Nursing Policy and Procedures Manual
TABLE OF CONTENTS
PART I INFECTION CONTROL IN THE HOME, 1
Chapter 1 Infection Control Procedures, 3
Applying Principles of Standard Precautions: General Guidelines, 3
Handwashing, 4
Gloves, 4
Impermeable plastic trash bag, 5
Additional personal protective equipment, 5
Sharp objects and needles, 5
Specimen collection, 6
Uniform, 6
Principles of cleaning, disinfecting, and sterilizing in the home, 6
Miscellaneous, 6
Immunizations, 6
Exposure incident, 7
OSHA Regulations, 7
Bag Technique, 8
Disposal of Soiled Dressings, 9
Equipment Cleaning, 10
Stethoscope, 10
Infant scale, 10
Glucose meters, 10
Thermometers, 10
Respiratory therapy equipment, 10
Other, 10
Handwashing, 11
Implementing a Tuberculosis Control and Personal Respiratory Home Health Protection Program, 12
Maintaining Medical Supplies and Equipment in the Car, 14
Management of Blood or Body Substance Spills in the Home, 15
Reporting and Managing an Exposure Incident, 16
Soiled Linen Management, 17
Solutions for Irrigation: Management and Storage Guidelines, 18
Solutions for Irrigation: Sterile Normal Saline, Dakins’, and Acetic Acid, 19
.9% Normal Saline, 19
25% Acetic Acid, 19
25% Dakins’, 19
Patient Education Guidelines: Reducing the Risk of Transmitting a Communicable Disease, 22
PART II ASSESSMENT AND THERAPEUTIC CARE, 25
Chapter 2 Physical and Psychosocial Assessment Procedures, 27
Adult Head to-Toe-Assessment, 27
General, 27
Head, 27
Eyes, 27
Ears, 27
Nose, 28
Mouth and throat, 28
Neck, 28
Skin, 28
Breasts, 28
Respiratory, 28
Cardiac, 28
Neurologic, 28
Peripheral vascular, 28
Gastrointestinal, 28
Fluid and electrolyte, 28
Musculoskeletal, 28
Endocrine, 28
Hematologic, 28
Urinary, 28
Genitoreproductive, 28
Psychiatric, 29
Medications, 29
Functional learning limitations, 29
Blood Pressure, 30
Edema, 31
Intake and Output (I/O), 33
Mental Health Assessment, 34
General appearance, 34
Current medication, 34
Concurrent drug/alcohol use, 34
Emotional status, 34
Thought processes, 34
Patterns of interaction, 34
General lifestyle, 35
Pain Assessment, 36
Pulse, 37
Apical Pulse, 37
Apical-Radial Pulse, 37
Radial Pulse, 37
Respirations, 38
Temperature, 39
Axillary Temperature, 39
Oral Temperature, 39
Rectal Temperature, 40
Weight, 41
Well Baby Assessment, 42
General, 42
Vital signs, 42
Growth, 42
Feeding patterns, 42
Mouth, 47
Cardiovascular, 47
Respiratory, 47
Gastrointestinal, 47
Fluid and electrolytes, 47
Genitourinary, 48
Neurologic, 48
Sleep patterns, 48
Skin, 48
Head, 48
Eyes, 48
Ears, 48
Nose, 48
Wound Assessment and Documentation, 42
Chapter 3 Therapeutic Nursing Procedures, 51
Ambulation, 51
Back Rub, 53
Bathing and Grooming, 54
Shower, 54
Tub Bath, 54
Cleansing Bed Bath, 54
Sitz Bath, 55
Bed Making, 56
Making an Occupied Bed, 56
Making an Unoccupied Bed, 56
Feeding the Dependent Elder Patient, 57
Foot Care, 58
Hair and Scalp Care, 59
Moving and Lifting Patients: Body Mechanics, 60
Assisting the Patient into a Chair when the Patient is Able to Assist, 60
Assisting the Patient into a Chair when the Patient is Unable to Assist, 60
Moving the Patient to One Side of the Bed, 60
Moving the Patient Up in the Bed When the Patient is Able to Assist, 61
Moving the Patient Up in the Bed When the Patient is Unable to Assist, 61
Nail Care, 62
Oral Care, 63
Brushing the Teeth, 63
Care of Patients with Dentures, 63
Oral Care for the Unconscious or Incapacitated Patient, 63
Positioning and Seating the Immobilized Patient, 65
Shampoo in Bed, 66
Shaving Patients, 67
Transfer or Gait Belt, 68
PART III MEDICAL-SURGICAL CARE, 69
Chapter 4 Cardiopulmonary Procedures, 71
Administration of Oxygen Therapy, 71
Oxygen Therapy: Implementation and Home Safety Precautions, 71
Nasal Cannula, 74
Oxygen Face Tent or Shield, 75
Oxygen Mask, 77
Tracheostomy Collar, 78
Aerosol Therapy, 80
Care of the Patient with an Automatic Implantable Cardioverter Defibrillator, 82
