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NURSING PROCEDURES

Procedure Name	Alpha Key	key words
Abdominal Paracentesis	spe01	.
Ankle-Brachial Indices	spe08	.
Aquapheresis, Aquadex Flexflow	car12	.
Beds:	.	.
Bed/Chair Alarms	equ09	.
Specialty Beds and Surfaces	skc15	.
Bladder:	.	.
Bladder Instillation of Medication	cat13	.
Bladderscan - Adult	cat14	.
Blood Components, Administration of :	.	.
Blood and Blood Components - Ordering, Obtaining	blo01	.
Blood and Blood Components - Identification	blo02	.
Red Blood Cells and Blood Component	blo03	RBC Platelets Plasma Cryoprecipitate
Albumin	blo08	.
Factor VIII, Factor IX	blo09	.
Reactions ot Blood / Blood Components	blo12	.
Blood / Fluid Warmer	blo05	.
Bone Marrow Aspiration	spe02	.
Blood Pressure, Measuring, Manual	equ04	.
Catheters, Urinary:	.	Foley
Catheter Care, Urinary	cat01	.
Catheter, External Male	cat02	.
Continuous Bladder Irrigation	cat03	.
Supra Pubic Catheter Change	cat04	.
Catheterizations, Straight and Retention, Removal of Catheter	cat05	.
Urinary Catheter Irrigation	cat06	.
Coude Catheter Insertion	cat07	.
Intermittent Self-catheterization	cat08	.
Urine Specimen Collection	cat09	.
Use of Urojet/Xylocaine Jell 2%	cat10	.
Centralized Telemetry Monitoring of Patients	ctm01	.
Chart Tabs – Medical Record	doc23	.
Chest Tubes-Adults	tub01	.
Chest Tubes-Discontinuation	tub09	.
Critical Care:	.	.
Autotransfusion for Cardiac Surgical	crc06	.
Storage of Blood in CVICU	crc07	.
Care of Pt. Mediastinal Chest Tubes- CVICU	crc08	.
Intracranial Pressure Monitoring and Drainage of Cerebrospinal Fluid	crc10	.
Return unused Blood to Blood Bank from CVICU	crc11	.
Assisting with Emergent Open Sternotomy and Internal Defibrillation	crc12	.
Care of Intra Aortic Balloon Pump IABP	crc13	.
Care of Pulmonary Artery Catheter	crc14	SWAN
Care of Radial Arterial Lines	crc15	.
Cardiac Output Determination by Thermodilution	crc16	.
Prone Positioning of the Mechanically Ventilated Patient	crc17	.
Percutaneous Tracheostomy	crc18	.
Measurement, Intra-Abdominal Pressure via Urinary Catheter	crc19	.
Therapeutically Induced Hypothermia for Cardiac Arrest or Acute Ischemic Stroke Pts.	crc20	.
Diabetic Procedures:	.	.
Diabetes Education	dia02	.
Blood Testing	.	.
“Saf-T-Pro” Fingersticking Device	dia03	.
Blood Glucose Testing-AccuChek Inform *	poc01	.
Quality Control Testing-AccuChek Inform	poc02	.
Insulin Administration	.	.
Intravenous Insulin Drip – Adults	dia10	.
7WT/ICU -DKA IV Patients Requiring Intravenous Insulin Drips - Adults	dia11	.
Subcutaneous Single and Mixed Dose Insulin	dia12	.
Management of Patient's own Insulin Pump / Continuous Subcutaneous Insulin Pump Infusion	dia13	.
Insulin Reaction Hypoglycemia Protocol - Adult Patient	dia14	.
Diabetes Foot Care	dia18	.
Dialysis Procedures - Hemodialysis:	.	.
Operational Guidelines for Hollow Fiber Dialyzer Preparation	dhd01	.
AV Graft and/or Fistula Venipuncture	dhd02	.
Fistula Points to Remember	dhd03	.
Initiation of Dialysis with Temporary Catheter site	dhd05	.
Obtaining Electrolytes, Culture and Sensitivity on Dialysis Machine and Dialysate	dhd06	.
Operational Guidelines for Discarding the Prime	dhd08	.
Blood Leak Guidelines	dhd09	.
Operational Guidelines for Recirculation	dhd10	.
Quality Control of Chlorine	dhd12	.
Termination Dialysis Using a Fistula Access	dhd15	.
Care of Dialysis Patient on the Inpatient Nursing Unit	dhd16	.
Termination of Dialysis Using Dual Lumen Catheter (sites: subclavian, femoral, internal jugular)	dhd18	.
Termination of CRRT using a Dual Lumen Catheter	dhd19	.
