electronic thermometer equipment consists of a battery pack with a probe attached and disposable probe covers. Read the instructions for each thermometer carefully before using. Use of the wrong probe (or probe cover) can result in inaccurate readings. 5. WELCH ALLYN/LIFESIGN VITAL SIGNS MONITOR: The Welch Allyn Vital Signs monitor is capable of taking an automatic Blood Pressure, oral temperature, and pulse oximetry reading. These monitors are located on all Individual units, in the Admission unit , Urgent Care Unit and in the Occupational Health Clinic. TAKING AN ORAL TEMPERATURE: The oral probe has a blue tip. Remove the probe from the holder and load the probe cover Hold the probe under the Individuals tongue for approximately 4 seconds When the temperature measurement is complete, a tone will sound and the temperature will be displayed Dispose of the probe cover in a appropriate waste receptacle Replace the probe in the holder before attempting to take another temperature measurement 6. CLEANING THE VITAL SIGNS MONITOR: The temperature probe should be periodically cleaned by wiping with an alcohol-dampened cloth or alcohol swab, warm water, or properly diluted nonstraining disinfectant. DO NOT IMMERSE the probes in any liquid. For additional information refer to the Welch Allyn Vital Signs Monitor Operators Manual. 7. GLUCOMETER:

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Follow manufacturers guidelines/ instructions for operating and cleaning glucometers. Should be cleaned with a clean dry cloth. Test Strips cannot be used beyond their manufacturers expiration date. The test strip container must be dated and initialed when first opened, and must be used within four months of the date first opened. Never use a discolored strip and keep containers capped when not in use. Fingerstick blood glucose testing is used for definitive testing for use with sliding scale insulin coverage, and for screening when a Individual is exhibiting signs and/or symptoms glucose instability such as hypoglycemia or hyperglycemia . 8. OXYGEN CONCENTRATOR: The Oxygen Concentrator is to be used for all individuals served who have prescribed oxygen therapy. The Oxygen Concentrator SHALL NOT TO BE USED in emergency situations; oxygen tanks are available for this purpose. The standard, portable oxygen tank with attached tubing and nasal canola shall be available for use by all individuals served during oxygen therapy in case of emergency (e.g. electrical power outage). As with all other forms/uses of oxygen, safety precautions shall be strictly followed. NO SMOKING signs shall be posted and all forms of potential ignition sources shall be kept away from oxygen sources. During oxygen therapy, all individuals served shall have their oxygen saturation (SPO2) checked and recorded at least once each shift, or more frequently as needed or ordered by the physician/authorized licensed practitioner. For more detailed information regarding the care, use, and cleaning of this equipment refer to Nursing Policy & Procedure Oxygen Concentrator.

9. CONTINUOUS POSITIVE AIR PRESSURE (CPAP) SYSTEM: The CPAP machine is used for those individuals served who have been diagnosed with Obstructive Sleep Apnea (OSA). Each Individual shall be issued his own CPAP machine, which shall be sent with the Individual upon transfer or discharge. Central Supply is to be notified whenever the location of the Individual/CPAP machine is changed. When the Individual is issued the CPAP machine, it will be entered on the Individual Clothing and Property Card and it shall be sent with the Individual at the time of discharge. The CPAP machine WILL NOT BE re-circulated or used by another Individual.

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The physician/authorized, licensed practitioner will order the specific settings for each Individual based on the sleep study laboratory recommendation. Individual(s) will be placed on 1:1, 1:2, or 1:3 observation during sleeping hours, based on the number of individuals served in a room on the CPAP machine, and as per physician/authorized licensed practitioner orders. Central Supply serves as the resource for all questions regarding medical equipment used on the units. If problems or questions arise after hours, or on week-ends/holidays, contact the NOD for assistance. Follow the Users Manual instructions for operating, testing, trouble shooting, and cleaning of the equipment. All licensed nursing staff who has received the CPAP inservice training may set-up the program or change settings as ordered by the physician/authorized licensed practitioner.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 815 Effective Date: August 31, 2006

SUBJECT: STORAGE / HANDLING OF TOOTHBRUSHES & TOOTHPASTE 1. PURPOSE: To prevent cross-contamination and reduce the incidence of nosocomial infections. 2. AUTHORITY: CDC, Title 22 3. POLICY: 1. Individuals served who are capable of handling their own toothbrushes safely, are to be provided their own toothbrush and tube of toothpaste that they will store in their own assigned locker space. 2. Individuals served who are unable to care for their own grooming supplies, shall be provided a toothbrush and toothpaste but these will be kept in the designated storage cabinet and dispensed by Nursing Staff. The individual drawer will be labeled with the Individuals name. (Items belonging to individuals served with communicable diseases shall be stored on the bottom shelf). The toothbrush and toothpaste shall be handed out after the Individual has been effectively prompted to brush their teeth. 3. The toothbrush shall be replaced every six months, when the bristles splay, or as needed. 4. Toothbrushes are NOT TO BE SHARED between individuals served. 5. Individual teaching shall be an ongoing endeavor with all individuals served and shall include discouraging the sharing of toothbrushes, proper care and handling of toothbrushes, and oral hygiene care and practices. All teaching shall be documented on the IDN notes.

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4. METHOD: Individuals served Incapable of Handling Their Own Toothbrush and Toothpaste: NURSING ACTION A. Store toothbrush in a parts cabinet, one toothbrush to each drawer. B. Assign a number to each Individual and place it on the appropriate drawer and engrave the number on the handle of the toothbrush. C. Maintain a list that identifies individuals served by numbers. KEY POINTS A. Individual drawers prevent toothbrushes from coming into contact with each other. B. This facilitates placing the toothbrush in the correct drawer.

C. This facilitates having numbers placed on the toothbrush and drawers. D. Never apply toothpaste directly to the brush. E. Disinfect individual drawer with a germicidal detergent used as directed per policy when Individual is transferred or discharged.

D. Dispense toothpaste on an individual piece of paper towel. E. Cleanse entire cabinet including drawers with soap and water weekly and as needed.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 820 Effective Date: August 31, 2006

SUBJECT: DISPENSING INDIVIDUALS LIQUID SOAP/BAR SOAP 1. PURPOSE: To promote Individual self-sufficiency in developing and maintaining Activity of Daily Living Skills while preventing cross contamination and minimizing the incidence of nosocomial infections. 2. AUTHORITY: Title 22 3. POLICY: 1. The Treatment Team of each unit will establish the specific process for dispensing of soap to individuals served for that unit. That process will be based on the individual treatment needs of the Individual and their level of care and capability. 2. Liquid soap dispensers, located in the Individual bathrooms and shower rooms, will be the means for hand Washing and bathing. No bar soap will be dispensed. 3. As part of shower time, staff will dispense liquid soap in a small paper cup for the Individuals use. 4. To encourage normalcy of environment, Individuals served capable of meeting their ADL skills may be issued individual bar soap along with a plastic personalized soap container (travel-size soap dish). 5. The plastic soap containers are dispensed by staff and shall be immediately labeled with the Individuals name by using a laundry marker. 6. Depending on the unit Treatment Team and skills level of the individual served, individuals served may keep their own individual bar soap in their

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locker or the unit may choose to keep the individualized soap containers locked in the shower room cupboard for use at shower time. 7. Shower-time shall be supervised by nursing staff. 8. Community bar soap is considered a contaminant and is prohibited. 9. If bar soap is discovered unattended in the Washroom or shower room, it is to be promptly removed and discarded. 10. Bar soap for bathing is SHALL NOT TO BE SHARED by individuals served. 11. Individual teaching shall be an ongoing endeavor with all individuals served and shall include: proper grooming and maintaining of ADL skills, effective hygienic practices, and the discouraging of sharing bar soap or other grooming articles. All teaching shall be documented on the IDN notes.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 825 Effective Date: August 31, 2006 SUBJECT: CLEANING OF REUSABLE INSTRUMENTS 1. PURPOSE: To provide guidelines for the appropriate cleansing of reusable instruments to prevent cross-contamination. 2. AUTHORITY: Manufacture Guidelines of Reusable Instruments 3. POLICY: Reusable instruments/utensils (e.g., Laryngoscope, suture sets, etc.) shall be cleaned on the unit before they are returned to Central Supply for autoclaving.

4. METHOD: NURSING ACTION A. Rinse all reusable instruments under cold running water to remove gross soil before returning to Central Supply. B. Rinse, dry, and place in original tray and place in paper bag. KEY POINTS A. Wear gloves.

B. Sharp reusable instruments should be placed in a clear plastic punctureresistant container (i.e. dust cover, plastic bag, etc.) for transporting. C. Bag all contaminated materials in a red plastic bag marked biohazardous waste. D. Take precautions to prevent injuries caused by needles and other sharp

C. Dispose of soiled sponges, drapes, used suture materials, etc., in the biohazardous waste container. D. Dispose of sharp disposable instruments in Sharps container.

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instruments. E. Return to Central Supply. E. Hands should be Washed immediately after gloves are removed.

5. PRECAUTIONS: 1. Nursing personnel, having direct contact or the potential for contact with exposure to blood, body fluids, or other potentially infectious material of individuals served, are expected to practice STANDARD PRECAUTIONS. 2. In all reasonably anticipated exposures to blood or other potentially infectious material, personal protective equipment and engineering controls shall be used. 6. DEFINITIONS: 1. Engineering controls: Controls that isolate or remove the blood borne pathogens hazard from the work place. 2. Types of Engineering Controls include, but are not limited to, the following: -Protective barriers, (personal protective equipment) such as gloves, masks, gowns, safety shield/goggles, and caps, are to be worn by an employee as the situation warrants for protection against a hazard. -Gloves shall be worn for handling items or surfaces visibly soiled with blood or other moist body substances. -Engineering controls are maintained in all locations of expected exposure and replaced on a regular schedule as needed, e.g. sharps disposal containers, Safety Loc syringes.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 830 Effective Date: August 31, 2006

SUBJECT: SAFE STORAGE AND DISPOSAL OF SYRINGES AND NEEDLES 1. PURPOSE: To uphold infection control regulations through proper disposal of contaminated syringes and needles into a sharps container and to provide accountability measures for syringes and needles to maintain safety and security. 2. AUTHORITY: CDC, TITLE 22 3. POLICY: 1. Nursing personnel having direct contact or the potential for contact with exposure to blood from sharps are expected to practice Standard Precautions according to the guidelines established by the CSH Infection Control Program. 2. All nursing staff shall be knowledgeable in and practice the safe disposal of used safety locking syringes, needles, and Vacutainers. 3. The licensed nursing employee administering the injection or withdrawing blood is responsible for the safe and proper discarding of the disposable needle, syringe, or Vacutainer following its use. 4. In all reasonably anticipated exposures to blood or other potentially infectious material, personal protective equipment and engineering controls shall be used. 5. The sharps container is utilized for the disposal of used and contaminated needles, syringes, and Vacutainers.

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6. If an injection or other use of sharps must be performed in a room that does not have a sharps container, the sharps container shall be taken to the room for the procedure to permit immediate, safe disposal. 7. Needles shall be retracted into the safety-locking sleeve of the syringe and disposed of directly into the sharps container without recapping. 8. The used safety syringe shall be disposed of in the sharps container. 9. No item is to be removed from the sharps container. 10. The sharps container must be taken to a biohazardous waste collection barrel and replaced when two-thirds full. 11. Safety locking syringes and needles shall be kept in the medication room and counted at the change of each shift using form (Controlled Syringe/Needle Count Signature Record). 12. Syringe and needle usage shall be recorded on (Syringe/Needle Usage Record.)

4. GENERAL INFORMATION: The Medical Waste Act defines sharps waste as any device having acute rigid corners, edges, or protuberances capable of cutting or piercing including, but not limited to all of the following: needles, syringes, blades, needles with attached tubing, broken glass items, e.g. vials. These items will be disposed of within the sharps container located on the unit. The sharps container is a red impermeable plastic, box-type container with a round-flanged opening. One side is clearly printed in white Caution Infectious Waste. The flanged opening contains a black cuff through which the assembled needle, syringe and other identified sharps are placed. When the container is two-thirds full, the round white cap is attached to the flange and pressed down until the cap securely snaps into place. Once the cap snaps into place, the cap cannot be removed. Do not seal this cap until ready to dispose of the container.

5. PRECAUTIONS: 1. When using syringes and Vacutainer with needles and sleeve, do not remove the needles. Retract needle into safety sleeve until the unit clicks. Dispose of the safety-locking sleeve and needle as a unit by placing in the sharps container.

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2. Used needles must not be recapped, bent, or broken by hand, removed from safety locking disposable syringes, or otherwise manipulated by hand as accidental puncture may occur. Needles used to withdraw medication for use with the safety syringe is to be removed from the special syringe and placed immediately in the sharps container. 3. Special caution must be used when handling Tubex systems to prevent accidental puncture, as the needle sheaths are made of thin rubber and do not resist puncture. Tubex systems should be avoided, but if alternative products are not available, no attempt should be made to recap the needles by any method. 4. Do not place fingers in the opening of sharps container or shake as needle stick injury may result. 5. Do not shake a sharps container in an attempt to make protruding syringes or needles settle into the container. A needle may be dislodged by shaking and fly through the air. 6. Keep the sharps container stabilized in its wire basket so contents will not spill. 7. Central Supply will monitor the use and distribution of the sharps container. 6. DEFINITIONS: Engineering controls: controls (e.g., sharps containers) that remove the blood borne pathogens hazard from the work place. Personal protective equipment: special clothing or equipment worn by an employee for protection against a hazard. 7. EQUIPMENT: -Sharps container (a special, red puncture-resistant container for sharp objects). -Wire basket (a special holder for the sharps container).

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8. PROCEDURES: COUNT PROCEDURE FOR USING SYRINGES: NURSING ACTION A. Syringes/needles shall be stored in a locked area inaccessible to individuals and staff without medication room keys. B. Used syringes and needles shall be recorded on the Syringe/Needle Usage Record. B. Assigned staff member responsible will record initials and document: a. date b. individual name c. time used d. remaining count C. If count is incorrect the off-going employee shall report the incorrect count to the Shift Lead and initiate a Special Incident Report. The Shift Lead or designee will insure that the NOD is notified. KEY POINTS

C. On-coming employee shall count all syringes/needles in presence of the off- going employee. If the count is correct, both on-coming and offgoing employees shall sign on the Count Signature Record form .

SYRINGE, VACUTAINER NEEDLE, AND SHARPS CONTAINER ORDERING: NURSING ACTION A. Return syringe wrappers or caps from vacutainer needles to Central Supply for exchange. B. Order sharps container from Central Supply. KEY POINTS A. Without correct exchange, Unit Supervisors signature is required. B. Central Supply will pre-label the sharps container with unit number.

SYRINGE AND NEEDLE DISPOSAL PROCEDURE: NURSING ACTION A. After injection, retract the safetylocking sleeve over the needle until sleeve locks in place. KEY POINTS A. If using the 2000 injection system the needle is to be removed and disposed of in the sharps container. (Needle was used for withdrawing medication not for injection; therefore

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B. Place intact needle and safety locking syringe or safety locking Vacutainer unit into container, needle first. Let it drop. C. When the container is 2/3 full place the cap firmly on container. D. Take sharps container to Biohazardous Waste storage barrel within 24 hours of closure.

needle has not become contaminated.) Do not recap this needle. B. Do not force syringe into the sharps container.

D. There is no need to place sharps container into a red plastic bag. It should go directly into the Biohazardous Waste storage barrel.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 835 Effective Date: August 31, 2006

SUBJECT: SAFE STORAGE AND HANDLING OF SHAVERS 1. PURPOSE: To provide staff with guidelines for the safe care and use of the rechargeable battery operated mens shaver. 2. POLICY: 1. Nursing personnel, having direct contact or the potential for contact with exposure to blood from sharps, are expected to practice Standard Precautions according to the guidelines established by the CSH Infection Control Program. Personal Protective Equipment (PPE) and engineering controls shall be used as needed. 2. Upon request, all individuals will be issued the rechargeable batteryoperated mens shaver or on admission to CSH. General Services will prelabel each shaver body & removable razor head with a designated number. Unit staff will label the razor head with the Individuals name and CSH #. The shaver shall be sent with the individual upon transfer to another unit. 3. When the individual is discharged or is sent to court visit for an extended Period of time (i.e. no bed is being held for the individual), the re-chargeable mens shaver (including the cord and brush) will be returned to Central Supply for disinfection and re-issue of the cord and shaver body only. ID Team approval must be obtained for use of personal electric razors/shavers owned by individuals. 4. All shavers (both state-issued and personally owned) shall be kept in a locked room and accounted for at the change of each shift. 5. Each individual desiring to shave at scheduled shave times shall be issued their assigned battery-operated shaver. Shavers/removable razor heads shall not be shared between individuals.

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6. Assigned unit staff shall inspect the shaver and razor heads for wear, damage, and to insure it is intact prior to giving it to the individual. When the shaver is returned, the assigned staff shall inspect the shaver and razor head to ensure it is intact. 7. There shall be at least one or two staff (based on unit circumstances) assigned to monitor shaving time(s)/razor call. All individuals shall be in direct line of sight of staff while in possession of a shaver. 8. Shavers/razor heads shall be cleaned by staff, or by individuals who have been appropriately instructed and who are under the direct supervision of staff while cleaning the shaver/razor head. 3. GENERAL INFORMATION/PRECAUTIONS: The shavers provided by the hospital contain removable parts which could be misused by the individuals committed to our facility. Each unit I.D. Team should evaluate each individuals potential for misuse of the shaver and/or removable parts. Those individuals with a history or an open problem of Pica, harboring contraband, making weapons, or other problematic behaviors, should be considered for 1 to 1 supervision when that individual uses a shaver. Other individuals may be monitored at a ratio of one staff to 3 or 4 (or more), at the discretion of the I.D. Team.

4. PROCEDURE FOR USE OF BATTERY-OPERATED SHAVER: NURSING ACTION A. Shavers/razor heads shall be stored in a cabinet inaccessible to individuals when not in use and accounted for at the change of each shift. B. Staff shall Wash hands before razor call and after razor call. Wearing gloves is optional, unless visible blood or other bodily fluids are present. KEY POINTS A. This prevents unauthorized access by individuals.

B. If visible blood or other bodily fluids are present, change gloves and Wash hands before handling another shaver/razor head.

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C. Provide individual with his rechargeable shaver. If not already attached, the individual should attach razor head to the body. If the individual has difficulty attaching the razor head, staff may assist.

D. Record the name of each individual receiving their shaver on form CSH
E. Staff may demonstrate how to turn on the shaver by pushing in and up on the on-off switch on the front of the shaver body.

D. To assure accountability of shaver and individual razor heads.

E.

F. Upon return of the shaver the assigned staff shall inspect the shaver to ensure that it remains intact and no parts are missing. G. Record (on form CSH 7047) when individual returns the shaver. H. Check individuals cassette drawer to ensure that the re-charging cord, cleaning brush, razor head and shaver body are all present, and that the numbers are all the same, before the individual leaves the area.

F. Ensure that shaver & razor head is cleaned and intact prior to storage. G. Ensures the same individual who received it has returned shaver. H. Ensure that shaver and all components are present and are that individuals to prevent potential cross-contamination, and to ensure that no potential contraband is taken by the individual.

5. PROCEDURE FOR CLEANING RECHARGEABLE SHAVER: Follow manufactures guidelines/ instructions for cleaning.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 840 Effective Date: August 31, 2006

SUBJECT: USE OF PERSONAL PROTECTIVE EQUIPMENTS, PPE

(GOWN, MASK, GLOVES, GOGGLES AND FACE SHIELD) 1. PURPOSE: To prevent contamination and to provide guidelines on use of barriers to prevent the spread of infectious materials. 2. AUTHORITY: CDC. 3. POLICY: Nursing staff shall use the Standard and Transmission Base Precautions for the care of all individuals. All nursing staff shall follow the guidelines for gowning, masking, and gloving from the Centers for Disease Control (CDC). Gowns and masks shall be removed and replaced if contamination occurs. Staff is required to wear masks to protect mucus membranes of the mouth and nose, and gowns to protect soiling of clothing during procedures and individual care activities that are likely to pose exposure to body and blood fluids. 4. METHOD: Sequence for donning PPE: Gown first Mask Goggles or face shield Gloves over the gown cuffs Combination of PPE will affect sequence- be practical. Sequence for removing PPE: Gloves -1N.P.P No. 840

Face shield or goggles Gown Mask

5. GOWNING: NURSING ACTION A. Remove jewelry and put in pocket. KEY POINTS A. Wash hands after removing jewelry (refer to Hand Hygiene, NPPM # 855 )

B. Select the right size of gown for you C. Put gown on with opening at back, C. Touch only the inside of the gown. slipping one arm at a time into sleeves. E. Overlap gown at back to completely cover clothing. F. Secure the gown at the neck and waist by fastening the ties. REMOVING GOWN: A. Wash hands. Refer to Hand Hygiene B. Unfasten tie at neck first then at waist. A. To avoid transfer of microorganism to other individuals or the environment. B. The neck is considered clean and should be handled with clean hands only. C. Remove gown with care to prevent contaminating clothing, keeping inside of gown clean. Only clean part of the gown should be visible. D. Shaking causes spread of organisms into the air. F. Remove and replace gown if contamination occurs.

C. Slip hands into sleeves carefully pulling off gown.

D. Fold the gown towards inside and roll into a bundle.

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E. Discard into waste or linen Container as appropriate. If contaminated place in biohazard Container. F. Wash hands again. F. See (A).

6. MASKING: Two types of masks: 1. The PARTICULATE RESPIRATORY MASK is used to block airborne organisms from entering the respiratory tract. The Particulate Respiratory Mask shall be used for caring for an individual is respiratory isolation or individual with infectious tuberculosis. 2. The regular mask is used to protect face from splashes of blood or body fluids. 7. PRECAUTIONS: 1. Use mask once only. 2. Wash hands before and after masking 3. Do not dangle around neck or place in pocket, because organisms continue to multiply on mask. 4. Do not touch mask during use. 8. PROCEDURE: NURSING ACTION A. Place the mask over mouth, nose and chin. B. Change mask if it gets moist. KEY POINTS A. Use appropriate mask for the situation. Adjust the mask to fit. B. Organisms freely pass through wet surfaces.

C. Wash hands before removing mask

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D. Remove mask by handling the ties starting with the bottom to the top ties. And discard in the appropriate waste container when leaving the room.

D. Masks used by individuals in isolation room should be disposed of as biohazardous waste. Masks worn by healthy staff may be disposed of in a regular waste container in the isolation room.

E. Wash hands after removing mask -For Particulate Respiratory Mask follow manufactures instructions for donning and removing the device. 9. GLOVING: 1. Use gloves only one time and discard properly. 2. Change gloves after use on each Individual and discard them. 3. Wash hands before and after using gloves. 10. PROCEDURE: NURSING ACTION A. Select the size of glove that best fits you. B. Insert each hand into appropriate glove. C. If wearing an isolation gown, tuck the gown cuffs securely under each glove D. Remove gloves (1) by grasping the outside of the opposite glove near the wrist. E. Remove gloves (2) by sliding one or two fingers of ungloved hand under the wrist of the remaining glove. F. Discard gloves after use in biohazardous waste container if contaminated with fluid blood or moist body substances. G. Wash hands after removing gloves C. This provides a continuous barrier protection for skin D. This prevents contamination KEY POINTS

F. Regular trash container should be used for unsoiled gloves.

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11. GOGGLES AND FACE SHIELD: Goggles are used to provide barrier protection for eyes 12. PRECAUTIONS: Goggles should fit snugly over and around eyes. Personal glasses are not a substitute for goggles.

13. PROCEDURE:

NURSING ACTION
A. Position goggles over eyes and secure to the head using ear pieces or headband. B. Position face shield over face and secure on brow with headband C. 3. Adjust to fit comfortable D. To Remove goggles and face shield: E. Grasp ear or head pieces with hands F. Lift away from face G. Discard them in appropriate waste receptacle. 14. KEY POINTS OF PPE:

KEY POINTS

C. Goggles should feel snug but not tight

Don it before you have any contact with Individual. Once you have PPE on, use it carefully to prevent spreading contamination When you have completed your tasks, remove the PPE carefully and discard appropriately. Then immediately perform hand hygiene before going to the next Individual.

15. PPE FOR STANDARD PRECAUTIONS:

Standard Precautions: Previously called Universal Precautions -5N.P.P No. 840

Assumes blood and body fluids of any Individual could be infectious Recommends PPE and other infection control practices to prevent transmission of common infectious agents.

Under Standard Precautions: 1. Gloves - shall be used when touching blood, body fluids, secretions, excretions, or contaminated items and for touching mucous membranes and no intact skin. 2. Gown - shall be used during procedures and Individual care activities when contact of clothing and/or exposed skin with blood, body fluids, secretions, or excretions is anticipated. 3. Mask and goggles - or a face shield shall be used during Individual care activities that are likely to generate splashes and sprays of blood, body fluids, secretions or excretions.

16. PPE FOR EXPANDEDED PRECAUTIONS:

Expanded Precautions (formerly called Transmission-Based Precaution), which sometimes are used in addition to standard precautions, include: Contact Precautions- Gown and gloves for contact with Individual or environment of care (e.g., medical equipment, environment surfaces) Droplet Precautions- Surgical masks within 3 feet of Individual Airborne Infection Isolation - Particulate respirator, Negative pressure isolation room are also required.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 845 Effective Date: August 31, 2006

SUBJECT: CLEANING PROCEDURE FOR ISOLATION ROOM 1. PURPOSE: To prevent cross contamination. 2. AUTHORITY: CDC, Title 22 3. POLICY: Nursing Services shall ensure that the isolation room is maintained in a clean and sanitary condition at all times. Terminal cleaning shall be completed between individuals served and as needed. 4. DEFINITION: The destruction of pathogenic organisms in room after use by an infected Individual. 5. PRECAUTIONS: 1. Follow Standard Precautions see Administrative Directive. 2. Follow the Blood Borne Pathogen Exposure Control Plan, found in the Infection Control Manual. 3. In all reasonably anticipated exposures to blood or other potentially infectious materials, personal protective equipment and engineering controls shall be used.

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4. When the isolation room is occupied, nursing staff shall be consulted regarding any special procedures or precautions before entering the room, including personal protective equipment as required. 5. Cleaning equipment used in the room shall be disinfected before being used elsewhere.

6. EQUIPMENT: 1. Basin with detergent germicide solution. 2. Clean cloths, gloves, gown. 3. Biohazardous waste bags (red plastic). 4. Contaminated linen bags (yellow plastic) and water-soluble bags.

7. RESPONSIBILITIES: 1. When an isolation room is occupied: a. b. Housekeeping shall clean floors and fixtures daily, following the procedures in the Housekeeping Manual, Procedure #1887. Housekeeping shall empty biohazardous waste cans daily; Nursing Services staff shall empty linen hampers and as needed, and empty biohazardous waste cans daily when no housekeeping staff are available. Nursing Services staff shall clean and return reusable medical supplies and equipment as needed.

c. 2.

After the Individual is discharged: a. b. Nursing Services staff shall clean the furniture, mattress, pillows, bed frame and other stationary items. Nursing Services staff shall clean and return all reusable medical supplies and equipment to their place of origin.

8. PROCEDURE: NURSING ACTION A. Bag all disposable items and trash in biohazardous waste bags. KEY POINTS A. See NPPM Biohazardous (Infectious) Waste. -2N.P.P No. 845

B. Bag soiled linen in clear plastic water-soluble bags, then in yellow contaminated linen bags. C. Clean all returnable articles and small equipment with soap and water solution and place in a semi-permeable bag, labeled with a biohazardous symbol and return to Central Supply. D. Clean large equipment with germicidal detergent before removing from room. E. Wipe down furniture, mattress, pillows, bed and other stationery items with germicidal detergent. F. Notify housekeeping for major cleaning of walls, floors and bathroom.

B. See NPPM Handling Procedures for Linen and Clothing. C. Central Supply will further decontaminate and sterilize articles and equipment.

E. Housekeeping will clean walls, windows and cubicle curtains.

F. Plant Operations will change the air filters upon notification.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 850 Effective Date: August 31, 2006

SUBJECT: CLEANING OF INDIVIDUALS INDIVIDUAL AREA(S) 1. PURPOSE: To provide guidelines for the cleaning of individuals area(s) this should prevent cross contamination.

2. POLICY: An individual area shall not be used for another individual until cleaning has been completed. Individual area(s) shall also be cleaned after each instance of drug interdiction searching to insure that all residual has been removed.

3. GENERAL INFORMATION: An individual area consists of bed, mattress, pillow, wall locker, small property locker, bedside table and floor area.

4. EQUIPMENT: 1. 2. 3. 4. Basin with germicide detergent Cleaning cloths Clean linen Isopropyl Alcohol (for removal of residue after drug interdiction search).

5. PRECAUTIONS: 1. Use hand hygiene before and after procedure 2. Follow Standard Precautions .

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6. PROCEDURE: NURSING ACTION A. Strip bed placing all linen in laundry B. Scrub mattress cover, pillow cover and bed frame thoroughly with approved detergent germicide. Allow to Air Dry. C. Remove everything from bedside stand and / or wall locker and clean with approved solution. D. Turn mattress and make up bed. E. Clean floor using appropriate, approved solution. F. Use isopropyl alcohol to decontaminate all areas registering a hit by either the Barringer Ion Scan detection system or by drug sniffing dog(s), as soon as possible after authorization by Law Enforcement personnel. F. Isopropyl Alcohol effectively eliminates drug residue, so that the same residual does not register another hit. If drug interdiction search has been performed by drug sniffing dog(s), area should be cleaned as well as decontaminated. KEY POINTS A. Infectious linen is Double-Bagged, B. Do not permit access to detergent solution without individual supervision. C. Allow to Air Dry.

D. Use Clean linen.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 855 Effective Date: August 31, 2006

SUBJECT: HAND HYGIENE 1. PURPOSE: To provide appropriate guidelines for hand cleansing, the first line of defense against infection, and a primary method of preventing cross-contamination of infectious diseases 2. AUTHORITY: CDC Hand hygiene guidelines April/ 2005 3. POLICY: All nursing services staffs shall proper hand hygiene to prevent the spread of infectiousDiseases. Wearing gloves shall not be a substitute for proper hand hygiene. 4. METHOD: HAND-CLEANSING TECHNIQUE (SOAP AND WATER): NURSING ACTION: A. Turn on faucet; adjust temperature of water and rinse hands. B. Apply soap and lather hands and wrists, using friction for at least 15 seconds (Tune of twinkle twinkle little star) C. Rinse and dry with paper towels. D. Turn off water faucet with a clean dry paper towel. KEY POINTS: A. Rinsing dilutes contaminating Organisms. B. Friction helps dislodge bacteria and soil. Spend one-half to one minute on each hand, depending on degree of contamination. C. Use as needed to dry hands D. Faucets are contaminated.

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HAND-ANTISEPSIS TECHNIQUE (ALCOHOL-BASED HAND RUB):

NURSING ACTION
A. Apply product to palm of one hand.

KEY POINTS A. Follow manufacturer guidelines regarding the amount of product to use ( see attachment)

B. Rub hands together, covering all surfaces of hands and fingers until hands are dry. 5. CDC RECOMMENDATIONS: These recommendations are designed to improve hand-hygiene practices of health care workers and to reduce transmission of pathogenic microorganisms to Individuals and personnel in health-care settings. This guideline and its recommendations are not intended for use in food processing or food-service establishments. As in previous CDC/HICPAC guidelines, each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and economic impact. The CDC/HICPAC system for categorizing recommendations is as follows: Category IA - Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. Category IB - Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiologic studies and a strong theoretical rationale. Category IC - Required for implementation, as mandated by federal or state regulation or standard. Category II - Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. No recommendation - Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exist. INDICATIONS 1. Indications for hand washing and hand antisepsis:

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A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water (IA). B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands. Decontaminate hands before having direct contact with Individuals (IB). C. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter (IB). D. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure (IB). E. Decontaminate hands after contact with a Individual's intact skin (e.g., when taking a pulse or blood pressure, and lifting a Individual) (IB). F. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled (IA). G. Decontaminate hands if moving from a contaminated-body site to a cleanbody site during Individual care (II). H. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the Individual (II). I. Decontaminate hands after removing gloves (IB). J. Before eating and after using a restroom, wash hands with a nonantimicrobial soap and water or with an antimicrobial soap and water (IB) . K. Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of health care workers, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap (IB). L. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis is suspected or proven. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores (II). M. No recommendation can be made regarding the routine use of non alcohol-based hand rubs for hand hygiene in health-care settings. Unresolved issue. 2. Hand-hygiene technique: A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry (IB). Follow the manufacturer's recommendations regarding the volume of product to use.

