Patient Care Services Policy and Procedure Manual

The Patient Care Services Policy and Procedure Manual contains over 270 evidence-based policies and procedures, sample forms and documents for assisting with development of a customized manual for the care of patients in a Critical Care Unit, Med-Surg Unit and Telemetry/Progressive Care Unit. As nursing practice is coordinated across the continuum of care, policies are consistent for all caregivers no matter the healthcare setting. This manual is cross-referenced to TJC and NIAHO standards.

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TOC for TJC standardsTOC for NIAHO standardsCopyrightDisclaimerApproval/Signature SheetIntroduction
A-B
1001 - Abdominal Surgery - Care of Patient1002 - Abdominal Paracentesis - Assisting with1003 - Admission Policy1004 - Admission Criteria - Critical Care1005 - Admission from the Emergency Department1006 - Admission Guidelines - Patients with Acute Coronary Syndrome or Possible Impending M.I.1007 - Assessment and Reassessment1008 - Admission Assessment Form1009 - Assessment for Self-Harm1010 - Assessment of the Critical Care Patient1011 - Allen's Test (Verification of Ulnar Circulation)1012 - Angiography of the Head and Neck1013 - Arterial Line Management1014 - Arterial Puncture1015 - Authorization for Autopsy1016 - Authorization for Autopsy Form1017 - Automatic Stop Orders for Surgery Patients and Transfer Patients1018 - Autotransfusion1019 - Bed Assignment1020 - Binders1021 - Blood Alcohol1022 - Blood/Blood Components - Patient's Guide to Blood Transfusions1023 - Blood Bank Requisitions1024 - Sign-Out Protocol for Blood/Blood Components1025 - Blood Transfusion Record1026 - Blood/Blood Components - Transfusion1027 - Blood/Blood Components - Transfusion Reactions1028 - Blood Transfusion - Filtration Protocol1029 - Blood Transfusion - Type-Specific Blood or Blood from a Universal Donor1030 - Blood/Blood Components - Transfusion: Albumin and Plasma Protein Fraction (PPF)1031 - Blood/Blood Components - Transfusion: Cryoprecipitate1032 - Blood/Blood Components - Transfusion: Fresh Frozen Plasma (FFP)1033 - Blood/Blood Components - Transfusion: Gamma Globulin1034 - Blood/Blood Components - Transfusion: Granulocytes1035 - Blood/Blood Components - Transfusion: Platelets1036 - Blood/Blood Components - Transfusion: Prothrombin Complex1037 - Blood/Blood Components - Transfusion: Deglycerolized or Washed Red Blood Cells1038 - Blood/Blood Components - Transfusion: Factor VIII1039 - Blood/Blood Components - Transfusion: Patient with Minor Typing Incompatibilities1040 - Blood/Blood Components - Transfusion: Whole Blood and Packed Cells1041 - Blood/Blood Components - Return and Reissue of Blood to Blood Bank1042 - Blood Donor Referrals1043 - Bone Marrow Aspirations - Assisting With1044 - Bronchoscopy1045 - Broviac/Hickman/Groshong Catheter and Implantable Vascular Access Devices - Care of
C-E
1046 - Capnography1047 - Cardiac Output Measurement - Intermittent Bolus Thermodilution Method1048 - Cardiopulmonary Resuscitation - Definitions1049 - Cardiopulmonary Resuscitation Protocol1050 - Code Blue Paging1051 - Cardiopulmonary Arrest Record Form1052 - Code Blue Evaluation Form1053 - Cardiovascular Patient - Care of1054 - Synchronized Cardioversion1055 - Care Planning1056 - Central Venous Lines and PICC Lines Bundle - Insertion of1057 - Central Venous Catheter and PICC Line Time Out Checklist1058 - What You Need to Know About Central Line Infections (CLI)1059 - Central Venous Pressure Insertion and Monitoring1060 - Central Venous Catheter - Removal1061 - Central Venous Catheter - Troubleshooting1062 - Peripherally Inserted Central Catheter (PICC) - Removal1063 - Chemotherapy Extravasation - Treatment of1064 - Chest Tube Insertion - Assisting with1065 - Chest Tube Drainage System1066 - Child, Adult, Disabled