Dialysis Temporary Catheter (Insertion,etc)	dhd21	sodium citrate
Care of the Patient in the Hemodialysis unit	dhd22	.
Administration of Blood	dhd24	.
Administration of Medication	dhd25	.
Maintaining Patency of Dialysis Catheters Using t-PA	dhd34	.
RO Water Testing for Chlorine and Chloramine	dhd36	.
Measurement of Recirculation in the Vascular Access	dhd37	.
Continuous Renal Replacement Therapy Using the Prismaflex	dhd40	.
Back-Up Use of Portable Reverse Osmosis	dhd41	.
Operational Procedure for Using the Crit Line	dhd42	.
Criteria for Dialyzing Outpatients	dhd44	.
Dialysis Procedures - Peritoneal Dialysis:	.	CAPD
Peritoneal Dialysis, General Information for Nursing	dpd01	.
CAPD Exchange Procedure	dpd02	.
Declotting Tenckhoff (CAPD) Catheter using t-PA	dpd07	.
CAPD Transfer Set Change	dpd12	.
Titanium Adapter Insertion Procedure	dpd13	.
Collecting and Preparing Peritoneal Effluent for Laboratory Testing	dpd16	.
Documentation:	.	.
Documentation - Manual	doc01	.
Admission Database – Adults (Downtime)	doc02	.
24 Hr. Integrated Record/Integrated Narrative Notes (Downtime)	doc03	.
Patient Discharge (Home Care) Instruction Form	doc06	.
Interdisciplinary Patient Plan of Care- Computerized	doc07	care plan
Interdisciplinary Patient Plan of Care- Downtime	doc08	care plan
Admission Database Pediatric Patient	doc12	.
Reassessment (CBS)-Pediatric Patient	doc13	.
Wound Progress Notes (Wound Healing Monitor)	doc17	.
Neuro Flowsheet (Documentation)	doc18	.
Ear Irrigation	spe11	.
Electric Hot Water Bottle	equ05	K-pad
Endoscopy:	.	.
Colonoscopy	end01	.
Endoscopic Retrograde Cholangiopancreatography (ERCP)	end02	.
Gastroscopy (Panendoscopy, Upper)	end03	.
Enemas-Irrigating / Retention	spe17	.
Enterostomal Therapy Procedures:	.	.
Colostomy/Ileostomy, Changing and Care of the 1-piece Ostomy Appliance	ent01	.
Colostomy Irrigation	ent03	.
Loop Ostomy, Care and Pouching	ent04	.
Urostomy / Ileal Conduit: Care	ent08	.
Ileal Conduit/Urostomy, Obtaining a Urine Specimen for Culture & Sensitivity	ent09	.
Ileostomy Lavage	ent10	.
Epicardial Pacing Wires:	.	.
Epicardial Pacing Wires, Grounding	pac01	.
Epicardial Pacing Wires, Dressing Change	pac02	.
Epicardial Pacing Wires-Discontinuation	pac06	.
Eye, Care of Prosthesis	spe13	.
Fecal Impaction, Removal	spe09	.
Femoral Sheaths:	.	.
Femoral Arterial Sheaths, Care of	car04	.
Femoral Venous/Arterial Sheaths and Groin Management, Discontinuation	car11	.
Gastric Lavage	spe10	.
Gastrostomy Tubes (G-Tubes, Peg Tubes, Jejunostomy Tubes), Care and Reinsertion	tub02	.
Hemoccult Slide/Fecal Occult Blood Screening	poc05	.
Hickman:	.	.
Hickman Catheters—General Information	hic01	.
Postoperative Care	hic02	.
Dressing Changes and Site Care	hic03	.
Needleless Connector Changes	hic05	.
Irrigations / Flushes	hic06	.
Drawing Blood	hic07	.
Administration/Discontinuation of Intravenous Fluids and Blood Components	hic08	.
Management of the Nonfunctioning Catheter—Slippage and Repair	hic09	.
Managing the Nonfunctioning Catheter—Declotting	hic10	.
Hyper / Hypothermia Blanket	equ06	.
Incentive Spirometry	equ02	.
Injections:	.	.
Preparation and Administration of Subcutaneous and Intramuscular	inj01	.
Z-Track Intramuscular *	inj02	.
Intermittent Pneumatic Compression Devices (IPCDs) with TED’s	equ08	SCD
Intravenous (IV) Procedures:	.	.
IV Therapy Services, Ordering	inv00	.
Summarized Protocol for Intravenous Therapy for Adult Patient	inv01	.
Peripheral Intravenous Therapy: Initiation and Care	inv02	.
Intermittent Fluid and Medication Therapy	inv03	.
Intravenous (IV) Tubing Changes	inv04	.