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B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. C. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (IB). Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis (IB). D. Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with a non-antimicrobial soap and water. When bar soap is used, soap racks that facilitate drainage and small bars of soap should be used (II). E. Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care settings (II). 3. Hand antisepsis (Surgical): A. Remove rings, watches, and bracelets before beginning the hand scrub (II). B. Remove debris from underneath fingernails using a nail cleaner under running water (II). C. Surgical hand antisepsis using either an antimicrobial soap or an alcoholbased hand rub with persistent activity is recommended before donning sterile gloves when performing surgical procedures (IB). D. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually 2--6 minutes. Long scrub times (e.g., 10 minutes) are not necessary (IB). E. When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer's instructions. Before applying the alcohol solution, pre wash hands and forearms with a non-antimicrobial soap and dry hands and forearms completely. After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves (IB) . 6. Other Aspects of Hand Hygiene: A. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non intact skin could occur (IC). B. Remove gloves after caring for a Individual. Do not wear the same pair of gloves for the care of more than one Individual, and do not wash gloves between uses with different Individuals (IB). C. Change gloves during Individual care if moving from a contaminated body site to a clean body site (II).

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6. PRECAUTIONS (SOAP AND WATER): Always Wash from area of least contamination to area of greatest contamination. Faucet handles and doorknobs are considered contaminated. Hand lotions should be used to prevent excessive drying of the skin as intact skin is the first line of defense against invasion of organisms. Wash keys daily as needed with soap and water, rinse well and dry with paper towels to keep as free from microorganisms as possible. 7. PRECAUTIONS: (ALCOHOL BASED HAND RUB): 1. Frequent use of alcohol-based formulations for hand antisepsis can cause drying of the skin unless emollients, humectants, or other skin-conditioning agents are added to the formulations. 2. Even well-tolerated alcohol hand rubs containing emollients may cause a transient stinging sensation at the site of any broken skin (e.g., cuts and abrasions). Alcohol-based hand-rub preparations with strong fragrances may be poorly tolerated by people with respiratory allergies. Allergic contact dermatitis or contact urticaria syndrome caused by hypersensitivity to alcohol or to various additives present in certain alcohol hand rubs occurs only rarely. 3. Alcohols are flammable. Flash points of alcohol-based hand rubs range from 21C to 24C, depending on the type and concentration of alcohol present. As a result, alcohol-based hand rubs should be stored away from high temperatures or flames in accordance with National Fire Protection Agency recommendations. It is emphasized that hands should be rub together after application of alcohol-based products until all the alcohol has evaporated. Store supplies of alcohol-based hand rubs in cabinets or areas approved for flammable materials (IC).

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 860 Effective Date: August 31, 2006

SUBJECT: BIOHAZARDOUS (INFECTIOUS) WASTE This cancels Nursing Procedure 860 dated 6/1/05

1. PURPOSE: To provide guidelines for the prevention of cross contamination and infection of employees and individuals served by the proper collection, handling, storage, and transportation of biohazardous wastes.

2. POLICY: 1. All biohazardous (infectious) wastes shall be collected, handled, stored, transported, and disposed of separately from all other solid waste and only as described in the procedure outlined below. 2. The entire system for dealing with biohazardous (infectious) wastes shall be approved periodically in writing by the Fresno County Department of Environmental Health Service and shall not be revised in any way without their approval and the approval of the Coalinga State Hospital Infection Control Committee. 3. Non-Biohazardous (non-infectious) waste should not be placed in the "Biohazardous (Infectious)" Waste receptacles. 4. Unit nursing personnel are responsible for the collection and, in most areas, the disposal of infectious waste. 5. The fluid blood and moist body substance of all individuals served, staff, and visitors shall be treated as though they were contagious. 6. Individuals served are never to handle any contaminated materials.

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3. DEFINITION OF BIOHAZARDOUS WASTE: -Significant laboratory wastes including microbiologic specimens (including cultures) from Individual, and disposable fomites; discarded live or attenuated vaccine or containers. -Human tissues and disposable materials from medical/dental clinics and unit examinations and treatment rooms suspected of being contaminated with infectious agents contagious to humans. -Waste which contains recognizable fluid blood or blood products (free, on equipment, or in containers) -Waste containing discarded materials contaminated with excretion, exudate, or secretions of individuals served placed in isolation room to protect others from highly communicable diseases. -Coalinga State Hospital also treats as Biohazardus Waste the following categories that are listed by CAL-OSHA as Regulated Waste. Regulated waste is defined as: contaminated items that would release blood or other potentially infectious materials (OPIM) if compressed, or that are caked with dried blood or OPIM, or that contains liquid OPIM. OPIM is defined to include: semen (except for discarded condoms), vaginal secretions (except for discarded peri pads or tampons), saliva from dental procedures, and fluid from internal body cavities. DOES NOT INCLUDE: -Paper towels, paper products, urine, feces, saliva (except from dental procedures) sputum, nasal secretions, sweat, tears, or vomits unless any of the preceding contain fluid blood. 3. PRECAUTIONS: 1. In all reasonably anticipated exposures to blood or other potentially infectious material personal protective equipment and engineering controls shall be used. Engineering controls isolate or remove the blood borne pathogen hazard from the work place (i.e. sharps containers). Personal protective equipment is special clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts, or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment. 2. It is the responsibility of all nursing personnel who handle "Biohazardous Waste" to ensure that it is not mixed with "non-infectious waste." -2N.P.P No. 860

3. If "Biohazardous Waste" is accidentally placed in a non-infectious container, the entire contents of the container must then be considered contaminated. It must be immediately bagged and disposed of as "Biohazardous Waste." The container from which it was taken shall be cleansed with detergent-germicide solution. If noninfectious waste is accidentally placed in the "Biohazardous Waste Container" it is considered contaminated and may not be removed. 4. IMPLEMENTATION AND INTERVENTION: PLACING INFECTIOUS WASTE IN RECEPTACLE: NURSING ACTION A. Biohazardous waste must be placed in the special receptacles marked Biohazardous Waste Only or Biohazardous with symbol on the cover and on visible lateral sides. B. These receptacles should be considered contaminated on all surfaces and care taken not to touch them except as necessary and with proper hand hygiene after each exposure. C. Never place biohazardous waste in a biohazardous receptacle which does not have the appropriate lettering and symbols

KEY POINTS A. Infectious waste must not be mixed with non-infectious waste.

B. All waste should be considered hazardous but known biohazardous waste requires special precautions.

C. All receptacles should have a transport container inside. An intact can liner prevents contamination of the receptacle. Placing contaminated waste directly in receptacle grossly contaminates it and it will require special cleaning with detergent germicidal solution immediately. D. Proper procedures require functioning equipment.

D. All biohazardous waste receptacles will have a foot pedal to open the lid. When the lid mechanism is not working properly, the receptacle should be replaced.

E. The lids of the biohazardous waste E. The closed lid prevents airborne receptacles must be closed except when contamination and helps control odors. briefly opened for placement of biohazardous material inside. No container without a lid should be used for infectious waste. -3N.P.P No. 860

F. Bio-hazardous waste should always be gently and carefully placed in the receptacle. G. Care should be taken to place the waste within the plastic bag can liner without contamination of the lid or outer surface(s) of the receptacle. H. Do not overfill the biohazardous waste receptacles!

F. Avoid all forceful agitation of infectious waste. Biohazardous waste can be life threatening.

H. Full means 2/3 full. Failure to follow this procedure will result in serious contamination of the environment.

I. Broken glass fragments and other sharp I. The sharps container must be delivered infectious waste items should be contained to the biohazardous waste barrel be the in a sharps disposal container. next day if blood or tissue is placed in it.

EMPTYING BIOHAZARDOUS WASTE RECEPTACLES: NURSING ACTION A. Get one (1) red plastic bag labeled Biohazardous Waste with a biohazard symbol . B. Care must be taken not to spill any of the biohazardous waste at any time. KEY POINTS A. Double bagging is no longer required. Transport containers are used.

B. If a spill should occur, clean up immediately. Wearing gloves, apply a solution of Powder Keg or other approved disinfectant to contaminated surface(s). Clean-up Kit should be used before wiping up liquid blood spills. C. Do not compress bag prior to tying.

C. Open the biohazardous waste receptacle, place hands under the cuff, and gently close the bag and tie. Lift transport container (with tied red bag inside) from the waste can and put transport container lid in place. D. Place a new transport container into the biohazardous waste receptacle.

D. The rigid container with tight fitting cover prevents accidental injury and spills, which may result in contamination of the environment. -4N.P.P No. 860

E. Place the clean red bag marked with the biohazard symbol and labeled Biohazardous Waste in the transport container. Carefully fold a cuff down around the top outside of the transport container. F. If the large drum is full, return to unit with biohazardous waste in transport container and notify Housekeeping or Public Health office.

E. Handle only the inside surfaces of the new can liner.

F. If after hours, leave word on the voicemail system.

TYPES OF CONTAINERS, WHERE OBTAINED AND WHERE DISPOSED OF:

MATERIAL TO BE BAGGED Infectious Linen Contaminated Laundry (Double Bagged) BIOHAZARDOUS WASTE (Does Not Include Infectious Sharps UNLESS IN SHARPS CONTAINER) Non-disposable Infectious Items (i.e. instruments, etc.)

TYPE OF BAG OR CONTAINER Clear, Yellow Water Plastic Soluble (outer) Bag Bag A SINGLE, RED PLASTIC BAG MARKED BIOHAZARDOUS WASTE

WHERE OBTAINED Laundry

WHERE DISPOSED OF Soiled Linen Room

Main Warehouse

Place in a BIOHAZARDOUS WASTE Barrel

Clean with soap and water on the unit and place in a puncture-resistant, plastic contained labeled BIOHAZARDOUS

Central Supply

Return to Central Supply

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 870 Effective Date: August 31, 2006 SUBJECT: CLEANING OF WATER PITCHERS ON UNITS 1. PURPOSE: To provide guidelines for the appropriate cleaning of water pitchers in order to prevent the spread of infection and communicable disease. 2. POLICY: 1. Fresh water and ice are provided, as needed, each shift for individuals served confined to bed. 2. All units providing water pitchers for individuals served shall have pitchers and lids cleaned daily. 3. The Unit Supervisor, or designee, is responsible for assuring the water pitchers and lids are cleaned as stated in this procedure. 3. PROCEDURE:

NURSING ACTION
A. Return water pitchers and lids to the dining room for sanitizing. B. Distribute clean pitchers, lids, water and ice daily, as needed.

KEY POINTS

A. Water pitchers and lids are usually sanitized after the evening meal. B. Kitchen personnel will sanitize pitchers and lids using the dishwasher and return them the following meal. C. Store clean pitchers & lids in a clean C. Unused pitchers and lids will be area. recycled through this procedure every other day.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 875 Effective Date: August 31, 2006

SUBJECT:

DISINFECTION OF COMMONLY SHARED GROOMING SUPPLIES AND/OR EQUIPMENT

1. PURPOSE: To maintain grooming supplies and/or equipment clean.

2. POLICY: The primary objective for disinfection of commonly shared grooming supplies and/or equipment is to minimize the risk of disease transmission. Crosscontamination is considered a high risk/ risk management concern associated with the potential for blood contaminant exposure. The procedures are established from State regulations and State and Federal Public Health guidelines. All efforts are to insure that the CSH Infection Control Program is followed. 1. Commonly shared grooming supplies and/or equipment that may be utilized by staff for individuals care are identified as follows: finger nail clippers; toenail clippers; tweezers; curling iron; electric curlers; steam curlers; electric hair trimmer. 2. Personal grooming items NOT TO BE SHARED between individuals are combs, hairbrushes and re-chargeable battery-operated shavers (men). 3. Nursing staff shall not allow commonly shared grooming supplies and/or equipment to be utilized by or for other individuals until these items have been properly cleaned and disinfected. 4. The unit Shift Leads of each shift, under the guidance and direction of the Unit Supervisor, are responsible for insuring staff compliance with the CSH Infection Control Program.

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5. Each unit shall have properly labeled receptacles for the care of those grooming supplies requiring disinfection. One receptacle will be designated for those supplies with the disinfecting process in progress. Another receptacle will be designated for those supplies that have been used on an individual and are considered contaminated and requiring disinfection. 6. All disinfectant solutions shall remain covered at all times, and be changed whenever visibly cloudy or dirty. 7. Non-electric items (e.g. hair accessories, curlers) shall be cleaned with soap (or detergent) and water, then disinfected by immersion for at least 20 minutes in a solution with bactericidal, fungicidal, tuberculocidal, and virucidal properties such as a quaternary ammonium compound or equivalent, approved by the Infection Control Committee. (See Infection Control List of Approved Cleaning and Disinfecting Agents) 8. Non-electrical items with a sharp point or edge that have the potential to pierce the skin and draw blood (e.g. scissors, tweezers, cuticle clippers, manicure- pedicure scissors, etc.) shall be disinfected by cleaning with soap (or detergent) and water and then totally immersing in a solution with bactericidal, fungicidal, tuberculocidal, and/or virucidal properties, approved by the Infection Control Committee for at least 20 minutes. 9. Electric and non-electric hair clippers/trimmer shall be disinfected prior to each use by first removing all foreign matter from the clipper blade followed by totally immersing the individuals clipper blade in an approved solution for at least 20 minutes. 10. An electric curling iron shall be disinfected by cleansing the contact site with an approved solution. 8. All disinfected grooming supplies and equipment shall be stored in a designated secure, clean, and covered location. 12. Safety, security, and supervision measures for these items will be maintained at all times. 13. Individual teaching, discouraging the sharing of personal grooming items and supplies, shall be an ongoing endeavor with all individuals. 3. PRECAUTIONS: 1. Grooming items with sharp points and edges are to be utilized with the utmost care to avoid any potential for individual or staff injury.

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2. IN ALL REASONABLY ANTICIPATED EXPOSURES TO BLOOD OR OTHER POTENTIALLY INFECTIOUS MATERIAL, PERSONAL PROTECTIVE EQUIPMENT AND ENGINEERING CONTROLS SHALL BE UTILIZED. EQUIPMENT NEEDED: 1. Emesis basin (to soak the item) Disinfectant solution approved by Infection Control Committee 3. Clean towel 4. Plastic container

2.

4. PROCEDURE: Non-electrical items (hair accessories): NURSING ACTION KEY POINTS

A. Remove all foreign matter, oils, and A. Apply friction as needed to other substances that can enhance this cleaning process. impair the disinfection process by scrubbing with soap and water. Rinse thoroughly. B. Immerse the items in an approved solution for at least 20 minutes. Place on a clean, dry towel to air dry. C. Maintain these items in a clean, dry, covered storage area. B. Total immersion of the objects and proper time span ensures effective disinfection.

C. Cover with a plastic container or plastic baggie or wrap in a clean towel before placing in a cabinet or drawer.

Non-electrical items with a sharp point or edge (e.g. scissors, nail clippers, tweezers, cuticle clippers, manicure pedicure scissors, non-electric hair clippers, etc.) A. Remove all foreign matter, oils, and other substances that can impair the disinfection process by scrubbing with soap and water. Rinse thoroughly. A. Initiate the cleaning process with the utmost care to avoid piercing the skin.

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B. Immerse the objects and leave them in approved solution for at least twenty (20) minutes. C. All disinfected items shall be stored in a clean covered place.

B. Total immersion of the objects and proper time span ensures effective disinfection. C. Place is a covered plastic container or plastic baggie, or wrap in a clean towel before placing in a cabinet or drawer.

Electrical Instruments (e.g. hair clippers/trimmer): A. Disinfect hair clippers and other electrical grooming instruments prior to each use. A. Personal electric razors owned by individuals and hospital issued re-chargeable & battery-operated shavers for all individuals are not to be shared. Hospital issued shavers may be obtained from the Warehouse. These batteryoperated shavers are to be considered the individuals property and are to be sent with the individual on transfer to another unit. . The mens shavers are to be sent to Central Supply for disposal of appropriate removable parts, disinfection, and re-issue. B. The methods for removing all foreign matter may differ depending upon the equipment. Some equipment may require a clean brush, other equipment may require a clean cloth or cotton swab. C. Allow to air dry on a towel.

B. Remove all foreign matter.

C. The clipper/trimmer blade shall be disinfected by cleansing with soap (or detergent) and water followed by totally immersing the clipper/ trimmer portion in an approved solution for at least 20 minutes. D. Closed cabinets and drawers are considered clean.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 880 Effective Date: August 31, 2006 SUBJECT: HANDLING AND STORAGE OF ICE ON THE UNIT 1. PURPOSE: To prevent the growth of microorganisms during the handling and storage of ice on the unit, sanitation procedures are established to minimize the risk of contamination. 2. POLICY: 1. All units providing ice for Individual use shall have a covered ice chest with a hard plastic liner. The ice scoop shall be in a covered plastic container. 2. On a daily basis, unit staff will bring their ice chest, ice scoop, container, and lid to the cafeteria to be sanitized by cafeteria personnel. 3. The Unit Supervisor/designee shall insure that the unit maintains the Schedule of Cleaning of Ice Chest/Scoop/Container - see attached) to show the ice chest, scoop, container, and lid have been brought to the cafeteria daily to be sanitized. Unit staff are to initial this schedule only after completion of sanitization. 3. GENERAL INFORMATION: Fresh ice may be obtained, as needed, from the ice machine in each building. An ice machine cleaning schedule is maintained in the area of each ice machine, including documentation of actual cleaning with date and initials. The Program Housekeeper Supervisor I (HSI) is responsible for the cleaning of the ice machine on a monthly basis. Ice scoops are kept in covered pans in the area of the ice machine. The scoop, ice chest, container, and lid are sanitized daily by the cafeteria staff. The Unit Supervisor, or designee, will assure the ice scoop, ice chest, container, and lid are sanitized daily as per policy and that the unit maintains the Schedule of Cleaning of Ice Chest/Scoop/Container showing evidence of compliance.

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4. PROCEDURE: NURSING ACTION A. The ice chest, scoop, container, and lid will be taken daily to the cafeteria to be sanitized. KEY POINTS A. Kitchen personnel will sanitize daily per Nutrition Services department procedure.

B. Use ice scoop available outside the ice B. Do not let the handle come in machine to fill ice chest. Replace contact with the ice. scoop in covered container when through. C. Store unit ice scoop in a covered plastic container. D. Ice chest will be placed in the specials room or other approved location, and will be supervised by a designated staff. C. To prevent contamination.

D. Shift Lead will assign the designated staff during the daily shift assignments. Dispensing of ice is the responsibility of staff, individuals served.

not

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 885 Effective Date: August 31, 2006 SUBJECT: CLEANING OF LEATHER RESTRAINTS ON THE UNIT 1. PURPOSE: To provide guidelines for proper maintenance and care of restraints to extend useful life and prevent transmission of nosocomial infections. 2. POLICY: 1. Leather restraints shall be cleaned between Individual use and when they are visibly soiled by blood or other body fluids. 2. The Shift Lead of each shift shall insure that leather restraints are cleaned and/or disinfected between individuals served. 3. Gloves are to be worn when cleaning the restraints. 4. Nursing staff shall not discard leather restraints merely because they are soiled by dry body substances. If grossly contaminated, the Unit Supervisor will determine if the restraints need to be discarded as bio-hazardous waste, or if the restraints can be reused after safely cleaning. 3. PROCEDURE: 1. Restraints soiled with the following: dried blood, urine, feces, saliva, sputum, nasal secretions, sweat, tears and vomitus (unless they contain fluid blood) are to be cleaned for reuse. However, restraints saturated with liquid blood should be treated as biohazardous waste, red bagged and discarded after evaluation and determination by the Unit Supervisor. Unit Supervisor will: a) document this action and request for replacement via memo, and b) sign the requisition form to request a replacement from Central Supply. 2. Leather restraints should never be laundered in an institutional laundry. Hot water, detergent and hot air drying will destroy the fiber of the leather. 3. Worn or damaged restraints should not be used. Promptly return worn or damaged restraints to Central Supply for replacement.

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4. NON-SOILED RESTRAINTS: NURSING ACTION A. Spray leather restraints with an approved disinfectant spray (which has bactericidal, fungicidal, tuberculocidal, and virucidal properties) between Individual use and allow to dry in a wellventilated environment, not in direct sunlight. KEY POINTS A. Use of a disinfectant spray assists with preventing transmission of nosocomial infections. (Refer MSDS for specific directions). (See Infection Control Policy List of Approved Cleaning and Disinfecting Agents.)

5. SOILED RESTRAINTS: A. Gloves are to be worn when cleaning the restraints. Soiled restraints may be wiped with a damp sponge or cloth moistened in an approved quaternary ammonium compound or equivalent (see Infection Control Policy List of Approved Cleaning and Disinfecting Agents). B. After the leather restraints have dried, apply Leather Restorer after each cleaning to preserve the life of the leather. A. Do not soak or scrub the leather; this may get it clean but will also cause leather fatigue. If restraints are soiled, use an approved quaternary ammonium compound or equivalent. Put on gloves and clean restraints with this solution. B. Leather Restorer can be obtained from the Warehouse. It is used after each cleaning to condition the leather and keep it from cracking. Periodic application of Leather Restorer will help preserve leather restraints.

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6. GROSSLY CONTAMINATED RESTRAINTS: A. Restraints saturated with liquid blood should be treated as biohazardous waste, red bagged, and discarded after evaluation and determination by the Unit Supervisor. A. If grossly contaminated, the Unit Supervisor will determine if the restraints need to be discarded as biohazardous waste, or if the restraints can be reused after safely cleaning. When the restraints are grossly saturated with blood, the restraints are to be placed in the red biohazardous bag disposal. Unit Staff will a) document this action and request replacement via memo, and b) sign the requisition form to request a replacement from Central Supply.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 890 Effective Date: July 7, 2007 SUBJECT: TUBERCULIN SKIN TESTING 1. PURPOSE: To determine the tuberculin status of patients in order to implement appropriate preventative and treatment measures. 2. AUTHORITY: Coordinator of Nursing Services; Public Health Nurse; California Code of Regulations Title 22 Section 73519 3. POLICY: Unless contraindicated, all patients admitted to Coalinga State Hospital shall receive tuberculin skin testing on admission and annually thereafter. A tuberculin skin test requires a Physicians Order before it can be administered. 4. METHOD: A. GENERAL Tuberculin skin testing (TST) is a useful screening tool in the identification of persons infected with Mycobacterium tuberculosis. Despite the advent of effective tools for screening for tuberculosis infection and antituberculosis drugs for treatment, tuberculosis (TB) remains a significant infectious disease. TB is of particular importance in the Coalinga State Hospital population, which is composed primarily of persons who have been incarcerated in prisons and jails. There are numerous factors in these settings which create an ideal environment for the transmission of TB. Current statistics indicate that TB occurs in the prison population at rates several times that of the general public. Additionally, subpopulations such as those co-infected with Human Immunodeficiency Virus (HIV) develop active TB disease more rapidly once infected and may have cases which are more resistant to treatment. Adding to the problem of TB control is the resurgence of multi-drug resistant (MDR) strains. Drug resistance leads to higher mortality rates and to increased transmission due to the longer time the person remains infectious.

B. New Admissions and Returnees Gone Longer Than 30 Days 1. The Public Health Nurse (PHN) or designee will be a part of the admitting team in the R&R unit and, unless contraindicated, will administer the TST. The PHN (RN in the absence of the PHN) will read the results 48 to 72 hours later and record results on MH-5667 Immunization and Communicable Disease Flow Sheet. Results will always be in mm of induration. 2. If a TST is contraindicated (e.g. patient had a previous positive TST) the physician will be informed and a chest x-ray will be ordered. The patient will also be assessed for signs of active TB. C. TST Results 1. An induration of 10mm is considered positive, except in high risk people (e.g. HIV positive) in whom a 5mm induration is considered positive. 2. If the PHN is unavailable (e.g. weekend or holiday) and an RN reads a TST as positive, the patient will be assessed for signs of active TB. If no signs are present, the RN will leave a message with the PHN of the results and need for follow-up the next business day. If the patient has any sign(s) of active TB, the RN will contact the NOD who will contact the MOC.

SECTION 9 CLOTHING AND LINEN

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 900 Effective Date: August 31, 2006

SUBJECT: HANDLING CLEAN, INFECTIOUS, OR SOILED LINEN AND CLOTHING 1. PURPOSE: The primary objective of this policy is to provide guidelines toward minimizing the risk of disease transmission during the handling of infectious or soiled linen and clothing. 2. AUTHORITY: Center for Disease Control 3. POLICY: 1. The proper care and handling of infectious, soiled linen and clothing are the responsibility of all nursing staff of each unit. 2. Standard Precautions shall be followed for any linen or clothing grossly contaminated with blood, body fluids or other potentially infectious materials. 3. Linen or clothing contaminated with blood or other potentially infectious materials shall be carefully gathered with a minimum of disturbance. These articles will be placed initially into a water-soluble bag, and then placed into a yellow plastic infectious linen outer bag. To minimize the risk of crosscontamination, this double bagging process will take place at the location of the infectious article then transported to the designated infectious linen area. 4. Hand Cleansing Procedures (refer to NPPM - Hand Hygiene) shall be followed prior to handling clean laundry and after handling soiled laundry. 5. Clean linen (bagged or wrapped) shall not be placed on the floor or stored on shelves less than 6" above the floor. No soiled linen, clothing and laundry bags should be left on the floor (on unit) or on the floor in soiled laundry room (off unit). 6. Hamper Hosts (linen hamper) and Soiled Laundry Carts shall be tightly closed when not in use. 7. Linen and clothing rooms shall be locked at all times unless nursing staff is present. -1N.P.P No. 900

8. The Soiled Laundry Cart shall be emptied at least daily even when the cart is not full. 9. To reduce the risk of cross-contamination Nursing staff will establish ongoing health teaching measures to discourage individuals from sharing their linen, clothing, hats, or shoes. This teaching shall be documented on Wellness and Recovery Individual/Family Health Education Record. 10. Hamper Host and Soiled Laundry Cart should not be over stuffed and should only be filled up to two-thirds full. If unit Soiled Laundry Cart is filled to two-thirds full, empty soiled laundry bags into other Soiled Laundry Carts that are not two-thirds full. 11. Do not stuff soiled laundry bags (not to weigh more than 40 pounds). 4. GENERAL INFORMATION: Each unit will be provided with three Hamper Hosts. Additional hampers will be issued depending on the number of bathing areas and needs of the unit. Hamper Hosts should be located in shower areas during shower times. Hamper Hosts should be taken to the dorms when bed linens are being changed or whenever soiled linen needs to be bagged. Each unit is provided with one Soiled Laundry Cart with a tight fitting lid and must be kept in the Soiled Laundry room on the unit. If the lid becomes damaged, a new one must be ordered immediately from General Services. 5. PRECAUTIONS: Any clean linen accidentally dropped on the floor is considered soiled and must be placed in the soiled linen hamper. Soiled laundry is not to be sorted and must be handled with caution to prevent the spread of airborne infection Bags of soiled laundry must be placed directly from the Hamper Host into the Soiled Laundry Cart. Only laundry bags with self-contained covers will be used in the Hamper Host. Linen and clothing contaminated with blood and/or body fluid shall be considered infectious and double-bagged in accordance with Infection Control protocols. Also refer to Administrative Directive Standard Precautions.

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6. PROTOCOL FOR HANDLING CLEAN LAUNDRY: PROCEDURE: NURSING ACTION A. Pick up clean laundry from dock. B. Before placing clean linen and/or clothing on the shelves make sure they are clean. C. Store on appropriate shelves in the clean linen area of unit. 7. PROTOCOL FOR HANDLING SOILED LINEN AND CLOTHING: PROCEDURE: NURSING ACTION A. Place soiled linen in Hamper Host bags. B. When bags are two-thirds full, wheel hamper to soiled linen area on unit. C. Close hamper bag by placing fingers under cuff of bag and pull self- contained lid up and over the open end. D. Remove bag and place directly into the soiled laundry cart. Replace lid tightly on cart. E. If needed, cleanse Hamper Host with germicidal detergent solution. F. Close sliding out sleeve and insert new bag through the top and fold over the outside rim to form a cuff. Close Hamper Host lid. KEY POINT A. Do not fill more than two-thirds full or it will be difficult to remove it from hamper host. KEY POINT A. Will be delivered in a plastic lined cart. B. Use detergent germicidal solution for cleaning if needed. A general purpose germicidal detergent is available on all units.

C. Wear gloves to minimize risk of cross contamination.

D. Lid must fit tightly and must be in place at all times. E. A general purpose germicidal detergent is available on all units.

8. PROTOCOL FOR HANDLING OF INFECTIOUS LINEN AND CLOTHING: PROCEDURE: NURSING ACTION A. Place a yellow plastic bag in the Hamper Host, then place a waterKEY POINTS A. The Shift Lead will assign responsibility for bagging and

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soluble bag inside the yellow plastic bag. B. Roll Hamper Host to area where infectious linen/clothing is to be collected. C. Wearing disposable gloves, staff will carefully place the infected articles in a clear water soluble bag and tie securely with the red tie tape that is attached to the bag. D. Securely close the yellow plastic bag, eliminating as much air as possible. E. The Nursing staffs that bag the infectious laundry shall mark the outer yellow plastic bag with their unit number. F. The bag is then taken to the soiled linen room of unit and placed in the units Soiled Laundry Cart.

removal of Infectious Linen and Clothing.

C. Remove disposable gloves prior to tying bag. Do not tie knot with end of bag. Discard used gloves in regular trash. D. Eliminating the air prevents the bag from breaking open when other (heavy) laundry is put on top of it.

F. Do not place in, on or against the infectious waste barrels.

9. PROTOCOL FOR HANDLING OF THE SOILED LAUNDRY CART: 1. Place Soiled Linen Bags from Hamper Hosts into Soiled Laundry Cart. 2. Replace lid tightly. If lid becomes damaged, replace immediately. 3. Roll Soiled Laundry Cart, with lid snugly in place, to Soiled Linen Room off unit. Empty laundry cart at least daily (full or not) or as often as necessary to assure that the lid will fit snugly. PROCEDURE: NURSING ACTION A. If needed, remove soiled material (from soiled laundry cart) by cleaning with detergent germicidal solution at least daily or whenever soiling occurs. B. Place Soiled Laundry Cart on dock monthly for steam cleaning. KEY POINTS A. Cleansers are available on all units for general purpose cleaning.

B. Will be picked up and returned to dock by the Motor Pool. Schedule to be posted.

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SECTION 10 CENTRAL SUPPLY

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 1000 Effective Date: August 31, 2006

SUBJECT: CENTRAL SUPPLY 1. PURPOSE: Central Supply serves as a resource for medical supplies and equipment for the hospital. The mission of Central Supply is to render contaminated material safe for employee handling, processed materials safe for individuals, proper storage of pre-sterilized and processed materials, and the ordering and dispensing of items to all units and clinical areas including specialty needs individuals. 2. AUTHORITY: Title 22 3. POLICY: The Unit Supervisor or designee (e.g. Treatment Room or Medication Room nursing staff) shall be responsible for assuring the following: 1. Sterile and non-sterile unit medical supplies (except those in Emergency Carts and Emergency Bags) shall be checked weekly, and outdated or damaged supplies shall be returned to Central Supply. 2. New supplies shall be ordered weekly as needed. 3. Suction machines shall be checked weekly to assure they are operational. Tubing shall be checked weekly and replaced as necessary. 4. Rubber supplies on the Emergency Cart (resuscitation bag and mask, esophageal airway, tourniquet, stethoscope tubing) shall be checked every three months and replaced as needed. 5. The unit supervisor shall retain written accountability for checking and updating of supplies. 6. All contaminated reusable sharps shall be placed in a puncture resistant, leak proof dust cover prior to transporting to Central Supply. 7. The supplies list shall be kept in stock on all units. -1N.P.P No. 1000

4. GENERAL INFORMATION: 1. Central Supply is open 0730 to 1600 Monday through Friday. Supplies are delivered weekly to all units. When closed, access to Central Supply will be by the NOD. When specific supplies are needed, unit staff is to make inquiry from adjacent units. If unable to obtain the necessary supplies or equipment from adjacent units, the unit will contact the NOD for assistance with obtaining the supplies. 2. A sign-off section at the bottom right of the Central Supply Requisition Form (see Attachment C) to document weekly checking for outdated or damaged supplies. The following are some criteria for outdated and damaged sterile supplies and non-sterile gloves: 2.1 Prepackaged Sterile Items from Vendors: These shall be returned to Central Supply if they have reached a listed expiration date. Central Supply will list an appropriate expiration date (usually 1 year from the date sent to the unit) if the manufacturer has not done so. 2.2 Packages Sterilized at Coalinga: These sets (e.g. suture sets) are put in dust covers and have expiration dates of 6 months from sterilization listed. 2.3 Pre-Expiration Date Damage: Sterile items should be returned prior to expiration dates if the integrity of the package has been compromised, i.e. water damaged, separating at the edges, or yellowing. 2.4 Non-sterile Gloves: Non-sterile latex gloves that have been opened deteriorate within a period of 6 - 12 months. If they are stiff or discolored, or if a glove rips as it is put on, the whole box might have deteriorated, so return it. Unopened boxes should last for several years but should be returned if deteriorated sooner. Vinyl gloves have a longer shelf life than latex and may last for many years. 3. Emergency Cart sterile supplies are usable for six months unless opened or damaged. Central Supply checks the Emergency Cart twice a year replacing outdated supplies and other items that need to be replaced. 4. The Emergency Cart & Red or White Bag Accountability Record will be utilized to replace items used or removed during an emergency. 5. Items not stocked routinely in Central Supply, when deemed clinically necessary by the Chief Physician/Surgeon and approved by the Administrator of Medical Services, may be ordered.

