CENTRAL STATE HOSPITAL
NURSING POLICY/PROCEDURE MANUAL

TABLE OF CONTENTS Posted 8/25/08
VOLUME I
(Deleted policies/procedures are referred to the reference books "Delmar’s Fundamental and Advance Nursing Skills Handbook" and "Lippincott Manual of Nursing Practice, eight Edition" as per the Central State Hospital Nursing Policy/Procedure I, 1.0 unless otherwise indicated.)

DDD  |  PTFS

I. INTRODUCTION

Policy #

Revision/Deletion Date
Purpose of Manual          1.0 7/2006
Plan for Nursing Care 2.0 6/2007
Pain Management 2.11 2/2006
Plan for Staffing for Nursing Services 3.0 6/2007
Nursing Services Code for Nurses  - Deleted --- 8/1998 / 6/2007

Registered Professional Nurse Service Standards

5.0 6/2007
General Instructions for All Procedures 6.0 8/2007

Responsibilities of the Registered Professional Nurse and the Delegation of Nursing Activities

7.0 4/2001
II. NURSING ADMINISTRATION

Appointment to the Nursing Staff and for Assignment of Clinical Responsibility

1.0 5/2001
Nursing License Validation 2.0 4/2008
Shift Report 3.0 11/2005
Client Identification - Deleted (See CSH 4.10A) 4.0 11/2005 / 9/2007
Assignment of Client Care 5.0 2002
Holdover Guidelines - Deleted  CSH Policy Staff Holdover Guideline 6.0 11/2002 / 2/2008
III. CLIENT EDUCATIONAL PROGRAMS
Self-Care Education 1.0 8/2007
Nursing Rehabilitation Program  - Deleted 2.0 1/1993 / 10/2007

Client and Family Education Provided by Nursing Service

3.0 8/2007
Breast Self-Examination – Teaching the Client  - Deleted 4.0 5/1990 / 10/2207
Breast Examination - Deleted 5.0 1/1993 / 8/2006
IV. PERSONAL CARE AND GROOMING
A.M. Care  - Deleted 1.0 6/1992 / 9/2006
Bed Bath  - Deleted 2.0 6/1992 / 9/2006
Tub Bath or Shower 3.0 6/1992
Tub Bath or Shower – Water Temperature -Deleted 3.2 3/1995
Hair, Combing and Brushing  - Deleted 4.0 1/1993 / 9/2006
Shampoo - Deleted 5.0 6/1992 / 9/2006
Shaving Clients  - Deleted 6.0 5/1990 / 9/2006
Shaving Clients – Razor Accountability 6.0A 8/2007

Brushing the Natural Teeth & Care of the Toothbrush - Deleted

 7.0 6/1992 / 9/2006
Care of Dentures  - Deleted 8.0 5/1990 / 9/2006
Special Oral Hygiene - Deleted 9.0 5/1990 / 9/2007
Nail and Callus Care  - Deleted 10.0 8/1993 / 9/2006
Assisting the Client to Dress and Undress 11.0 3/2008
P.M. Care  - Deleted 12.0 1/1993 / 10/2007
Prosthetic Eye and Eye Socket Care  - Deleted 13.0 5/1990 / 9/2006
Foot Care  - Deleted 14.0 5/1990 / 9/2006
Perineal Care, Female and Male  - Deleted 15.0 6/1990 / 9/2006
Menstrual Monitoring 16.0 8/2007
V. CARE OF THE SKIN
Back Massage - Deleted 1.0 6/1992 / 9/2007
Prevention of Pressure Ulcers - Deleted 2.0 6/1999 / 9/2007
Treatment of Decubiti - Deleted 3.0 4/1984 / 9/2007
VI. INFECTION CONTROL
Infection Control Policy Statement 1.0 10/2007