Person or Elderly Abuse - Recognition and Reporting1067 - Clinical Alarms - Maintenance and Use of1068 - Critical Care 24-Hour Flow Sheet1069 - Critical Care Monitoring Flow Sheet1070 - Clinical Laboratory Specimens - Collection and Care1071 - Critical Points in Arterial Blood Gases1072 - Defibrillation1073 - Defibrillator Check1074 - Diabetic Chart1075 - Diabetic Patients NPO for Diagnostic Exams or Surgery1076 - Discharge Planning1077 - Discharging a Patient1078 - Discharge Guidelines - Telemetry Unit1079 - Documentation - Nursing1080 - Drains - Type and Care1081 - Drains - Removal of1082 - Drawing Blood When a Fluid Challenge is Infusing1083 - Dressing Change - Surgical1084 - Dressing Change - Wet-to-Dry1085 - Dressings - Transparent Film1086 - The Dying Patient - Care of1087 - End of Life Issues1088 - Education of Patient and Family1089 - Eggcrate Mattress Use1090 - Emergency Crash Carts1091 - Emergency Crash Cart Security and Accountability1092 - Sample Crash Cart and Defibrillator Checklist Signature Form1093 - Emergency Management - Patient Care Unit Responsibilities1094 - Emergency Response to Patient Crisis - Guidelines1095 - Endotracheal Intubation - Maintenance and Care1096 - Endotracheal Extubation1097 - Endotracheal Suctioning1098 - Enteral Feeding via Nasogastric or Gastrostomy Tube1099 - Esophageal Tube Insertion - Assisting with
F-O
1100 - Fall Prevention1101 - Fall Review Sheet1102 - Flow Sheet - Nursing1103 - Forensic Patients (Prisoners)1104 - Forensic Patient Checklist1105 - Fractures - Care of Patient1106 - Gastrointestinal Assessment1107 - Genitourinary/Renal System Assessment1108 - Glasgow Coma Scale1109 - Groshong Catheter1110 - Hemodialysis AV Fistula - Care of1111 - Hemodialysis Patient - Routine Care1112 - Hemodialysis Catheter, Dual Lumen - Care of1113 - Hemovac - Care of1114 - Hoyer Lift1115 - Hypoglycemia Treatment Protocol1116 - Hypothermia Blanket1117 - Incentive Spirometry1118 - 24-Hour Incentive Spirometer Form1119 - Indwelling Urinary Catheter Insertion and Maintenance - Female Patient1120 - Indwelling Urinary Catheter Insertion and Maintenance - Male Patient1121 - Integumentary System Assessment1122 - Intralipids - 10% Solution1123 - Invasive Procedure Site Identification (Outside of the OR)1124 - Invasive/Surgical Procedure Verification/Time Out Checklist1125 - Involuntary Hold Patient Admitted to a Patient Care Unit1126 - IV Therapy - Starting Peripheral IV1127 - IV Therapy - Changing Bag, Tubing and IV Site Dressing1128 - IV Therapy - Removal of Peripheral IV1129 - IV Therapy - Monitoring1130 - IV Therapy - Complications1131 - IV Therapy - Extravasation Management1132 - Extravasation Management Guidelines1133 - IV Therapy - Removal of Air from Tubing1134 - IV Therapy - Saline Lock Flush1135 - IV Therapy - Blood Sampling for Tunneled Catheter and Implantable Vascular Access Devices1136 - Latex Sensitive Patient - Care of1137 - Latex Allergy Assessment Form1138 - Latex and Non-Latex Alternatives1139 - Liver Biopsy - Assisting with1140 - Logrolling1141 - Lumbar Puncture - Assisting with1142 - Medical Surgical 24-Hour Flow Sheet1143 - Medication Administration1144 - Medication Patient Information and Reconciliation1145 - Medication Patient Information and Reconciliation Form1146 - Morgue Lift1147 - Nasogastric Tube - Insertion of1148 - Nasogastric Tube - Removal of1149 - Neurological Assessment1150 - New Onset of Chest Pain1151 - Nourishment Distribution via Meal Trays1152 - Nutritional Screening1153 - Oral Care for Ventilator Patients1154 - Organ/Tissue/Eye Donation1155 - Organ/Tissue/Eye Donation - Nursing Staff Responsibilities
P-X