BiPAP® Support Ventilator Management, 84
Breathing Exercises, 86
Diaphragmatic Breathing, 86
Lateral Base Expansion, 86
Pursed-Lip Breathing, 87
Chest Physiotherapy, 88
Chest Tube Management, 90
Pneumothorax Catheter, 90
Empyema Chest Tube, 91
Chest Drainage System, 91
Controlled Cough Exercise, 93
Coronary Precautions in the Home, 94
Home Dysrhythmia Monitoring, 95
Home Ventilator Management, 99
Incentive Spirometer, 102
Inhalation (Steam) Therapy, 103
Manual Ventilation with a Hand-Held Resuscitator or Ambu-Bag, 104
Metered Dose Inhaler Use, 106
Open Mouth Technique, 106
InspirEase Technique, 106
Pulse Oximetry, 108
Suctioning, 110
Tracheostomy Button or Plug: Changing, Cleaning, and Care, 111
Tracheostomy Care: Inner Cannula Change and Nondisposable Cannula Care, 112
Tracheostomy Care: Outer Cannula Tube Change for the Ventilator-Dependent Patient, 113
Cuffed Tracheostomy Tube Change, 113
FOME-Cuf Tracheostomy Tube Change, 115
Patient Education Guidelines: Tips for Energy Conservation in the Home, 117
Chapter 5 Dermatologic and Wound Care, 118
Butterfly or Steri-Strips, 118
Dressing Changes: Biobrane, 119
Dressing Changes: Calcium Alginate, 121
Dressing Changes: Dry to Dry, 122
Dressing Changes: Foam Dressing, 123
Dressing Changes: Hydrocolloid Dressings and Transparent Adhesive Films, 124
Dressing Changes: Hydrogel, 126
Dressing Changes: Sterile Technique, 127
Dressing Changes: Unna Boot, 128
Dressing Changes: Wet-to-Dry, 130
Moist Compress, 131
Montgomery Straps, 132
Pediculosis, 133
Scabies, 135
Skin Care, 136
Skin Suture and Staple Removal, 138
Skin Suture Removal, 138
Skin Staple Removal, 138
Wound Irrigation and Debridement, 139
Wound Care: Scoring of Eschar, 140
Wound Management, 141
Wound Packing, 143
Patient Education Guidelines: Wound Care Management, 147
Chapter 6 Gastroenterologic and Ostomy Care, 148
Bowel Training, 148
Colostomy Irrigation, 150
Fecal Impaction: Manual Removal, 152
Gastrostomy Tube Care: General Guidelines, 153
Gastrostomy Tube Feedings, 155
Bolus Feeding, 155
Continuous or Intermittent Feeding, 155
Feeding Pump, 155
Gastrostomy Tube Replacement, 157
Nasogastric Tube Feeding, 159
Nasogastric Tube Insertion, 161
Ostomy Care, 163
Ostomy Pouch Change, 164
Rectal Tube Insertion, 165
Patient Education Guidelines: Colostomy Irrigation, 166
Patient Education Guidelines: Stoma Management in the Home, 167
Chapter 7 Head, Eyes, Ears, Nose, Throat (HEENT) Care, 171
Care of the Patient with an Artificial Eye, 171
Care of the Patient with Cataract or Retinal Surgery, 173
Care of the Patient with Contact Lenses, 174
Care of the Patient with Depressed Corneal Reflex, 176
Care of the Patient with a Hearing Aid, 177
Care of the Patient with Visual Impairment, 179
Chapter 8 Intravenous Therapy Procedures, 180
Administration of Intravenous Therapy: General Guidelines, 180
Central Venous Catheter Management, 183
Blood Sampling, 183
Cap Change, 183
Dressing Change, 184
Irrigation and Heparinization, 185
Changing Intravenous Solutions, 186
Changing Intravenous Tubing, 187
Declotting an Implantable Vascular Access Device, 188
Discontinuation and Removal of Peripheral Intravenous Fluids, 189
Groshong Catheter Management, 190
Blood Sampling, 190
Irrigation, 191
Implantable Vascular Access Device Management, 192
Blood Sampling, 192
Bolus Injection, 193
Continuous Infusion, 193
Multiple-Lumen Nontunneled Catheter Management, 194
Blood Sampling, 194
Intermittent Infusion, 194
Peripheral Inserted Central Catheter: Insertion Guidelines, 196
Peripheral Inserted Central Catheter: Removal of the Catheter, 198
Peripheral Intravenous Management, 199
Insertion of a Peripheral IV and Initiation of Hydration Fluids, 199
Inserting a Winged-Tip Needle for Blood Sampling, 200
Managing a Heparin Lock: Initiating a Heparin Lock, 200
Managing a Heparin Lock: Transferring a Continuous Infusion to a Heparin Lock, 200