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5. ORDERING AND RETURNING OF SUPPLIES AND EQUIPMENT: NURSING ACTION A. Return syringe wrappers or caps from vacationer needles for exchange Without correct exchanges, Unit Supervisors signature is required on requisition. B. Rinse all suture sets in cold water and return to Central Supply KEY POINTS A. Do not return disposable items (e.g. suture removal, I&D set, etc.).

B. Do not return loose non-used suture needles from suture set with clean instruments. Reusable contaminated sharps shall be rinsed in cold water.

6. ATTACHMENT A: Supplies and equipment (sterile and non-sterile) available from central supply) *ABD Pads *Betadine Swabs -Adapters Plastic and Metal -Adhesive Products: -Band-Aids 3/4" x 3", 2" x 4 " -Butterflies - Medium -Montgomery Straps -Tape: Adhesive - ", 1", 3" -Hypoallergenic: Dermicel - 1" -Transparent 1" -Steri-Strips - packet of 3 -Airways *Alcohol Swabs -Anoscope, Disposable *Applicators: (Bulk 100/package) -2/package *Asepto Syringe Disposable -Bandages: -Ace - 2", 3", 4", 6" -Conforming gauze - 2", 4" -Conforming gauze - 1", 2", 3" -Band-Aids See Adhesive Products -Blood Pressure Apparatus *Bowls Disposable -Cahill Valve Masks *Catheter Sets (Disposable) -Clean Catch - Urine Disposable -Colostomy Bags Coloplast Disposable -3-Enema Unit Disposable -Eye Pads -Exam Paper - Table -Gloves: Vinyl and Latex Examining, Small, Medium, Large, and X Large - 100/box *Gloves: Medium or Large - 1 pr/pack -Goggles *Graduate (Disposable) -Hernia Belts -Ice Bags -Ice Packs - Instant Disposable *Incision and Drainage Sets disposable -Incontinent Pads (24 X 24), and Disposable Incontinent Pads (lg.) -Irrigation Sets - Disposable -Isolation Gowns - Disposable -Lavage Tray -Lemon Glycerin Swabs *Levine Stomach Tube -Masks - Disposable -Mayo Stands *Nasal Packing Set *Needles - Assorted sizes *Ophthalmoscope - otoscope *Oxygen Supplies: Catheters, cannula, mask, connecting tube, -Humidifier Disposable -Oxygen Tanks -Oxygen concentrators N.P.P No. 1000

-Connectors: 5" plastic, Y plastic -Cotton Balls *Culture Tubes -CPAP Machine, and tubing -Dental Floss -Drinking Set Carafe -Doppler -Ear Curettes - Disposable *Ear Syringe - Bulb, (1) Metal Set -Disposable

*INDICATES STERILE SUPPLY

Supplies and equipment (sterile and non-sterile) available from central supply: -Packing: Iodoform gauze - 1/4", ", 1" Plain gauze - 1/4", , 1" -Percussion hammer -Resuscitator - Manual, bag-valve-mask device (e.g. Ambu-type bag) -Sharps-container for needles and razors -Sitz Bath Kit - Disposable *Skin Scrub Tray Disposable -Slings - Triangular *Sponges: 4" x 4" (2/pkg.) 4" x 4" (100/pkg.) *Sputum Cups -Stethoscope -Stockings - Elastic: Small, Medium, Large,Extra-Large -Stool Specimen Cups *Suction Catheter Disposable -Suction tubing -Suction Machines -Suspensory - Medium, Large *Suture Removal Set - disposable *Syringes: 3cc/21g, 3cc/22g, 3cc/25g, 10cc, 20cc, 60cc, Insulin, Tuberculin Disposable -Thermometer Sheaths -Tongue Blades - Air-filled Plastic Wooden - Bundle *Wooden One Tourniquet - 1" *Towels - 1/pkg. - Disposable (Barrier) -Tuning Fork *Urinary Drainage Sets and Leg Bags (Disposable) -Urine Specimen Cups -Utensils: -Bedpans -Emesis Basins -Foot Basins -Urinals -Vacutainer Needles, Sleeves, and Blood Collection Tubes -Vaginal Speculums - Small Disposable *Vaseline Gauze - 3" x 9" -Vital Signs Monitor -Washcloths (Disposable) *INDICATES STERILE SUPPLY

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N.P.P No. 1000

7. ATTACHMENT B: Checklist of supplies kept on all units All supplies on the units shall be checked weekly and outdated or damaged supplies shall be returned to Central Supply. 1. Diagnostic Equipment: -Blood Pressure Cuff -Stethoscope -Otoscope/Ophthalmoscope and 2 batteries. -Percussion Hammer -Tuning Fork -One Touch II or One Touch Profile -Glucose Measurement Machine -Digital thermometer (Specific to work site) -Vital Signs Monitor 2. Emergency Equipment: -Oxygen Equipment, Wrench, and Tubing -Suction Machine with Tubing Units with Crash Carts ONLY 3. Sterile Supplies: -Applicators -Clean Catch (2) Funnel and -Specimen Container -Conforming Gauze 2" and 4" -Ear Syringe -Over sponges - 3" x 4" -Suture Removal Set -Syringes - 10 (5cc), 10 (3cc)

4. Non-Sterile Supplies: -Adhesive Tape - ", 1" -Anoscope disposable -Applicators -Bandage Scissors -Band-Aids (Large and Small) -Cotton Balls -Emesis Basin -Enema Unit -Gloves - Examining (100/box) -Ice Cap -Prep Alcohol Swabs -Requisition Pad -Roller Gauze - 1", 2", 3" -Sharps-container -Temp-A-Dots -Tongue Blades -Tourniquet -Urinal -Vaginal Speculum -Disposable (Female Units) -Washcloths Disposable -Wash Packs -Wipes (6)

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N.P.P No. 1000

8. ATTACHMENT C:

Ordered

CENTRAL SUPPLY REQUISITION Weekly orders must be in by 10:00 A.M. (S) = Sterile (NS) = Non Sterile Circle item(s) desired if multiple choice Received Description Ordered Received Description ABD's Tape, Adhesive (1/2") (1") Ace Wraps (2") (3") (4") Tape Hypoallergenic 1" (6") (transparent) (nylon) Alcohol Swipes Ted Hose (sm) (med) (lg) (ex-lg) Applicators (S) (NS) Asepto Syringes, 60cc Temperature Probe Cover disposable (S) (ABCO Digital) Band-Aids (small) (large) (Welch Allyn) Basins (round) (square) Temp-a-Dot Bowels (S) Tissue Catheterization Tray Tongue Blades Chux Tourniquet Clean Catch Kit (S) Urinal, Disposable Cotton Balls (NS) WCSH Cloth, Disposable Culturettes (S) WCSH Pack Cups (stool) (urine) Water Carafe (NS) Diapers Ear Specula for Otoscope Ear Syringe Bulb(S) Blood Draw Items: Egg Crate Mattress Pad Lavender Tube Emesis Basin Red Tube Enema Unit Gold Tube Eye Pads, Oval Blue Tube Gauze, conforming (2") (4") (S) Gauze, roller (1") (2") Vacutainer Holders (3") (NS) Gauze, oversponge Vacutainer Needle 21g (4X4) (S) Gauze(2X2) (4X4) (NS) Gloves (NS) (sm) (med) Lab Bags (lg) (ex-lg) Gloves (S) (sm) (med) (lg) Humidifier I & D Set One Touch II Supplies -6N.P.P No. 1000

Ice Pack Instant Cold Pack Lemon & Glycerin Swabs Nasal Cannula Needles (1") (1-1/2") Gauges (25) (23) (22) (21) (20) (18) O2 Mask & Tubing Requisition Pad Sharps - Container (needle) (razor) Sling (sm) (med) (lg) (ex-lg) Sputum Cup (S) Suction Catheter (14" Fr) (18" Fr) Suture Removal Set Syringe (3/21g) (3/22g) (3/25g) (5/21g)(butterfly, 23g) Syringe (10cc) (20cc) (TB) (Insulin, 1cc)

Test Strips Lancets Strip Holder "J" Battery "AAA" Battery High/Low Solution

Exchanges: Blood Pressure Cuff (adult) (lg adult) Stethoscope Suture Set from Crash Cart

Restraints: Contact Central Supply for order form

MED ROOM STOCK CHECKED Unit #___________ Date______________ Requester____________________________________________________ Date ______________________FOR DAMAGED / OUTDATED ITEMS

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Infection Control POLICY NUMBER: 1001 Effective Date: August 31, 2006 SUBJECT: MEDICAL EQUIPMENT TEACHING 1. PURPOSE: To assist the individual to assume maximum independence in caring for his needs when using medical equipment. 2. PROCEDURE: A. IF TEACHING OF THE INDIVIDUAL IS DONE ON UNIT: When the individual has orders for medical equipment, which is to be used on the living unit (crutches, wheelchair, walker, splint) the teaching will be done on the unit by the unit Registered Nurse. The teaching will be incorporated into the Nursing Care Plan, and documented on the Wellness and Recovery note. B. IF TEACHING OF THE INDIVIDUAL IS TO BE DONE IN CENTRAL MEDICAL SERVICES (CMS) THE UNIT STAFF WILL: Inform the individual of his appointment; assist the individual if necessary to and from his appointment with the CMS department; deliver and/or pick up the unit record to CMS utilizing chart transportation system as available; attend and observe all initial teaching sessions with the individual in CMS; reinforce the initial teaching done by CMS, using the Standardized Individual Education tool located on each living Unit; document the incorporation of nursing interventions and teaching into the Nursing Care Plan, WaRMSS, and document; and evaluate, together with the Wellness and Recovery team, the current I.D. Team plans, which require activities, needed to be curtailed during the period of use of medical equipment. C. INITIAL TEACHING OF MEDICAL EQUIPMENT - MED/SURG CLINIC NURSE WILL: If medical equipment is applied (e.g. a cast) or dispensed (e.g. splint) in Medical Services clinic the Clinic Nurse will teach the individual about the use of the equipment; review the individuals chart regarding, physical condition, mental status, possible barriers to individuals learning use the teaching

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N.P.P No. 1001

information contained in the Standardized Education Tool Manual that is located in the Clinic; document the education sessions and the individuals ability to understand in the IDN notes; Contact RN/PT to discuss teaching done in Clinic; and if the teaching is extensive, contact the RN/PT to attend the session. D. ECG DEPARTMENT: If the individual has an order for HOLTER MONITOR, ECG or PACEMAKER the ECG Technician will do the teaching in the ECG department (Unit staff will accompany the individual at his appoint to observe teaching) will review the individuals chart regarding, physical condition, mental status, possible barriers to individuals learning use the teaching information contained in the Standardized Education Tool Manual that is located in the Clinic and document the education sessions and the individuals ability to understand on the Wellness and Recovery note of the Chart. E. OUTSIDE REFERRAL REGISTERED NURSE WILL: If the individual has an order for a hearing aid or prosthetics, do the teachings along with the contract /audiologist/prosthetics/physician. If the teaching is extensive the ORC nurse will notify the Unit so that the Unit staff may accompany the individual at his appointment to observe teaching) will review the individuals chart regarding, physical condition, mental status, possible barriers to individuals learning will document the education sessions and the individuals ability to understand on the Wellness and Recovery note in the Chart. If prosthesis or other orthopedic equipment is ordered the individual may be referred to Physical Therapy for further training. F. EQUIPMENT USED ON URGENT CARE AND INFIRMARY: Only Units, Urgent Care and Infirmary nursing personnel have specialized training on the equipment used on Unit 1, and will reinforce the teaching done by the Consultant. For ongoing teaching the Urgent Care and Infirmary nursing staff will use the teaching information contained in the Standardized Education Tool that is located on each Unit. This manual contains teaching information on the medical equipment that is to be used by individuals. The Infirmary nursing staff will document the education sessions and the individuals ability to understand on the Wellness and Recovery in the Chart.

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N.P.P No. 1001

SECTION 11 ORIENTATION AND EDUCATION

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Orientation POLICY NUMBER: 1100 Effective Date: August 31, 2006

SUBJECT: HOSPITALWIDE ORIENTATION OF NURSING SERVICES STAFF 1. PURPOSE: 1. To introduce new Nursing Service employees to the hospital's mission, vision, philosophy, values, responsibilities, and requirements. 2. To provide new Nursing Services staff with information that will assist the employee to adapt more readily to a new environment. 3. The New Employee Orientation Course is designed to provide the employee with the initial job training and information as well as assess his or her abilities to fulfill specified responsibilities. 2. POLICY: 1. All Nursing Services staff shall complete the New Employee Orientation (NEO) Course at the Training Center, which begins usually on his/her first day of employment at Coalinga State Hospital. 2. All Nursing Services staff should successfully complete the New Employee Orientation Courses within the first 30 days of employment. 3. The Training Center is responsible for coordinating and keeping track of employees orientation to the facility and providing Hospital wide orientation. 4. All employees new to a worksite, including float staff, shall receive an orientation to the new work area from the supervisor, Shift Lead or designee, and shall sign that they received Orientation; this shall be sent to the training office and another copy will be sent to the Central Staffing office. 5. All employees must successfully complete all mandated training throughout his/her employment at CSH, in order to meet the minimum requirements for individual care and safety. 6. All Registered Nurses shall receive an Orientation to their role as a case coordinator, and a program specific orientation by the NOD. After New Employee Training and Orientation within the first 30 days.

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3. GENERAL INFORMATION: Hospital wide orientation for all new Nursing Services staff will include training in:
Prevention and Management of Assaultive Behavior (PMAB) CPR Emergency Procedures First Aid Infection Control Fire, Life and Safety Suicide Precautions Individual Rights Therapeutic Relations Search for Contraband Continuous Quality Improvement (CQI) Organizational Ethics Sexual Harassment Special Incident Report Writing Age-Specific Training Group Techniques Bio-psychosocial Program Psychopharmacology Nursing Management of Psychopharmacology Principles of Medication Administration & ADR One Touch Glucose Monitoring System The Science of Forensic Psychiatric Nursing which includes: * Forensic Psychiatric Nursing * Charting format of WaRMS * Nursing Process * Nursing Documentation * Behavioral Systems Overview * Individual Acuity and Classification Department Presentations and Overview: * Human Resources * Labor Relations * Safety Center * Volunteer Services * Standards Compliance/Special Investigator * Employee Assistance Program * Equal Employment Officer Issues & Answers * Community Forensic Liaison Department * Rehabilitation Therapy Department * Multicultural Awareness

2.

Registered Nurses will also receive training in the following: -Blood Draw -PPD administration -Emergency Response -I.V. review -Change in Condition -Pain Management

4. PROCEDURE: 1. Hospital wide orientation shall be conducted during New Employee Orientation (NEO) by the Training Center. 2. When the Hospital wide orientation is completed the Orientation Checklist will be Forwarded to Human Resources to be placed in the employees hospital file. A copy will be forwarded to the Program Director or Department Head for retention, and a second copy will be provided for the employee.

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N.P.P No. 1100

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Orientation POLICY NUMBER: 1101 Effective Date: August 31, 2006

SUBJECT: PROGRAM ORIENTATION 1. PURPOSE: This policy will outline the requirements and procedures for appropriate orientation of Nursing Service staff to each Program/Worksite. Worksite Orientation provides for the following: -Introduces the employee to the treatment philosophy of the program and unit. -Allows the employee to adapt to a new environment. -Assists the employee to feel confident in the performance of his/her new duties and responsibilities. -Provides on-site training to better assist the employee to become competent in their job performance in order to provide quality individual care or service as defined in his/her Duty Statement. 2. POLICY: 1. It is the policy of Coalinga State Hospital to provide staff with initial and ongoing training required according to his/her Duty Statement, licensing and accreditation agencies, departmental policy and agreements between the State of California and employee organizations. 2. All nursing service employees new to any worksite, (including float staff), shall receive an orientation to the new work area from the Supervisor, Shift Lead, or designee. The orientation for the Psychiatric Technician new to CSH shall be one week (7 days). The orientation for the RN new to CSH shall be 2 weeks (14 days). 3. All nursing services staff transferring to a new assignment shall receive a worksite orientation by his/her Supervisor, Shift Lead, or designee. The length of the worksite orientation shall be determined by the Program Director. 4. The orientation to the Program/worksite must be initiated within the first five- (5) working days of reporting to a unit. N.P.P No. 1101

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5. During the Program Worksite Orientation, the new employee shall not be counted in meeting unit staffing minimums. 6. An orientation checklist Worksite Orientation shall be completed by the Supervisor, Shift Lead or designee within 30 days after the employee reports to his/her worksite. 7. Upon review and understanding of each item on the Worksite Orientation Checklist, The employee will initial each designated section. Both the employee and supervisor/designee will then sign and date the document upon its completion. 8. The Shift Lead or designee shall conduct worksite orientation for float staff. A record of this orientation shall be kept on the unit with a photocopy to the Program Nursing Coordinator. 9. All employees shall complete additional training mandated by his/her Program Director, Department Head, or Service Chief. 10. All employees are required to maintain a current license for their Civil Service classification (e.g. PT, LVN, and RN) and must complete the mandated training requirements for that discipline. 11. All Registered Nurses shall receive an orientation to their role as a Case coordinator from the NOD to their Program/Area during their Program/Worksite Orientation. 3. PROCEDURE: 1. The Unit Supervisor, Shift Lead, or designee shall conduct program Worksite Orientation within the established time frame. 2. Employees transferred to another program or unit shall receive orientation to the physical layout of the new program/unit, characteristics of the individual population, treatment concept and security requirements, ethical conduct, and any other instructions specific to all new programs/units. 3. When the Program worksite orientation is concluded, the completed checklist is to be distributed as follows: -Original to Staff Development Center for input into the employees training record ---Copy forwarded to Human Resources -Copy to the Nursing Coordinator for the Program Employee file -Copy for the employee

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N.P.P No. 1101

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Orientation POLICY NUMBER: 1102 Effective Date: August 31, 2006

SUBJECT: HSS/NOD ORIENTATION OF NEW RNS TO THE PROGRAM 1. PURPOSE: To orient the Registered Nurse in their role as a Case coordinator and to orient the newly assigned Registered Nurse to the Program-specific roles and expectations. 2. POLICY: 1. All new level-of-care RN's, and RNs reporting to a new unit assignment from within the hospital, shall receive a clinical orientation to the program by the HSS/NOD within the first five (5) days of reporting to the Program. 2. The Program will notify the HSS/NOD of the expected arrival of all new RNs, and the HSS/NOD and Program will collaborate on the worksite specific clinical nursing issues orientation for all newly assigned RNs. The Program Management will provide time for the HSS/NOD for this orientation. 3. The newly assigned RN shall spend at least one full day in orientation with the HSS. The HSS and Program will collaborate on scheduling this day. 4. The HSS will use the HSS Orientation of RN: Role of the RN/Case coordinator Working in Collaboration with Other Disciplines checklist form, and will cover all areas included in the form. The employee and HSS conducting the orientation shall sign and date the HSS Orientation of the RN checklist indicating that all items have been completed and understood. 3. PROCEDURE: 1. Program Management is to notify the HSS assigned to the building of a new or transferring RN to the program. Program Management will collaborate with the HSS to determine the schedule for orientation. 2. All areas of the HSS Orientation of the RN: Role of the RN/Case coordinator Working in Collaboration with the Other Disciplines checklist will be covered. The checklist may be obtained through the CNS office. In addition to the Program Worksite

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3. Orientation, the Registered Nurse shall be given additional instructions by the HSS/NOD in Case Management activities and RN roles and expectations. 4. Once the orientation of the RN by the HSS/NOD is concluded, the completed checklist is to be distributed as follows: a. b. c. d. Original copy with signatures to Human Resources. Copy for Nursing Coordinator for Program Employee file. Copy for retention in the HSS/NOD office. Copy for the employee.

HSS ORIENTATION OF RN ROLE OF THE RN/CASE COORDINATOR (CM) WORKING IN COLLABORATION WITH OTHER DISCIPLINES: I. RN/Case coordinators with PSYCHIATRIST
Communicating individuals progress with treatment plan (NPPM vii and xxii) Communicating current general medical conditions that are potentially relevant to the understanding or management of the individuals mental disorder (Axis III of DSM IV-TR) Notification of individuals behavior changes Indication of need for individuals medication review Notifying adverse effects of medication Notification of any abnormal lab results

Date

RN initials HSS initials

II. RN/Case coordinators Role with MEDICAL DOCTOR

Notification of any medical or physical changes of the individual Notification for need of change in individuals medication Notification of adverse effects of medication Notification of abnormal PPD results Notification of abnormal and panic lab results Communicating current general medical conditions that are potentially relevant to the understanding or management of the individuals mental disorder (Axis III of DSM IV-TR) Assisting with physical exams

Date

RN initials HSS initials

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III. RN/Case coordinators Role with HSS/NOD

Timely notification of HSS/NOD for the following: Emergency situations Physical and behavioral changes of individual Infectious and reportable condition of individual Abnormal lab results All PPD findings/test result

Date

RN initials HSS initials

IV. RN/Case coordinators Role with CONFERENCE COORDINATOR

Participation in treatment planning conference; If Treatment Planning conference is held on the CMs day off, leave input in writing Reviewing, revising, and updating nursing plan of care at each quarterly conference; date and initial(even if individual is not on their caseload) Establishing objective criteria based on nursing assessment that is realistic, measurable, and consistent therapy recommended by the treatment planning team, using nursing tools and other non-nursing measuring tools e.g. DRS, BPRS

Date

RN Initials HSS Initials

V. RN/Case coordinators Role with UNIT STAFF

Participation and responsibilities in Change of Shift Procedure NPPM Re-evaluating individual/s and updating the Acuity Outcome Log as clinically indicated Notifying staff with new information Completing and updating Nursing Assessment Developing pre-conference nursing plan of care consistent with medical and psychiatric plan of treatment of individuals Coordinating with US and Shift Lead to assign individuals to counselors based on individuals clinical needs Coordinating with Shift Lead Individual Care Assignments

Date

RN initials HSS initials

Leading and co-leading recovery mall class Initiating and documenting in education form Completing monthly notes on assigned individual caseload

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Completing transfer note for individual transferring to another unit; acceptance note when an individual arrives and nursing discharge summary upon notice of individuals discharge Referring individuals to appropriate disciplines as needed Collects lab specimens and sends them to lab Administers and documents Individuals immunizations as ordered

VI. RN/Case coordinators Role with PSYCHOLOGIST

Collaboration in individuals progress and indication of individuals needs of specific groups Participation in treatment planning conference

Date

RN initials HSS initials

VII. RN/Case coordinators Role with SOCIAL WORKER Date

Indicating needs of individual/s regarding social and legal issues and discussing progress with present treatment

RN initials HSS initials

VIII. RN/Case coordinators Role with DIETICIAN

RN/Case coordinator (CM) referring high-risk Individual for nutritional screen, significant change in weight and non-adherence to ordered special diet Notifying dietician of Individuals refusal to eat, food preference and cultural factors affecting food intake

Date

RN Initials HSS Initials

IX. RN/Case coordinators Role with REHABILITATION THERAPY

Indicate individuals physical limitations to RT when assigning to groups, discusses individuals progress and participates in selection of appropriate groups for individuals

Date

RN Initials HSS Initials

X. RN/Case coordinators Role with PUBLIC HEALTH

Notify Public Health Nurse and HSS of individuals PPD results; following up with any positive PPD and abnormal chest x-ray and lab (i.e. RPR) results. Notify PHN and NOD of any individual/s admitted with history of infectious diseases Notify the PHN of the planned discharge, court visit or return from court visit of individuals with non-specified viral illness, active TB or Hepatitis C that currently receives Interferon treatment

Date

RN Initials HSS Initials

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Health issues and individual infectious diseases)

RN Initials XI. RNs Role: MISCELLANEOUS

Chain of Command; Matrix System Criteria-Based Performance Evaluations by HSS of the RN Criteria-Based Performance Evaluations by the RN of the PT Monthly Medication Review with physician Medication/Treatment Room Communication Book Lab Tracking Lithium Tracking WBC tracking for individuals receiving Clozaril Responsibilities for individuals in S&R) Role of RN with Special Incident Reports Emergency equipment and RN responsibilities Advantages of ACLS certification in responding to emergency situations Handling of soiled linens and potentially infectious blood and body fluids Unit administrative responsibilities covered in absence of Shift Lead Unit manual resources

Date HSS Initials

_________________________________ Employee Signature

_____________________ Print Name

______________ Date _____________ Date

__________________________________ ______________________ HSS Signature Print Name

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Orientation POLICY NUMBER: 1103 Effective Date: August 31, 2006

SUBJECT: ORIENTATION OF STAFF TO UNITS NOT USUALLY ASSIGNED TO A UNIT 1. PURPOSE: To provide guidelines for orienting unit staff, staffing pool or Registry staff that covers other units other than usually assigned units. 2. POLICY: 1. Staff covering from other units including overtime staff from another shift, staffing pool and Registry staff, will receive a report from the Shift Lead/designee, at the beginning of the shift. They will be advised of the individuals on specific ALERTS (including containment risks), 1:1s, High/Low Risk Observations, pertinent acute medical or behavior issues, a formal orientation to the unit physical environment, including new equipment specific for that unit and expectations of care. 2. The orientation shall be documented on the unit. 3. When float and/or Registry staff is assigned to perform 1:1 observations, they shall be provided with a thorough orientation, to include as much specific information as possible about the reason for the 1:1 observation, prior to the assignment. 4. The use of float/Registry staff for Medication/Treatment Room assignments should include, if possible, having a regular unit staff member present when medications/treatments are being administered to individuals to assist with positive identification of the individual(s). This will reduce the risk of medications and/or treatments being administered to the wrong individual(s).

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SECTION 12 INSIDE AND OUTSIDE FACILITY CONSULTATION

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION In & Outside Facility Entrance POLICY NUMBER: 1200 Effective Date: August 31, 2006 SUBJECT: STAFF ESCORT OF INDIVIDUALS TO OUTSIDE MEDICAL FACILITIES 1. PURPOSE: To identify security needs and staffing requirements for escorting individuals off grounds to an outside facility. 2. POLICY: Nursing staffs are not required to accompany individuals who are sent to an outside medical facility for treatment. This includes clinic visits and inIndividual care. There are only three exceptions to this policy: When the physician has ordered a 1:1 for clinical reasons (e.g. High Risk Suicide Observation) When a non-ambulatory Individual is unable to transport to a vehicle without a lift (e.g. requires assistance in transferring from the wheelchair to the transporting vehicle). If the wheelchair van is available, nursing staff will not need to accompany the Individual. During an emergency or after-hours transport when Corrections does not have the staff to accompany the Individual. In this instance Nursing Staff will accompany the Individual and will be relieved when Corrections is able to provide an officer (usually within one hour). The overriding rule for all of this is that nursing staff will be sent if Corrections will not transport a Individual without the nursing staff. Nursing Services staff is to ensure that the Individual gets to the facility for treatment. Individual care is the first priority. 3. GUIDELINES WHEN NURSING STAFF ARE REQUIRED TO ESCORT: 1. All individuals will be transported in both wrist-to-waist and ankle restraints unless medically contraindicated per signed physician order.

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2. Only licensed staff shall accompany individuals being transported to an outside medical facility for evaluation/treatment. 3. Coalinga nursing staff providing supervision SHALL NOT perform any duties that are the responsibility of the staff at the treating medical facility. However, it is still expected for the nursing staff member to provide therapeutic counseling and support as needed or appropriate. 4. Coalinga nursing staff shall request and obtain a copy of written reports from the clinic service area and return this written report to Medical Clinics and a copy to the NOD. The escort is also responsible to apprise the Unit Shift Lead of the outcome findings. 5. Authorization for temporary removal shall be completed and signed by the Program Director/designee and the Correctional Captain or designee on all routine transfers. For after hours and emergency transfers obtain a physician's order and complete CSH 7136 (formerly MR 295) External Medical Services Referral and have signed by physician. If CSH 7136 is not filled out, an Authorization for Temporary Removal form signed by a physician is acceptable. In paramedic transfer situations; paperwork shall be waived with a mandatory chase unit from Corrections. It is the responsibility of the nursing staff escort to keep the unit apprised of treatment decisions and actions to be taken for the Individual by the outside facility. The Unit Shift lead or designee shall in turn appraise the ACNS/Staffing Office to assure staff coverage at the outside facility particularly when it is determined that the Individual will be admitted to the medical facility and a 1:1 is ordered for clinical reasons. 6. When the Individual has been an in-Individual of the medical facility, and the physician of the medical facility determines the Individual will be discharged back to CSH, the CSH escort shall IMMEDIATELY notify the ACNS/NOD office. The ACNS/NOD will notify the unit to be admitted and the treating physician (during business hours) or the MOD (after-hours) for the Individual to be cleared to return to CSH. Once the ACNS/NOD receives authorization from the physician or MOD that the Individual may return to CSH, the ACNS/NOD will notify the Watch Sergeant stating that the Individual has been cleared to return to CSH and fax the appropriate documentation authorizing clearance to return. 7. Upon return from an after-hours emergency transfer or from being an inIndividual at an outside medical facility, the Individual shall be brought to the

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N.P.P No. 1200

Urgent Care or Medical Clinic for evaluation by the physician or MOD. The physician shall determine appropriate unit placement.

Procedure when escort needed for clinic appointments or for transfer escort to the emergency room: NURSING ACTION A. Escorting employee will take all appropriate materials to the facility. KEY POINTS A. Individuals medical record shall not be taken to another facility. Pertinent material may be duplicated and taken with the Individual. Complete authorization for Temporary Removal and have signed by appropriate staff. B. A Nursing employee and Correctional employee shall accompany Individual. All individuals shall be in full restraints unless medically contraindicated. C. At the facility you will be taken directly to the Security area next to the Emergency Room. Obtain the key from the Security Office and place the Individual in the Holding Area and lock the door. Do not mix CSH individuals with other individuals. If no Holding Area is available or you have problems, notify the Emergency Room Charge Nurse. D. The Correctional Officer shall remain with the Individual in the Security Area while the escorting nursing staff completes all necessary paperwork and check-in procedures. When ambulating, individuals shall be in ankle and waist/wrist restraints and escorted by CSH employee. When using the bathroom facilities, ankle restraints shall be intact and the bathroom door is to remain partially -3N.P.P No. 1200

B. Department of Correction shall be responsible for transportation and security of Individual in transit.

C. Each facility will have a varying procedure. Custody duties at outside facilities are the responsibility of Corrections staff. Proceed as directed by Corrections and the Emergency Room or Clinic staff.

D. Call the appropriate clinic from the Security Area to advise them you have arrived for the clinic appointment.

open. Ankle restraints are removed only when medically contraindicated. Decision is made by treating physician after mutual agreement with CSH Corrections Department.

E. You will be called as soon as the clinic is ready to examine the Individual.

F. After treatment is completed, the nursing escort will return to the Holding Area and notify Corrections for return transportation. (Do not call for transportation until all medical services have been completed.)

E. Do not wait in the clinic waiting room. Remain with the Individual during the exam process. Restraints may be partially removed as required for the examination. Replace immediately following the exam. F. After treatment is completed, the Individual and escort must remain inside the Holding Area while awaiting return transportation. The nursing staff escort and the Individual are not permitted to wait outside the security room. G. A copy of the finding and recommendations need to be given to the CSH Medical Ancillary Services.

G. Obtain a copy of the written report and/or consultation findings from the clinic nursing personnel.

GUIDELINES FOR SUPERVISION OF INDIVIDUALS ADMITTED TO OUTSIDE FACILITIES: NURSING ACTION A. A licensed nursing staff member may be required to supervise a Individual admitted to an outside facility if the physician has ordered a 1:1 for clinical reasons. KEY POINTS A. The need for 1:1 shall be determined by the sending physician/MOD. Keep Individual in line of sight at all times.

B. Coalinga nursing staff providing supervision shall not perform any duties that are the responsibility of the staff at the treating facility.

B. Do not assist or perform any duties which are the responsibility of the staff at the treating facility as this is considered violation of Contract Law and you will be held liable. Your sole duty is to serve as an escort. Individuals are denied access to telephones and -4N.P.P No. 1200

visitors unless prior approval is received from the Executive Director and/or Correctional Administrator. A Correctional Officer supervises all approved visits only. When discharged, ambulatory individuals will be escorted in full restraints to the Holding Area in the Emergency Room for transportation.