1156 - Pain Assessment, Reassessment and Management1157 - Pain Scale1158 - Pain Scale Examples1159 - Pain Scale - Behavioral-Physiological Scale for Nonverbal or Preverbal Patients1160 - Pain - Patient Controlled Analgesia (PCA)1161 - Panic Values1162 - Patient Identification for Clinical Care and Treatment1163 - Patient Monitoring1164 - Surgical Interventions and Post Anesthesia Care - Comparable Level of Care1165 - Physician Notification of Change in Patient Condition1166 - Physician Order Review - RN Verification1167 - Post Anesthesia Care of Critical Care Patients1168 - Preoperative Care1169 - Postoperative Care - Patient Care Units1170 - Postmortem Care1171 - Preoperative and Postoperative Patient Education1172 - Pressure Ulcer Prevention Program1173 - Pressure Ulcer Assessment Form - Sample1174 - Photographing Pressure Ulcers/Suspected Physical Abuse1175 - Request For Photographs Documentation Form1176 - Tubing/Catheter Misconnections - Prevention of1177 - Psychiatric Evaluation1178 - Pulmonary Assessment1179 - Pulse Oximetry1180 - Rapid Response Team1181 - Releasing Deceased Patients1182 - Receipt for Body Form1183 - Respiratory Function Assessment and Therapy1184 - Restraint or Seclusion Use1185 - 24-Hour Restraint Record Form1186 - Restraint and Seclusion - Staff Training and Competency1187 - Restraint Use Competency Checklist - Restraint for Management of Nonviolent, Non-Self Destructive Behavior1188 - Right Heart Catheter - Mixed Venous Blood Gas Sampling1189 - Seizures - Nursing Management1190 - Sitters1191 - Suctioning - Nasotracheal1192 - Suctioning - Tracheostomy1193 - Telemetry1194 - Telemetry - Application of1195 - Telemetry Monitoring Station1196 - Telemetry Monitoring Remotely1197 - Telemetry Monitoring When the Patient is Off the Unit1198 - Telemetry Monitoring - Troubleshooting1199 - Telemetry Unit 24-Hour Flow Sheet1200 - Telemetry Unit 24-Hour Flow Sheet Form1201 - Thoracentesis - Assisting with1202 - Transfer of Patients1203 - Transfers from a Critical Care Unit to Patient Care Units1204 - Transport of Adult Critical Care Patients Within the Facility1205 - Transfers to Skilled Units/Intrafacility1206 - Transfer Summary Form - Nursing1207 - Transfer and Referral Record (Nursing)1208 - Transjugular Intrahepatic Portosystemic Shunt1209 - Transportation of Patients by Gurney1210 - Transferring Patient to a Wheelchair1211 - Urine Specimen from an Indwelling Urinary Catheter1212 - Vascular Surgery - Care of Patient1213 - Ventilator Bundle1214 - Ventilator Bundle Checklist Form1215 - Ventilator Maintenance/Monitoring - Recommended Parameters1216 - Weighing Patients1217 - X-Ray Procedures
MEDICAL SURGICAL UNIT
6001 - Scope of Services - Medical Surgical Unit6001A - Assignments for RNs/LPNs/LVNs/CNAs6002 - Position Description/Performance Evaluation - Medical Surgical Unit Nurse Manager6003 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Surgical Unit Nurse Manager6004 - Annual Competency Clinical Skills Assessment - Medical Surgical Unit Nurse Manager6005 - Position Description/Performance Evaluation - Medical Surgical Unit Registered Nurse6006 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Surgical Unit Registered Nurse6007 - Annual Competency Clinical Skills Assessment - Medical Surgical Unit Registered Nurse6008 - Position Description/Performance Evaluation - Medical Surgical Unit LPN/LVN6009 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Surgical Unit LPN/LVN6010 - Annual Competency Clinical Skills Assessment - Medical Surgical Unit LPN/LVN6011 - Position Description/Performance Evaluation - Medical Surgical Unit Nursing Assistant6012 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Surgical Unit Nursing Assistant6013 - Annual Competency Clinical Skills Assessment - Medical Surgical Unit Nursing Assistant6014 - Position Description/Performance Evaluation - Medical Surgical Unit Secretary6015 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Surgical Unit Secretary6016 - Annual Competency Skills Assessment - Medical Surgical Unit Secretary