Interruption of Peripheral IVs for Blood Samples	inv05	.
Lifecare 5000 Plum Infusion System	inv06	.
Intraosseous Needle Care and Removal	inv08	.
Insertion of Venous Central Line Catheters	cen01	.
Dressing Change for Venous Central Line Catheters	cen02	.
Aspirating Blood from Venous Central Line Catheters	cen03	.
Removal of Venous Central Line Catheters	cen04	.
Parenteral Nutrition-Adults/Peds	inv11	TPN Hyperal
Harvard Mini-Infuser Pump	inv14	.
Kidney Biopsy	spe03	.
Liver Biopsy	spe04	.
Lumbar Puncure (Adult)	spe05	.
Medications, Administration of:	.	.
Administering Medications - Adults and Pediatrics	med01
Administration of Meds via Nasogastric Feeding Tube	med02
Thrombolytic Agents, Cerebral and Coronary	med04	.
Amphotericin B-Adult (IV)	med05	.
Administration of Cytovene-IV (Gancyclovir Sodium)	med06	.
Gamma Globulin (lgG) (IV)	med07	.
Care of the Patient Receiving Intravenous Phenytoin (Dilantin) and Fosphenytoin (Cerebyx)	med09	.
Pain Control Local Infusions	med11
Dexamethasome	med12	Decadron
Regitine Protocol, Infiltrations	car08	.
Bladder Irrigation with Amphotericin B	med13	.
Transdermal Patches	med14	.
Sincalide Injection for Cholescintigraphy	med15
Medtronic Pump - Medtronic Synchromed Infusion Sustem	med08	.
Mid-line Catheters:	.	.
Midline IV Catheters: Insertion and Removal	mlc01	.
Midline IV Catheters: Care and Maintenance	mlc02	.
Administration and Discontinuation of IV Fluids & Blood	mlc03	.
Nasal Specimen Collection Protocol	spe18	.
Nasogastric Tubes:	.	.
Administration of meds via Nasogastric Feeding Tube	med02	NG
Nasogastric Tube Insertion and Removal	nas01	.
Nasogastric Tube Irrigation	nas02	.
Insertion and Maintenance of a Feeding Tube - Small Lumen	nas04	keofeed
Nephrostomy Tube, Irrigation and Care of	tub03	.
Neurological Procedures:	.	.
Intracranial Pressure Monitoring Using Fiber-optic Monitoring Belt	neu03	.
Lumbar Intrathecal Subarachnoir Cerebrospinal Fluid Catheter (Set-up and Maintenance) - Adults	neu02	.
National Institute of Health Stroke Scale	neu04	NIH
Nursery Procedures:	.	.
Admission of Infant via Cesarean Delivery	nur01	.
Admission of Infant to MBU after Vaginal Delivery	nur02	.
Breastfeeding Guidelines for Normal Newborn Infants	nur03	.
Care of Fetal, Neonatal and Infant Deaths	nur06	.
Photographing Infants	nur08	.
Neonatal Intra-Arterial Blood Pressure Monitoring	nur10	.
Gavage Feeding	nur11	.
Exchange Transfusion of the Infant	nur12	.
Circumcision	nur13	.
Phototherapy for the Treatment of Hyperbilirubinemia	nur14	.
Chest Tube Insertion in the Infant	nur15	.
Umbilical Catheter, Insertion of	nur16	.
Transportation for Patients To/From Neonatal Services	nur17	.
Packed Red Blood Cells for the Neonatal Patient	nur18	.
Use of IV Prn Adapters-NICU	nur19	.
Care of Neonate-High Frequency Oscillating Ventilator	nur20	.
Surfactant Administration	nur21	.
Storage and Handling of Breast Milk	nur24	.
Electric Breast Pump/Breast Pump Room	nur25	.
Skin Care Protocol for the Very Low Birth Weight Infant	nur26	.
Sucrose Administration in the NICU, Peds and MBU	nur27	.
Guidelines for Neonatal Abstinence Syndrome - Assessment Management	nur28	.
Neonatal Pain Management Protocol	nur29	.
Vital Signs for the Micro-Preemie Patient	nur30	.
Lighting, Positioning and Bedding Guidelines for Infants - NICU	nur31	.
Developmentally Supportive Care of the Premature Infant’s Sensory System in the NICU	nur32	.
Developmentally Supportive Care During Resuscitation	nur33	.
Kangaroo Care	nur34	.
Isolette Covers	nur35	.
PICC’s and Midlines: Insertion	nur36	.