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N.P.P No. 1200

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION In & Outside Facility Entrance POLICY NUMBER: 1201

SUBJECT: CENTRAL MEDICAL CLINIC 1. POLICY: The reason for referral and services requested is to be indicated on the consultation form. It is important to specify if outside services are being requested, otherwise the Individual will be seen in the Central Medical Clinic. After completion, the consultation form is to be hand-carried by unit staff for delivery to the Individual Clinic or placed in the mailbox in the main hallway by key control. If the unit physician has indicated that the Individual's problem is "urgent" (to be seen within 24 hours), Central Medical Clinic is to be telephoned immediately by nursing services staff to request an appointment for the same day, or within the next working day. If the appointment is for the same day, the consultation form may be placed inside the Individual's chart for delivery to the clinic. Under no circumstances should an urgent referral be sent through the hospital mail. 2. PURPOSE: The purpose is to facilitate the referral of individuals from their unit/program to the Central Medical Clinic. The day before the appointment the clinic staff will put an Appointment Card (duplicate copies) in the lab distribution box for the units (located in main hallway). Day of the Appointment A clinic nurse will telephone the unit on the day of the Individual's appointment, giving the time of the appointment and the clinic for which he is scheduled. The staff member receiving this call will: a) Note the appointment in unit specific assigned place(s), i.e. office calendar and/or appointment log. b) Attach copy 2 of the appointment card to Individuals chart. c) Inform the Individual of his appointment and if required transcribe the information on the Individual activity board or other notification area. Give 1st copy of appointment card to the Individual.

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d) The Unit will provide STAFF ESCORT for Clinic Appointments when Individual is: 1. Forgetful, unreliable, or regressed. 2. Has a PAS level 1 e) Examine the chart to ensure that it contains pertinent records and forms with an adequate space available for recording the clinic visit. (i.e. Physician's Order Sheets, Wellness and Recovery Notes, Physician's Progress Notes, Medication Record, Treatment Record, Vital Signs Record, Lab Reports, Seizure Record, etc.) f) Review the last Clinic Physician's Orders Sheet for laboratory tests, consultations, diagnostic procedures, etc., which needs to be available at the time of the Individual's clinic appointment. If these items are not available, ascertain when they will be. Reschedule Individual's appointment if necessary. g) The Unit Supervisor/designee will ensure that there is a tracking system in place on the units to account for all unit records off the unit, i.e. unit records sent to clinics. h) When transportation service is available (usually M-F, 0745 to 1500) the majority of charts for routine appointments will be picked up. When chart transportation service is not available, staff will need to deliver charts to the clinic. i) Ensure that the Individual arrives in the clinic 10 minutes prior to the scheduled appointment time. 3. RETURNING CHARTS TO THE UNIT: A. Clinic Staff 1. When the clinic physician is finished with the Individual's chart, the notes and orders will be checked for legibility, medications, treatments, consultations and return appointment orders. 2. Clinic Referral Form AT 2518 will be completed by checking items 1-4 as appropriate. 3. Chart transportation service will deliver charts to Unit by 1500, when available. After 1500 and any time transportation service is not available, the clinic nurse will call when charts are ready for pick-up.

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4. Clinic staff will FAX all new medication orders to the Pharmacy. For STAT or emergency orders (see III. B) The unit will be called as soon as the chart is available for pick-up. 5. When chart transportation is not available, charts not picked up by 1130 or by 1630, will be placed in the chart locker, located in the Physical Therapy treatment room located on Unit 1. Unit staff should check there as part of their regular chart/lab pick-up routine. B. Unit Staff 1. Review physician's note and orders with the clinic nurse as necessary, paying particular attention to any medications or supplies, which must be obtained, before the order can be carried out. All requests for lab work, consultation, x-ray, EEG/ECG, etc will be completed by the clinic staff and marked with the date of the Individual's next clinic appointment. The clinic staff will mark "ordered in clinic" next to the order for each request prepared. 2. On the unit, the medication person will be notified of new orders. 4. TRANSCRIBING CLINIC ORDERS: 1. A designated unit staff member shall be responsible for noting and transcribing clinic orders. This includes posting follow-up appointment and initiating treatment or medication and checking that forms for any ordered tests or consultations are completed. 2. Medication orders for pain, nausea/vomiting, diarrhea, and antibiotics must have the first dose administered within two (2) hours from the time the order is written (N.P. 308). (See II. 4 above.) 3. The Clinic Checklist on the front of the unit record will be removed after the orders have been noted and progress notes or consultation forms have been reviewed and initialed by the unit physician. To ensure review, the Individual will be added to the medical appointment log.

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N.P.P No. 1201

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION In & Outside Facility Entrance POLICY NUMBER: 1202 Effective Date: August 31, 2006

SUBJECT: DENTAL SERVICES 1. GENERAL: All individuals will have a dental examination after they are admitted from the admission unit to their home unit and yearly thereafter or as needed. At the time of the first exam the Individual is informed of his dental needs and if he desires to return, appointments are made for him. Dental Clinic hours are 0800 to 1630, Monday through Friday with the exception of State of California holidays. Dental Clinic staff will schedule appointments for the initial examination, routine dental care and yearly examinations for individuals by telephone. Individuals will not make their own appointments. When a Individual complains of a toothache, unit staff, after evaluation, may make an appointment by calling the Dental Office and stating the problem. If possible, Individuals will be seen the same day that the call is received. Unit staff will call as early as possible to facilitate scheduling. After hours, NOD/MOD should be contacted for significant Individual complaint or condition, unmanageable with present treatment. The Dentist may be called twenty-four (24) hours a day, seven days a week only for dental emergencies screened by the MOD or NOD. If unable to contact a Dentist, the MOD may make an alternate referral arrangement. 2. DENTAL CLINIC SCHEDULING: The Dental Assistant will normally phone the unit on the day before a scheduled appointment to notify them what time is available. The unit also receives a call on the morning of the appointment from the person who schedules medical-surgical clinic Individual visits. In the event of a last minute cancellation or schedule change, the Dental Assistant may call the unit on short notice. Emergency visits take precedence over regularly scheduled dental appointments and may necessitate rearranging the schedule. The unit staff member receiving this call will:

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N.P.P No. 1202

1. Note the appointment in the Unit Log or desk calendar. 2. Inform the Individual of his appointment. Give the Individual 1st copy of appointment card. The staff member responsible for preparing the chart for the clinic will: 1. Attach copy #2 of Appointment Card to the outside cover of the chart. 2. Examine the chart to ensure that it contains current physician's progress notes, physician's orders for treatment and medication, Wellness and Recovery Notes, current medication records, and other information relevant to the dental appointment (i.e., daily BP record, Clinitest/Acetest record, seizure record, etc.) and ensure that there is sufficient space on these records for the dentist's notes, etc. 3. Note in the Unit Log the time, method of chart transportation. 4. Ensure that the Individual arrives in the Dental Office at the time of the scheduled appointment. 3. MEDICATION ORDERED BY THE DENTIST: When the Dentist orders medication for a Individual, the unit record will be flagged for attention of unit staff. The dentist will fax the new orders to the pharmacy for processing. 4. RETURNING CHARTS TO THE UNIT: The chart delivery system will be used whenever possible to return the chart to the unit. If the chart delivery system is not available, the Dental Assistant will call the unit after the Individual has completed his dental appointment and the unit nursing staff will pick up the chart from the Dental Office no later than 1100 for morning appointments or 1600 for afternoon appointments. Charts not picked up before the office is locked will be placed in the chart distribution cabinet located in the Physical Therapy room on Unit 1, unless unit staff request that the chart be left in the dental office to be picked up after lunch break. The staff member receiving the chart on the unit will examine the chart for new orders, new problem issues and notify the medication person. 5. TRANSCRIBING DENTAL ORDERS: The medication person shall be responsible for noting and transcribing the Dentist's orders and initiating treatment or medications. The medication person shall be responsible for posting follow-up dental appointment.

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N.P.P No. 1202

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION In & Outside Facility Entrance POLICY NUMBER: 1203 Effective Date: August 31, 2006

SUBJECT: REFERRING INDIVIDUALS TO OUTSIDE PHYSICIAN OR FACILITY 1. GENERAL: It is sometimes necessary to refer a Individual to an outside physician, treatment or diagnostic center. This may be done only by Central Medical Clinic physicians, with privileges during the regular workweek. On evenings, holidays and weekends the Medical Officer of the Day (M.O.D.) may refer individuals directly to outside medical facilities. 2. PREPARING THE INDIVIDUAL: A. Individuals will not be made aware of the specific time or place of the appointment. B. Efforts should be made to alleviate any anxiety the Individual may have regarding the medical treatment and outside trip. He should also understand that as in any custody trip he might be required to wear restraints. C. The Individual is to be neatly dressed in well-fitting, clean, khaki clothing. He should be as well groomed as possible. D. If the appointment should extend through the Individual's regular mealtime, unit staff would make arrangements to pick up an appropriate food tray for the Individual upon his return. 3. PREPARATION OF FORMS NECESSARY FOR TRANSFER AND TREATMENT: The Individual's unit nursing staff will be contacted by the Medical Care Coordinator (MCC) in Central Medical Services prior to the appointment time to give pertinent information and instructions pertaining to the appointment. The MCC will specify the forms to be completed. It is the responsibility of the unit staff to properly complete the forms and secure the Physician's, Social Worker's and Program Director's signatures, as necessary, and return the forms to the MCCs office located in Central Medical Service (CMS). NOTE: CLINICAL RECORDS NEVER ACCOMPANIE THE INDIVIDUAL. A. Release Form

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1. This form is to be prepared, in duplicate, by the Individual's unit staff for all outside medical trips. 2. It must state whether and to what degree the Individual security risk and medical precaution or is an assault, drug, escape, suicide or weapons risk. 3. It must indicate number and type of personnel needed to safely escort the Individual. (Two Department Police Officers unless the Program management feels a licensed nursing staff should also accompany the Individual.) 4. It must be reviewed and signed by the Program Director or designee if they agree that the release is safe and necessary. 5. The Medical Care Coordinator (MCC) will ensure that the Chief Physician/Surgeon reviews and signs the form. B. Consent for Treatment Forms 1. This form is to be prepared in duplicate by the Individual's unit for all first visits to an outside consultant or facility. 2. It must be signed by the Individual and witnessed by a licensed staff member. 3. If the Individual has a psychiatric diagnosis and is having an invasive procedure performed, a psychiatric evaluation (consultation form or a copy of the physicians progress note) must accompany the consent form. The psychiatric evaluation essentially must state whether or not the Individual is able to understand the proceedings and in the psychiatrist's professional opinion is competent to give his own consent. C. Authorization for Release of Information Form (MH 5671) 1. This form is to be prepared in duplicate by the Individual's unit staff for all first visits to an outside consultant or facility. 2. It is usually completed for a six month time period. Two sets of this form are necessary: -One releasing the information from Coalinga State Hospital to the outside consultant or facility. -The other releasing the information from the outside consultant or facility to Coalinga State Hospital. -The completed forms must be signed by the Individual and witnessed by a licensed staff member.

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D. Transfer Information Form 1. This form is required whenever a Individual leaves the hospital for any outside medical trip. 2. This form is prepared in duplicate. 3. It is to be signed by the nursing service employee who completes the form. 4. All current medications are to be included in the appropriate section. If the Individual was on Clozapine and it has been discontinued within the last two weeks, this must also be included. 5. An entry must be made for special nursing consideration. The completeness of this information will aid the outside provider(s) in delivering quality care in an expedient manner. Psychiatric consideration examples include Individual is reluctant to accept direction from female staff or a language barrier. Medical consideration examples include monolingual, hearing impaired, and physical disabilities. Also, include any precautions Individual is on (i.e. blood and body fluid precautions). 6. When the Individual is being admitted to an acute care hospital, please include under "nursing care" whether or not an advance directive exists. (See II. H below) 7. The Transfer Information form must also be reviewed and signed by the unit physician/designee. 8. When the Individual is being admitted to an acute care community hospital attach a copy of his latest history & physical. E.Consultation Referral and Report Form (MH5722) This form is to be initiated by the referring physician. The information on this form should include the specific Individual complaint that led to referral, pertinent Individual history, diagnostic assessments, current therapy, (include present medications and allergies), special requirements or conditions of treatment and desired treatment objectives. Specify if the Individual has special needs which must be met for the referral visit to be completed, (i.e. monolingual, hearing impaired, non-ambulatory, and incontinent, etc.). If the Individual is being admitted to an outside hospital, include any special clinical management requirements. The MCC will attach copies of any pertinent clinical information; i.e., x-rays, clinical reports or previous consultations. F. After the required forms are completed and signed they are brought to the MCC's office in Central Medical Services. The MCC will check for completeness and secure the approval of the Chief Physician and Surgeon.

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The forms and any accompanying information will be taken to the Admission Suite to wait the time of the trip. G. If the Individual has an Advance Directive, (review the legal section for form GA 16.1) we are to ensure a copy is to be sent with the Individual when the Individual leaves the hospital for acute hospitalization. Note: Refer to for definitions of advance directives and their types. Indicate on the Transfer Information Form whether or not an advance directive exists prior to forwarding to the MCC during regular working hours or to Unit 1 if leaving under emergency conditions. The Department Police Services escort will be responsible for and will hand carry the forms and any additional items that are required. 4. ESCORTS: A. Department Police Services (DPS) will provide two officers as escorts. The Program may send additional escort(s) at their discretion. B. For hospitalized individuals, the number and kinds of escorts on a continuing basis will be determined by N.O.D. in consultation with the affected program management and Department Police Services. For individuals on routinely scheduled appointments, the Program Director shall be responsible for numbers and types of nursing services escorts. C. DPS on a routine basis will provide two officers to act as driver and coescort. D. The Individuals unit record is to be delivered to Unit 1 upon Individuals transfer to an outside acute facility. Individuals who are returning from an outside hospital surgery or from same day outIndividual surgery shall be evaluated on Unit I to determine whether the Individual may return to his home-unit or whether he requires more specialized care available on Unit IV. HANDLING OF COMPLETED CONSULTATION REFERRAL AND REPORT FORM (MH 5722) A. The original of this form shall be placed in the unit record upon the Individual's return to Coalinga State Hospital. The original must be reviewed, dated and initialed by the unit physician. NOTE: Enter the Individual's name and copy of the consult in the Medical Appointment Log for the physicians review and/or follow-up. If the consult

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does not arrive on the same day as the Individual, assure that the consult, when it does arrive on the unit, is entered along with the Individual's name into the Medical Appointment Log for the physician's review. B. After the Individual returns to CSH, the second copy of this form will be picked up in the Admission Suite by the MCC and distributed for follow-up to the individuals unit and the Central Medical Clinic as necessary. This is necessary to ensure continuity of care. C. The outside facility or physician may retain the third copy for their records. D. If consultations are not received in a timely fashion - notify the MCC. 5. EMERGENCY TRANSFERS: If a medical emergency situation occurs during a Medical Officer of the Days (M.O.D.) tour of duty he/she may refer the Individual directly to an outside facility. A. The MOD will: 1. Determine the mode of transportation, (i.e., Department Police Services, ambulance) and if an R.N. is to accompany the Individual. 2. Make contact with the receiving facility's Emergency Room physician. 3. Complete and sign the Referral and Report Form (). 4. Sign the Release Form. 5. Sign the Release of Information Form MH 5671. 6. Notify the Individual's family of the Individual's condition. Information on next of kin and persons to notify in case of emergency is located in the identification section of the unit record, MH 1710, and on the fingerprint card. B. The Nursing Officer of the Day (NOD) will: 1. Notify the Executive Officer of the Day (EOD) and sign release form in lieu of Executive Officer of the Day. 2. Arrange transportation as ordered by Medical Officer of the Day (MOD). 3. Inform Department Police Services (DPS) of the need for transfer and any escape assault or suicidal risks. 4. Notify the affected Program Officer of the Day (POD) of emergency transfer. 5. Determine the number of escorts required after consultation with POD and DPS. 6. Verify that all forms for transfer are appropriately completed and signed. 7. Verify whether or not an Advance Directive exists. 8. After Individual has been transferred, route all required forms to the MCC's Office. 9. Have the Individual evaluated by the MOD upon return to Coalinga State Hospital. 10. Check on Individual's condition before end of shift.

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N.P.P No. 1203

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION In & Outside Facility Entrance POLICY NUMBER: 1204 Effective Date: August 31, 2006

SUBJECT: EEG-ECG REFERRALS 1. GENERAL: Requests for either electrocardiograph (ECG) or electro-encephalographic (EEG) examinations are made only by order of a physician. Requests for electrocardiograms are made out using the electrocardiogram Request and Report Form (MH 5643). Requests for electroencephalograms are made using the Electroencephalographic Examination Form (MH 5642). The forms are not interchangeable. These forms may be mailed or brought to the EEGECG Department in the CMS hallway. If a Individual requires an escort, a unit staff member will escort the Individual(s) to the EEG-ECG Department and remain with the Individual until the exam is completed. 2. ELECTROCARDIOGRAMS: The physician will fill out the "Request" portion of the form. Note whether any pericardial pain and/or cardiac decompensation are suspected and the dosage of medications that the Individual is currently taking. If a Individual is a candidate for a drug that requires an ECG that information must be noted on the Request portion of the form. It is important to have the entire request portion completed so that the requests may be prioritized. In the event an emergency ECG (STAT) is ordered by the physician/Nurse Practitioner, call the EEG-ECG Department. If no answer or after 4:30 p.m. or on a weekend, contact the Urgent Care or NOD. 3. ELECTROENCEPHALOGRAMS: A. The physician will state the type of examination he is requesting, e.g., routine, sleep-deprivation, etc., giving as much information as possible concerning pertinent history, findings, current medications, trauma, etc. A referring diagnosis is also noted. B. EEG's may be ordered STAT Monday through Friday between the hours of 0800 - 1630. (Refer to I. B. above.)

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C. Unit staff will instruct the Individual as to what is expected of him. The EEG-ECG Department will, upon request, aid the unit staff in this instruction. D. Unit staff will see that the Individual washes his hair and showers the evening prior to the EEG examination. Instruct Individual not to use any hair dressing after shampoo and shower. E. The unit will be notified by the EEG-ECG Department, at least one day prior to the date and time of the scheduled examination. When a sleep deprivation test is requested, the Individual will be kept awake on his own unit. 4. DOCUMENTATION: The EEG-ECG report will be reviewed by the ordering physician/nurse practitioner and then filed into the clinical record.

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N.P.P No. 1204

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION In & Outside Facility Entrance POLICY NUMBER: 1205 Effective Date: August 31, 2006

SUBJECT: PHYSICAL THERAPY SERVICES 1. GENERAL: Physical Therapy services are provided at Coalinga State Hospital on a contractual basis through Central Medical Services. A physician orders the physical therapy evaluation and assessment. Secondly a physicians order is required prior to initiation of physical therapy services. The Physical Therapist can write the orders and the physician will countersign. 2. PURPOSE: The purpose is to assist the Individual with acute or prolonged physical movement dysfunction or pain to maximize his functional independence. 3. PROCEDURE: A. Physical Therapy is located in the Central Medical Clinic. B. Physical therapy services are provided usually Monday through Friday. Services may only be scheduled 3 - 4 days/wk. (as Individual needs require). C. Chart transportation will deliver charts to Physical Therapist and return them to the units when Physical therapy services are finished by 1500 hr. D. The Physical Therapists treatment and weekly progress notes and Physical Therapy Care Plans are filed in the consultation section of the clinical record. E. THE UNIT STAFF WILL: 1. Deliver the completed Consultation Referral and Report (MH 5722) to Physical Therapy. 2. Inform the Individual of his appointment. 3. Deliver the Individuals record to Physical Therapy utilizing chart transportation as available. 4. Pick up Individuals record from physical therapy (utilize chart transportation as available) after the appointment is completed. 5. Document refused, missed or canceled appointments. 6. Refer individuals who are non-compliant (refusing) with the physical therapy service ordered to their unit physician.

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7. Flag the chart for the physician to countersign the orders if written by the Physical Therapist. 8. Schedule Individual for physician appointment monthly 9. Incorporate nursing interventions into the Nursing Care Plan. Evaluate, together with the Wellness and Recovery Team, the current I.D. Team planed activities that may need to be curtailed during the period of physical therapy treatment, e.g. gym groups requiring strenuous activity, weight lifting, etc. Individual teaching will be recorded on the Individual/Family Education Tool. F. THE PHYSICAL THERAPIST WILL: 1. Provide the Physical Therapy schedule to CMS so Individuals appointments with times are phoned to the unit the day of service. 2. Call the unit if Individual and unit record still needs to be brought to Physical Therapy. 3. Perform an initial evaluation and assessment before the provision of any services and document this assessment on the Consultation Referral and Report MH 5722. 4. Write recommendation orders at the time of the initial evaluation which are to be reviewed along with the Consultation Report by the reviewing physician who will either co-sign or write appropriate physical therapy orders before Physical Therapy services are initiated. 5. Develop a Physical Therapy Care Plan (GA overlay 420) based on the initial physical therapy evaluation and assessment. 6. Write an I.D. Note at the time of each physical therapy visit on the P.T. Treatment and Weekly Progress Note (form GA 491). 7. When Physical Therapy is discontinued, write recommendation, orders and a corresponding I.D.N. addressing Individual's level of participation, amount of benefit (level of improvement) and any complications or other problem. These are to be reviewed by the physician who will co-sign or write appropriate Physical Therapy orders.

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N.P.P No. 1205

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION In & Outside Facility Entrance POLICY NUMBER: 1206 Effective Date: August 31, 2006

SUBJECT: REFERRING SPECIAL NEEDS INDIVIDUALS FOR NURSING CONSULTATION 1. GENERAL: Coalinga State Hospital individuals may be admitted with, or develop while here, acute or chronic medical conditions which require specific medical nursing interventions. This is the type of care for which there is usually no pre-existing nursing procedure and which requires a more specialized expertise than is currently available on the Individual's psychiatric treatment unit. Examples of individuals who might require such a consultation are: -Amputees who use an extremity prostheses. -Those that have had an enucleation and use an ocular prosthesis. -Those with paralysis such as paraplegia or hemiplegia. -Those with a stoma such as a colostomy or gastrostomy. -Those needing post surgical care with or without casting. -Those with chronic infectious diseases having special medical nursing needs. -Those individuals with pressure ulcers. -Other individuals who require unusual or otherwise specialized nursing needs. A Nurse Practitioner (NP) assigned through Central Medical Clinic will provide this service. The Nurse Practitioner may contact resources at Coalinga State Hospital and outside to assist in determining what types of care and equipment are necessary and available. 2. PURPOSE: To provide effective nursing care to mentally ill individuals with special medical nursing needs. 3. PROCEDURE/REFERRAL PROCESS: A. Unit/Area Nursing Service Staff Will:

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Prepare Consultation Request and Report Form (MH 5722). 1. Write "Special Needs" in the service box on top right. 2. Write reason for request giving as much information as possible to facilitate prioritization and gathering of resources. 3. Date and sign request portion. 4. Send the third copy to the Individual's Program. 5. Mail or take referral to the Central Medical Clinic. B. Upon receipt of Consultation Nurse Practitioner Services Will: 1. Prioritize request. 2. Contact unit and set up a time to see Individual and nursing staff on unit or in clinic as appropriate. 3. Assess Individual needs. 4. Contact resources as necessary. 5. Provide Individual and staff education as needed. 6. Write report on Consultation Form in the Subjective, Objective, Assessment, Plan (SOAP) format. 7. When necessary, orders may be written on the Physicians Order Form. 4. POST APPOINTMENT: Unit Nursing Staff will assure: A. Consultation Report is filed in the Individual's unit record and initialed by the unit M.D. B. If required, orders must be co-signed by the unit physician within 24 hours (See Standardized Procedures Family/Adult Nurse Practitioner Protocols. C. Nursing Service review of consultation recommendations with staff education as needed. D. Follow-up appointments made per recommendations. E. Any supplies and/or equipment are obtained.

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N.P. P No. 1206

SECTION 13 PSYCHIATRIC NURSING INTERVENTIONS

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1300 Effective Date: August 31, 2006

SUBJECT: WITHDRAWN BEHAVIOR 1. PURPOSE: To provide guidelines for the appropriate care and treatment of Individuals exhibiting withdrawn behavior. 2. POLICY: All Individuals at Coalinga State Hospital shall be provided with the highest possible quality of evidenced-based, appropriate care and treatment, based on their diagnosis, in a professional manner, with respect and dignity. 3. DEFINITION: Withdrawal is a behavior in which persons retreat from relationships and contacts with the external world into a world of their own as a defense against anxiety related to increased stress or increased threat. 4. ASSESSMENT: Withdrawal may appear anywhere on a continuum from mild to severe. Withdrawn behavior may be related to overwhelming stress, or it may occur in conjunction with other illnesses such as depression or psychosis. Severe withdrawal can interfere with the Individuals ability to function and if untreated it could lead to coma and death. -Behaviors which might be observed when withdrawn behavior is due to overwhelming stress include: -Lack of spontaneity -Lackluster appearance -Decreased or absent verbal communication -Lack of awareness of surroundings -Retention of urine or feces -Apathy -Inattention to grooming & personal hygiene -Isolation -Inadequate food or fluid intake -Decreased motor activity

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-Psychological immobility -Lack of energy -Changes in body posture

-Inability to attend -Low self-esteem -Fear or Panic

When the withdrawn behavior is due to severe depression, schizophrenia, or psychosis, behavior which might be observed (in addition to those characteristics listed above) includes: -Physical immobility -Fetal position (eyes closed, teeth clenched, muscles rigid) -Incontinence (of urine and/or feces) -inability or refusal to eat and/or drink 5. PARTIAL LISTING OF NURSING DIAGNOSES: Loss of reality contact related to: a. Feelings of fear b. Disordered thoughts c. Psychological immobility d. Isolation Disrupted homeostasis related to: a. Physical retardation or immobility b. Psychological immobility c. Failure to eat and/or drink Decreased motor activity related to: a. Apathy b. Lack of awareness of surroundings c. Feelings of fear d. Lack of energy Decreased ability to express feelings related to: a. Isolation b. Decreased or absent communication with others and the environment Inattention to personal hygiene related to: a. Lack of energy b. Psychological immobility c. Low self-esteem 6. PLAN: The Individual will: a. Be physically safe b. Establish and maintain an adequate food and fluid intake c. Establish and maintain normal elimination pattern

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d. e. f. g. h. i. j. k.

Become physically mobile Express feelings, verbally and non-verbally Interact with others and the environment Demonstrate alternative methods of dealing with stress Function at his optimal level Maintain contact with reality Attend planned, scheduled treatment activities Attend scheduled recreational and/or social activities

7. IMPLEMENTATION AND INTERVENTION: Establish contact and rapport with the Individual: NURSING ACTION A. Assess the Individuals current level of functioning and communication and begin to work with the Individual at that level. KEY POINTS A. In order to make contact with the Individual you must begin where he is at the present time.

B. If the Individual is completely withdrawn B. Your physical presence conveys caring and mute; begin by spending scheduled and acceptance to the Individual. periods of time with him. C. Talk with the Individual in a soft voice to express your caring and interest in him. Continue to do this with the positive expectation of a response. D. Give positive feedback for any response and encourage him to continue to reach out. C. A soft voice can be comforting and nonthreatening. Expecting the Individual to respond increases the likelihood that they will do so. D. Our encouragement can foster attempts to reestablish contact with reality.

Promote adequate food and fluid intake, and adequate elimination: NURSING ACTION A. Remain with the Individual during meals. B. Feed the Individual if necessary. C. Monitor elimination pattern. KEY POINTS A. Your physical presence can stimulate the Individual and promote reality contact. B. The Individual needs to reestablish nutritional intake. C. Constipation may occur due to decreased food and fluid intake, decreased motor activity, or the Individuals inattention to elimination.

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Help the Individual maintain contact with the environment: NURSING ACTION A. Encourage or help the Individual to spend short periods of time with one other person at first. B. Avoid allowing the Individual to isolate him-self in a room for long periods of time. C. Gradually increase the amount of time the Individual spends with others, and the number of people the Individual is with. KEY POINTS A. The Individual will initially deal more readily with minimal stimulation and minimal change. B. Isolation will foster continued withdrawal. C. The Individual will respond more positively to a gradual increase in stimulation.

Encourage the Individuals expression of emotions. Promote a supportive and secure environment: NURSING ACTION A. Encourage the Individual to express himself non-verbally (through writing and/or drawing). B. Encourage the Individual to progress to verbal communication as tolerated. C. Interact on a one-to-one basis initially, and then help Individual progress to small groups, and to larger groups as tolerated. Increase the Individuals physical activity: NURSING ACTION A. Walk slowly with the Individual at first. Progress gradually from gross motor activity. B. If the Individual is immobile or in a fetal position provide passive range of motion exercises. Turn the Individual at least every two hours. Provide skin care and observe for pressure areas and skin breakdown. 8. EVALUATION: Documentation should reflect: 1. Individuals current status and progress towards meeting nursing objectives and compliance (or lack of) with treatment plans. KEY POINTS A. Progress from walking gestures with the hands to activity requiring fine motor skills, e.g. jigsaw puzzles, writing. B. You must be alert to the prevention of physical complications due to immobility. KEY POINTS A. Non-verbal communication is usually less threatening than verbalization initially. B. Use a non-threatening approach. C. Gradual introduction of people minimizes the threat perceived by the Individual.

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2. 3. 4. 5. 6. 7. 8.

Changes in Individual condition. Nursing interventions for unusual or sudden behavior changes. Response to treatment program. Attendance and participation in scheduled groups. Response to medication. Effect illness has on eating, sleeping, hygiene, elimination, behavior. Individual education.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1301 Effective Date: August 31, 2006

SUBJECT: ALTERED NUTRITIONAL STATUS: THE INDIVIDUAL WHO IS NOT EATING 1. PURPOSE: The purpose of this policy is to direct and guide the nursing staff on care of the Individual who is refusing to eat and to provide a uniform approach to evaluation, intervention, and treatment of the Individual who is not eating. 2. POLICY: 1. All Individuals who present a pattern of refusing to eat are to be monitored closely for the amount of food and fluids taken at meals and at snack or specials time. The Individuals intake, or lack of intake, is to be recorded on the Daily Care Flow Sheet (MH 5504). This information will also be shared at the Change of Shift Report so that continuity of care and observation can be consistent on all three shifts. As the pattern of refusing to eat becomes evident, the Unit and Med/Surg Physician, Dietitian, and HSS will be apprised of the Individuals refusal to eat. 2. All Individuals shall be weighed at least monthly and results reported to the physician, dietician, and NOD on the Monthly Weight and Vital Signs Record (CSH 7090). 3. The Referral for Nutritional Screening for High Risk Individuals (MH 5711) form shall be initiated and sent to the dietitian when clinically indicated or when there is unplanned weight loss. The Lab/Consult Tracking process (see NPPM #502) shall be used to insure that the consult results are reviewed and evaluated in a timely manner. An MHDS (CRDS) problem shall be established to address the nutritional problem/barrier and care plans developed as appropriate. 4. Nursing Services staff is to be sensitive to the Individuals age, culture, ethnic, and religious background and report to the Physician and Dietitian of any food preferences or needs. 3. GENERAL INFORMATION: There are a number of problems which may contribute to a Individual not eating, such as depression, confusion, manic behavior, delusions, self destructive feelings, phobias, manipulative behavior, physical problems, etc. A thorough physical assessment is important to rule out any physical problem. If an eating disorder is -1N.P.P No. 1301

suspected the Individuals a) weight, b) eating, c) activity, d) psychosocial issues, and e) physical signs and symptoms need to be evaluated.