CSH Infection Control/Occupational Health And Injury Services - Deleted

 2.0 4/2000 / 2/2008
Handwashing - Deleted 3.0 11/1983 / 9/2006
Applying and Changing Dressings  - Deleted 4.0 11/1983 / 9/2006
Linen Handling  - Deleted 5.0 1/1982 / 9/2006
Glove Technique  - Deleted 6.0 11/1983 / 9/2006
Handling Sterile Articles and Supplies  - Deleted 7.0 11/2002 / 9/2006
Cleaning of Whirlpools and Century Tubs  - Deleted 8.0 4/1984 / 9/2006
VII. BEDMAKING
Unoccupied Bed  - Deleted 1.0 6/19925 / 9/200
Occupied Bed  - Deleted 2.0 5/1992 / 9/2006
VIII. BODY MECHANICS
Moving/Positioning the Client in Bed - Deleted 1.0 4/1984 / 9/2007
Transfers - Deleted 2.0 4/1984 / 9/2007
Use of Hoyerlift - Deleted 3.0 1/1993 / 9/2007
IX. BODY ALIGNMENT AND POSITIONING
Position in Bed - Deleted 1.0 5/1999 / 9/2007

Supportive Aids for Positioning the Client in Basic Positions of Rest - Deleted

 2.0 11/2002 / 9/2007
Range of Motion Exercises - Deleted 3.0 12/1983 / 9/2007
Adaptive Supportive Intervention - Deleted CSH Policy Adaptive Supportive 4.0 3/2008
Limb Holder - Deleted 7.0 5/1992 / 5/2007
Safety Roll Belt - Deleted 8.0 5/1992 / 5/2007
X. MAINTAINING NUTRITIONAL STATUS
Feeding the Client Orally 1.0 6/2000
Feeding the Client by Tube 2.0 3/2008

Continuous Gastrostomy Feeding by Enteral Infusion Pump

5.0 6/2006
Measuring Height and Weight 6.0 8/2007
Assistance with Eating Provided by Family 7.0 9/2007
Monitoring Nutritional Status 8.0 1/2006
Feeding the Client by Jejunostomy Tube 9.0 2/2007
XI. ELIMINATION OF URINE
Assisting with Bed Pan  - Deleted 1.0 9/2000 / 7/2006
Assisting with Urinal  - Deleted 2.0 9/2000 / 7/2006
External Catheter, Application and Care  - Deleted 3.0 7/2000 / 7/2006
Catheter Removal  - Deleted 4.0 11/2002 / 7/2006
Simple Catheterization (Non-Retention) 5.0 8/2007
Retention Catheterization (Foley)  - Deleted 6.0 9/2000 / 7/2006
Care of Foley Catheter  - Deleted 7.0 7/2000 / 7/2006
Catheter Irrigation (Closed Technique)  - Deleted 8.0 8/2000 / 7/2006
Catheter and Irrigation of Suprapubic Catheter - Deleted 9.0 9/2000 / 10/2007
Bladder Training  - Deleted 10.0 9/2000 / 10/2007
Reinsertion of Suprapubic Catheter 11.0 8/2007
XII. BOWEL ELIMINATION
Enema Administration  - Deleted 1.0 9/2000 / 7/2006

Digital Removal of a Fecal Impaction (Removing Stool Digitally)  - Deleted

 2.0 8/2000 / 7/2006
Bowel Program 3.0 8/2000 / 2/2008
Colostomy Irrigation  - Deleted 4.0 9/2000 / 7/2006
Colostomy and Ileostomy Care  - Deleted 5.0 8/2000 / 7/2006
Bowel Elimination 6.0 2/2008
XIII. SPECIMEN COLLECTION
Blood Specimen Collection - Deleted 1.0 10/2000 / 9/2007
Routine Urinalysis - Deleted 2.0 3/2008
Clean Catch (Midstream) Urine  - Deleted 3.0 10/2000 / 7/2006
24 Hour Urine 5.0 10/2000
Urine Specimen from Foley Catheter  - Deleted 6.0 10/2000 / 7/2006
Stool Specimen 7.0 10/2000
Anal Smear 8.0 10/2000
Collection of a Sputum Specimen - Deleted 9.0 10/2000 / 9/2007

Gastric Content Collection (Gastric Analysis) - Deleted

 10.0 8/2008
Throat Culture 11.0 10/2000 / 9/2007

Collecting Wound Specimens (With or Without Drainage)