Removal of Umbilical Artery Catheter	nur38	.
Peripherally Inserted Central Catheter - Dressing Change and Site Care - (for NICU initiated PICCS)	nur39	.
Breast Milk ID Scanner Procedure	nur40	.
Alternative Feeding Methods	nur41	.
Admin. Meds-NICU/Nursery	nur42	.
Parenteral Nutrition-Neonatal	nur43	.
Reconstituting Ampicillin-NICU	nur44	.
Glucose Monitoring-Neonatal	nur45	.
NICU-Catheter Exchange for PICC Lines	nur46	.
Apnea of Prematurity & Bradycardia (Cardiorespiratory Events) Management, Monitoring & Documentation	nur47	.
Obstetrics Procedures:	.	.
Cesarean Births, Care of the Patient	obs01	.
Magnesium Sulfate Administration for Antepartum, Intrapartum and Postpartum Patient with Pre-Term Labor	obs02	.
Magnesium Sulfate Administration for Antepartum, Intrapartum and Postpartum Patients with Pre-Eclampsia	obs03	.
Non-Stress Testing	obs05	.
Oxytocin Induction of Labor	obs08	.
Protocol for Cervidil/Misoprostol (Cytotec)	obs09	.
Delivery of Twin Gestation by Means of Double Set-up in the Labor and Delivery Setting	obs11	.
Obtaining Blood Gas from the Umbilical Cord	obs13	.
Amnioinfusion (Al)	obs19	.
Quantification of Amniotic Fluid	obs22	.
Termination of Pregnancy	obs23	.
Care of the Intrapartum Patient Receiving Continuous Intravenous Insulin Administration	obs25	.
Blood Type/Rh Testing	obs27	.
Cordocentesis	obs28	.
Nitroglycerin Administration in the Intrapartum Setting	obs29	.
Care of the Patient Requiring an External Version	obs31	.
Fetal Fibronectin Specimen Collection	obs32	.
Extraamniotic Foley Catheter Balloon Placement-Cervical Ripening	obs33	.
Intrauterine Catheter Replacement	obs34	.
Fetal Spiral Electrode Placement	obs35	.
Oncology Procedures:	.	.
Administration of Chemotherapeutic Agents and Biotherapies - Adult	onc01	.
Use of Drug Information Cards when Administering Chemotherapy	onc02	.
Administering Chemotherapeutic Agents via IV Push	onc05	.
Handling Excreta from Patients Receiving Chemotherapy	onc07	.
Disposing of Chemotherapy Tubings, Solution Bags and Syringes	onc08	.
Handling Liquid Chemotherapy Spills	onc09	.
Chemotherapy Extravasation Management Guidelines	onc10	.
Groshong Central Venous (CV) Catheter	onc11	.
Tenckhoff Catheter for Administering Intraperitoneal Chemotherapeutic Agents	onc12	.
Care of the Patient Receiving High Dose ARA-C Chemotherapy	onc16	.
Radiation Therapy	onc18	.
Calculation Doses Per Meter Squared and Usual Dose Sample Chart	onc19	.
Mucositis	onc20	Mouth Care
Thrombocytopenia Precautions	onc21	.
Neutropenia Precautions	onc23	.
Intraperitoneal Access Port/Peritoneal Access Port	onc24	.
Administration of Taxol	onc25	.
Administration of Peripheral Vesicant Chemotherapy (PVC)	onc26	.
Use of the CADD-Legacy Plus Infusion Pump	onc27	.
Orthopedic Procedures:	.	.
Casts, Application and Care	ort02	.
Cast Cutting	ort03	.
Traction: Overhead Frame	ort05	.
Traction: Unilateral or Bilateral Leg Traction (Buck's Traction)	ort06	.
Traction: Cervical	ort07	.
Traction: Side Arm or Humerus	ort09	.
Cervical and Lumbar Fusions, Turning a Patient	ort10	.
Cervical Traction/Immobilization: Gardner Wells Tongs, Halo Crown Philie Collar, Soft Collar	ort11	.
Pin Care of Traction	ort12	.
Orthopedic Blue Spreader - Abduction Pillow	ort13	.
Log Rolling	ort14	.
Arthrocentesis	ort16	.
Harris Splint with Pearson Attachment	ort17	.
Intracompartmental Pressure Monitor System	ort20	.
Cast Room Supplies	ort21	.
Orthopedic Drainage/Reinfusion System	ort23	.
Pacemaker:	.	.
Temporary Pacemakers (Transvenous, Epicardial)	pac03	.
Determining Pacemaker Threshold	pac05	.