Managing a Heparin Lock: Stopping/Discontinuing a Continuous Infusion, 201
Patient Education Guidelines: Home IV Therapy, 202
Patient Education Guidelines: Troubleshooting IV Therapy, 204
Chapter 9 Infusions, 205
Antibiotic Therapy: Intermittent Infusion, 205
Chemotherapy, 207
Lasix Intravenous Push, 209
Total Parental Nutrition and Intralipid Administration, 211
Chapter 10 Medications, 213
Administration of Medications: General Guidelines, 213
Bladder Instillation and Irrigation, 215
Coumadin Administration: Bleeding Precautions, 216
Ear Instillation and Irrigation, 217
Instillation, 217
Irrigation, 217
Enema Administration, 219
Cleansing Enema, 219
Fleet Enema, 219
Oil Retention Enema, 219
Eye Compresses, 221
Cold Compress, 221
Warm Compress, 221
Eye Instillation and Irrigation, 222
Eye Drops, 222
Eye Irrigation, 222
Eye Ointment, 223
Gold Injection, 224
Injections, 225
Intramuscular (IM) Injections, 225
Subcutaneous (SQ) Injections, 226
Z-Track Intramuscular Injections, 226
Nose Drops, 228
Patient/Caregiver Self-Medications Errors at Home, 229
Prefilling Insulin Syringes, 230
Suppositories, 231
Rectal Suppositories, 231
Vaginal Suppositories, 231
Topical Medications, 232
Tuberculin (TB) Skin Test, 234
Chapter 11 Rehabilitative Care and Palliative Care Procedures, 236
Aphasia Care, 236
Arm Sling, 238
Cane, 239
Cast Care, 240
Elastic Bandage, 241
Hoyer Lift, 243
Pain Management, 244
Range of Motion Exercises: Passive, 248
Stump Wrapping, 251
Support Devices: Care of Immobilized Patients, 253
Bedboard, 253
Bed Cradle, 253
Footboard, 253
Hand Roll, 253
Heel/Elbow Protector, 254
Pillows, 254
Sheepskin, 254
Trochanter Roll, 254
Thromboembolitic (TED) Hose, 256
Transcutaneous Electrical Nerve Stimulation (TENS) Unit, 258
Walker, 259
Wheelchair, 260
Chapter 12 Specimen Collection and Transport, 261
Blood Glucose Monitoring, 261
Blood Sampling, 264
Arterial Blood Gas Sampling, 264
Venous Blood Sampling, 265
Culture Collection, 268
Throat, 268
Ova and Parasite, 268
Sputum, 269
Stool, 269
Wound, 269
Fecal Occult Blood, 271
Glucose and Ketone Urine Testing: Reagent Strip, 272
Specimen Labeling and Transport, 273
Urine Collection, 274
Midstream Urine Collection, 274
Routine Urine Collection, 274
Sterile Urine Specimen Collection from a Foley Catheter, 274
Sterile Urine Specimen from a Urostomy, 275
Chapter 13 Urologic and Renal Care, 276
Arteriovenous Fistula and Shunt Care, 276
Shunt Dressing Change, 276
Preserving Patency of the Arteriovenous Fistula, 276
Bladder Training, 278
Bladder Training for Patients with an Indwelling Catheter, 278
Bladder Training for Patients without an Indwelling Catheter, 279
Closed Urinary Drainage Management, 281
Condom Catheter Care, 283
Coudé Catheter Insertion, 284
Indwelling Foley Catheter Insertion and Care, 286
Intermittent Straight Catheterization: Female, 288
Sterile Technique, 288
Clean Technique (For Self-Catheterization), 288
Intermittent Straight Catheterization: Male, 290
Sterile Technique, 290
Clean Technique (For Self-Catheterization), 291
Nephrostomy Catheter Care, 292
Pessary: Removal and Insertion, 333
Suprapubic Catheter Care, 294
Catheter Change, 294
Dressing Change: Clean Technique (Patient Administered), 294
Urinary Pouch for Females, 296
Patient Education Guidelines: Caring for the Urinary Catheter at Home, 297
PART IV NUTRITIONAL CARE IN THE HOME, 299
Chapter 14 Nutrition Procedures, 301
Medical Nutrition Therapy: Assessment of Patient?s Nutrient Requirements, 301
Medical Nutrition Therapy: Chronic Obstructive Pulmonary Disease, 306
Medical Nutrition Therapy: Congestive Heart Failure, 310
Medical Nutrition Therapy: Coronary Heart Disease, 313
Medical Nutrition Therapy: Diabetes Mellitus, 317
Medical Nutrition Therapy: Enteral Nutrition Support, 323
Medical Nutrition Therapy: Failure to Thrive, 326
Medical Nutrition Therapy: Hypertension, 331
Medical Nutrition Therapy: Pressure Ulcers, 333
Medical Nutrition Therapy: Weight Management, 337