12.0 10/2000

XIV. MEASURING AND RECORDING INTAKE AND OUTPUT
Intake and Output 1.0 10/2007
NPO Orders 2.0 9/2007
XV. VITAL SIGNS AND RECORDING
Oral Temperature - Deleted 1.0 1/2001 / 9/2007
Rectal Temperature - Deleted 2.0 1/2001 / 9/2007
Axillary Temperature - Deleted 3.0 1/2001 / 9/2007
Using the Electronic Thermometer (IVAC) - Deleted 4.0 1/2001 / 9/2007
Using the Tympanic Thermometers - Deleted 5.0 1/2001 / 9/2007
Pulse, Radial, Carotid, Femoral, Apical, Brachial - Deleted 6.0 3/2008
Respirations - Deleted 7.0 3/2008
Blood Pressure - Deleted 8.0 1/2001 / 9/2007
XVI. APPLICATION OF HEAT
Hot Moist Compresses/Heat Application  - Deleted 1.0 1/1993 / 7/2006
Hot Soaks  - Deleted 2.0 1/1993 / 7/2006
Sitz Bath - Deleted 3.0 1/1993 / 7/2006
Portable Sitz Bath - Deleted 3.1 1/1993 / 7/2006
Heat Lamp  - Deleted 4.0 1/1993 / 7/2006

XVII. APPLICATION OF COLD

Application of Ice Bag/Collar  - Deleted 1.0 1/1993 / 7/2006
Moist Cold Compresses  - Deleted 2.0 1/1993 / 7/2006
XVIII. RESPIRATORY CARE
Suctioning - Deleted 1.0 6/1992 / 9/2007
Oxygen Administration - Deleted 2.0 6/1992 / 9/2007
Postural Drainage - Deleted 3.0 1/1993 / 9/2007

XIX. APPLICATION AND CARE OF BINDERS, BANDAGES, SPLINTS, AND CASTS

Bandages-Circular, Figure-8, Recurrent Montgomery Straps  - Deleted

 1.0 7/1991 / 7/2006
Splints - Deleted 2.0 7/1991 / 7/2006
Application of Sling  - Deleted 3.0 7/1991 / 7/2006

General Care of a Client with an Extremity Cast  - Deleted

 4.0 7/1991 / 7/2006
XX. SPECIAL DIAGNOSTIC PROCEDURES
EEG (Electroencephalogram) 1.0 3/1982
EKG (Electrocardiogram) - Deleted 2.0 / 4/2008
Mammography - Deleted 3.0 1/1990 / 10/2007

Standardized Laboratory Collection Times (Clinical Laboratory Policy) - Deleted

4.0 1/2003
XXI. SPECIAL THERAPEUTIC PROCEDURES
Suture Removal - Deleted 1.0 3/1988 / 9/2007
Insertion of Nasogastric Tube (Levin Tube)  - Deleted 2.0 2/1988 / 7/2006
Removal of Levin Tube  - Deleted 3.0  / 7/2006
Gastric Lavage - Deleted 4.0 7/1984 / 3/2007
Gastrostomy Tube Reinsertion 5.0 7/2006
Managing Gastric Tubes: Site Care 5.2 10/2007
Care of the Client Pre and Post Dialysis (Hemo) 6.0 1/1993

Care of Client Pre-Post Electro-Convulsive Therapy (ECT)

7.0 8/2003
Medical Protective Device  - Deleted  CSH Policy Medical protective 8.0 4/2004 / 10/2007
XXII. MEDICAL EXAMINATIONS
Assisting With Medical Examination - Deleted 1.0 4/1995 / 4/2008
Assisting With Vaginal Examination - Deleted 2.0 3/1977 / 4/2008
Assisting With Rectal Examination - Deleted 3.0 11/1994 / 4/2008
XXIII. MEDICATIONS

XXIV. INTRAVENOUS INFUSION AND WITHDRAWAL OF BLOOD

Intravenous Infusion and Withdrawal of Blood by Registered Nurse - Deleted

 1.0 7/1992 / 1/2007

Intravenous Infusion and Withdrawal of Blood by Licensed Practical Nurses - Deleted

 2.0 7/1992 / 1/2007
Venipuncture - Deleted 3.0 5/2006 / 9/2007
Intravenous Therapy - Deleted 4.0 8/2003 / 1/2007
Maintenance of Infusions - Deleted 5.0 8/2003 / 1/2007
XXV. PATIENT MOVEMENTS
Admissions 1.0 2/1988
Transfer In 2.0 3/1984