Discontinuation of Epicardial Pacemaker Wires	pac06	.
Temporary Epicardial Pacemakers	pac07	.
Patient Transfer (Unit to Unit)	trn02	.
Pediatrics Procedures:	.	.
Apnea Bradycardia Monitor, Pediatric	ped01	.
Gastrostomy Tubes (G-tube) Care and Re-insertion (PEG, G-Tube, Button)	ped05	.
Nasogastric, Orogastric or Nasoduodenal Tube Insertion, Ped.	ped06	.
Enteral Tube Feeding, Pediatric	ped07	.
Accessing/Deaccessing of an Implanted Vascular Device for Continuous Intravenous Infusion or Adapter, Pediatrics	ped08	.
Gastric Suction, Gravity Drainage and Irrigation	ped15	.
Peripheral IV Therapy: Initiation	ped16	.
Pelvic Exam-Preparing Patient and “Pap” Smear	gyn03	.
GYN/Post-partum Perineal Care	gyn01	.
Peripherally Inserted Central Catheter: (PICC line)	.	PICC
Insertion and Credentialing	pic00	.
Dressing Change & Site Care	pic02	.
Administration & Discontinuation of IV Fluids and Blood	pic03	.
Needleless Connector Changes	pic04	.
Blood Drawing	pic05	.
Declotting	pic06	.
Removal	pic07	.
Management of Potential Problems	pic09	.
Catheter Exchange	pic10	.
Day Treatment-PICC and Midlines	pic11	.
Pleurodesis, Assisting	spe06	.
Preoperative Care -- Preparation of Patient for Surgical Operation	pso01	.
Procedure Review and Writing	spe16	.
Pulse Oximetry	equ03	.
Rectal Tube - Malecot	tub05	.
Rectal Tube	tub04	.
Rectal Tube (Flexiseal)	tub08	.
Restraints:	.	.
Hard Restraints	res01	.
Soft Restraints	res02	.
Posey Bed Enclosed (Ordering and Use)	res05
Seizure Precautions	neu05	.
Skin Care:	.	.
Protective Barrier Wipes – Preppies	skc01	.
Duoderm – Hydrocolloid Gel	skc02	.
Polymem Wound Dressing	skc03	.
Incontinent Patient	skc04	.
Film Dressings (Thin Transparent)	skc05	.
Skin Tears	skc06	.
Hydrocolloid Skin Barrier	skc08	.
Wet to Moist Dressings	skc09	.
Preventive Skin Care	skc10	.
Gel Wound Dressing	skc11	.
Calcium Alginate Fiber/Aquacel	skc13	.
Skin Care upon Admission	skc16	.
Slider Roller Board	trn03	.
Stool Specimen	poc06	.
Suction:	.	.
Pharyngeal	suc01	.
Nasotracheal	suc02	.
Endotracheal	suc03	.
Gastric-Gomco	suc04	.
Closed Tracheal System	suc05	.
Suture Removal	spe14	.
Suture Removal, Auto Suture (Skin Staple or Clip)	spe15
Thoracentesis, Assisting with	spe07	.
Tracheostomy Care	tub07	.
Transfer/Gait Belts	trn01	.
T-Tubes	tub06	.
Tube Feedings:	.	.
Tube Feedings, Continuous	tuf02	.
Tube Feedings with Catheter Tip-Adult	tuf03	.
Tube Feeding or Medication via a Gastrostomy Tube	tuf04	.
Tube Feeding, Jejunostomy	tuf05	.
Tube Feeding, Flexiflo Quantum	tuf08	.
Vaginal Douche	gyn02	.
Vascular Access Devices: (Port, Lifeport)	.	.
Vascular Access Devices - Implanted	vad01	.
Converting Continuous Intravenous Infusion via an Implanted Vascular Access Device to an Adapter	vad03	.
Discontinuing IV Access via an ImplantedVascular Device	vad04	.
Blood Withdrawal via an Implanted Vascular Access Device	vad05	.
Monthly Irrigation of Implanted VascularAccess Device to Maintain Patency	vad08	.
Initiating Access of an Implant VascularAccess Device for Continuous Intravenous Infusion Adapter -Adult	vad09	.
De-clotting VAD’s using t-PA-Adult	vad10	TPA
Wound Care:	.	.
Hemovac, Davols & Jackson-Pratts, Care of Patient	wou02	JP J-P
Steri-Strip Skin Closures	wou03	.
Dressing, Sterile	wou04	.
Hemovacs, Davols & Jackson-Pratts, Discontinuation	wou05	JP J-P
Penrose Drain: Withdrawal /Discontinuation	wou06	.
Wound Debridement	wou07	.
Vacuum-Assisted Closure (VAC) Therapy (Wound VAC)	wou08	VAC
Medical Maggot Debridement Therapy	wou09	.
MedX Phototherapy	wou10	.
Wound and Ostomy Care	wou11	.
Medicinal Leech Therapy	wou12	.

