MCN Healthcare: Policy Management and Compliance Tools

Home » Policy Library » Neonatal Intensive Care Unit Policy Procedure Manual

Neonatal Intensive Care Unit Policy and Procedure Manual

Neonatal Intensive Care Unit Policy and Procedure Manual

About this Manual

Own it? Sign in.

Neonatal Intensive Care Unit Policy and Procedure Manual is a manual containing many of our policy and procedure templates for the medical office, hospital, and other healthcare organizations. The policies cover: Joint Commission (JCAHO or TJC) • CMS • HIPAA • CDC • AAAHC and more.
Want access to all our manuals? Click here

$229.99

1 Year Online Subscription

Add to Cart

Changes Table of Contents - TJC standards Copyright Disclaimer Introduction

SECTION I - ETHICS, RIGHTS AND RESPONSIBILITIES

Patient Rights and Responsibilities Pediatric Rights and Responsibilities of Parents/Guardians Ethical Issues Ethics Consult Ethical Dilemmas in Patient Care Resolution of Potential Conflict with Staff Member's Cultural/Ethical/ Religious Belief System Baptism Informed Consent Informed Consent - Blood/Blood Component Transfusion Blood/Blood Component Transfusion Consent Form Refusal of Blood/Blood Component Transfusion Refusal to Permit Blood/Blood Component Transfusion Form Confidentiality of Information - General Issues Child Abuse and Neglect - Identification and Reporting Criteria

SECTION II - PROVISION OF CARE, TREATMENT AND SERVICES

Admission and Assessment

NICU - Admission Criteria Admission to NICU from Labor and Delivery Readmission of Newborn to NICU Assessment, Newborn Examination of Newborn - Guidelines Gestational Age Evaluation Newborn Screening (NBS)Rh Sensitization Pain Management Pain Assessment in Neonates Behavioral-Physiological Pain Scale for Nonverbal or Preverbal Patients Care of the Latex Sensitive Patient Latex and Non-Latex Alternatives

Patient Care Procedures

Patient Identification for Clinical Care and Treatment Invasive Procedure Site Identification Abdominal Girth Measurement Arterial Blood Gas from Umbilical Arterial Lines Blood Glucose Monitoring Blood Cultures - Neonatal Blood Gasses - Capillary Breast Milk Collection and Storage Breastfeeding - Assisting the Mother Bulb Syringe Use Car Seat Test Cardiac Monitors 15-Lead EKG - Neonatal Care Planning Chest Tube Insertion Circumcision Clinical Laboratory Tests Cord Care Cord Clamp Removal Endotracheal Intubation - Assisting with Exchange Transfusion - Treatment of Polycythemia Eye Exam Feeding the Newborn Formula Gavage Feeding - Intermittent Gavage Feeding - Continuous Central Parenteral Nutrition (CPN)Peripheral Parenteral Nutrition (PPN)Hearing Screening Test Infusion Pumps - Equipment Inspection, Care and Maintenance Inhaled Nitric Oxide (iNO) - Care of the Infant Intravenous Therapy - Insertion Intravenous Therapy - Monitoring Heparin Flush Administration of Medication via Heparin Lock Heparin Lock Conversion Central Lines Central Line - Dressing Change Percutaneous Central Venous Catheter (PICC) Insertion - Assisting Heparin Lock Flush for PICC, Midclavicular and Midline Catheters Lumbar Puncture - Assisting with Monitoring Intake and Output Phototherapy Portable X-Rays in the NICU Pulse Oximetry Resuscitation of Newborn in Labor and Delivery Transillumination Umbilical Arterial Catheter Insertion Urinary Catheterization Use of Clinical Alarms on Medical Equipment Venipuncture Ventilating Infants with Ambu Bag Patient-Ventilator Maintenance/Monitoring - Recommended Parameter Weighing Infants Care of the Dying Infant Waived Testing Blood Glucose Monitoring - Quality Assurance Hemoccult Testing

Patient Education

Family Education in the NICU

Discharge/Referral/Transfer

Discharge Planning - Nursing's Role Discharge Criteria for the NICU Discharge of Infant from NICU Discharge of Infant to Someone Other Than Mother Neonatal Transport - NICU RN Training Transfer of a Neonate to Another Facility Neonatal Transfer Preparation Neonatal Transport - Convalescent Transport from a Tertiary Facility Neonatal Transport - Return Transport to a Referring Hospital Retrotransfer Transfer Form - Neonatal Clinical Information Transfer Summary and Certification Transfer Summary and Certification Form Referral to Outside Agency - Infant