PART V EMERGENCY CARE IN THE HOME, 341
Chapter 15 Emergency Procedures, 343
Accidentally Severed Central Venous Catheter, 343
Repair of Raaf/Quinton/Hickman Catheter, 343
Replacement of Groshong Catheter Tip, 344
Air Embolism, 346
Airway Obstruction, 347
Partial Airway Obstruction, 347
Complete Airway Obstruction, 347
Animal, Insect, Snake, Spider, and Tick Bites, 350
Animal Bite, 350
Hymenoptera Bites and Stings, 350
Snake Bite, 351
Spider Bites, 352
Tick Bite, 352
Bleeding and Soft Tissue Injury, 354
Burns, 356
Cardiopulmonary Resuscitation (CPR), 358
Adult, 358
Child, 359
Infant, 359
Falls and Fractures, 361
Heat Related Illness, 363
Heat Exhaustion, 363
Heat Stroke, 363
Hyperglycemia, 365
Hypoglycemia, 366
Hypothermia, 368
Poisoning and Substance Abuse and Misuse, 369
Poisoning, 369
Substance Abuse and Misuse, 369
Seizure, 373
Shock, 374
Suicidal Thoughts or Harmful Psychotic Ideation, 375
Transfusion or Anaphylactic Reaction, 377
PART VI THE HOME MILIEU, 379
Chapter 16 Case Managing in the Home Environment, 381
Child or Dependent Elder Abuse or Neglect, 381
Clinical Documentation: Guidelines for Medicare Reimbursement, 383
Clinical Indicators for a Home Health Aide Referral, 390
Clinical Indicators for a Hospice Referral, 391
Clinical Indicators for a Psychiatric Home Health Nurse Referral, 392
Clinical Indicators for a Rehabilitation Referral, 393
Physical Therapy, 393
Occupational Therapy, 393
Speech language Pathologist, 393
Clinical Indicators for a Social Service Referral, 394
Domestic Violence, 395
Do Not Resuscitate (DNR) Status, 398
Fire Safety Assessment, 399
Home Environment (Potential Toxins) Assessment, 400
Home Improvisation of Equipment, 404
On-Call Guidelines, 405
Post Mortem Care, 406
Safety in the Community, 407
Appearance, 407
Precautions When Traveling, 407
Precautions During Visits, 407
Socioenvironmental Assessment, 408
Personal Data, 408
Household Data, 408
Support Systems, 408
Home, 408
Neighborhood, 408
Food, 408
Economic Data, 408
Telephone Visit, 409
Patient/Caregiver Education Guidelines to Promote a Toxin-free Home Environment, 410
Patient Education Guidelines: Safety in the Home, 411
Original procedures copyright © 2000 by Mosby, Inc.
Applying Principles of Standard Precautions: General Guidelines
PURPOSE
To identify work-practice controls that eliminate or minimize employee exposure to bloodborne pathogensand communicable diseases
To identify work-practice controls that promote safe and competent patient care in the home
To promote self-care in the home
RELATED PROCEDURE
Physical Assessment (see Chapter 2)
GENERAL INFORMATION
Standard Precautions synthesize the major features from Universal Precautions (originally designed to reducethe risk of transmission of bloodborne pathogens) and Body Substance Isolation (designed to reduce the risk oftransmission of pathogens from moist body substances). The following infection control guidelines reflectcurrent recommendations from the Centers for Disease Control and Prevention (CDC); the Occupational Safetyand Health Administration’s (OSHA) bloodborne pathogen standard; the Hospital Infection Control PracticesAdvisory Committee (HICPAC), a CDC-supported committee; and the Association for Professionals inInfection Control and Epidemiology (APIC). These guidelines are designed to reduce the transmission of bloodborne and other pathogens and apply to allpatients regardless of their diagnosis. These guidelines reinforce the idea that all body substances (oral and bodysecretions; breast milk; blood; feces; urine; droplet or airborne spray from a cough; tissue, vomitus, wound, orother drainage) can be a source of infection. These guidelines also emphasize that the environment is a potentialsource for infection; they contain recommendations to prevent droplet, direct or indirect contact, and trueairborne transmission of infectious disease.