Nursing Policies

Administrative Department Policies	code	key words
Clinical Practice/Standards of Care References	126.001	.
Accountability for Nursing Care at SMH	126.003	.
Professional Peer Review for Nurses	126.004	.
Nursing Development Program	126.007	.
Clinical Coach Program / Clinical Preceptors	126.008	.
Assignment and Performance of Nursing Students	126.021	.
Nursing Competency Validation Program	126.033	.
Nursing Education and Travel	126.041	.
Private Duty Nurses	126.044	.
Private Duty Sitters	126.046	.
Nurse Staffing	126.048	.
Ultimate Schedule for Nursing	126.050	.
Assignment of Nursing Care	126.052	.
Patient Care Delivery	126.054	.
Education and Training Programs for Nursing Personnel	126.068	.
Performance Based Development System (PBDS)	126.070
Orientation for Nursing Personnel	126.074	.
Vacation Guidelines for Patient Care Services	126.075	.
Nursing Quality Improvement and Safety Council Council Guidelines	126.076	.
Nursing Research	126.077	.
Nursing Department Policies and Procedures: Initiation, Review and Distribution	126.080	.
Maintenance of Required Records and Reports	126.082	.
Standards of Nursing Care	126.225	.
.	.	.
Patient Care Department Policies	.	.
Medication Administration Times	126.151	.
Controlled Substances: Not Dispensed from Pyxis Medstations	126.152	.
Administration and Nursing Care of Adult Patients Receiving Cardiovascular and/or Vasoactive Medications	126.155	vasopressor
Dilutions of Selected Pharmaceuticals	126.157	.
Discharge of a Patient from SMH to Bayside Center for Behavioral Health	126.164	.
Oxygen Administration	126.167	.
DVT/VTE Nursing Protocol	126.168	.
Acute and Post-Operative Epidural and Intrathecal Pain Control	126.169	.
Patients Requiring Acid-Fast Bacilli Testing	126.170	.
Criteria for the Performance of Cardiovascular Diagnostics at the Bedside	126.171	.
Alternate Sites for Collection of Blood Specimens	126.178	.
Admission of Post-Partum Mother and Baby Following Initial Discharge From Hospital	126.179	.
Ordering of ECG Requests and Reporting of any Critical Results	126.181	.
Radiation Monitoring and Care of Permanent Implant Patients	126.182	.
Maintenance of Emergency Equipment	126.185	.
Protocol for Passy-Muir Tracheostomy Speaking Valve	126.186	.
Intravenous Patient Controlled Analgesia (PCA) and Narcotic Infusions	126.187	IV PCA
Self Administration of Medications by Patients	126.202	.
Medication Storage and Compliance Monitoring	126.203	.
Medication Order Processing and Distribution	126.204	.
Management of Patients' Own Medications	126.205	.
Medication-Limited Prescription Dispensing	126.206	.
Nursing/Pharmacy Protocol for the Admin. of Flolan (Epoprostenol) and IV Remodulin	126.207	.
Medication Administration Record Review	126.208	.
Pyxis Medstation 2000 System Operational Procedures	126.209	.
Essential Equipment Breakdown	126.210	.
Electrical Safety for Handling Patient care Equipment	126.211	.
Pyxis Medstation 2000 System-Override of Medications	126.212	.
Intake and Outputs/Daily Weights - Adult Patients	126.213	.
Pyxis Connect System or Equipment Failure Procedures (scanning of Pharmacy Orders)	126.215	.
Pyxis Medstation System or Equipment Failure Procedures (Troubleshooting)	126.216
Centralized Telemetry Monitoring (CTM)	126.218	.
Care of the Suicidal Patient in the Acute Care Setting	126.219	suicide
Alcohol Withdrawal Protocol (Non-ICU)	126.220	.
Pyxis Medstation User Authorization and Verification	126.221
Potassium Chloride Replacement	126.222	.
.	.	.
Cardiac Policies	.	.
Standards of Care/Standards of Practice: Cardiac Acute	126.234	.
Standards of Care/Standards of Practice: Cardiac Progressive Units	126.235	.
Admission/Discharge Criteria: Cardiac Acute (CAC)	126.325	.
Admission/Discharge Criteria: Cardiac Progressive Units CP1, CP2	126.327	.
Admission/Discharge Criteria: Cardiac Step-down	126.329	.
.	.	.
Center for Wound Healing (CWH) Outpatients	200.000	.
.	.	.
Day Treatment Center Policies	.	.
Standards of Care - Day Treatment Center	126.256	.
Discharge Criteria for Day Treatment Center	126.927	.
Day Treatment Center Services Scheduling System	126.929	.
Day Treatment Center - Medical Record and Documentation	126.945	.
.	.	.
Discharge Services Policy	.	.
Admission Criteria: for Discharge Services	126.285	.
.	.	.
General Surgical Policies	.	.
Standards of Care: General Surgical Unit	126.241	.
Admission/Transfer Criteria: General Surgical Unit	126.281	.
.	.	.
Hemodialysis Policies	.	.
Hemodialysis Standards of Care/Standards of Practice	126.231	.
Guidelines for Hemodialysis Treatments	126.503	.
Hemodialysis Code Blue	126.513	.
Sarasota Memorial Hospital Dialysis and Outpatient Chronic Center Protocol	126.531	.