SECTION III - MEDICATION MANAGEMENT

Automated Dispensing Machines - Access to Controlled Drug Management on Patient Care Units Automated Dispensing Machines - Controlled Substances Narcotics Decreasing Medication Errors Concentrated Electrolyte Solutions Emergency Crash Carts Emergency Crash Cart Security and Accountability Emergency Medications Resuscitation of Infant - Equipment/Supplies/Medications Emergency Crash Cart and Defibrillator Check Signature Form Prescribing/Ordering - General Practices Medication Ordered STAT and at Specified Time Intervals Standing Orders Automatic Stop Orders Automatic Stop Orders for Surgery Patients and Transfer Patients Titrating Medications Tapering of Medications Range Orders for Medications Telephone, Verbal and Written Orders for Medication Pediatric Dosing - General Guidelines Automated Dispensing Machines - Emergency/STAT Medication Orders Safe Medication Practices Medication Administration Medication Administration to Pediatric Patients Automated Dispensing Machines - Removing Medications Use of Multidose Vials Verification of Insulin, Heparin and Cardiac Drugs Eye Treatment of Newborn Gentamicin Dosage and Administration for the Neonate IV Therapy - Medication Administration IV Push Medications Intramuscular (IM) Injection Neonate Survanta Administration Vitamin K (Aquamephyton) Administration Medication Errors Adverse Drug Reaction Reporting Form Medication Inadvertent Incident Report Medication Inadvertent Incident Report Form Medication Error Analysis Tool Performance Improvement Analysis - Medication Inadvertent Incident Form

SECTION IV - SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION

Infection Control Isolation of the Newborn Visitors in the NICU Standard Precautions Asepsis Attire in the NICU Hand Hygiene Surgical Hand Scrub Gowning and Gloving Technique HBsAg Hospital Report Form - Perinatal Hepatitis B Sharps Injury Protection Plan Sharps Injury Log Form Event-Related Shelf Life - Sterile Storage Handling of Biohazardous Waste

SECTION V - IMPROVING ORGANIZATION PERFORMANCE

Performance Improvement Plan NICU PI Monitoring and Evaluation Plan NICU PI Trending Sheet NICU PI Outcome Evaluation NICU PI Volume Measures/Statistics Standard of Care - Pre-Term Baby Standard of Care - Phototherapy Performance Improvement Department - Notification Form Sentinel Event Incident Reporting Staff Questionnaire Form

SECTION VI - LEADERSHIP

Scope of Service Staffing - General Staffing Plan Organ/Tissue/Eye Donation - Nursing Staff Responsibilities

SECTION VII - MANAGEMENT OF THE ENVIRONMENT OF CARE

Safety Practices Identification of Infants Car Seat Infant Security Plan Infant/Child Abduction Response Plan Infant/Child Abduction Flowsheet for Communication Department Court Hold Guidelines Violence Management Recognizing Inappropriate Behavior Conduct to Minimize Violence Hazardous Materials and Waste - Nursing Services How to Read Safety Data Sheets (SDS)Emergency Management Fire Safety Types of Fire Extinguishers Electrical Safety Use of Electrical Equipment in Oxygen Enriched Environment Reporting Equipment Malfunction

SECTION VIII - MANAGEMENT OF HUMAN RESOURCES

Position Description/Performance Evaluation - NICU Nurse Manager Performance Evaluation - Age-Related Competency - NICU Nurse Manager Annual Competency Clinical Skills Assessment - NICU Nurse Manager Position Description/Performance Evaluation - NICU Registered Nurse Performance Evaluation - Age-Related Competency - NICU Registered Nurse Annual Competency Clinical Skills Assessment - NICU Registered Nurse Position Description/Performance Evaluation - NICU Unit Secretary Performance Evaluation - Age-Related Competency - NICU Unit Secretary Annual Competency Skills Assessment - NICU Unit Secretary New Employee Orientation Staff Competency Blood Glucose Monitoring Competency Checklist Educational Requirements for Inserting PICC Lines Inservice Programs Employee Preparation Checklist for Peer Review

SECTION IX - MANAGEMENT OF INFORMATION

Acceptable Abbreviations List Unacceptable Abbreviation and Symbol List Legibility of Medical Record Documentation Verbal and Written Orders - General Acknowledgment of Results of Diagnostic Testing Critical Test Result Reporting Panic Values