4. DEFINITIONS OF EATING DISORDERS: Anorexia nervosa - a disorder characterized by a distorted body image, an extreme fear of obesity, refusal to maintain a minimally normal body weight, and in women, the absence of menstrual periods. Bulimia nervosa - characterized by a repeated binge-purge cycle that is an episodic uncontrolled, rapid ingestion of large quantities of food over a short period of time often followed by purging (vomiting). Binge eating disorder - bingeing without purging. 5. ASSESSMENT: 1. It is important to assess not only the present weight and how much the Individual has recently lost but also the presence of distorted body image and the influence of mood (anxiety, guilt, depression) or events that may impact weight status. 2. The nurse assesses not only the exact eating patterns but also the feelings and behaviors that surround the persons eating. Is there a binge-purge cycle? Are there feelings of anxiety and shame? What is the degree of impulse control? Is the Individual aware of rigid or compulsive feelings toward eating? Are there any psychosocial patterns of eating or attitudes toward food? 3. Because the eating disorders can be seriously debilitating and in some cases lead to death, careful physical assessment and awareness of specific signs and symptoms are crucial. 4. Some physical signs and symptoms of anorexia nervosa often seen in severe cases include cachexia, hair loss, yellowish skin, cyanosis of the extremities, and cessation of menses, peripheral edema, and hypotension. 5. Some physical signs and symptoms of bulimia nervosa resulting from frequent vomiting are parotid gland enlargement (called chipmunk facies) chronic hoarseness, sore throat, dental caries from acid regurgitation, electrolyte imbalances (hypokalemia and alkalosis), and dehydration. When evaluating the Individuals nutritional status, consider the following: -Refusal to eat/fasting -Denial of or loss of appetite -Preoccupation with losing weight -Epigastric distress -Vomiting -2- Manipulative behavior - Weight loss - Confusion - Sedation - Hyperactivity N.P.P No. 1301

-Nausea -Difficulty swallowing or dry mouth -Constipation -Depression

- Intense fear of gaining weight or becoming fat - Preoccupation with ones bodyweight, size, or shape

6. PARTIAL LISTING OF NURSING DIAGNOSES: Refusal to eat related to: a. Body image distortion intense fear of gaining weight or being fat b. Denial of appetite or loss of appetitec. Delusions (Paranoia) Disruptive homeostasis related to: a. Inadequate food and/or fluid intake b. Vomiting c. Hyperactivity d. Sedation e. Fasting Resistive to treatment related to: a. Suicidal ideas, feelings, and intentions Manipulative behavior related to: a. Secondary gain from not eating b. Refusal to eat 7. EXPECTED OUTCOME: 1. 2. 3. 4. Will be able to verbalize concerns why not eating. Provide nutritional counseling/Individual teaching. Individual will increase caloric and nutritional intake. Weight will be maintained within Ideal Body Weight (IBW) range

8. IMPLEMENTATION AND INTERVENTION: NURSING ACTION A. Establish sense of trust. Encourage Individual to verbalize concerns to not eating. B. Assess the Individual's physical status. C. Monitor food intake and weight. KEY POINTS A. Determine factors contributing to the Individual not eating.

B. Rule out any physical cause. C. Chart percentage of food eaten each meal on Daily Care Flow Sheet (MH 5504). Document percent offered and amount taken. Weigh and record weekly or as ordered for Individuals with unplanned weight loss. -3N.P.P No. 1301

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D. Determine any food allergies or preferences.

D. Be alert for any food/drug contraindications. Consult with the Pharmacist as needed. E. Be sensitive to Individuals age, culture, ethnic, and religious needs and issues. F. Be alert to decreasing distractions. Assist with creating a supportive environment. G. Refer to NPPM #318 Feeding of Individual H. Positive support tends to reinforce desired behavior. I. To prevent dehydration. Refer to NPPM #320 Fluid Monitoring. J. Refer to NPPM #x Individual and Family Teaching.

E. Encourage food intake. Offer substitutions when possible. Work closely with the Dietitian. F. Provide a quiet area to eat or encourage eating at a table with compatible peers. G. Assist the Individual to eat.

H. Give positive support for eating.

I. Offer fluids frequently.

J. Collaborate with the Dietitian to establish an optimal Lesson Plan for Individuals nutritional teaching.

9. EVALUATION AND DOCUMENTATION: 1. Documentation should reflect Individuals current nutritional status and progress towards meeting Individual plans and expected outcomes. a. Observe Individual for signs of nutritional deficits and changes in Individuals condition. b. Observe Individual for signs of dehydration. Palpate skin for loss of turgor. c. Any unplanned loss or gain of 5% of body weight must be reported to the Dietitian, physician, NOD and at Change of Shift. Label IDN entry as Weight Change Note. d. Document nursing interventions for unusual or sudden behavior changes. e. Document Individuals response to treatment plan. 2. All meals shall be documented on the Daily Care Flow sheet (MH 5504) based on the amount of food consumed. 3. Utilize the Wellness and Recovery Individual/Family Health Education Record (CSH 7156) to document Individual education.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1302 Effective Date: August 31, 2006

SUBJECT: DELUSIONS 1. PURPOSE: The purpose of this policy is to provide appropriate guidelines for the nursing staff that will assist with identifying precursor signs of an individual who may be having delusions, and to provide a uniform approach to evaluation, intervention and treatment of the individual experiencing delusions. 2. POLICY: All individual/s experiencing delusions shall receive individualized appropriate treatment to alleviate those symptoms in a structured, safe, and secured environment. 3. DEFINITIONS: Delusions - false personal beliefs that are inconsistent with the individuals intelligence or cultural background. The individual continues to have the belief in spite of obvious proof that it is false or irrational. Fixed delusions - delusions that may persist throughout a lifetime. Transient delusions - delusions that are episodic and do not persist over time. 4. GENERAL INFORMATION: 1. Irrational thinking does not follow the laws of logic according to the persons intelligence and cultural background. Even when facts are presented, an individual with a delusional disorder is unable to modify the delusion. 2. Unlike other psychotic systems, delusions usually respond poorly to antipsychotic medication. Delusions often persist for months. Delusional thinking may never resolve completely. 3. Delusional individuals tend to jump to conclusions based upon very little evidence.

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4. Affected individuals may conceal their thoughts. They do not believe they have a mental disorder. The disorder can only be detected by observing unusual behavior(s) that is/are a consequence of the delusional thinking. 5. Delusional individuals are leery of those who challenge their thinking and may harm anyone who confronts their delusional ideations. 5. ASSESSMENT: Assess the individuals mental/emotional status by evaluating the following: 1. Appearance and behavior. 2. Consciousness. 3. Speech activity. 4. Thought process, content, and perceptions. Three phases have been identified in the process of delusional thinking: Phase 1 - The individual is totally involved in the delusions. Phase 2 - Reality testing and trust in others co-exist with the delusions. Phase 3 - The individual no longer experiences delusions (or is not bothered by them in the case of fixed delusions). Examples of disorders may include: -Delusions of control -Delusions of grandeur -Delusions of persecution -Delusions of infidelity (regarding self or .partner) -Ideas of reference -Delusions of being accused -Delusions of wealth -Erotomanic delusions -Delusions of poverty -Delusions of contamination -Somatic delusions -Paranoid delusions -Delusions regarding eating and food. -Nihilistic delusion (feeling of impending .doom) -Magical thinking -Bizarre delusions

6. PARTIAL LISTING OF POTENTIAL NURSING DIAGNOSES: Low self-esteem related to: a. Ineffective interpersonal relationships b. The threat of the loss of a relationship c. Lack of trust d. Ineffective coping strategies Feelings of fear and insecurity related to: a. Delusions b. Lack of trust

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c. Feelings of helplessness or powerlessness Decreased ability to express feelings related to: a. Delusions b. Decreased verbal interactions with others c. Lack of insight d. Psychotic symptoms Feelings of overwhelming anxiety related to: a. Delusions b. Lack of trust c. Limited ability to deal with stress 7. PLAN: Promote development of a trusting relationship Decrease individuals anxiety and fear by assisting individual in finding healthy ways of dealing with emotions. When low self-esteem is evident, assist individual learn assertive skills, adequate social skills, and selfmonitoring and self-evaluation skills. Help individual recognize delusions. Help individual work on accepting responsibility for successes as well as failures and promote homeostasis. 8. IMPLEMENTATION AND INTERVENTION: NURSING ACTION A. Build a trusting relationship. KEY POINTS A. Be honest and sincere in communication with individual or client and avoid vague or evasive remarks. Be consistent in setting expectations, enforcing rules, etc. Do not make promises. Encourage the individual to talk but do not pry. B. Give positive feedback for successes. Recognize and support the accomplishments and ideas. Engage the individual in one-to-one activities at first, then in small groups, and gradually activities in large groups. Give support for efforts to interact with others and/or attending activities.

B. Assist to increase the individuals selfesteem.

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C. Decrease the individuals anxiety and fears; help the individual feel at ease and identify situations where feelings could be easily expressed.

C. Recognize the individuals delusions as his perception of the environment. Interact with the individual on the basis of real things; do not dwell on the delusional material. Show empathy regarding the individuals feelings. Avoid being judgmental, or belittle, or joke about the beliefs. D. Never conveys that delusions of reality are true. Directly interject doubt regarding delusions as soon as the individual seems ready to accept this. Attempt to discuss the delusional thoughts as a problem in the individuals life. E. To provide a stable environment.

D. Help the individual recognize delusions as such.

E. Maintain a routine of daily activities. Be consistent in setting expectations for individual. F. Monitor food/fluid intake. Assist the individual as needed. G. Assist individual with ADL skills as needed. Encourage him to do as much as possible for self.

F. Maintain adequate nutrition.

G. To increase self-esteem.

H. Provide praise for positive behaviors.

H. To reinforce positive behaviors.

9. EVALUATION AND DOCUMENTATION: Documentation should reflect: 1. The individuals current status and progress towards meeting TX objectives. 2. Changes in individuals condition and responses to medication regimen. 3. Nursing interventions for unusual or sudden behavior changes. 4. Response to treatment program. 5. Attendance and participation in scheduled groups. 6. Effect illness has on: a. Eating b. Sleeping c. Hygiene

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d. Elimination e. Behavior 7. Education

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1303 Effective Date: August 31, 2006

SUBJECT: SCHIZOPHRENIA

1. PURPOSE: The purpose of this policy is to provide appropriate guidelines that will assist nursing staff with the individual who is Schizophrenic and to provide a uniform approach to evaluation, intervention, and treatment. 2. POLICY: All individuals with Schizophrenia shall receive individualized treatment to alleviate those symptoms in a structured, safe, and secured environment. 3. DEFINITIONS: Schizophrenia - Characterized as disturbances of language and communication, thought, perception, affect, and behavior. Usually of psychotic proportion, it is a disturbance that lasts for at least 6 months. Thought disturbances are marked by alterations of concept formation that may lead to misinterpretation of reality, misconceptions, and sometimes to delusions and hallucinations. Mood changes include ambivalence, blunting, inappropriateness, and loss of empathy with others. Behavior may be withdrawn, regressive, and bizarre. Negative symptoms - Include reduced range of expression of emotion (flat or blunted affect), markedly reduced amount or fluency of speech, and loss of the will to do things (avolition). They are called negative because they give the impression that something has been taken away from the individual, not added, as is the case with hallucinations and delusions. Negative symptoms reduce the apparent textural richness of an individuals personality. Positive symptoms - Hallucinations, delusions, positive formal thought disorder and bizarre behavior. Positive symptoms predict better response to medication and less permanent disability. 4. GENERAL INFORMATION: The following list of recognized subtypes of schizophrenia is the official diagnostic terms in the DSM IV Diagnostic and Statistical Manual of Mental Disorders: Disorganized (hebephrenic) - Behavior shows disorganized speech, disorganized behavior, and flat or inappropriate affect (often the form of random giggling). Other -1N.P.P No. 1303

elements commonly associated are odd facial grimaces, extreme social withdrawal, and very peculiar mannerisms. Social functioning is severely disrupted. Catatonic - Psychomotor disturbance in which movement is severely reduced and catatonic stupor, rigidity, or posturing is evident. Some show waxy flexibility. The agitated catatonic is marked by uncontrollable verbal and motor behavior. These individuals may break into a frenzied violence in which they hurt themselves or others. Paranoid - Present a symptom picture dominated either by preoccupation with one or more delusions or with frequent auditory hallucinations. They show more concern with erecting boundaries in tasks and in their personal worlds. Undifferentiated - There are several symptoms from the various subtypes. The criteria for one of the other categories are not quite fulfilled. Residual - Individual has been already labeled Schizophrenic but the disorder has lessened to the point that there are no longer any prominent characteristic symptoms. 5. ASSESSMENT: 1. Assess and identify disturbances in areas of functioning: -Health management/health perception -Nutritional/metabolic -Elimination -Activity/exercise -Role relationships -Coping/stress tolerance -Cognitive/perceptual -Sleep/rest -Self-perception/self-concept -Sexuality/reproductive -Value/belief

2. Assess and record symptomatology data (subjective and objective): -Autism -Associative looseness -Neologisms -Word salad -Regression -Emotional ambivalence -Echolalia -Concrete thinking -Delusions -Religiosity -Inappropriate affect -Echopraxia -Clang Associations -Hallucinations

3. Assign a Nursing Diagnosis (Use your clustered data to select appropriate Nursing Diagnosis. 6. Sample Nursing Diagnoses: Potential for Violence: Self-Directed or Directed at others R/T Hallucinations as evidenced by receiving auditory "suggestions" of a threatening nature.

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Other commonly used Nursing Diagnoses: -Social isolation -Ineffective individual coping -Sensory-Perceptual alteration: Auditory/visual -Alteration in Thought Process -Impaired verbal communication -Self-Care Deficit (identify specific area) -Sleep Pattern Disturbance -Ineffective family coping -Altered Health Maintenance -Impaired Home Maintenance Management 7. IMPLEMENTATION/INTERVENTION: NURSING ACTION A. Establish a trusting relationship. KEY POINTS A. Be honest and sincere in communication with individual.

B. Provide a safe and secure environment. B. Remove items that can be used to overtly harm self or others if in an agitated or confused state. C. Maintain a low level of stimuli in individuals environment (e.g. low lighting, simple dcor, low noise level). D. Reinforce and focus on reality. Discourage long running ruminations about irrational thinking. E. Monitor food/fluid intake, elimination, sleep patterns, and activity levels. F. Monitor activities of daily living. C. Anxiety level rises in stimulating environment.

D. Discussions that focus on the false ideas are purposeless, useless, and may aggravate the psychosis. E. Assist as needed. Refer and record on appropriate form. F. To help prevent and intervene with decompensation. G. Increase feelings of self-worth. Facilitate trust. H. Positive reinforcement enhances selfesteem and encourages repetition of acceptable behaviors. I. To avoid creating suspiciousness in the

G. Convey an accepting attitude. Make frequent contacts. H. Give recognition and positive reinforcement for individuals who voluntarily interact with others. I. Observe individuals behavior frequently

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while carrying out routine activities.

individual.

8. EVALUATION AND DOCUMENTATION: Documentation should reflect: 1. Individuals current status and progress towards meeting ID Team objectives and nursing interventions 2. Changes in individuals condition 3. Nursing interventions for unusual or sudden behavior changes 4. Response to treatment program 5. Attendance and participation in scheduled groups 6. Response to psychotropic meds (effect on "target symptoms") 7. Effects of diagnosis have on functional health patterns.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1304 Effective Date: August 31, 2006

SUBJECT: BIPOLAR DISORDERS 1. PURPOSE: To provide guidelines for the appropriate care and treatment of those Individuals diagnosed with Bipolar Disorder. 2. POLICY: All Individuals at Coalinga State Hospital shall be provided with the highest possible quality of evidenced-based, appropriate care and treatment, based on their diagnosis, in a professional manner, with respect and dignity. 3. DEFINITION: A major mood disturbance characterized by episodes of mania (highs) and depression (lows). 4. ASSESSMENT: Bipolar disorder is sub-classified as mixed, manic, or depressed, depending on the clinical features of the current episode (or most recent episode if the disorder is currently in partial or full remission). In Bipolar Disorder the initial episode that occasioned hospitalization is usually manic. Frequently a Manic or Major Depressive episode is immediately followed be a short episode of the opposite kind. In many cases there are two or more complete cycles (a manic and a major depressive episode that succeeds each other without a period of remission) within a year. Generally Bipolar disorders with a mixed or rapid cycling episode have a poorer prognosis than those without this type of episode. Examples of abnormalities may include: -Restlessness, hyperactivity -Exaggeration of achievements -Push of speech (rapid, forced speech) -Decreased concentration, short attention .span -Agitation -Loose associations -Tangentiality of ideas and speech -Grandiose schemes, plans, or stated self.image

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-Sexual acting-out; flirtatious, seductive .behavior -Buying sprees -Hostile behavior -Insomnia -Delusions -Threatened or actual aggression toward .self and/or others

-Inappropriate, bizarre, or flamboyant .dress or use of make-up or jewelry -Low self-esteem -Fatigue -Hallucinations -Poor nutritional and fluid intake

5. PARTIAL LISTING OF POTENTIAL NURSING DIAGNOSES: Potential for disrupted homeostasis related to: -Inadequate food and fluid intake -Hyperactivity -Effects of medication(s) Disturbance in balance of rest, sleep, and activity related to: -Hyperactivity -Agitation -Insomnia Disorientation related to: -Delusions -Hallucinations -Disordered thoughts Potential for self-inflicted injury related to: -Agitation -Delusions -Hallucinations -Hostility Potential for injury to others related to: -Agitation -Hostility -Disordered thoughts -Delusions -Hallucinations Disturbance in interpersonal communication related to: -Disordered thoughts -Tangential speech -Push of speech -Decreased concentration or short attention span

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Bizarre or inappropriate behavior, dress or appearance related to: -Delusions -Low self-esteem -Disordered thoughts 6. PLAN: The Individual will: -Establish or maintain adequate nutrition, hydration, and elimination -Establish or maintain an adequate balance of rest, sleep, and activity -Demonstrate a decrease in restlessness, hyperactivity, and agitation -Demonstrate orientation to person, place, and time -Experience decreased hallucinations, delusions, and hostility -Not harm self or others -Demonstrate an increased attention span -Talk with others about present reality -Demonstrate decreasing push of speech, tangentiality, etc. -Demonstrate knowledge of his illness -Demonstrate knowledge of the signs and symptoms of lithium toxicity -Demonstrate knowledge and acceptance of the need for continuing chemotherapy, regular blood testing for lithium levels, etc. 7. IMPLEMENTATION AND INTERVENTION: Establish rapport and build a trust relationship: NURSING ACTION A. Show acceptance of the Individual as a person. B. Use a firm, yet calm and relaxed approach. KEY POINTS A. The Individual is acceptable as a person regardless of their behaviors which may or may not be acceptable. B. Your presence and manner will help to communicate your interest, expectations and limits as well as your self-control.

Prevent the Individual from harming themselves or others: NURSING ACTION A. Provide a safe environment for the Individual. KEY POINTS A. Physical safety of the Individual and others is a priority.

Decrease disorientation, hallucinations, delusions, bizarre behavior, dress, sexual acting out, and so forth: NURSING ACTION A. Reorient the Individual to person, place, KEY POINTS A. Repeated presentation of reality is

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and time as indicated. B. Spend time with the Individual. C. Ignore or withdraw your attention from bizarre dress, behavior, and sexual acting out as much as possible.

concrete reinforcement. B. Your physical presence is reality. C. It is important to minimize attention to unacceptable behaviors.

Decrease hyperactivity, restlessness and agitation: NURSING ACTION A. Decrease environmental stimulation whenever possible. Respond to cue of increased restlessness or agitation by removing stimuli and/or isolating the Individual. B. Limit group activities in terms of size of group and frequency of activities based on the Individuals level of tolerance. C. Provide a consistent, structured environment. D. Provide physical activity as an outlet for relief of tension and energy. E. Evaluate how much stimuli and responsibility the Individual can tolerate with respect to group activities and interactions with others and attempt to limit these accordingly. Promote rest and sleep: NURSING ACTION A. Provide time for a rest period, nap, or quiet time during the daily schedule. B. Observe closely for signs of fatigue. Monitor his sleep patterns. C. Decrease stimuli before the Individual retires (e.g. dim lights, turn down radio, provide a warm shower). D. Encourage Individual to follow a routine of sleeping at night rather than during the day. KEY POINTS A. The Individuals increased activity level increases their need for rest. B. The Individual may be unaware of fatigue or may ignore the need for rest. C. Limiting noise and other stimuli will help encourage rest and sleep. KEY POINTS A. The Individuals ability to deal with stimuli is impaired.

B. The Individuals ability to respond to others and to deal with increased stimuli is impaired. C. Consistency and structure can be reassuring. D. Physical activity can relieve tension in a healthy manner. E. The Individual is unable to provide limits and may be unaware of his impaired ability to deal with others.

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Encourage a nutritious diet: NURSING ACTION A. Monitor the Individuals eating patterns and food / fluid intake. KEY POINTS A. The Individuals increased activity level increases need for nutrients.

Assist the Individual in meeting their basic needs and in carrying out necessary activities of daily living: NURSING ACTION A. Monitor the Individuals elimination patterns. B. If necessary assist the Individual with personal hygiene, including mouth care, bathing, and dressing. Provide emotional support: NURSING ACTION A. Give the Individual positive feedback when appropriate. KEY POINTS A. Do not give attention to unacceptable behaviors. KEY POINTS A. Constipation is a frequent adverse effect of antipsychotic medication. B. Good personal hygiene and grooming can foster feelings of well-being and self-esteem.

Promote compliance with Lithium therapy: NURSING ACTION A. Inform the Individual about lithium therapy: dosage, the need to take it only as prescribed, the toxic symptoms, and the need for blood tests, salt and diet considerations. B. Stress to the Individual that lithium must be taken regularly and continually to be effective; just because they feel better or because their mood is level is not sufficient cause to discontinue the drug. KEY POINTS A. Any condition that depletes salt in the body (e.g. crash diets, increase in perspiration, vomiting, or diarrhea) may increase serum lithium levels and cause toxicity. B. A relatively constant serum lithium level is necessary for successful maintenance treatment with lithium.

Side effects that can be expected form lithium include: -Mild intermittent nausea -Thirst, increased liquid intake, increased urination -Metallic taste -Slight intermittent hand tremor Signs that indicate a near toxic blood level of lithium which the Individual should report to staff: -Insatiable thirst

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-Persistent diarrhea -Persistent vomiting -Lack of coordination -Muscular weakness -Dizziness -Slurred speech -Trembling of the hands -Difficulty concentrating -Decreased speed in thinking -Confusion -Buzzing, ringing, or whistling in the ears The Individual should be seen by a physician immediately if the following occur: -No feeling in the skin -Movement of eyeballs side-to-side -Muscle twitching, jerking or twisting of arms or legs -Blackout episodes, convulsions, stupor, seizures 8. EVALUATION: Documentation should reflect: 1. Individuals current status and progress towards meeting nursing objectives and compliance with planned treatment. 2. Changes in Individuals condition. 3. Nursing interventions for unusual or sudden behavior changes. 4. Response to medication and lithium blood levels. 5. Attendance and participation in scheduled groups. 6. Effect illness has on: a. Eating b. Sleeping c. Hygiene d. Elimination e. Behavior f. Individual education.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1305 Effective Date: April 23, 2007

SUBJECT: CONTINUOUS SUPERVISION OF INDIVIDUALS 1. PURPOSE: This policy and procedure will provide appropriate guidelines to assure that the care given to the individual on Line-of-Sight, 1:1, or 2:1 continuous observation and supervision is consistent with the Master Treatment Plan, Nursing Care Plan, and Acuity Level, and to assist nursing staff with a providing a uniform approach to evaluation, intervention, and treatment of the individual. 2. POLICY: 1. An individual on Line-of-Sight, 1:1, or 2:1 Observation is under direct and continuous supervision at all times (refer to page 814.2 for observation requirements). 2. Personnel assigned to any individual ordered to be on a continuous observation for any reason shall be held accountable for that individuals safety and care. 3. The Shift Lead, under the direction and supervision of the Unit Supervisor, shall insure that nursing personnel assigned to continuous observation comply with the following requirements: a) That the treatment plan developed for the individual by the Treatment Team is being followed; b) Will assign staff in accordance with the individuals need and staff experience; c) Shall insure staff provide and maintain proper documentation and record pertinent observations and treatment encounters, including documenting the type of restraints in use every 15 minutes on the appropriate log; Provide updates on individuals status at Change of Shift reports; All three shifts follow the same guidelines established by the ID Team; Staff conducting the 1:1 shall not be preoccupied with personal, non-related activities (e.g. reading newspaper, watching TV, conversing with other staff). 4. Staff floated from other units, Registry staff, and those staff on duty unfamiliar with specific individual care being provided, will receive a report

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from the Shift Lead/designee advising of the individual(s) on specific ALERTS, 1:1s, High/Low Risk Observations, pertinent acute/chronic medical or behavior issues, containment risk(s), or any other clinically significant information. All staff will communicate pertinent nursing concerns to the Shift Lead, RN/Case Manager, and the NOD throughout the shift. 5. The same staff member who is assigned the observation shall complete the documentation. 6. Placing an individual on an emergency 1:1, or Line-of-Sight Observation requires an order by the unit psychiatrist/MOD to be obtained within one hour of the incident. Nursing staff shall document individuals behavior in the I.D. notes (MH 5624). The Registered Nurse shall conduct an assessment of the individual, and working in collaboration with the Shift Lead, shall notify the unit psychiatrist/MOD or unit psychologist/ODP and NOD, immediately, and shall insure documentation of findings and actions taken. The unit physician/MOD and the I.D. team should evaluate the individual within two (2) hours of obtaining the order. 7. To initiate a 2:1 for an individual during regular work hours the clinician must first receive approval of the Medical Director or designee. Once approval is obtained the PD/EOD must be notified (by nursing staff). After hours and on weekends/holidays, collaboration of two MODs, (one of which must be a psychiatrist) is required. The individual must be seen in person by the physician for a face-to-face evaluation within one hour of the initiation of the order and the clinical indication and justification for the 2:1 must be so documented in the individuals chart. The initial order for 2:1 shall be time limited to a maximum of 4 hours, but may be renewed every 4 hours if clinically appropriate and justified, but the individual must be seen, face to face no longer than every 24 hours. The order must specify the duties of each of the two staff on 2:1. No individual will be maintained on 2:1 while asleep. If the individual remains on 2:1 beyond 72 hours, a BMTP must be immediately developed and initiated to justify the continued use of the 2:1, and approval process completed within 7 days. 8. Pre-licensed nursing staff, e.g. Pre-Licensed PT (PLPT), Interim Permit RN (IPRN), Psychiatric Technician Assistant (PTA), who have the experience and expertise, as determined through the individual care assignment process, may be used on Line of Sight, 1:1, and 2:1 supervision. 9. Preliminary nursing plans of care will be established within 8 hours of identification of the problem and placement on observation. Once the ID Team meets and a consensus is reached regarding the goals for the identified problem, the nursing plan goal must be consistent with the shortterm goal recommended by the Treatment Planning Team. The nursing plan

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shall include nursing interventions that are designed to help the individual reach the goal. 10. An individual status report shall be provided to the HSS on duty each shift and shall be reported at each Change of Shift Report. 11. The Shift Lead/designee shall insure that the staff member on 1:1 assignment shall be offered a break at least once every two hours and should be rotated to another assignment after two hours if possible. 12. Staff taking over the 1:1 shall receive a brief history of the individual including alerts, individual limitations, and severity of risk. Off-going staff and the on-coming staff will initial together on the Q 15 Minute Observation Sheet (CSH 7108) thus insuring this interaction. 13. Staff member being relieved of the 1:1 will give an account to the relief staff member of the individuals behavior while they were attending the individual. 14. Staff shall be sensitive to gender issues, especially during toileting/bathing. Privacy should be afforded in a manner that will maintain the clients safety and security at all times. 3. DEFINITIONS: Line-of-Sight Supervision - Continuous observation by a designated employee, with no visual barriers between the employee and the individual. The employee shall be close enough to the individual to intervene in case of an emergency including when the individual is asleep. Additional staff may (or may not) be provided by Central Staffing office, depending on availability of staff on duty. One-to-One Supervision - Continuous observation by a designated employee, with no barriers between the employee and the individual. The employee will be within a designated distance from the individual as indicated in the order. Additional staff will be provided for each 1:1 ordered by the Central Staffing office per the Staffing Policy. Two-to-One Supervision - Continuous observation with no barriers between two designated employees and the individual. Both employees will be within a designated distance from the individual as indicated in the order. Seclusion All individuals newly placed in seclusion must be monitored for the first hour by continuous observation through Line-of-Sight supervision by an assigned PMAB certified staff member. After the first hour, an individual in seclusion may be continuously monitored using simultaneous video and audio

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equipment if available and if the physicians order permits video/audio monitoring. If such equipment is available and if authorized by unit psychiatrist/MOD order, one staff member may monitor more than one individual via this equipment. Voluntary Time Out The individual willingly goes alone into a room that is left unlocked. The therapeutic intent, with the individuals voluntary agreement, is to deliberately separate the individual to another area that allows unrestricted exit, provides a non-threatening environment, and reduces the individuals level of agitation. Involuntary Time Out a procedure used only for those individuals who have a Behavioral Management Treatment Plan. To assist the individual to regain control by removing him from the immediate environment and restricting him to a quiet area or unlocked quiet room for 30 minutes or less consistent with the individuals treatment plan. LINE OF SIGHT 1:1 (NOT TO BE CONFUSED WITH LINE-OF-SIGHT SUPERVISION) Continuous observation by a designated employee for the purpose of preventing aggressive/assaultive behavior. To be ordered by the unit psychiatrist/MOD for those individuals who have a history of aggressive/assaultive behavior, to facilitate release from wrist-to-waist restraint. Staff will be within a distance as designated in the physicians order (e.g. close enough to prevent assault upon others). Additional staff will be provided per Staffing Policy. Medical Supervision Observation by a nursing staff for medical reasons. Physician orders must specify type of observation, frequency of checks, and frequency of documentation. Physician must document justification of need for 1:1, 1:2, 1:3, etc, supervision. 1:2, 1:3, Supervision Observation by one nursing staff of more than one Individual, either for medical reasons (e.g. Oxygen/C-PAP therapy at night), or for behavioral reasons (e.g. Audio/Video monitoring of more than one Individual in seclusion), if ordered by a physician. Barrier can be any object (e.g. privacy screen, toilet stall door, blanket, sheet, etc.) which interferes with staffs ability to visualize an individuals activity or behavior while on continuous supervision. Staff shall be alert for any type of barrier when providing continuous supervision, and shall be expected to use appropriate clinical judgement when making decisions regarding the importance of appropriate barriers for privacy versus the need to ensure an individuals safety and security.

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4. GENERAL INFORMATION: ROLE OF THE ONE-TO-ONE OR TWO-TO-ONE PROVIDER: One-to-One or Two-to-One Supervision is an opportunity to provide intensive intervention for the individual. Staff assigned should have good communication skills, positive attitude, and ability to listen and remain objective. The duties of the provider includes searching individual for contraband or any hazardous material when risk is suspected, talking to the individual, active listening, and escorting individual to regularly scheduled treatment as appropriate. The Two-to-One or One-to-One provider shall not be occupied with other activities that take attention away from the individual. It is recommended that a copy of the individuals daily PST schedule be attached to the Observation Record (CSH 7108) clipboard and that the individuals activities be described on the back of the tracking record. -Keep the individual busy. -Teach coping skills so that the individual can feel more competent to solve lifes every day problems as well as stressors. -Give the individual hope. The individual needs to be given specific problems to work on to assist with maintaining a feeling of hope. Keep the individual apprised of the progress they make. -Escort the individual to regularly scheduled treatment as appropriate. -The 1:1 staff person is recommended to have recreational material available to utilize with the individual, e.g. a bag of games. The 1:1 Supervision Kit, available from the Program Office, consists of such items such as a deck of cards, dominoes, art supplies, and travel size games, stationary to write letters, a card game that involves engaging the individual in conversation. The Kit is intended for use during the individuals free time. The individual is still expected to attend their prescribed groups. Use of the games is on an individual basis according to the assessment by the Treatment Team. 5. STAFF DUTIES: 1. The 1:1 provider shall not be occupied with other activities that take attention away from the individual. Staff shall investigate all unusual noise(s) and/or movement(s) that may lead to and/or be indicative of self-abusive or suicidal behavior(s). 2. The 1:1 staff person is to encourage the individual to attend all scheduled treatment activities as appropriate. The 1:1 staff person shall have the individuals schedule immediately available, e.g. attached to a clipboard or in the teal folder. 3. A copy of the individuals treatment plan, plan of care, or nursing care plan shall be kept on the clipboard/in the teal folder with the assigned 1:1 staff.

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4. Staff shall be selected to do 1:1 observation based on their individual strengths: a. Counseling skills b. Positive attitude c. Rapport with the particular individual 5. Selection of Floats to do 1:1 observation should be avoided. If it does prove necessary at any point to assign staff unfamiliar with the individual to do 1:1 observation, then the Unit Supervisor or designee is responsible to ensure that the staff member is briefed on the individuals current clinical status. 6. PRECAUTIONS: Observe safety regulations. Lock potentially dangerous areas such as janitors closet, storage room, and medication/treatment room. At initial placement on the observation, and every shift during the length of the observation, the individual, bed and storage area are to be searched for contraband, potentially dangerous items, and confirmed free of harmful objects. Because of risk management issues, whenever possible the use of floats for 1:1 assignment is to be discouraged if they are not familiar with the individual or their risk behavior signs. Any unsafe request by the individual should be discussed with the unit I.D. Team (or mini team after-hours) before staff complies with the individuals request.

7. PROCEDURE:

NURSING ACTION A. If order is not clear, clarify with the unit psychiatrist/MOD or unit psychologist/ODP who wrote the order.