Maternal Services Policies .	.	.
Standards of Care:MBU	126.239	.
Standards of Care/Standards of Practice: Maternity Care Center	126.240	.
Admission Criteria: Maternity Care Center	126.700	.
Neonatal/Maternal Transport Team Accident Procedure	126.702	.
Electronic Fetal Monitoring Antepartum/Intrapartum	126.703	.
Oxytocin Induction or Augmentation of Labor	126.706	.
Mode of Response for Maternal & Neonatal Transport Vehicles	126.707	.
Maternal/Neonatal/Cardiac Transport Teams: Disaster or Breach in Homeland Security	126.708	.
Maternal/Neonatal Transport Team: Mobilization Time	126.709	.
Rapid HIV Testing and STD Testing of Mothers in the Labor, Delivery and Post Patrum Settings	126.710	.
Unscheduled Cesarean Section Classification	126.712	.
Placement and Care of Neonates of Questionable And/or Non-Viability	126.715	.
The Role of the RN in the Application of Fundal Pressure	126.716	.
Utilization of Neonatal Resuscitation Team	126.718	.
Assignment for Medical Care for Obstetrical Walk-in Patients	126.720	.
Videocamera and Still Photography Use in LDR and Satellite OB/OR	126.721	.
Management of the Pregnant Patient with Epidural Anesthesia	126.722	.
Anesthesia Care and Intra-operative Monitoring	126.726	.
Unintended Intra-operative Awareness During General Anesthesia	126.732	.
Perioperative Safety Basic Standards	126.733	.
Proper Identification and Warming of IV Fluids and Irrigation Solutions - surgery, PACU, & OB	126.734	.
Chain of Command for Resolution of Interpretative Differences in Obstetrics	126.735	.
On Call Rotation, Maternal Services	126.736	.
Cord Blood Collection and Labeling for LDR	126.737	.
Quantification of Amniotic Fluid Index (AFI) by RN Staff	126.741	.
Collaborative Care of the High Risk Obstetrical Patient	126.742	.
Prostin/Misoprostol Utilization for Cervical Ripening/Dilation	126.745	.
Concentrated Oxytocin Infusion Protocol for Midtrimester Labor Induction	126.746	.
Maternal Transport Team	126.748	.
Transportation of Maternal Patients Off Campus (Outside of Hospital)	126.749	.
Collaborative Care of the Surgical Pregnant Patient (23 Weeks Gestation or Greater)	126.750	.
Newborn Infant / Pediatric Security	126.752	.
Intrauterine Fetal Resuscitation with Terbutaline	126.754	.
Collaborative Care of the Pregnant Patient Being Cared for by a Licensed Midwife	126.755	.
Parental Refusal to Comply with Florida Statutes Regarding Routine Treatment and Screening of Newborn	126.761	.
Adoptions	126.774	.
Discharge Criteria, Mother/Baby Unit	126.776	MBU
Visitation on Maternal Services	126.777	.
Visitation on the Mother Baby Unit	126.778	.
Admission of Post-Partum Mother and Baby Following Initial Discharge From Hospital	126.779	.
Admission Criteria, Mother/Baby Unit	126.781	MBU
Temporary Release and Return of Infant's Body From Morgue	126.785	.
Childbirth Educators	126.790	.
Surgical Specimens	126.800	.
Admission/Discharge Criteria: Post Anesthesia Care Units	126.802	.
Malignant Hyperthermia	126.805	.
.	.	.
Meckler Admission Center	.	.
Admission Center: Patient Placement Criteria	126.950	.
.	.	.
Medical 1 Department Policies	.	.
Standards of Care/Standards of Practice -6ET	126.230	.
Medical One Admission/Transfer Criteria	126.275	.
.	.	.
Medical/Wound Care/Renal/Diabetic Policies	.	.
Standards of Care/Standards of Practice: Medical/Wound Care/Renal/Diabetic	126.228	.
Admission/Transfer Criteria: Medical/Wound Care/Renal/Diabetic	126.283	.
.	.	.
Neonatal Services Policies	.	.
Standards of Care: NICU	126.242	.
Standards of Care: Neonatal Transport Team	126.245	.
Admission of Infants Born Outside of SMH	126.602	.
Placement and Care of Neonates of Questionable and/or Non-Viability	126.603	.
Admission Criteria, Mother/Baby Unit	126.604	MBU
Discharge Criteria, Mother/Baby Unit	126.605	MBU
Newborn Infant/Pediatric Security	126.608	.
Family Care Time and Visitors in the NICU	126.609	.
Neonatal ICU Intravenous (IV) Therapy	126.610	.
Neonatal Outpatient Eye Clinic-Medical Record and Documentation	126.611	.
Visiting on the Obstetrical, Neonatal, and MBU Units	126.631	MBU
Adoptions	126.632	.
NICU: Discharge Criteria and Planning	126.651	.
Utilization of Neonatal Resuscitation Team	126.655	.
NICU: Admission, Care and Transfer	126.660	.
Parental Refusal to Comply with Florida Statutes Regarding Routine Treatment and Screening of Newborns	126.661	.
Neonatal/Maternal Transport Team Accident Procedure	126.662	.
Mode of Response for Maternal and Neonatal Transport Vehicles	126.663	.
Maternal/Neonatal/Cardiac Transport Teams: Disaster or Breach in Homeland Security	126.664	.
Car Seat Protocol Essentials for NICU Patients	126.665	.
Maternal/Neonatal Transport Team: Mobilization Time	126.666	.
Car Seat Protocol Essentials for MBU Patients	126.667	.
Vaccine/Immunization Administration in the NICU	126.682	.
High Patient Volume: NICU	126.683	.
Oxygen Saturation Guide Infants <1500GM PR <32 WK on Supplemental Oxygen	126.684	.
.	.	.
Neuro/Uro Comprehensive (S2) Unit Policies	.	.
Standards of Care/Standards of Practice: Neuroscience/Urology Unit	126.236	.
Admission/Transfer/Discharge Criteria: Neuro-Uro Comprehensive Unit (9WT)	126.279	.
.	.	.
Oncology Department Policies	.	.
Standards of Care/Standards of Practice - Oncology	126.227	.
Admission/Transfer Criteria: Oncology Unit (M9)	126.821	.
.	.	.
Orthopedics Unit Policy	.	.
Standards of Care/Standards of Practice: Orthopedics	126.229	.
Admission/Transfer Criteria: Orthopedic Unit (OM)	126.840	.
.	.	.
Pediatrics Nursing Policies	.	.
Standards of Care: Pediatric Unit	126.244	.
Admission Criteria for Pediatrics	126.850	.
Pediatric Fall Prevention Program	126.853	.
Newborn Infant / Pediatric Security	126.854	.
Pediatric Pain Management for Needle Sticks	126.855	.
Visitors on the Pediatric Unit	126.858	.
Pediatric Intravenous (IV) Therapy	126.868	.
.	.	.
Special Care Policies	.	.
Standard of Care/Standard of Practice: Cardiac Intensive Care	126.233	.
Standard of Care/Standard of Practice: Intensive Care Unit	126.248	.
Admission/Discharge Criteria: CVICU	126.400	.
Admission/Discharge Criteria: ICU	126.401	.
Collaborative Care of the High Risk Obstetrical Patient	126.437	.
Guidelines for Intra-Hospital Transporting of Adult Special Care Patients	126.442	.
Propofol Sedation Protocol in the Critical Care Setting	126.443	.
Monitoring Neuromuscular Blockade in the Critical Care Setting	126.445	.
Mechanical Ventilation Weaning and Extubation of the Post Open Heart Surgical Patient	126.480	.
Oral Care Procedure for Critically Ill Adult Comatose Patients or Patients Requiring Mechanical Ventilation	126.483	.
.	.	.