Transferring a Client to and from the Medical Surgical Hospital  - Deleted

 3.0  / 7/2006
Temporary Leave/Trial Visit - Deleted (See CSH Policy 4.19 and 4.19A) 4.0 2/1988 / 4/2008
Discharge Procedure 5.0 6/1998

XXVI. GENERAL PRINCIPLES OF RECORDING FORMS AND RECORDS

Charting - Deleted 1.0 4/1984 / 10/2007
XXVII. PHYSICAL EMERGENCIES
Management of Severe Bleeding  - Deleted 1.0 1/1993 / 10/2007
Heimlich Maneuver  - Deleted 2.0 1/1993 / 10/2007
Insertion of an Oral Airway  - Deleted 3.0 3/1988 / 10/2007
Care of the Client with Head Trauma 4.0 10/1998 / CSH Policy
Insulin Shock-Diabetic Coma - Deleted (See CSH Policy XXIX 2.0) 5.0 7/1998 / 7/2008

XXVIII. MENTAL HEALTH POLICIES AND PSYCHIATRIC EMERGENCIES

Suicidal Precautions  - Deleted 1.0 5/2003 / 10/2007
Special Observation Policy  - Deleted 3.0 3/2000 / 10/2007
Alternatives to Seclusion/Restraint  - Deleted 4.0 8/1998 / 10/2007
Behavioral Seclusion/Restraints  - Deleted 5.0 3/2000 / 10/2007
Application of Safety Vest (A) - Deleted 7.0 8/2000 / 3/2007
Application of Safety Vest (B) - Deleted 7.2 1/1993 / 3/2007
Application of Soft Wrist Restraints: To Bed - Deleted 8.0 4/2000 / 3/2007
Application of Restraint Net (*Posey) - Deleted 9.0 8/2000 / 3/2007
Four Point Restraints – Five Point Restraint - Deleted 10.0 8/2000 / 3/2007
Leather Restraint - Deleted 11.0 12/1999 / 3/2007
XXIX. EPISODIC ILLNESS
Care of the Terminally Ill  - Deleted 1.0 2/1981 / 10/2007
Care of the Diabetic Client/Diabetic Emergerncies 2.0 4/2008
Seizure Precautions  - Deleted 3.0 2/1981 / 10/2007
Physical Signs and Symptoms - Deleted 4.0 3/1988 / 4/2008
Gastrointestinal Bleed 5.0 5/2006
XXX. DEATH
Client Death 3.0 3/2006
Care after Death 5.0 3/2006
XXXI. STAFF EDUCATION AND TRAINING
Orientation Program – Licensed Nurses 1.0 4/2008

Competency Based Orientation and Cross Training of Nursing Staff

2.0
Clinical Skills Competency Evaluation 4.0
Employee Safety  - Deleted 5.0 1/1993 / 10/2007

Cardiopulmonary Resuscitation (CPR) & Code Teams Training Guidelines - Deleted

 6.0 10/2001 / 5/2007
XXXII. PROTOCOLS

CSH Standing Orders Protocol for Nursing Personnel

7.0 9/2005
Fall Prevention - Deleted (See CSH Policy 4.27 and Procedure 4.27A) 8.0 9/2002 / 7/2006
XXXIII.  BYLAWS, RULES, AND REGULATION OF THE LICENSED NURSING STAFF

Nursing By Laws

 6/2007

DDD
General Organization Policy 700 6/7/2007
Nursing Philosophy and Objectives 700A 6/19/2007
Obtaining Emergency Medical Services 700B 3/30/20047
Detection of Signs of Abuse 700C 6/19/2007
Monitoring of Vital Signs 702 6/19/2007
Measurement of Height and Weight 706 2/7/2007
Client Inspection 707 2/7/2007
Body Checks 707A 2/7/2007
Clients Discharged from Med Surge 709 2/7/2007
Transcription of Diet Orders 713 2/7/2007
Code Blue Plan 714 3/30/2004
Code Blue Drills 714A 3/30/2004
EWAC Medication Administration 715 2/7/2007
Guidelines for Monitoring Medication 716 6/19/2007
Progress Note 721 2/7/2007
Meds to Control Behavior 722 6/20/2007
Pap Smear 727 2/7/2007
Self-Administration of Medication 728 6/20/2007