Good judgment should be used in all circumstances.
The guidelines provide general policy recommendations regarding infection control practices in the home(henceforth referred to as Standard Precautions). The remaining infection control procedures in this chapterprovide more detailed steps for implementing such policy. In addition, as government regulations change, it isexpected that home health agencies will keep current with and adhere to federal and individual state
requirements for infection control. Although the information in this manual is designed for use by home health and hospice nurses, the infection control procedures are applicable to all field staff who provide patient care in the home.Use Standard Precautions when implementing all clinical procedures (the word {STOP}) indicates that thehome health /hospice nurse is to review the procedure before proceeding any further with patient care).
EQUIPMENT
1. Personal protective equipment provided to the employee by the home health / hospice agency should include thefollowing:
a. Disposable nonsterile or sterile gloves
b. Utility gloves
c. Disinfectants recommended for blood or body substance spills, including the following:
(1) Chemical germicides that are approved for use as agency disinfectants and are tuberculocidal whenused at recommended dilutions
(2) Products registered by the Environmental Protection Agency (EPA) with an accepted label that areeffective against hepatitis B
(3) A solution of 5.25% sodium hypochlorite (household bleach) diluted to 1:10 parts with tap water;mix a fresh supply of bleach every day for effective disinfection
a. Masks, disposable cardiopulmonary resuscitation (CPR) masks, goggles, National Institute ofOccupational Safety and Health (NIOSH)-approved respiratory protection devices, moisture-proofaprons or gowns, shoe covers, caps, and an extra uniform stocked in the car
b. Liquid soap (bacteriocidal), soap towelettes, dry hand disinfectants (bleach and alcohol based), handlotion
c. Paper towels
d. Plastic bags with a seal and marked with a biohazard sign for use when transporting laboratoryspecimens
e. Leak-proof and puncture-proof containers marked with a biohazard sign on the outside of the containersfor use when transporting laboratory specimens
f. Sharps containers
g. Large plastic container or cardboard box to store nursing bag and supplies in trunk of field staff car
h. Impermeable plastic trash bags for soiled dressings, etc.
i. Sterile bottled water
PROCEDURE
Handwashing
The hands should be washed before and after patient contact. The hands are to be washed during patient care ifthey become soiled. Wash the hands with liquid soap and water immediately after removing gloves. If soap andwater are not available, use antiseptic hand cleanser or towelettes. The hands should then be washed with soap
and water as soon as possible. See specific procedure for Handwashing for further recommendations.
Gloves
Wear gloves if the possibility of contact transmission may occur. Change gloves between each patient procedureor when going from dirty to clean (e.g., multiple dressing changes). Wear disposable nonsterile nonlatex gloveswhen performing any clinical procedure that may expose you to the patient’s blood or other body substances
(e.g., during venipuncture or perineal care). Sterile disposable nonlatex gloves are to be worn during certainclinical procedures that require sterile technique (e.g., during certain dressing changes or when inserting aurinary catheter). Sterile and nonsterile nonlatex disposable gloves are to be disposed of after each use in a leakresistantwaste receptacle, such as a plastic trash bag.Utility gloves are to be used to clean up equipment, the work area, or spills. Utility gloves are to be issued toeach household. Utility gloves may be disinfected and reused. Dispose of and replace utility gloves that showsigns of cracking, peeling, tearing or puncture, or other signs of deterioration.
Impermeable PlasticTrash Bag
Place all soiled dressings, disposable gloves, etc. in an impermeable plastic trash bag, then secure it. Place thetrash bag in the family trash. Follow federal, state, and local ordinances regarding disposal of biohazardouswaste in the community.
Additional Personal Protective Equipment
This type of equipment is provided to home health / hospice nurses by the agency for use in appropriateclinical circumstances and includes the following:
Blood Spill Kit
The blood spill kit travels with the nurse and should be kept in the car supply container. The kit should at leastcontain utility gloves, plastic trash bags, and paper towels. The kit should also contain a 1:10 bleach solution,bleach wipes, or an approved home health / hospice agency disinfectant for cleaning up blood or body substance spills inthe patient’s home. Make a new batch of bleach solution daily because chlorine deteriorates and loses efficacyover time.
Gowns, Aprons, Shoe Covers, Caps