SMH Patient Care Policies	Code	key words
Visitors	01PAT01	.
People with Special Needs (PSN) Operations During a Disaster	01PAT02	.
Code Blue Management and Responsibilities	01PAT03	.
Breast Milk Exposure	01PAT04	.
Antiplatelet Medication Management for Cardiac Stent Patients Undergoing Invasive Procedures	01PAT05	.
Release of Patient Condition / Status	01PAT07	.
Transfer of Patients to and from Sarasota Memorial Hospital	01PAT08	.
Patient Identification - Inpatient / Outpatient	01PAT09	.
Organ and Tissue Donor Procedure	01PAT14	.
Patient Expiration Including Fetal Death, Pronouncing of Patient, Autopsy Requests, Post-Mortem Care & Medical Examiner Cases	01PAT16	morgue
Food Stored on Nursing Units	01PAT17	.
Correct Patient, Procedure and Site Verification	01PAT18	.
Counts: Sponges, Sharps and Instruments	01PAT19	.
Transportation and Monitoring of Patients	01PAT23	.
Handoff Communication Guidelines	01PAT25	.
Photographing / Videotaping / Audio Recording of Patients	01PAT28	.
Termination of Pregnancy, First and Second Trimester	01PAT30	.
Code Blue Cart Management and Replacement	01PAT46	.
Admission, Discharge and Transfer Process	01PAT52	.
Sarasota Memorial Hospital (SMH) Patient Flow and Over Capacity Alert Plan	01PAT53	.
Patient Transport to Procedures or Special Exams Scheduled Outside of SMH	01PAT58	.
Fall Safety Program	01PAT60	falls
Restraint and Seclusion	01PAT64	.
Using Abbreviations, Acronyms and Symbols in Health Record Documentation	01PAT66	.
Blood Bank Identification Bands	01PAT67	.
Patient Belongings	01PAT74	valuables
Infant Screening Program	01PAT78	.
Pneumococcal Vaccination	01PAT80	.
Medication Reconcilliation	01PAT81	.
Disruptive Patient Behavior	01PAT82	.
Rapid Response Team	01PAT83	.

Corporate Patient Care Policies	Code	key words
Administration of Blood and Blood Components	00PAT00	.
Code Blue Classification and Do Not Resusicitate (DNR) Orders	00PAT02	.
Patient and Family Education	00PAT05	.
Cytoxic Chemotherapeutic Agents - Safe Handling, disposal and Cleanup	00PAT06	.
Care of the Prisoner	00PAT08	forensic
Critical Test Result Reporting	00PAT12	.
Discharge Planning	00PAT15	.
Safe Haven for Newborns	00PAT16	.
Identification, Treatment and Reporting of Suspected Abuse (Children, Elderly and Disabled)	00PAT21	.
Telephone / Verbal Orders - Receiving and Documenting	00PAT32	.
Interpreter Services - Hearing Impaired / Foreign Language	00PAT34	.
Moderate Sedation	00PAT38	.
Pain Management	00PAT44	.
Exclusion from Patient Care	00PAT54	.
Patient Assessment / Reassessment Policy	00PAT66	.
Latex Allergy	00PAT68	.
Computerized Order Management	00PAT82	.
Patient Identification Label Management	00PAT84	.

Medications, Administration of:

Nursing Policies

Administrative Department Policies

code

key words

126.001

.

126.003

.

126.004

.

126.007

.

126.008

.

126.021

.

126.033

.

126.041

.

126.044

.

126.046

.

126.048

.

126.050

.

126.052

.

126.054

.

126.068

.

126.070

126.074

.

126.075

.

126.076

.

126.077

.

126.080

.

126.082

.

126.225

.

.

.

.

126.151

.

126.152

.

126.155

vasopressor

126.157

.

126.164

.

126.167

.

126.168

.

126.169

.

126.170

.

126.171

.

126.178

.

126.179

.

126.181

.

126.182