KEY POINTS A. Discuss alternative supervisory approaches with the unit psychiatrist/MOD/unit psychologist/ ODP and make sure the order is clearly understood.

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B. Involve the I.D.Team in Treatment Care Planning. A copy of the Specialized Treatment Plan is to be kept on a clipboard with the 1:1 staff to insure continuity of care between staff. C. Afford as much privacy as appropriate and necessary continuous observation will allow, especially with regard to toileting/ bathing issues. Stall door may be open or closed depending on level of individual continuous observation necessary (e.g. 1:1 for Suicide or Self-Harm vs. 1:1 for Protection from Harm by Others).

B. The Treatment Team should plan constructive activities. Provide individual teaching so that the individual is aware of the treatment goals. All shifts are expected to follow the same guidelines. C. Be sensitive to gender issues. When sitting in a restroom stall, individual may be partially observed (feet movement) or by hearing (unusual sounds). If something irregular is suspected, talk to individual, look over stall and call for help as necessary and appropriate to the situation.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1306 Effective Date: June 21, 2007 This policy replaced NPP 1306 Dates August 31, 2006 SUBJECT: SUICIDE PREVENTION AND INTERVENTION 1. PURPOSE: Individuals at CSH are a high-risk group for suicidal behaviors. The frequency with which these behaviors occur makes it especially important for nursing personnel to be skilled in understanding the dynamics of suicidality and other suicide-related behaviors. The purpose of this policy is to assist the nursing staff member with identifying precursor signs of suicidal intent and to provide a uniform approach in evaluation, intervention, and treatment of the suicidal individual. 2. POLICY: Each Shift Lead/designee, under the guidance and supervision of the Unit Supervisor, shall insure nursing personnel of their shift comply with Administrative Directive 526 Suicide Prevention. All individuals shall be considered at risk for potential suicide. All staff is required to document in the individuals chart potential suicidal behavior or ideation and notify the psychiatrist/physician and the unit psychologist. The Suicide Risk Assessment form (MH-C 9002) is to be completed by the unit psychiatrist or psychologist within 5 days of admission. This form shall be updated at all subsequent Team Conferences, and within one working day of any change in the individuals risk category or enhanced observation. Immediate action shall be initiated for any suicide-related behavior. This includes: verbalized suicidal ideations, threats, aggressive acts to self, suicidal gestures, or attempts. The Unit Supervisor/designee, Shift Lead/designee and the RN have the combined responsibility to coordinate and insure the following: 1. When an increase in an individuals suicide risk is suspected as evidenced by individual verbalizing suicidal ideations, threats, aggressive acts to self, suicidal gestures, or attempts, the person in charge of the treatment unit shall

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immediately initiate measures to protect the individual from harm and notify the NOD. 2. During evening, weekend, and holiday hours, the NOD shall immediately see the individual. If the individual has attempted suicide or succeeded to commit suicide, the NOD shall ensure that program management and the chaplain are notified. 3. Program management shall immediately notify the Executive Director/EOD, Monday through Friday during business hours. During weekends, holidays, and evenings the NOD will notify the EOD. 4. Nursing staff shall immediately notify the psychiatrist/physician and unit psychologist when an increase in an individuals suicide risk is evident or suspected. An order for enhanced supervision of individuals with increased suicide risk shall be obtained from the psychiatrist/physician. Nursing staff shall document in the individuals medical record which medical staff member was contacted for the order. The order will specify the risk category, frequency of observation, and any other actions to be taken by nursing staff. 5. The psychiatrist/physician shall be notified as soon as possible. The psychiatrist/physician who has given the order shall see the individual within one hour. 6. The Suicide Risk Assessment form (MH-C 9002) shall be updated within one working day of any change in risk level or enhanced observation by the treatment team. Following any high-risk suicide behavior, grounds privileges will be restricted. The treatment team shall meet within 24 hours or on the first working day after a weekend or holiday, to develop a treatment plan for the individual, with relevant objectives and plans. 7. Focus 3, Suicidal Behavior, shall be opened (as appropriate) and documented in accordance with current documentation policies and guidelines. An Integrated Treatment Intervention shall be developed to reflect each disciplines treatment intervention(s) for the problem. Nursing staff shall document the individuals status on each shift. 8. Once an individual is identified as Low or High Risk Suicide Observation, it shall be the responsibility of the Unit Supervisor and each Shift Lead/designee to ensure that nursing staff assigned to care for the individual, adhere to the level of risk observation requirements and the psychiatrist/physician orders. Individuals on Low or High Risk Suicide Observation are never placed in Locked Door Seclusion. If necessary, they must be placed in 5-Point Restraint. Individuals on enhanced supervision should be assigned to a peer for additional support (e.g. buddy system)

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whenever possible. Individuals on enhanced suicide observation are the responsibility of all staff members for appropriate observation and treatment. The following precautions shall automatically be activated: High Risk Suicide Observation: The frequency of observation is to be determined by a physician The order shall be specific as to the type of observation (e.g. Line of Sight, 1:1); One-toOne Supervision: continuous observation by an assigned employee with no barriers between the employee and the individual, and the employee shall be within a designated distance of the individual as described in the order.

Line-of-Sight Supervision: Continuous observation by a designated employee with no visual barriers between the employee and the individual. The employee shall be close enough to intervene in case of an emergency including when the individual is asleep. Individuals status shall be documented every 15 minutes on the Individual Observation Record. 15 Minute observation The staff assigned will monitor the individual every 15 minutes and document their observations on the (observation form). The staff assigned will also document every two hours on the individual in the IDN section of the chart. This documentation should include any statements made by the individual and all observations during the past two hours. Low Risk Suicide Observation: The frequency of observation shall be at least every thirty (30) minutes, unless otherwise specified by the order. Observations shall be recorded on the Individual Observation Record The following procedures shall be followed for any decrease in suicide risk level: Enhanced observation shall not be discontinued without a face-to-face evaluation of the individual by a psychiatrist. When a psychiatrist determines the individual is no longer a high risk, the rationale must be documented in the individuals chart. The psychiatrist shall update the Suicide Risk Assessment. Before returning the individuals grounds privileges, the treatment team shall consider graduated grounds privileges before full grounds are returned, and shall document this effort. 3. PLAN: Establish a Therapeutic Relationship Providing a therapeutic relationship begins when the nursing staff member conveys interest in the individual and an unshakable attitude of acceptance of the individual. Knowing that even

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one person accepts them and is interested might be enough to influence them to abandon suicidal plans. Communicate the potential for suicide to team members Protecting the individual from self-destruction is a team effort. Nursing Staff often relate to the individual on a significant level and may be the first team member to pick up on the clues of a potential suicide. Even if the clues seem insignificant, it is important to immediately alert the team. Stay with the individual Initiate informal nursing staff observation by staying with the individual while awaiting the unit psychiatrist/physician or unit psychologists evaluation of the individual. Be available to listen and give a sense of reassurance and protection to help the individual gain control of selfdestructive impulses. Accept the Individual Demonstrate an unshakeable attitude of acceptance toward the individual. Individuals who see suicide as their only choice may change their plans if they feel accepted by even one person. Acceptance helps assure the individual of a sense of worth to others. Listen to the Individual Once the individual realizes that the nursing staff member is interested in them and accepts them, they may openly express their hostility, pain, or other ambivalence about living. The suicidal individual may be encouraged to express themselves by asking open-ended questions such as, What has been happening to you lately? This can help them identify, examine, and share the source of their pain. If the individual feels that someone knows, hears, and understands the intense pain they feel, the suicidal act is less likely. Secure a promise that the individual will not make a suicide attempt (e.g. Contract for Safety) Get the suicide idea out in the open. Individuals feel a certain amount of relief when they tell a significant person about their suicidal ideas, Secure a promise or contract from the suicidal individual that they will make no suicide attempt and that if they feel suicidal, they will tell the nurse immediately. A written contract, signed by both individual and staff, may be the most effective. A documented verbal contract is also acceptable. Give the individual a message of hope Individuals under intense mental strain and may not have hope that life can be better. They may not be sure that they want to die, but they may not want to live either. This seemingly unsolvable problem can be worked out, although the process will be difficult in many situations. Do not attempt to talk the individual out of their depressed feelings or offer false reassurances. False hope or false reassurance can be destructive. Help the individual to express thoughts and feelings and then look to available options for solving the problem. Work with them to establish

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concrete solutions to abstract problems (e.g. Im lonely, help the individual establish contact with family members). Give the individual something to do Provide meaningful activity to let out tension and hostility (e.g. exercise, an active sport, attending groups and scheduled activities). 4. EXPECTED OUTCOMES: -Verbalizes thoughts and feelings regarding suicide -Demonstrates compliance with suicide precautions (e.g. remains in visual contact) -Understands rationale for present level of care -Agrees to written contract -Verbalizes perception of present situation -Identifies present stressors or issues related to suicidal ideation and attempt to harm self -Identifies one or two positive aspects of self -Verbalizes absence of suicidal ideation -Communicates feelings of self worth -Acknowledges need for continuing therapy, once mood stabilizes, to enhance self-esteem 5. IMPLEMENTATION AND INTERVENTION: NURSING ACTION A. Provide a safe environment and protect the individual from self-destructive tendencies. KEY POINTS A. Physical safety of the individual is the top priority. Make a contract with individual if appropriate. Utilize the "5 KEY TASKS (Engage, Identify, Inquire, Assess, & Action) of INTERVENTION. (Refer to Working With Suicidal Individuals, SDC Training Manual.) B. Assess the individuals suicidal potential B. Utilize crisis intervention skills. and evaluate the level of suicide Remember as depression lessens, the precautions. individual may have the energy to carry out a plan for suicide. C. Increase feelings of self-worth. C. Convey that you care about the individual and that you believe the individual is a worthwhile human being. Encourage individual to express feelings, convey your acceptance. Do not joke about death or belittle the individuals wishes or feelings. D. Decrease withdrawal, increase D. Give support for efforts to interact with communications with others. others and/or to attend activities.

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E. Help the individual develop insight and increase ability to express and deal with his feelings in a healthy manner.

F. Help individual identify reasons to continue living. 6. DOCUMENTATION:

E. Encourage and support the individuals expression of anger. Help the individual deal with the fear of expressing anger, the fear of subsequent consequences and feelings, etc. Encourage the individual to express fears and ventilate feelings, and support the individual in expressing feelings or making plans to directly express feelings when they occur. Help individual identify situations in which he would feel more comfortable expressing feelings. F. Give individual a message of hope.

IDN FOR NOTIFICATION OF APPROPRIATE STAFF: -RN notification for assessment, evaluation, and nursing care plan documentation -NOD notification -Physician/physician and unit psychologist -Chaplain notification 7. IDN SHIFT SUMMARY EXPECTATIONS FOR SUICIDE PRECAUTIONS: The following items should be considered when documenting the shift and weekly summary for the individual on suicide observation: -Current suicidal ideations -Person/room check for contraband/dangerous items -Appearance, posture, grooming -ADL skills -Meal, fluid intake -Sleep disturbance(s) -Thinking or thought pattern, level of concentration -Any physical symptoms expressed -Energy level -Evaluation of interaction with peers, staff -Expression of feelings verbally, nonverbally -Expression of anger -Verbalized level of insight to thoughts, behavior -Discussion of ways to deal with his feelings without using suicidal behavior -Measures to increase self-worth -Measures to diminish withdrawal

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-Measures to deal with agitation or to assist individual to express thoughts and feelings 8. STAFF TRAINING: Nursing Service staff is required to attend the Suicide and Awareness and Prevention at new employee orientation and annually as part of Mandated training.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1307 Effective Date: August 31, 2006

SUBJECT: EXPECTORANT SHIELD 1. PURPOSE: This attachment will provide guidelines for the appropriate use of the Expectorant Shield device to prevent the spread of potentially infectious bodily fluids. 2. POLICY: The expectorant shield requires a separate physician order, which may be obtained after its application. In addition, the physician must evaluate the individual to ensure that he is free from such complications as nausea, vomiting, respiratory conditions and claustrophobia. The order and evaluation should be obtained as soon as possible after application, and must be done within two (2) hours. Any individual requiring the application of this device over an extended period of time (8 hours or more) or on more than two occasions in 30 days, will receive a mandatory referral to the behavioral consultant for development of a Behavioral Management Treatment Program (BMTP) by the Wellness and Recovery Team. In addition, documentation in the individuals chart must coincide with the rationale for the expectorant shield and the need for the BMTP. Expectorant shields may be considered for use any time an individual attempts to spit upon self or others. The expectorant shield may be applied by staff trained in its use. Individuals shall have their wrists appropriately contained (via wrist to waist, 5-Point restraint, or Geri-Chair) PRIOR TO the application of the expectorant shield. Continual 1:1 supervision shall be required during the use of the expectorant shield. The individuals air exchange and respiratory rate shall be monitored and documented during the use of the expectorant shield. The expectorant shield shall be a single use device. Upon removal, it shall be disposed of in a plastic-lined trash container. If saturated with blood or other potentially infectious materials (see A.D. #10.07) it shall be considered, and shall be disposed of, as biohazardus waste.

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3. IMPLEMENTATION / INTERVENTION: NURSING ACTION KEY POINTS A. Explain to the individual the rationale for A. To ensure the well being of the using the device prior to application. individual and to keep individual informed of necessary procedures. B. Approach individual from the side or B. Individuals wrists must be contained rear. prior to application. Approaching from the side or rear reduces risk of being spit on during application. C. Hold expectorant shield device by the C. Stretch the opening far enough to fit open, stretchable bottom cuff. Align seams over the individuals head in netting with individuals nose. D. Place the device over the individuals D. Make sure that the net portion does head so that the net portion covers the not go below the nose. eyes and nose. E. The elastic at the bottom should be E. This will ensure that the device placed below the individuals chin. remains in place. F. If necessary, the plastic adjustment F. This will aid in keeping the net device at the top of the expectorant shield portion of the device above the may be utilized to fit the upper net portion individuals mouth. of the device to the individuals head. 4. SUGGESTED GUIDELINES CHECKLIST FOR RESTRAINT OR SECLUSION: The following checklist is provided as a guideline for care of the individual in restraint or seclusion. Other items not identified on this checklist may be pertinent for the individual. The following is considered to be the suggested minimum guideline. 5. NOTING THE RESTRAINT OR SECLUSION ORDER: The staff member noting the physicians order for Seclusion or Restraint needs to insure the order is complete with all components: -Psych MHDS Problem # identified on the order sheet -Precise form of Restraint or Seclusion -The order is time limited not exceeding 4 hours in duration -The reason for Restraint or Seclusion is written in full behavioral terms (e.g. Danger to Self, Assaultive to Peer, Striking out, etc.) -Behavioral Exit Criteria for Release

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6. NURSING PROGRESS NOTE IDENTIFYING INDIVIDUAL BEHAVIOR AND NURSING ACTION(S) PRIOR TO RESTRAINT OR SECLUSION: Nursing progress note documents use of less restrictive measures prior to placement into Restraint or Seclusion: -Offered voluntary quiet time prior to Restraint or Seclusion -Offered 1:1 counseling -Redirection/alternate activity encouraged/offered -Offered PRN -Other intervention(s) prior to Restraint or Seclusion specify in ID note -Documents agitated/aggressive behavior escalated too rapidly to allow for prior .intervention(s) 7. IDN AT INITIAL PLACEMENT INTO RESTRAINT OR SECLUSION: The IDN at initial placement into Restraint or Seclusion should include: -Documents individual searched and confirmed free of contraband (e.g. jewelry, comb, belt, items in pockets . . . . . ) -Documents individual informed of why he was placed into Restraint or Seclusion -Documents individual informed what he needs to do to be released (Behavioral Exit Criteria) or documents why individual was not informed 8. RN ASSESSMENT OF INDIVIDUAL AT INITIAL PLACEMENT INTO RESTRAINT OR SECLUSION: The individual placed into Restraint or Seclusion must be evaluated by a RN within 15 minutes of placement into Restraints or Seclusion. The unit RN or the HSS can accomplish the assessment. This assessment must be documented (in SOAP Note format) and must include: -Individuals behavior -Individuals physical condition -Circulation check -Proper Restraint placement and/or action taken to remedy incorrectly applied restraint(s) -Full set of Vital Signs, including Pain Rating Assessment 9. NURSING CARE PLANS: Nursing Care Plans should be completed or updated to MHDS requirements within one hour of the Individuals placement into Restraint or Seclusion.

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The Care Plan should include:

-The criteria established by the MD for this Individual, identified in behavioral terms of what the individual needs to do to be released -The behavioral exit criteria for release, which should be related to the current Restraint or Seclusion incident 10. POST INCIDENT CRITIQUE: Once the unit is stabilized from the incident activity a Post Incident Critique is held. The Unit Supervisor/Shift Lead conducts an assessment and evaluation of the incident with all staff that were present during the incident. The critique discussion should establish the who, what, when, where, why, and how of the incident. Much of the information obtained during the discussion will be useful for writing the Special Incident Report. Items to consider for the post incident discussion: -Establish the circumstances surrounding the incident -The actions of staff taken before, during and after the incident -Identify what actions worked well -Identify barriers (e.g. what didnt work well and why not) -Identify alternative actions staff could have used in order to improve future events The holding of the Post Incident Critique is documented on MH 2506, Special Incident Report, under the Level I Review section whenever: -Behavioral Restraints or Seclusion are used -For each incident involving PMAB physical intervention -For each incident involving team formation into crisis intervention mode when physical intervention is avoided 11. SUBSEQUENT ID NOTES: An ID Note by nursing staff is required at least 2 hours throughout the duration of the Restraint or Seclusion, ideally coinciding with the rotation of the 1:1 staff. Items to include in the documentation: -A full set of Vital Signs, including Pain Rating assessment, is required once per shift, or documentation of why this was not done -Document Individuals condition and behavior, including alerts, containment risk(s), physical/medical limitations, injuries (with degree of severity), etc -Document if individual meets the behavioral exit criteria for release

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-Document Individuals level of understanding of what he thinks is the reason for being in restraint or seclusion, and if they are able to verbalize what they need to do to be released from restraint or seclusion -Be sure the IDN Shift Summary includes pertinent observations from the Q 15 Minute Observation form 12. Q 15 MINUTE OBSERVATION AND CARE: Q 15 Minute Observation Log (CSH 7108): At the top of the Q 15-Minute Observation Log is the section to write the Individuals Behavioral Exit Criteria for Release. This section needs to identify what behavior the MD, with ID Team input, has determined the individual needs to exhibit in order to be released. This log shall be kept with the 1:1 staff on a clipboard (or in the teal folder). At every 15 minute intervals staff will assess the individual for appropriateness for release from, or continuation of, restraint or seclusion. All Individuals in restraint or seclusion need to be evaluated every 15 minutes, with findings and care provided documented on the Observation Log (CSH 7108). Items to identify on the Observation Log: -Whether individual meets the behavioral exit criteria for release -Behavior status -Individuals activity, investigate any/all unusual noise or motion that might lead to or be indicative of self-abusive or suicidal behavior -Physical condition (skin color & condition, respirations, body position, etc.) -Restraint/circulation check (pull back the bed covers to assess the areas at the points of restraint) -Shower/bath daily -Exercise (Range of Motion, ambulation); Release from restraint q 2 hours, during normal waking hours, for a period of 10 minutes -Fluids offered every 2 hours -Toileting offered every 2 hours -Fluid intake recorded in ccs -Food intake recorded in % of amount eaten 13. ASSESSING THE INDIVIDUALFOR READINESS FOR RELEASE: At every 15 minute intervals assess the Individuals emotional and behavioral status to determine if the behavioral exit criteria for release have been met. Assess the following: -Does the individual remain loud?

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-Does the individual remain threatening to self or others? -Does the individual remain aggressive to self or others? -Does the individual verbalize he is calm? -Can the Individual, without becoming verbally or emotionally agitated, describe the events that led to being placed into restraint or seclusion? -Can the individual verbalize what he could have done differently (e.g. alternative actions) that would have kept them from needing restraint or seclusion? -Does the individual remain physically agitated? -Does the individual display quick body movements? -Are the BP, Pulse, Respirations, and Pain Rating Assessment within Individuals normal limits? -Does the individual display excessive muscle contractions? -Is the individual resisting/straining/pulling at the restraints? -Will the individual verbally agree to remain in an unlocked room without restraints for a period of time? -Is the individual asleep? 14. TEAM APPROACH TO INDIVIDUALCARE: A multi-disciplinary approach is strongly encouraged for assessing and counseling the individual while in restraint or seclusion. All members of the Team should participate with the individual during this emergency crisis period. Establish an aggression or behavior profile of the individual that led (or leads) to restraint or seclusion use. Identify known or suspected precursor behavior, signs, or verbal cues to the aggression or behavior requiring restraint or seclusion. This data should be reflected in the Team Conference Report. It will be required for floats, other Team members, accepting units, or other facilities to know this information about the Individual. 15. DEBRIEFING WITH THE INDIVIDUAL: The Shift Lead shall coordinate with the physician and other shift staff to insure the debriefing is held with the individual and staff to discuss the restraint or seclusion episode. Debriefing is important in reducing the recurrent use of restraint or seclusion. The Individual, and if appropriate, the Individuals family, participate with staff who were involved in the episode and who are available in a debriefing about each episode of restraint or seclusion. The debriefing occurs as soon as possible and appropriate, but no longer than 24 hours after the episode. The results of the individual debriefing shall be documented utilizing the Post Seclusion/Restraint Debriefing form (CSH 7286). Identify what led to the incident and what could have been handled differently

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Ascertain that the Individuals well-being, psychological comfort, and right to privacy were addressed. Evaluate the individual involved for any trauma (physical and/or psychological) that may have resulted from the incident When indicated, modify the Individuals treatment plan.

16. OTHER IMPORTANT CONSIDERATIONS TO DOCUMENT: All individuals in restraint or seclusion are to be reviewed by Program Management the next working day. Program Management will meet with the ID Team and discuss the plan for treatment for these individuals on the next working day. Program Management will provide a report to the Clinical Administrator the next morning following the meeting with the ID Team. If the individual is in restraint or seclusion longer than 24 hours then the ID Team is to meet with the Medical Director, Clinical Administrator, Chief of Medical Staff, Chief of Psychology, Chief of Psychiatry, and the Coordinator of Nursing Services the next working day to discuss the plan for treatment for this individual. Refer to A.D. #15.09 for those individuals with Behavioral Management Treatment Plans. 17. ESSENTIAL ELEMENTS OF REQUIRED NURSING CARE & DOCUMENTATION: ACTION Provide prior crisis intervention counseling Obtain a physicians order within one hour authorizing the use of restraint or seclusion Search Individual for contraband and dangerous articles. Remove shoes, belts, jewelry, etc, and empty pockets Examine the room to assure it is free of dangerous articles Document in I.D. notes event(s) leading to restraint or seclusion, including less restrictive measures attempted Prepare a Special Incident Report (MH 2506). Include less restrictive measures attempted Notify RN immediately. If the RN is not available notify the float RN, rounds coverage, or NOD RN will assess the Individual within 15 minutes and document finding in the PRN MED X X * TIME OUT X

1:1 X X *

W:W X X X

Seclusion X X X

Restraint X X X

X X X

* X X

X X

X X

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Individuals chart RN will assess and document recommendation for release from or continued use of restraint or seclusion every four hours and notify the physician/MOD of this assessment Review, update, or initiate nursing care * plans The Unit Supervisor/Shift Lead/Designee will insure that a post-incident critique is conducted Take temperature, pulse, respiration, and * blood pressure (TPR, BP), and pain rating assessment at the beginning of each shift, and as clinically indicated Bathe Individual daily Document food/fluid intake (at least q shift) Release the Individual when the behavioral exit criteria for release in the written treatment plans have been met Maintain a daily log of hours in restraint or seclusion on all shifts Report all uses of restraint or seclusion to the Program Director or designee daily Complete Denial of Rights form if a right is requested and denied Review by Program Management next working day. Treatment plan review by ID Team and Medical Director, Clinical Administrator, Chief of Medical Staff, Chief of Psychology, Chief of Psychiatry, and Coordinator of Nursing Services if in restraint or seclusion > 24 hours. Send a Referral to Clinical Management Committee (CMC) if in restraint or seclusion for seven consecutive days or if more than three times in any thirty-day period. Exceptions: CMC referral done in past 90 days, or individual is in first 30 days of admission.

X X

X X

X X

* X X X

* X *

* X X X X

* X X X X * X

* X X X X * X

* X

SYMBOL KEY:X = Action to be completed = Action to be completed as clinically indicated

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18. DEFINITIONS: Voluntary Time Out - is defined as an individuals voluntary change in previous activity and/or location (unlike seclusion which is involuntary) for the purpose of re-establishing self-control. Staff may well suggest such a change, but the individual must freely consent. The individual willingly goes alone into a room that is left unlocked. The therapeutic intent, with the individuals voluntary agreement, is to deliberately separate the individual to another area that allows unrestricted exit, provides a non-threatening environment, and reduces the individuals level of agitation. Seclusion - is defined as confinement of an individual in a room denying the individual voluntary exit. Involuntary Time Out - is defined as a procedure used only for those individuals who have a Behavioral Management Treatment Plan (refer to A.D. 15.09). This procedure assists the individual to regain control by removing the individual from his immediate environment and restricting the individual to a quiet area or unlocked quiet room for 30 minutes or less, consistent with the individuals treatment plan. Restraint - is defined as mechanical device(s) controlling an individuals physical activity. Restraint or Seclusion Guesting - is defined as the use of restraint or seclusion on a unit other than the unit on which the individual normally resides. One-to-One Nursing Observation for the individual in any form of restraint: an assigned staff member remains with the individual at all times, keeping him under constant observation. The assigned employee stays within a designated distance from the individual as indicated in the physicians order. Two-to-One Nursing Observation for the individual in any form of restraint: two assigned staff remains with the individual at all times. Such an order is utilized for selected individuals where restraint or seclusion measures are insufficient to insure the safety of others. Barrier - any object which interferes with staffs ability to visualize an individuals activity or behavior during continuous supervision. Examples include but are not limited to: toilet stall doors, privacy screens, blankets, sheets, walls, etc. All staff shall be alert for any type of barrier when providing continuous supervision, and shall be expected to use appropriate clinical judgment when making decisions regarding the

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importance of appropriate barriers for privacy versus the need to ensure an individuals safety and security. 19. ROLE OF THE SHIFT LEAD: Under the guidance and supervision of the Unit Supervisor, the Shift Lead of each shift shall insure all nursing personnel of their shift comply with the following requirements: -Adhere to A.D. 15.14, 15.08, and 15.09. -Keys to locks on restraints must be immediately available for emergency release of restraints, i.e. on every employees key ring set. -Devices to cut leather straps are to be available at all times. These shall be kept and clearly marked in the Sharps Cabinet in the Nursing Station. -Five-point leather restraints have been properly applied to the individual and to the authorized restraint bed. -The individual is searched for contraband and/or dangerous articles during placement into restraint or seclusion. -NOD is notified when an individual is placed into restraint or seclusion and the -NOD is appraised if the family needs to be notified (by the NOD) after hours. -Insure staff provide and maintain proper documentation. -A Special Incident Report (SIR MH 2506) is completed each time an individual is placed into restraint or seclusion, except when wrist-to-waist restraint was immediately preceded by five-point restraint, or vice versa, or if the individual has been released from restraints and his behavior requires re-application of restraints within the time frame of the most recent order. -Insure that a Post-Incident Critique is conducted and documented. -Every 15 minute face-to-face observation checks are conducted. -Individual is exercised every two hours during normal waking hours. This can be accomplished by ambulating individual to bathroom for toileting or be range of motion exercise for a period of 10 minutes, as clinically indicated. -Ensure backboard and gurney is utilized to transport individual to restraint or seclusion room from floor containment. -Ensure adequate staff (minimum two staff members) when specialing an individual in five-point restraint (e.g. giving medications, ambulating, checking restraints, checking for release criteria, toileting, etc.). -Individual privacy issues are maintained. -A face-to-face assessment at Change of Shift is conducted by an on coming and an off going Shift Lead or designee. -Status of individual(s) in restraint or seclusion is reported at the Change of Shift meeting with the oncoming shift. -Insure the restraint room is kept orderly during the restraint or seclusion process (e.g. no individual belongings such as shoes or clothes, and no

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other items on the floor). Unit will establish where the individuals labeled bedpan or water pitcher will be kept during the restraint or seclusion period. -Works with the RN and other team members on each shift to assist the individual in achieving the behavioral exit criteria so the individual can be released from restraint or seclusion as soon as the behavioral exit criteria is met. Bed, mattress and linen, and restraints shall be cleaned after each use, before use by another individual. -The restraint or seclusion bed is set up and readied prior to the next shift. Shift Lead will insure Daily Report on Seclusion/Restraint (CSH 7014) is kept on the 1:1 log during the period of 1:1 observation of the individual. When the seclusion or restraint period is concluded it is filed in the individuals record under the Evaluation Tools section tab. -Staff shall meet with the individual in a debriefing session to discuss the event and offer alternatives to restraint or seclusion to assist individual with gaining insight to their behavior. The individuals responses to how the incident might have been prevented are to be documented and incorporated into the care plan. 20. ROLE OF THE NOD: The NOD, as part of clinical supervision, will observe and assess for compliance of the restraint or seclusion individual care requirements. During NOD rounds to the unit, each individual in restraint or seclusion shall be assessed by the NOD and the NOD will document on the Q 15-Minute Observation Log (CSH 7108). The NOD will appraise the Shift Lead and RN of any deviation from the requirements and offer guidance as needed. The NOD shall document in the NOD 24-Hour Report the time of the practitioners face-to-face individual evaluation of those individuals in restraint or seclusion, and those individuals with Behavioral Management Treatment Plans. 21. FAMILY NOTIFICATION PROCEDURE AND THE HSS ROLE: As indicated in A.D. #15.14 Seclusion or Behavioral Restraint, there is a shared responsibility among Social Workers and the NOD to notify family members in the event of the use of restraint or seclusion. This notification can only occur when there is prior written consent of both the individual and designated family member as documented on form CSH 7285 Initial Seclusion/Restraint Risk Assessment. When indicated on this form, the social worker will call the family during regular working hours. The NOD will be responsible for calls that need to be made outside of regular working hours. However, no calls are to be made during the hours of 2000 to 0800. The following guideline may be helpful to use as a script when making the call to family members:

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May I speak with Mr./Mrs. _________, Hello, Mr. /Mrs. _______. I am __________, with Central Nursing Services at Coalinga State Hospital. Do you recall that (individuals name) gave us written permission to call you when restraint or seclusion are used as part of a necessary intervention? I need to let you know that at (time) today/yesterday, he was placed in (restraint or seclusion) with observation. This was necessary because it seems that he (action/behavior). At this time I am unable to provide further details, however you will be notified when the Treatment Team is able to use less restrictive measures and the restraint or seclusion are no longer necessary. We will be happy to include your responses and suggestions in our Teams debriefing with (individuals name). During the meeting, we will include a discussion of how (restraint or seclusion) can be avoided in the future. If you would like additional information, please call (individuals names) assigned social worker, (name), at (XXX) XXX-XXXX during regular business hours. The NOD will document in the IDN and the 24-Hour Report action taken. The NOD is also expected to ensure documentation of this information in the Day Book-Individual Information section, Individual Care Assignments page, so that it can be reported at the Change of Shift meeting and to the individuals Treatment Team. (To be completed by the Admissions Psychiatrist and filed in the Current Treatment Plan tab of the Individual's medical record) QUESTIONS (This information may be gathered from Individual, medical records, and /or Individual family members) Past history of assaultive behavior? Past history of behavior requiring use of seclusion or restraint (early warning signs)? Any tools, techniques or methods that have helped Individual to control behavior? List: Any medical/physical conditions that would place Individual at increased risk if placed in prone position, seclusion or restraint? List: History of physical/sexual abuse that would place Individual at a greater risk if placed in seclusion or restraint? List:

YES

NO

UNKNOWN

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STATEMENT OF RESTRAINT/SECLUSION PHILOSOPHY: It is the philosophy of Coalinga State Hospital to promote the norm of non-violence. All efforts are made to prevent and/or control behavior that is dangerous to the Individuals or others. Restraint or seclusion may be used in response to an emergency to protect Individuals or others from harm. The hospital's policy is to utilize the least restrictive measures to contain an emerging crisis or control dangerous behaviors.

QUESTIONS YES Individual informed of hospital's philosophy on seclusion or restraint? (If clinically contraindicated at this time the rest of the questions shall be completed by Treatment Team at next conference held for the Individual) If placed in seclusion or restraint does the Individual want family member/significant other notified? If yes, who: ___________________________________________________________ _____
(Name/Relationship to Individual) (Telephone #)

NO

UNKNOWN

I,_____________________________ give permission to CSH staff to contact the above stated family member in regards to placing me in seclusion or restraint. ___________________________________________________________ _____
(Individual's Signature)

Does the Individual have an Advance Directive with respect to behavioral health care?
(Physician's Signature) (Date)

Family member listed above was contacted on _______________ and does or does not (circle as appropriate) wish to be contacted when Individual is placed in seclusion or restraint. _________________________________________________________________________________ _______
(Social Worker's Signature) (Date)

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22. INITIAL SECLUSION/RESTRAINT ASSESSMENT: Confidential Individual/Client Information See W&I Code Sections 5328 REVIEW/UPDATE OF INITIAL SECLUSION/RESTRAINT RISK ASSESSMENT INSTRUCTIONS: Discuss at each conference and document any changes or new information regarding the following areas in the conference report: -Assaultive behavior -Behavior requiring use of seclusion or restraint -Tools, techniques or methods that have helped Individual to control behavior -Medical/physical conditions that would place Individual at increased risk if placed in -prone position, seclusion or restraint.

DATE OF CONFERENCE

CHANGES YES NO

PHYSICIANS SIGNATURE

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1308 Effective Date: August 31, 2006

SUBJECT: EMERGENCY USE OF BEHAVIORAL RESTRAINT OR SECLUSION 1. PURPOSE: This policy will provide the guidelines, which shall outline the requirements and guidelines established by the regulatory agencies of DHS Licensing Division (Title 22), JCAHO, and A.D. #15.14. Limit the use of restraint or seclusion to emergency situations when other less restrictive measures have been found to be ineffective. Maintain individual dignity and rights using the least restrictive means possible. Reduce the risk of injury to self or others by protecting the individual from suffering a loss of physical or emotional control by limiting his movements. Ensure the appropriate use of and care for the individual requiring behavioral restraints or seclusion. 2. POLICY: Restraint or seclusion shall be used only for psychiatric emergencies when treatment approaches and prior intervention are insufficient to prevent the individual from injuring himself or others. The Hospital strives to prevent, reduce, or eliminate the use of restraint or seclusion and to attempt to prevent the types of emergencies that have the potential to lead to the use of these procedures. When these procedures are necessary, they are to be used for the shortest time possible. Whenever clinically possible, the use of nonphysical interventions is preferred. Nursing Services staff is to utilize the least restrictive measures to contain an emerging crisis or control dangerous behaviors. Nursing Service staffs are required to maintain competency in early intervention techniques which will prevent escalation of the situation and reduce the use of restraint(s). Administrative Directive 15.14 (Seclusion and/or Behavioral Restraint) details Coalinga State Hospitals policy with regard to the use of seclusion or restraint. All staff is required to strictly adhere to these directives.

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The initial assessment of each individual at the time of admission assists in obtaining information that could help minimize the use of restraint or seclusion. All individuals at this facility shall have the opportunity to be involved in their care and treatment, including the use of restraint(s) or seclusion. Staff shall provide assistance to the individual to meet the established behavioral criteria for the discontinuation of restraint or seclusion. The individual shall be made aware of the rationale for the use of restraint or seclusion and shall be made aware of the behavioral criteria for its discontinuation. Nursing staff shall be trained and competent to minimize the use of restraint or seclusion, and when their use is indicated, to use them safely. Restraint or seclusion shall be applied using standardized techniques taught at the Staff Development Center on Prevention and Management of Assaultive Behavior (PMAB). Restraint or seclusion may be initiated by nursing staff (RN, PT, or LVN) without a physicians orders but in all cases the order must be obtained within one hour. This procedure shall be implemented to the best of staffs ability in keeping with human dignity and shall be respectful of privacy issues of the individual and will not be used in a manner that causes undue physical or emotional discomfort to the individual. Individuals are not to be restrained in uncomfortable, unnatural, or awkward positions. Seclusion or restraint must always be ordered by a Physician and shall be used to the least extent and for the shortest time possible. Seclusion or restraint shall never be ordered on a PRN basis. Restraint or seclusion shall never be used for any other purpose, such as coercion, discipline, convenience, retaliation by staff, as aversive treatment, as punishment or as a substitute for less restrictive alternative forms of treatment. The use of restraint or seclusion is not based on an individuals restraint or seclusion history or solely on a history of dangerous behavior. Restraint or seclusion shall not be a part of any individual treatment plan. Staff shall not threaten the use of restraint or seclusion in an attempt to gain compliance from an individual. Threatening individuals with seclusion or restraints is psychological abuse and is prohibited. Failure of staff to adhere to the standards may constitute cause for Disciplinary Action. All orders for restraint or seclusion will be written for a maximum of (4) four hours. If the clinical condition of the individual requires restraint or seclusion longer than 4 hours, new orders must be obtained at a maximum of 4-hour intervals. The physician must perform a face-to-face assessment of the individual within 2 Hours of the order placing the individual in restraint or seclusion and must write a progress note documenting the individuals clinical

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condition necessitating the procedure, the individuals physical condition, and the exit criteria. (Per A.D. #15.14, 2/01/04) If the clinical condition of the individual requires restraint or seclusion longer than the (8) hours, the physician must perform a new face-to-face assessment of the individual and write a progress note. A face-to-face assessment by a physician must occur at least three (3) times in any 24 hour period, spaced no more than 8 hours apart. The Shift Lead and RN of the unit will be alert to these time periods working closely with the physician to insure this requirement is met. (See page 816.11 & 816.12 for individuals on BMTP.) Any telephone orders for restraint or seclusion must be based on the RN assessment of the clinical need for these procedures. All individuals in restraint or seclusion must be continuously monitored both for safety and to provide additional opportunity for staff to assist the individual toward meeting the exit criteria. Although individuals in restraint are allowed to have blankets/sheets for privacy issues, the staff member on the 1:1 must investigate any unusual noise or motion that might lead to, and/or be indicative of self-abusive or suicidal behavior. Individuals in restraint must be monitored on a one-to-one basis with open door for as long as the individual is in restraints. All individuals newly placed in seclusion must be monitored for the first hour by continuous observation through Lineof-Sight supervision by an assigned PMAB certified staff member. . The physician and/or registered nurse reevaluates the efficacy of the individuals treatment plan and work with the individual to identify ways to help him gain control. Individuals in restraint or seclusion are assessed by a PMAB certified staff member at the initiation of restraint or seclusion and every 15 minutes thereafter. This assessment shall include the type of restraint or seclusion employed and the following, as appropriate: signs of any injury associated with the application of restraint or seclusion; nutrition/hydration; circulation and range of motion in the extremities; vital signs, with pain rating assessment; hygiene and elimination; physical and psychological status; and comfort; maintenance of privacy issues; readiness for discontinuation of restraint or seclusion. All individuals in restraint or seclusion are to be reviewed by Program Management the next working day. Program Management will meet with the ID Team and discuss the plan for treatment for these individuals on the next working day. Program Management will provide a report to the Clinical Administrator the next morning following the meeting with the ID Team. If the individual is in restraint or seclusion longer than 24 hours, the individuals ID

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Team shall meet with Members of the Executive Administrative staff (Medical Director, Clinical Administrator, Chief of Medical Staff, Chief of Psychology, Chief of Psychiatry, and the Coordinator of Nursing Services) the next working day to discuss the plan for treatment for this individual. On weekends and holidays the MOD, OPD and HSS will perform this review on behalf of the Executive Administrative staff. (See page 816.11 & 816.12 for individuals on BMTP.) Restraint and seclusion use is discontinued when the individual meets the behavior criteria for their discontinuation. The individual and staff who were involved in the episode and who are available are to participate in a debriefing about the restraint or seclusion episode. The debriefing occurs as soon as possible and appropriate, but no longer than 24hours after the individual is released from restraint or seclusion. The Nursing PI Coordinator collects data on the use of restraint and seclusion in order to monitor and improve its performance of processes that involve risks or may result in sentinel events. All individuals shall be assessed for being AT RISK for containment upon admission to CSH. Each individuals Containment Risk(s) (if present) shall be identified in the following areas: -Nursing Assessment (Initial/Update) form -Initial Seclusion/Restraint Assessment form (CSH 7285) -Unit Rand, Float Orientation book. All staff, including Floats and Registry staff, will be oriented to those individuals at risk everyday, at every change of shift report, via use of the cardex by the Shift Lead or designee. Float and Registry staff shall also be oriented via the Float Orientation book. All staff shall be expected to be aware of individuals at risk by information provided at every change of shift and information passed along by the staff person sitting with the 1:1. When gathering for Prevention and Management of Assaultive Behavior (PMAB) show of support, and containment risk will be evaluated by the RN and/or Shift Lead. The PMAB containment team will verbalize the containment risk(s) when the use of MAB is imminent and when the strategy for approaching the individual in crisis is being presented.

3. GENERAL INFORMATION: Restraint or seclusion is a high-risk/risk management procedure that is intended to be used only when less restrictive methods have not succeeded or clearly are not likely to succeed in preventing injury to an individual and/or others.

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Nonphysical techniques are the preferred intervention in the management of inappropriate behavior. Restraint and seclusion are two separate interventions and are not to be conceptualized as a single process. The application of restraint(s) or seclusion indicates that the current therapeutic efforts have become ineffective and therefore calls for a review of the individuals nursing care plan. Nursing staff assignments are made according to staff qualifications to care for individuals based on the individuals acuity level, age, and developmental functioning, to minimize circumstances that may give rise to restraint or seclusion use and to maximize safety when restraint or seclusion are used. The key to preventing the need for restraint or seclusion is intervention at the earliest possible time. The key to early intervention is ongoing assessment of the individual by the treatment team and identification of antecedent behavior(s). Treatment Planning should include identification of antecedent behavior(s) and identification of effective interventions to be used when antecedent behavior(s) are observed.

5. PRECAUTIONS: Undesirable effects of restraints: Restraint has been demonstrated to produce serious negative physical, psychological, and social effects including skin lesions, overheating and dehydration, temporary or permanent incontinence, feelings of demoralization and humiliation, and temporary or permanent disruption of adult identity. In evaluating the applicability of restraint to any clinical situation, the individuals susceptibility to these effects must be taken into account. And when an individual is restrained, periodic observation of the individuals condition should include consideration of whether any of these undesirable effects is developing. Types of physical injury or death associated with use of restraints: Injuries and death are sometimes attributed to improper application of restraints or fastening of restraints to improper points on the bed. Physical restraints that limit an individuals freedom of movement and autonomy may cause several negative physical effects such as muscular weakness, skin damage, joint injury, or circulatory problems. Dehydration - individual may become severely dehydrated while in restraints or during a struggle over applying the restraints. This dehydration, which is usually combined with overheating due to exertion, can produce

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cardiovascular collapse or even death particularly in individuals who are already ill. Individuals easily become dehydrated because they are completely dependent upon others to provide liquids for them. Choking - individual restraints where they must remain on their back are at risk of choking on emesis, food, liquid, or saliva; Circulatory and skin problems - pressure on the skin from tight restraints and immobilization may interfere with arterial and venous circulation. The individual has a potential to develop skin deterioration and pressure sores; Back pain; Incontinence - Restrained individuals experience the loss of bowel or bladder control when they are not given access to the toilet frequently enough; Injury from others - an individual in walking restraints may be physically attacked by other individuals. If restraint or seclusion is used frequently, indiscriminately, and without careful clinical judgment, the impact of the treatment value declines to the point of a reversal of behavior control. That is, the use of restraint or seclusion will be ineffective and may produce undesirable behavior. The determination of the presence of precursors to dangerous/violent behavior rests upon the professional judgment of the staff. It does not require the staff to defer restraint or seclusion until dangerous behavior occurs, but may be based upon knowledge of the individual and its predictive value. There should be documentation in the chart to support staff decisions. 6. AUTHORIZED FORMS OF RESTRAINT: The following forms of restraints are authorized for CSH. EXCEPTIONS TO HOSPITAL POLICY REQUIRE APPROVAL BY THE EXECUTIVE DIRECTOR OR DESIGNEE. 1. Mechanical supports: Used to protect individuals undergoing treatment and/or diagnostic procedures, e.g., intravenous therapy or tube feeding, or to protect the individual who is infirm, sedated, or markedly confused secondary to cognitive or neurological impairment. [Refer to NP&P #327 Protective Mechanical Support Devices (NEW Feb. 2004)] a) Soft tie, or wide piece of muslin or sheet, placed over the torso in a restraining manner -- the physician must specifically order this as an adjunct to five point restraints! b) Mittens without thumbs which are securely fastened around the wrist with a small tie. c) Other protective and supportive devices as ordered by the physician.

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2. Behavioral Restraints: Five-point leather restraints consist of one leather waist belt, two ankle cuffs, two wrist cuffs, two figure 8 belts to attach the wrist cuffs to the waist belt, and three leather belts to secure the individual to a designated restraint or seclusion bed; a) Wrist-to-Waist restraint consists of 2 leather wrist cuffs attached to a leather waist belt to secure the wrists of an ambulatory individual; b) Ankle restraints consist of 2 leather ankle cuffs attached to a single leather belt, which are not authorized for routine use as restraints due to increased risk of fall and the vulnerability of the individual in the event of an emergency. However, ankle restraints with wrist to waist restraints may be utilized for transportation outside hospital security areas for security purposes; during toileting and exercise of individuals in five-point restraints; and for transferring an individual in a psychiatric emergency to a seclusion room. C) Wrist-to-Waist with Ankle Restraints may be ordered by the physician only with a referral to the Clinical Management Committee (CMC) at the time the order is written or CMC authorization had been given within the last 30 days. Documentation addressing the need for ankle restraint in behavioral terms shall be entered in the individual record.

Expectorant Shields may be utilized any time an individual attempts to spit upon self or others. This device may be initiated prior to receiving a physicians order. An order must be obtained as soon as possible, and an assessment must be done by the physician, within two hours of initiation. The expectorant shield may be applied by all level of care staff that has received training in its use. It is imperative that the individuals wrists be contained (via wrist to waist, 5-point or Geri-chair) prior to its application. Once the net is applied and secured, continual 1:1 supervision is required. The purpose of this procedure is to reduce/prevent the spread of infection or disease directly resulting from the transmission of spit or other body fluids. The expectorant shield will be utilized on a singular basis only. Upon removal of the net, it will be treated as regular waste unless contaminated with blood or O.P.I.M. in which case it will be treated as biohazardous (infectious) waste. (See NP&P #816 A, Attachment Expectorant Shield, attached to this policy) 7. MEALS OF INDIVIDUALS IN RESTRAINT: Feeding an individual while in restraints has always been a troublesome task at best. The following options may be utilized for meals for individuals in restraints.

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Individual may be taken to the Day Hall in wrist-to-waist restraint, sit at a table (with assigned 1:1 staff person), and with the non-dominant hand extended and self-feed. If the individual is able to cooperate with eating in the day hall with other individuals around, perhaps he or she is ready for less restrictive interventions. Individual may be seated in a Geri-Chair (if available) in the Day Hall, following: #1 above. On some occasions this would not be advisable (e.g. the individuals peers being very angry at him; the individual repeatedly struggling with restraints; or the individual exhibiting behaviors such as spitting that would preclude him from going to the day hall). The individual would be allowed to sit on the side of the bed after the restraint that is attached to the opposite side of the bed is released. The restraint that is attached to the foot of the bed is released. The individual would still be in restraints, with one hand still attached to the side of the bed. The individual could hold the tray with this hand while feeding him with the other hand. THE INDIVIDUAL IS NEVER OUT OF RESTRAINTS. The non-dominant hand may be released from restraint, or it may be extended so that the individual may self-feed. (See Attachment #8 Choking Prevention, attached to this policy.) 8. REST PERIODS FOR INDIVIDUALS IN WRIST-TO-WAIST OR WRIST-TO-WAIST AND ANKLE RESTRAINTS: The individual is allowed one hour of rest period while in Wrist-to-Waist restraints. OPTIONS FOR PROVIDING REST PERIODS: a) Individual may return to full 5 point restraints if the same behavior warrants its use (refer to A.D. #15.14); b) Individual may rest/sleep on his bed. The bed should be placed up against the wall to help prevent rolling out of the bed. The assigned staff member will remain within the room in close proximity (maximum of six feet with no physical barriers) to the individual. 9. SHOWER FOR INDIVIDUALS IN RESTRAINTS: The showering of the individual in restraints requires a minimum of two staff or more for safety. The individual is to be afforded as much privacy as possible when in the shower. Staff is to be alert to the potential that the individual may purposely slip the waist belt off from around their body allowing him to use the belt as a potential weapon.

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a) The individual in restraint is to be the only individual in the shower area. b) The Privacy Curtain is to be used as necessary. c) The individual is to be undressed one appendage at a time (never allowing both arms to be unsecured). d) Precautions are to be used when taking off the ankle restraint. e) Plastic shower restraints should be used. OPTIONS: a) Have individual kneel on a chair facing the wall; b) Have individual sit/stand unlocking and taking the restraint from the side to prevent a direct aggressive act; At staff discretion, may leave the ankle restraints on after undressed. After the shower is finished, towel dry the individual and redress with clean clothing using the reverse process of undressing. If an individual becomes uncooperative or resistive to the process of showering, use proper PMAB technique to regain control. Identify in the ID note and on the Q 15-Minute Log (CSH #7108) the reason for not showering the individual. 10. PROCEDURE: RESTRAINT OR SECLUSION GUESTING 1. When a restraint/seclusion room is needed and none are available on the unit, the home unit will contact other units located close to the home unit to locate the closest available seclusion and restraint bed. 2. Upon placement of the individual into the guesting unit restraint/seclusion room nursing staff from both units shall assess the individuals physical condition. The findings shall be entered in the chart and signed by both guesting and home unit nursing staff. The same shall occur when the home unit nursing staff picks up the individual. 3. The home unit will establish the nursing care plans. 4. The guest unit will do the q 15 minute individual observations. The guesting unit Shift Lead will assign unit staff to do the every 15 minutes checks as soon as the individual is restrained in the bed. 5. The home unit will be responsible for the two-hour & four-hour RN assessments and individual care needs, i.e. exercise, bathroom needs, meals, vital signs, etc.

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6. The guest unit will provide fluids, urinal, and any immediate needs and document results. 7. The guest unit will contact the home unit if they feel the individual has met the release criteria. The home unit will then assess individuals readiness for release and make the final decision on releasing the individual. 8. In the event no guest beds are available, each individual in restraint or seclusion within the building is to be assessed for release. If no individual is determined to be ready for release, the unit is to inform the unit physician/MOD. If no resolution can be attained, the Shift Lead shall contact Program management/POD for direction. 9. The individuals record (chart) is to go with the individual and remain on the guest unit until the individual is returned. 10. The home unit will leave the room clean and remake bed with restraints in place. The NOD, during the course of checking on individuals in seclusion and restraint, will reflect compliance/deficits in the NOD 24-Hour Report.

11. WHEN CONTINUATION OF RESTRAINT OR SECLUSION IS NECESSARY: PROLONGED RESTRAINT OR SECLUSION: If the clinical condition of the individual requires restraint or seclusion longer than (8) hours, a physician must perform a new face-to-face assessment of the individual and write a progress note. A face-to-face assessment by a physician must occur at least three (3) times in any 24 hour period, spaced no more than 8 hours apart. The Shift Lead and RN of the unit will be alert to these time periods working closely with the physician to insure this requirement is met. Any telephone orders for restraint or seclusion must be based on the RN Assessment of the clinical need for these procedures. Individuals who are in restraint or seclusion are evaluated for release on a continuous and ongoing basis. A physician and/or qualified Registered Nurse reevaluates the efficiency of the individuals treatment plan and works with the individual to identify ways to help him gain control. All individuals in restraint or seclusion will be reviewed by Program Management the next working day. Program Management will meet with the ID Team and discuss the plan for treatment for these individuals on the next

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working day. Program Management will provide a report to the Clinical Administrator the next morning following the meeting with the ID Team. If the individual is in restraint or seclusion longer than 24 hours the ID Team shall meet with the Medical Director, Clinical Administrator, Chief of Medical Staff, Chief of Psychology, Chief of Psychiatry, and the Coordinator of Nursing Services the next working day to discuss the plan for treatment for this individual. On weekends and holidays the MOD, PMOC and NOD will perform this review on behalf of the Executive Administrative staff. (See pages 816.11 & 816.12 for individuals on BMTP.) If an individual requires seclusion or behavioral restraints more than seven consecutive days or more than three times in any 30 DAY PERIOD, a Clinical Management Committee (CMC) consult is mandatory unless a CMC consult has been completed within 90 DAYS OR THE INDIVIDUAL IS WITHIN THE FIRST 90 DAYS OF ADMISSION. Within (3) THREE working days of such an occurrence, the Unit Supervisor or designee shall mail an Addressograph consult form signed by the Unit Physician to the Chair of the CMC. The Unit Physician shall order the CMC referral on the Physicians Order Sheet. 12. USE OF RESTRAINT OR SECLUSION WITH SPECIAL CIRCUMSTANCES: In rare cases, wrist-to-waist with ankle restraints (per A.D. 15.14 #4.3.2.4) may be ordered by the physician only with a referral to the Clinical Management Committee (CMC) at the time the order is written or CMC authorization had been given within the last 30 days. Documentation addressing the need for ankle restraint in behavioral terms shall be entered in the individual record. One-to-one supervision is necessary for individuals placed in any form of restraints and for the first hour that an individual is placed into seclusion. The one-to-one supervision will be within a designated distance from the individual as indicated in the authorized order (with no physical barriers). Individuals with a history of suicidal ideation or attempt or who are currently identified as Low Risk Suicide shall be assessed by a physician for need of restraint vs. the use of seclusion. 13. INDIVIDUAL(S) WITH A BEHAVIOR MANAGEMENT TREATMENT PROGRAM: Refer to A.D. 15.09 Behavior Management of Individuals The primary emphasis in behavior management shall be on the use of positive measures to promote socially desirable behavior patterns. Behavior

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Management Treatment Plans (BMTP) are defined as a specialized treatment technique relying on scientific analysis of behavior and a set of procedures adopted to systematically encourage the individual to engage in socially acceptable and health enhancing behaviors while reducing, if not eliminating, maladaptive behaviors. These plans shall employ positive and non-aversive programming and use the least restrictive and intrusive treatment strategy always safeguarding the dignity of the individual as a human person. The plan(s) clearly outline and describe in understandable language, measurable objectives towards reducing the use of restraint or seclusion. For those individuals who require restraint or seclusion to prevent danger to self or others, the plan will outline and describe the plans, measurable goals, and objectives that will be used to reduce and work towards the elimination of restraint or seclusion application. This plan will be attached to the clipboard (or teal folder) for use by the 1:1 staff in assisting the individual. If restraint or seclusion is used as part of the BMPT then the usual Restraint or Seclusion policies and standards will not apply and the Plan will discuss how restraint or seclusion will be applied. The parameters for the use of restraint or seclusion, including exit criteria, how and when restraint or seclusion shall be used, and under what conditions, will be delineated in the individuals BMTP. The Plan must specify that the individual will have a face-to-face evaluation by the Psychiatrist/Medical Officer of the Day (MOD), at least twice in a 24hour period.

Such evaluations shall: -Include an assessment of the individual for physical as well as psychiatric indications for continued restraint or seclusion, and any contraindications for their use. -Occur no sooner than 8 hours apart and would typically occur during normal working hours of 0800 to 1730 and shall be documented in the individuals Physician Progress Note. Restraint or Seclusion orders may be obtained by telephone or verbal order by a licensed nursing staff or may be written by the Psychiatrist/MOD but must not exceed 12 hours. These orders may be renewed by Psychiatrist/MOD telephone order obtained by a licensed nursing staff for 12-hour increments if, after RN assessment, the individual continues to meet the criteria established in their BMTP.

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15. CARE OF THE RESTRAINT OR SECLUSION INDIVIDUAL WITH HEARING IMPAIRMENT: The staff member who provides the 1:1 observation should be a staff member who is competent in American Sign Language for communication purposes. The individual must be able to communicate to staff by signing or by other means of communication, e.g. dry erase board and pen, chalkboard and chalk, or pen and paper. Relax restraints in order to provide opportunity to communicate at least every hour. A well-lit room is necessary to assist with communication. 16. OTHER IMPORTANT CONSIDERATIONS FOR RESTRAINT OR SECLUSION: 1. I.D. team members will establish an aggression or behavior profile identifying known or suspected precursor behavior or verbal cues that may precede aggressive behavior requiring restraint or seclusion. 2. The physician shall identify release criteria specifying in behavioral terms what the individual needs to accomplish to be released.

17. STAFF TRAINING AND COMPETENCY EVALUATION: All staff participating in the use of restraint or seclusion shall successfully complete and demonstrate competence through testing at the completion of initial orientation and annual re-certification of the approved training in the Prevention and Management of Assaultive Behavior (PMAB) provided at CSH. Individual staff members may also be asked to take additional training or undergo testing if observations by supervisors or the occurrence of work related incidents with individuals suggest a need to do so. 18. PERFORMANCE IMPROVEMENT: Evaluation of any use of restraint or seclusion is a constant priority for this hospitals performance improvement program. Daily reports of all restraints or seclusion used are to be submitted to the Program Director or designee. Each Program as part of the CSH Performance Improvement activities prepares quarterly reports describing the use of restraints or seclusion. Health Service Specialists conduct a QA/I performance improvement evaluation for each restraint or seclusion placement. 19. CROSS-REFERENCE:

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California Department of Mental Health Special Order # 119 Restraint and Seclusion, Special Order #DMH-902.01 Prevention and Management of Assaultive Behavior (PMAB) Training The Federal Omnibus Budget Reconciliation Act (OBRA) of 1987 (for longterm care facilities) California Code of Regulations, TITLE 22; JCAHO Comprehensive Accreditation Manual for Hospitals, 2001 Administrative Directive Manual: A.D. #15.14 Seclusion or Behavioral Restraint, A.D. #15.09 Behavior Management of Individuals, A.D. #1.03 Administrative Directives, Purpose and Procedures, A.D. #5.05 Mandated Training; A.D. #2.03 Clinical Management Committee, A.D. #2.09 Special Incident Reports, A.D. 15.08 Supervision of Individuals, A.D. #15.29 Individuals Sexual Behavior, A.D. #4.28 Nursing Staff Change of Shift Procedure, A.D. Rights of Civilly and Judicially Committed Individuals, A.D. 10.03 Suicide Prevention Staff PMAB Training Manual: Prevention and Management of Assaultive Behavior. -Procedural Phases -Suggested Guidelines Checklist for Restraint or Seclusion -Essential Elements of Required Nursing Care and Documentation Definitions: Role of the R.N Role of the Shift Lead Role of the NOD Choking Prevention Pictorial Initial Seclusion/Restraint Assessment form (CSH 7285, revised March 04) 5-Point Leather Restraint Application Position NP&P #816-A Expectorant Shield (Dated April 2004)

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1309 Effective Date: August 31, 2006

SUBJECT: APPROACHES FOR PASSIVE-AGGRESSIVE (NEGATIVISTIC) OR MANIPULATIVE BEHAVIOR 1. PURPOSE: The purpose of this policy is to assist the nursing staff member with the Individual who is exhibiting passive-aggressive (negativistic) or manipulative behavior and to provide a uniform approach to evaluation, intervention, and treatment. 2. POLICY: Each Individual exhibiting passive-aggressive (negativistic) or manipulative behavior shall receive appropriate individualized treatment to alleviate those symptoms in a structured, safe, and secured environment. Each Individual diagnosed with passiveaggressive (negativistic) or manipulative behavior shall have an individualized nursing care plan with short and long-term goals, which shall be compatible with the Master Treatment Conference goals. 3. GENERAL INFORMATION: It is especially important to remember your professional role when working with Individuals who manifest passive-aggressive (negativistic) or manipulative behavior. It is neither necessary nor particularly desirable for the Individual to like you personally. It is not your purpose to be a friend to him. Maintaining your professional role with the Individual will be a firm basis on which to establish a therapeutic relationship in the best interest of the Individual. 4. DEFINITIONS: Passive-aggressive (negativistic) - behavior is a type of indirect expression of feelings whereby a Individual does not express aggressive (angry, resentful, etc.) feelings verbally, but denies these feelings and reveals them instead through behavior. This behavior may be indicative of a personality disorder "characterized by use of passive behavior to express hostility. The behavior includes obstructionism, pouting, procrastination, stubbornness, intentional inefficiency, and criticism and scorn of authority. These individuals are unaware that on going difficulties are the results of their own behavior. -1N.P.P No. 1309

Manipulative behavior - is characterized by the Individual's attempts to control his interactions and relationships with others, often to satisfy some immediate desire or need; or to avoid discomfort, change, or growth. Individual's who manifest manipulative behavior may have little genuine motivation to change their ways of relating to others and of dealing with situations in general. In seeking treatment, the Individual may want to get out of a bind, crisis, or stressful situation (employing manipulative behavior with regard to treatment). Examples of abnormalities may include:

-Denial of problems or feelings -Lack of insight -Resistance to therapy; preoccupation with other Individuals problems, with staff members, or with unit dynamics to avoid dealing with his own problems -Inability or refusal to express emotions directly -Manipulation of staff, family, and other Individuals -Playing one person against another -Attempting to gain special treatment or privileges -Attention-seeking behavior -Somatic complaints

-Intellectualization or rationalization of problems -Seductive behavior or sexual acting out -Refusal to participate in activities -Dependency -Low self-esteem/ low self-confidence -Forgetfulness -Dishonesty -Anger or hostility -Covert aggressive behaviors are chosen over self-assertive behaviors -Procrastination -Stubbornness

5. PARTIAL LISTING OF POTENTIAL NURSING DIAGNOSES: Manipulative behavior related to: -Anger, hostility or resentment -Fear of vulnerability -Dishonesty Disturbance in interpersonal communication related to: -Decreased ability to express feelings -Anger or hostility -Dishonesty Lack of insight related to: -Denial of problems -Denial of feelings such as anger -Resistance to change -Low self-esteem -Early rejection by significant other -2N.P.P No. 1309

Denial of problems or feelings related to: -Fear of feelings -Feelings unacceptable to the Individual -Fear of dependency or inadequacy -Feelings of helplessness Powerlessness related to: -Interpersonal interaction -Lifestyle of helplessness -Difficulty connecting own passive-resistive (negativistic) behaviors with hostility or resentment Resistance to treatment related to: -Anger or hostility -Lack of insight Low self-esteem related to: -Feelings of worthlessness -Guilt 6. INDIVIDUAL OUTCOME/GOALS: The Individual will be expected to: -Verbalize increased insight into their behavior -Express feelings verbally and non-verbally -Express anger and hostility in a non-destructive manner -Develop or increase feelings of self-worth -Demonstrate decreased manipulative, attention-seeking, and/or passive-aggressive (negativistic) behaviors -Participate in the treatment program and activities -Communicate directly and honestly with other Individuals and staff about self and personal feelings -Decrease somatic complaints -Establish and maintain mature, non-manipulative relationships and patterns of dealing with other people and situations 7. IMPLEMENTATION AND INTERVENTION: Deal effectively with the Individual who uses passive-aggressive (negativistic) and manipulative behavior in interactions, relationships, and life situations: NURSING ACTION A. Be consistent. Set clear limits for expected behavior. Do not debate, KEY POINTS A. To deal effectively with and to decrease passive-aggressive (negativistic) and -3N.P.P No. 1309

argue, or bargain with Individual. B. Be direct and confrontational if necessary. Enforce all hospital policies and regulations. Decrease manipulation of staff members: NURSING ACTION A. Do not discuss yourself or other staff members with this Individual. Set limits on frequency and length of interactions with Individual. B. Withdraw your attention if Individual begins saying that you are "the only staff member I can talk to.... or the only one who understands" and so forth.

manipulative behaviors B. Explain; DO NOT apologize for enforcing hospital policies and regulations.

KEY POINTS A. Sharing information about yourself or others is inappropriate. To decrease manipulative behaviors.

B. If you are "the only one" the Individual may be too dependent or may be flattering as a basis for manipulation.

Decrease the Individual's denial of problems, promote their insight: NURSING ACTION A. Discuss the Individual's behavior with him in a non-judgmental manner. KEY POINTS A. To decrease denial of problems and increase effectiveness of therapy and increase insight. B. Reflection and feedback can be effective in increasing insight.

B. Help identify the results and the dynamics of their behavior and relationships.

Decrease the Individual's attention-seeking behavior, acting out, and secondary gains: NURSING ACTION A. Withdraw your attention when Individual refuses to be involved in activities or other therapies or when the Individual's behavior is otherwise inappropriate. KEY POINTS A. It is important to minimize attention given to unacceptable behaviors. Withdrawing attention can be more effective than negative reinforcement in decreasing unacceptable behaviors.

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Promote healthy and appropriate adult behavior and interactions; promote the Individual's self-esteem: NURSING ACTION A. Give attention and support when Individual exhibits appropriate behaviors. KEY POINTS A. To reinforce healthy and appropriate adult interaction.

Decrease the Individual's somatic complaints: NURSING ACTION A. When the Individual voices somatic complaint, treat the issue immediately then tell the Individual that you will discuss other things; do not engage in lengthy conversations about physical complaints or physical condition. B. Observe and note patterns in somatic complaints. KEY POINTS A. Treating the somatic complaint in a matter-of-fact consistent manner will minimize reinforcement of attention seeking behavior.

B. To decrease somatic complaints as passive aggressive symptoms.

8. EVALUATION: Documentation should reflect: 1. Individuals current status and progress towards meeting nursing objectives and plans. 2. Changes in Individual condition. 3. Nursing interventions for unusual or sudden behavior changes. 4. Response to treatment program. 5. Attendance and participation in scheduled groups. 6. Response to medication. 7. Effect illness has on eating, sleeping, hygiene, elimination, and behavior. 8. Individual education.

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1310 Effective Date: August 31, 2006

SUBJECT: APPROACHING THE HOSTILE INDIVIDUAL 1. PURPOSE: This policy will provide nursing staff with guidelines for the provision of treatment for the individual who is hostile and will provide a uniform approach to evaluation, intervention, and treatment. 2. POLICY: All individuals who exhibit hostile behavior shall receive individualized, appropriate treatment to alleviate those symptoms in a structured, safe, and secured environment. 3. DEFINITION: Hostility - the manifestation of anger, animosity, or antagonism in a situation where such a reaction is unwarranted. 4. GENERAL INFORMATION: Hostile behavior, or hostility, is characterized by verbal abuse, threatened aggressive or violent behavior, uncooperativeness, and in the therapeutic milieu, behaviors that have been defined as undesirable, unacceptable, or in violation of set limits. Often the individual is afraid to express anger appropriately, fearing a loss of control. Hostility may be considered different from anger in that hostility is characterized as destructive, while anger can be seen as constructive. 5. ASSESSMENT: In assessing the individual who exhibits hostile behavior, it is important to be aware of the individual's past behavior: -How has the individual been hostile in the past? -What are the individuals own limits for himself? -Be alert to your own feelings

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It is very important to be aware of your own feelings. If you are angry at the individual, you may let the individual know and explain why, thereby showing the individual an appropriate expression of anger. DO NOT react to the individual in a hostile or punitive way. Examples of abnormalities may include:

-Feelings of anger or hostility -Verbal aggression or abuse -Physical combativeness or destruction of property -Agitation -Restlessness -Inability to control voice volume (shouting) -Outbursts of anger or hostility -Low self esteem

-Uncooperative or belligerent behavior -Lack of insight -Resistance to hospitalization or treatment program, medication, etc. -Delusions or hallucinations -Personality disorder -Suicidal ideation of feelings -Homicidal ideation or feelings

6. PARTIAL LISTING OF POTENTIAL NURSING DIAGNOSES: Agitation or restlessness related to: -Inability to deal with feelings of anger or hostility -Disordered thoughts -Delusions Disturbance in interpersonal communication related to: -Verbal aggression or abusive behaviors -Low self-esteem -Delusions Difficulty with interpersonal relationships related to: -Low self-esteem -Lack of trust -Anger or hostility -Personality disorder Resistance to treatment related to: -Lack of trust -Denial and projection of feelings -Personality disorder -Denial of problems Potential of injury to others related to: -Anger or hostility

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-Denial and projection of feelings -Lack of impulse control -Delusions Potential for self-inflicted injury related to: -Anger or hostility -Lack of impulse control -Suicidal feelings or ideas Decreased ability to express feelings related to: -Denial of feelings -Feelings unacceptable to the client -Personality disorder 7. PLAN: The individual will: 1. Decrease hostile behavior 2. Increase appropriate expression of anger, hostile feelings. 3. Build a trust relationship. 4. Participate in the treatment program. 5. Identify nondestructive ways to deal with hostile feelings and urges. 6. Not harm others or destroy property. 8. IMPLEMENTATION AND INTERVENTION: Decrease hostile behavior. Increase appropriate expression of angry, hostile feelings. Build a trust relationship. NURSING ACTION A. Be consistent and firm, yet gentle. KEY POINTS A. Your behavior, as you set and provides limits, serves as a role model for the individual. B. The individual is acceptable as a person regardless of his behavior.

B. Make it clear that you accept the individual as a person, but that certain behaviors (be specific are unacceptable. C. Give support and positive feedback for controlling aggression, assuming and fulfilling responsibilities, appropriate expression of anger and hostile feelings, and verbalization of feelings in general.

C. Positive feedback provides reinforcement for growth and can enhance self-esteem. It is essential that the individual be supported in positive ways and not be given attention for unacceptable behaviors.

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Increase the individual's verbalization of feelings. Increase the individual's insight into his behavior. NURSING ACTION A. Involve the individual in treatment planning as much as possible. KEY POINTS A. Being involved in planning will reinforce the participation in the treatment program and give the individual some control in his treatment. B. The individual may need to learn how to identify feelings and ways to express them.

B. Discuss with the individual what their feelings are and different ways to express and deal with them.

C. When the individual is not agitated, discuss their feelings about their hostile behavior, past experiences, consequences, etc. in a matter of fact manner. D. Identify goals and expectation for verbalization and behavior.

C. The individual may be ashamed of his behavior, feel guilty, or lack insight into behavior.

D. Establishing goals lets the individual know what is expected and gives the individual something to work toward.

Increase the individual's ability to control his behavior NURSING ACTION A. Encourage the individual to seek out staff when he is becoming upset or having strong feelings. KEY POINTS A. Seeking staff assistance allows intervention before the individual can no longer control their behavior and encourages the individual to recognize feelings and seek help.

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Decrease the resentment that the individual has of staff members or the treatment program. Increase the individual's cooperation. NURSING ACTION A. Involve the individual in decision making regarding treatment as much as possible. KEY POINTS A. Participation in planning treatment prevents the individual from feeling like a victim or that he or she has no choice in the treatment program.

B. Do not argue with the individual B. Arguing with the individual regarding treatment, rules, interjects doubt and undermines limits. expectations or responsibilities. Be specific, firm, and consistent regarding expectations of the individual. Don't make exceptions. C. If necessary, withdraw your attention if the individual is verbally or physically abusive. C. It is important to minimize attention given to unacceptable behaviors.

Decrease the individual's use of verbal abuse NURSING ACTION A. Do not become personally insulted or defensive. KEY POINTS A. Remember it is not necessarily desirable for the individual to like you. B. Others must establish limits when the individual is unable to use internal controls effectively. C. Your behavior provides a role model for the individual.

B. Set and keep limits.

C. Remain calm. Be in control of your behavior and communicate that control.

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D. Remain aware of your own feelings. It may be helpful if staff members express their feelings informally to each other in private.

D. A hostile individual may be difficult to work with and may engender feelings of anger, frustration, and resentment in staff members. These feelings need to be identified and expressed so that they are not denied and subsequently acted out with the individual.

9. EVALUATION: Documentation should reflect: 1. Individuals current status and progress towards meeting nursing objectives and plans. 2. Changes in individuals condition. 3. Nursing interventions for unusual or sudden behavior changes. 4. Therapeutic modalities and interventions that were used with the individual and their effect. 5. Attendance and participation in scheduled groups. 6. Response to psychotropic mediation if used. 7. Effect illness has on: a. Eating b. Sleeping c. Hygiene d. Elimination e. Behavior 8. Individual education provided

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1311 Effective Date: August 31, 2006

SUBJECT: GRIEF REACTION 1. DEFINITION: The emotional response that follows the loss of someone or something significant to that person. The loss may be anticipated when the Individual is aware that a loss will take place (such as when the Individual or a significant other is dying) or actual when the loss has already occurred or is occurring. A loss may be observable to others or may be perceived only by the Individual (as with the loss of a fantasy or ideal the Individual has held). Grief may be in response to a change since change involves loss. 2. ASSESSMENT: The normal grief process has been described by various authors as a process consisting of stages including shock and denial, developing awareness, anger, ambivalence, depression, release, acceptance, and integration of the experience. This progression does not necessarily occur in a certain order. Moreover, skipping stages or going from one into another and back again is common and the time spent in each phase and in the process as a whole varies considerably among individuals. Grief may be called grief work as the Individual must actually work through these phases of the process, expressing and accepting the feelings involved. When the Individual does not do this work, unresolved grief or a morbid grief reaction may result in which the Individual may deny the loss, deny feelings, exhibit depressive and/or withdrawn behavior, or develop symptoms of physical or psychiatric illness. The goal in grief work is not to avoid or eliminate painful feelings. Rather, it is to experience, express, work through, and become comfortable with the "uncomfortable" emotions. Examples of abnormalities may include: -Perceived or observable loss -Difficulty in accepting significant loss -Denial of loss -Denial of feelings -Inability to express feelings

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-Fear of intensity of feelings -Rumination -Ambivalent feelings toward loss object -Guilt feelings -Crying -Anxiety -Agitation -Fatigue -Insomnia -Loss of appetite, refusal to eat -Social isolation -Physical symptoms or illness -Self-destructive behavior, accident proneness -Suicidal ideation -Anger or hostility -Depressive symptoms such as withdrawn behavior 3. PARTIAL LISTING OF POTENTIAL NURSING DIAGNOSES: Depressive behavior related to: -Grieving -Inability to express feelings -Denial of loss -Guilt feelings Withdrawn behavior related to: -Feelings of depression -Guilt feelings -Denial of loss or feelings -Lack of interest in social activities Inability to express feelings related to: -Fear of intensity of feelings -Denial of feelings -Guilt Potential for self-inflicted injury related to: -Guilt feelings -Conflicting feelings -Anger or hostility -Inability to express feelings Potential for disrupted homeostasis related to: -Lack of appetite -Lack of interest in caring for self -Inadequate food and fluid intake

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-Constipation Disturbance in balance of rest, sleep, and activity related to: -Fatigue -Physical stress of loss and grief work -Insomnia -Lack of exercise 4. PLAN: The Individual will: 1. Identify the loss. 2. Establish and maintain adequate nutrition, hydration, and elimination. 3. Establish and maintain an adequate balance of rest, sleep and activity. 4. Decrease suicidal ideation and depressive symptoms. 5. Express feelings, verbally and nonverbally. 6. Progress through the phases of grieving. 7. Verbalize acceptance of the loss. 8. Demonstrate initial integration of the loss into their life. 9. Demonstrate changes in lifestyle and coping mechanisms incorporating the fact of the loss. 10. Demonstrate physical recuperation from the stress of loss and grieving. IMPLEMENTATION AND INTERVENTION Establish rapport and build trust so the Individual feels comfortable expressing feelings that may be difficult for him to accept or express. NURSING ACTION A. At first assign the same staff member to the Individual then gradually vary the staff person. KEY POINTS A. The Individual's ability to respond to others may be impaired.

Facilitate the Individual's progression through the stages of grieving. Decrease fears of being overwhelmed by feelings and of having feelings that are destructive, harmful, or undesirable: NURSING ACTION A. Discourage rumination or stopping in one stage of grief work. KEY POINTS A. The Individual needs to identify and express the feelings that underlie the rumination and to proceed through the grief process.

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B. Convey that, although feelings are uncomfortable, they are natural and necessary.

B. The Individual may fear the intensity of their feelings.

Decrease denial; help the Individual grasp the fact of the loss: NURSING ACTION A. Bring up the loss in a supportive manner. Talk with Individual in realistic terms about changes that need to be made as a result of the loss. Encourage expression of feelings in ways that are comfortable to the Individual verbal, written, artistic, etc. KEY POINTS A. To decrease denial and assist Individual to accept the fact of the loss.

Facilitate the Individual's expression of ambivalent or angry feelings toward the lost object or person and toward themselves (anger, hatred, guilt, betrayal, resentment of grief work and the energy it takes, feeling of being deserted) NURSING ACTION A. Limit times and frequency of interactions. Encourage independent, spontaneous expression of feelings. KEY POINTS A. The Individual needs to develop independent skills of communicating and to integrate the loss into his daily life. B. It is important to minimize attention given to unacceptable behaviors and to reinforce the Individuals growth. C. The Individual needs to integrate loss and grief into their life outside the hospital.

B. Expect Individual to fulfill their own responsibilities and support Individual for doing so. C. As much as possible, include in each interaction with the Individual some discussion of goals and future plans.

Encourage ventilation of feelings within the therapeutic milieu. Facilitate a supportive environment for the Individual (such as the larger Individual group): NURSING ACTION A. Encourage the Individual to talk with others, individually and in small groups, about loss. KEY POINTS A. The Individual needs to develop independent skills of communicating.

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B. Facilitate sharing, communication, ventilation of feelings, and support.

B. Sharing grief and experiences with others can help identify and express feelings and feel normal in grieving. Dwelling on grief alone in social interactions can result in people's discomfort with their own feelings and may lead to the Individual being avoided by friends and significant others.

Help the Individual recuperate from the stress caused by the loss (attain optimal level of health and functioning): NURSING ACTION A. Encourage good nutrition, hydration, and elimination as well as adequate rest and daily exercise. B. Facilitate activities that promote development of the Individual's strengths. KEY POINTS A. The Individual may be unaware of the stress of the loss or may lack interest in the activities of daily living. B. The Individual's own strengths are a major factor in their ability to deal with continuing grief work.

5. EVALUATION: Documentation should reflect: 1. Individuals current status and progress towards meeting nursing objectives and plans. 2. Changes in Individuals condition. 3. Nursing interventions for unusual or sudden behavior changes. 4. Response to treatment program. 5. Attendance and participation in scheduled groups. 6. Response to medication. 7. Effect illness has on: a. Eating b. Sleeping c. Hygiene d. Elimination e. Behavior 8. Individual education

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1312 Effective Date: August 31, 2006

SUBJECT: CONVERSION DISORDER 1. PURPOSE: This policy will provide guidelines for the appropriate care and treatment of those Individuals with a diagnosis of Conversion Disorder. 2. POLICY: All Individuals at Coalinga State Hospital shall be provided with the highest possible quality of evidenced-based, appropriate care and treatment, based on their diagnosis and presenting symptoms, in a professional manner, with respect and dignity. 3. GENERAL INFORMATION: Conversion disorder is classified as a type of Somatoform Disorder, which are characterized by complaints of physical symptoms that cannot be explained by known physical mechanisms. All of these disorders have the common belief that the physical symptoms are real despite any evidence to the contrary. The physical symptoms are not under the Individuals voluntary control. The Individual experiences changes or loss in physical function, and there is significant impairment in social or occupational functioning. Conversion disorders are characterized by the development of a symptom or deficit suggesting a neurological disorder (blindness, deafness, loss of touch or pain sensation), or an involuntary motor function (aphonia, impaired coordination, paralysis, seizures, etc.). The symptom or deficit is not due to malingering or factitious disorder and is not culturally sanctioned. The symptom or deficit causes marked distress, impairment in occupational and/or social functioning, and/or requires medical attention. 4. ASSESSMENT: A complete and thorough physical and mental status evaluation is especially important for Individuals suspected with this disorder. The Individual with a known history of a somatoform disorder may also have a co-existing medical condition that may go undiagnosed. Careful screening is essential to rule out

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medical problems. There is an increased risk of suicide and substance abuse/dependence disorders in Individuals with an untreated somatoform disorder. Mood disorders, especially depression, are a common co-morbid problem in individuals with somatoform disorders. The following are some of the important components of a thorough nursing assessment. MENTAL STATUS -Appearance and behavior -Consciousness -Speech activity -Thought process, content and perceptions PHYSICAL COMPLAINTS -Current and past history as well as duration of problems -Insure diagnostic testing is completed -Number of health care providers consulted -Types and amounts of medications taken and whether self medicating (over the counter) or prescribed PSYCHOLOGICAL PROCESSES -Perception of illness and current stressors -Self-concept and body image -Secondary gains from physical symptoms -Mood -Suicide potential SOCIAL FUNCTIONING -Ability to function in social and work situations -Impact of symptoms on the Individuals relationships, especially family relationships -Diversional and recreational behavior -Identification of stressors related to self-concept, role performance, life values, social status, and support systems -Benefits (primary and secondary gains) and risks of the presenting symptoms 5. PARTIAL LISTING OF POTENTIAL NURSING DIAGNOSES: Decreased adaptation to stress related to: -Feelings of inadequacy -Ineffective interpersonal relationships -Diminished interpersonal strengths and coping strategies

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Limitation(s) in physical functioning related to: -The physical conversion symptom -Inability to resolve the precipitating conflict Decreased ability to express feelings related to: -Feelings of inadequacy -Feelings of fear or guilt -Ineffective interpersonal relationships Anxiety related to: -Multiple physical symptoms -Belief that serious disease exists Ineffective Individual coping related to: -Preoccupation with physical symptoms 6. PLAN: The Individual will: 1. Experience relief from acute stress or conflict 2. Be free of actual physical impairment 3. Identify the conflict underlying the physical symptom 4. Verbally express feelings of fear, guilt, or inadequacy 5. Successfully resolve the conflict without recurrence of the conversion disorder. 6. Develop interpersonal and intrapersonal strategies to handle life stresses 7. IMPLEMENTATION AND INTERVENTION: Identify the source of conflict or stress: NURSING ACTION A. Obtain a thorough history. Contact family or significant others. Determine the basis of the symptom(s): NURSING ACTION A. Observe Individual closely when symptoms occur. Look for precipitating events. KEY POINTS A. To determine the basis of the symptom(s) and R/O organic basis. KEY POINTS A. To identify the source of the conflict or stress.

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Relieve the Individuals stress or conflict: NURSING ACTION KEY POINTS A. Avoid making demands or requiring A. Such demands would recreate or decisions that are similar to the Individuals intensify the conflict. pre-hospitalization conflict.

Diminish the Individuals focus on the physical symptom(s). Prevent secondary gain from the symptom(s): NURSING ACTION A. Involve Individual in usual activities. Do not excuse due to physical limitations. B. Assess food and fluid intake, elimination, and rest as unobtrusively as possible. KEY POINTS A. To decrease Individuals focus on physical symptoms and to reduce secondary gain. B. To maintain adequate nutrition, hydration, elimination, and rest; to minimize the physical aspects of the Individuals problem.

Encourage expression of feelings and discussion of conflict. Facilitate recognition of the relationship between the conflict and the physical symptom(s): NURSING ACTION A. Encourage Individual to discuss feelings and conflicts. Avoid discussing physical symptoms. Withdraw attention if necessary. B. Give praise when the Individual is able to discuss the physical symptoms as a method used to cope with conflict. KEY POINTS A. To facilitate recognition of the relationship between conflict and physical symptoms.

Help the Individual resolve the conflict, or deal with it in ways other than by producing physical symptoms: NURSING ACTION A. Explore alternative methods of expressing feelings and coping with conflict. 8. EVALUATION: Documentation should reflect: 1. Individuals current status and progress towards meeting short and longterm goals KEY POINTS A. Offer suggestions, alternative methods. Avoid telling Individual what to do and/or how to do it.

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2. Changes in Individuals condition 3. Nursing interventions for unusual or sudden behavior changes 4. Response to treatment interventions 5. Attendance and participation in scheduled groups 6. Response to medication 7. Effects illness has on: -Eating -Sleeping -Hygiene -Elimination -Behavior -Individual education

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1313 Effective Date: August 31, 2006 SUBJECT: PSYCHOSOMATIC DISORDER 1. PURPOSE: To provide guidelines for the appropriate nursing care and treatment of those Individuals diagnosed with Psychosomatic Disorders. 2. POLICY: All Individuals at Coalinga State Hospital shall be provided with the highest possible quality of evidenced-based, appropriate care and treatment, based on their diagnosis, in a professional manner, with respect and dignity. 3. GENERAL INFORMATION: The term psychosomatic disorder has no precise definition. The term is most often applied to physical disorders though to be caused by psychological factors. No physical disorder is caused exclusively by psychological factors; a physical disorder has a necessary biologic component, a factor essential for the disease to occur. Other factors are needed to produce an illness, possibly including hereditary susceptibility, environmental factors, and social or psychological stress. The term psychosomatic covers the combination of biologic, environmental, social, and psychological factors that make someone infected with an organism ill. Social and psychological stress can trigger or aggravate a wide variety of diseases, such as diabetes mellitus, systemic lupus erythematosus (lupus), leukemia, and multiple sclerosis. However, the relative importance of psychological factors varies widely among different people with the same disorder. Most people, on the basis of either personal experience or intuition, believe that emotional stress can precipitate or alter the course of even major physical diseases. How these stressors might do this isnt clear. Emotions obviously can affect certain body functions, such as heart rate, sweating, sleep patterns, and bowel movements, but other relationships are less obvious. For example, the pathways and mechanisms by which the brain and immune system interact still have not been identified. Can the mind (brain) alter the activity of white blood cells and thus an immune response? If so, how does the brain communicate with the blood cells? After all, white blood cells travel through the body in blood or lymph vessels and arent attached to

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nerves. Nevertheless, research has shown that such relationships do exist. For example, a physical allergy or a psychological reaction can bring on hives. Depression can suppress the immune system, making a depressed person more susceptible to certain infections, such as those by the viruses that cause the common cold. Stress, therefore, can cause physical symptoms even though no physical disease may be present. The body responds physiologically to emotional stress. Stress can cause anxiety, which then triggers the autonomic nervous system and hormones such as adrenaline to speed up the heart rate and to increase the blood pressure and amount of sweating. Stress can also cause muscle tension, leading to pain in the neck, back, head, or elsewhere. The emotional disturbance that triggered the symptoms may be overlooked when the Individual and doctor assume that a physical disease caused them. Psychological factors can also indirectly influence the course of a disease. Some seriously ill people deny having a disease or deny its seriousness. Denial is a defense mechanism that helps reduce anxiety and makes a threatening situation more tolerable. If denial just relieves anxiety, it may be beneficial. However, denial may prevent the individual from complying with treatment and this can have serious consequences. A person who is anxious or depressed may instead express concerns about a physical problem. This phenomenon is most common in depressed people who are unable to accept that their symptoms are primarily psychological. The depression may lead to insomnia, lack of appetite, weight loss, and fatigue. Instead of admitting to feeling depressed the person focuses on the symptoms in the belief that they are caused by a physical disorder. This is referred to as a masked depression. 4. PARTIAL LISTING OF POTENTIAL NURSING DIAGNOSES: Exacerbation of physical illness related to: -Unresolved life stresses -Inability to express feelings -Ineffective interpersonal relationships -Lack of insight Resistance to therapeutic intervention related to: -Denial of emotional problems -Comfort in the role of physically ill person -Secondary gains received from physical illness -Lack of insight Low self-esteem related to: -Inability to express feelings -Feelings of guilt or resentment

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-Ineffective interpersonal relationships Lack of effective coping strategies related to: -Inability to express feelings -Repression of feelings of guilt, anger, or fear -Patterns of coping through physical illness with resulting secondary gains 5. IMPLEMENTATION AND INTERVENTION: Accurately assess and treat the Individuals acute physical problems (actual physical condition). NURSING ACTION KEY POINTS

A. Thoroughly assess all physical complaints and refer to physician as needed. B. Do not over emphasize physical problems or care but remember that the Individuals problems are physically real and not hypochondriacal in nature.

A. An adequate database is necessary since this Individual does have path physiology. B. You must consider the Individuals physical care but not as the primary focus.

Involve the Individual in planning his care. Gain the Individuals acceptance of the treatment plan: NURSING ACTION A. Talk honestly with Individual about correlation of emotions and physical symptoms; ask for Individuals perceptions and expectations of hospitalization. KEY POINTS A. To involve Individual in treatment planning and gain cooperation.

Help the Individual identify stress, anxiety, and related feelings. Promote the Individuals ability to express feelings: NURSING ACTION A. Encourage Individual to express feelings in writing or verbally to staff and then in small groups at first then progressing to larger groups. B. Give positive feedback for focusing on interpersonal issues rather than on physical symptoms of disease. KEY POINTS A. It is generally easier to express feelings in writing or to an individual, then to a small group, than to begin expressing oneself to a large group. B. Positive feedback increases the likelihood that the Individual will continue to express feelings and to deal with

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interpersonal issues. Decrease the Individuals denial, anxiety, and anger. Increase the Individuals insight: NURSING ACTION A. Point out possible or apparent stresses or feelings of the Individual and ask for feedback. B. Gradually attempt to identify the connections between anxiety and the physical symptoms. Increase the Individuals self-esteem. NURSING ACTION A. Provide simple activities at first where Individual may succeed easily. Gradually introduce more challenging activities. B. Give direct positive feedback for accomplishments. C. Encourage Individual to continue to identify stresses and deal with them directly. Decrease secondary gains for the Individual. NURSING ACTION A. Talk with the Individual about secondary gains and together develop a plan to reduce them. B. Together with Individual identify the needs they are attempting to meet (e.g. need for attention as a means of dealing with perceived excess responsibilities or with stress). KEY POINTS KEY POINTS KEY POINTS A. Directly confronting the Individuals denial can make the denial stronger if the Individual is not ready to deal with it.

B. Do not flatter or be otherwise dishonest. C. To develop alternative ways to deal with stress or anxiety.

6. EVALUATION: Documentation should reflect: 1. Individuals current status and progress towards meeting identified short and long term goals. 2. Changes in Individuals condition. 3. Nursing interventions for unusual or sudden behavior changes. 4. Response to psychotropic medication(s).

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5. Attendance and participation in scheduled groups. 6. Response to other prescribed medication(s). 7. Effect(s) illness has on: -Eating -Sleeping -Hygiene -Elimination Behavior Individual education

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COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Psychiatric Nursing Interventions POLICY NUMBER: 1314 Effective Date: August 31, 2006

SUBJECT: HYPOCHONDRIACAL BEHAVIOR 1. PURPOSE: The purpose of this policy is to assist the nursing staff with identifying signs of hypochondriasis and to provide a uniform approach to evaluation, intervention, and treatment of the Individual experiencing hypochondriasis. 2. POLICY: Each Individual experiencing hypochondriasis shall receive appropriate individualized treatment to alleviate symptoms of hypochondriasis in a safe, structured, and secure environment. Each Individual diagnosed with hypochondriasis shall have an individualized nursing care plan with short and long-term goals, which shall be compatible with the Master Treatment Conference goals. 3. DEFINITION: Hypochondriasis is a preoccupation with the fear of having a serious disease (or the belief that one has a serious disease) based on a misinterpretation of one or more bodily signs or sensations. Although the belief is not of delusional intensity (so the Individual can acknowledge that he or she may be exaggerating the extent of any disease or that he or she may have no disease), the preoccupation or belief persists despite medical evaluation and reassurance. This disturbance must have lasted at least six months. 4. ASSESSMENT: The Individual may feel real symptoms, such as pain, even though an organic basis for the symptoms cannot be found. Carefully assess the Individuals physical condition and refer somatic complaints to the physician for evaluation. Do not assume a complaint is hypochondriacal until after this evaluation.

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Individuals may present their medical history in great detail. The Individuals preoccupation in hypochondrias is typically involving one or more of the following: -Bodily functions (e.g. heart beat, sweating, and peristalsis) -Minor symptoms (e.g. a small sore, an occasional cough) -Ambiguous or vague symptoms (e.g. tired heart, aching veins) Additional Assessment Data: -Denial of emotional problems -Difficulty identifying and expressing feelings -Self pre-occupation, especially with physical functioning -Fears of or rumination on disease -Sensory complaints (loss of taste sensation, olfactory complaints) -Reluctance or refusal to participate in psychiatric treatment program or activities -Reliance on medication or physical treatments (such as laxative dependence) -Extensive use of over-the-counter medications, home remedies, enemas, etc. -Secondary gains (attention, evasion of responsibilities) due to ailments -Fatigue -Insomnia -Loss of appetite -Numerous somatic complaints (may involve many different organs or systems) -Repeated examinations, laboratory tests, x-rays, and reassurance fail to bring relief to the Individual. Individuals with hypochondriasis may become worried on reading or hearing about a disease or when someone they know becomes ill. Hypochondriasis is more common in those who have suffered serious illness in the past, particularly in childhood, and those with ill family members. Hypochondriasis is more common in Individuals with generalized anxiety disorder, depression, obsessive-compulsive disorder, schizophrenia, and mood disorders. 5. PARTIAL LISTING OF POTENTIAL NURSING DIAGNOSES: Genuine physical complaints related to: -Medical illness -Effects of stress Excessive, unfounded physical or sensory complaints related to: -Denial of emotional problems -Ineffective coping strategies

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-Secondary gains received for physical problems Decreased ability to express feelings related to: -Denial of emotional problems -Ineffective coping strategies Overuse of and dependence on medications and physical treatments related to: -Need to legitimize physical illness -Denial of emotional problems -Preoccupation with bodily functions Decreased adaptation to stress related to: -Ineffective coping strategies -Limited gratification from interpersonal relationships -Lack of emotional support system Ritualistic behaviors regarding bodily functions related to: -Preoccupation with bodily functions -Need to feel in control -Denial of stress or conflict 6. PLAN: The Individual will: 1. 2. 3. 4. 5. Express feelings verbally Decrease the number and frequency of physical complaints Identify life stresses and anxieties Identify the relationship between stress and physical symptoms Demonstrate increased insight into the dynamics of stress related physical symptoms. 6. Increase attendance and participation in group and individual treatment. 7. IMPLEMENTATION AND INTERVENTION: Accurately assess and treat somatic complaints. NURSING ACTION A. Thoroughly assess all physical complaints and refer to physician as needed. B. Establish a trusting relationship with the Individual. KEY POINTS A. An accurate data base is necessary. The Individual could really be ill or injured. B. Reassure Individual that you will address his complaints.

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Decrease the number and frequency of physical and sensory complaints: NURSING ACTION A. Minimize the amount of time and attention given to complaints. If the complaint is not acute, ask the Individual to save the complaint until regular medication review. B. Withdraw your attention if the Individual insists on making complaints the sole topic of conversation. KEY POINTS A. If physical complaints are unsuccessful in gaining attention, they should decrease in frequency over time.

B. It is important to make clear to the Individual that attention is withdrawn from physical complaints, not from the Individual as a person. C. Arguing with the Individual constitutes attention, even though it is negative.

C. Do not argue with the Individual about his somatic complaints. Acknowledge the complaint as the Individual's feeling.

Decrease ritualistic physical behaviors, ruminations, and/or excessive fears of disease: NURSING ACTION KEY POINTS

A. Encourage the Individual to discuss A. Focus is on feelings of fear, not their feelings about the fears (not the fear of physical problems. fears themselves). B. Explore the Individual's feelings of lack of control over stress and life events. B. The Individual will usually have helpless feelings, but will not recognize this independently.

Help the Individual identify life stresses and problems. Increase the Individual's insight into the disorder. Increase the Individual's expression of feelings:

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NURSING ACTION A. Talk with the Individual about sources of satisfaction and dissatisfaction in his daily life, family and other significant relationships, employment, and so forth.

KEY POINTS A. Open ended discussion is usually non- threatening and helps the Individual begin self assessment.

B. The Individual can begin to see the B. Gradually help the Individual identify possible connections between relatedness of stress and physical problems at his own pace. stress or anxiety and the occurrence or exacerbation of physical symptoms. Points you might assess are: -What makes the Individual more comfortable? -Less comfortable? Decrease secondary gains for the Individual: NURSING ACTION A. Reduce the benefits of illness as much as possible. KEY POINTS A. If physical problems do not get the Individual what he or she wants, the Individual is less likely to cope in that manner.

Decrease the Individual's reliance on and use of medications and physical treatments: NURSING ACTION A. Work with the doctor to limit the number, variety, strength, and frequency of medications, enemas, and so forth, which are made available to Individual. B. When the Individual requests a medication or treatment for a complaint, encourage them to identify what precipitated the complaint, and to deal with the discomfort in other ways. KEY POINTS A. A team effort helps discourage the Individual's manipulation of some team members to obtain additional medication.

B. If the Individual can obtain stress relief in a non-chemical, non-medical way they are less likely to use the medication or treatment.

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Help the Individual develop alternative ways of dealing with stress and anxiety: NURSING ACTION A. Help the Individual identify and use non- chemical methods of pain relief such as relaxation techniques. KEY POINTS A. Learning nonchemical pain relief techniques will shift the focus of coping away from physical means, and increase the Individual's sense of control. B. Optimal physical wellness is especially important with Individuals using physical symptoms as a coping strategy.

B. Teach the Individual more healthful daily living habits in regard to diet, sleep, comfort measures (such as conscious relaxation techniques), adequate fluid intake, adequate program of daily exercise, the importance of decreased stimuli, rest, possible connection between caffeine and anxiety.

8. EVALUATION: Documentation should reflect: 1. Individuals current status and progress towards meeting nursing objectives/plans. 2. Changes in Individuals condition. 3. Nursing interventions for unusual or sudden behavior changes. 4. Response to treatment program. 5. Attendance and participation in scheduled groups. 6. Response to psychotropic medication. 7. illness has Effect on: a. Eating b. Sleeping c. Hygiene d. Elimination e. Behavior 8. Individual education.

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