name: Dark field examination, with specimen collection


name: Dark field examination, without specimen collection


name: Microbiologic smear with interpretation, routine stain


name: Microbiologic smear with interpretation, special stain for inclusion bodies or intracellular parasites


name: Microbiologic smear with interpretation, acid fast stain method


name: Microbiologic smear with interpretation, fluorescent stain method


name: Rhodamine-auramine fluorochrome stain method


name: Ova and parasites, specimen concentration, direct smear, and interpretation


name: Ova and parasites, dry smear interpretation


name: Microbiologic smear with interpretation, wet and dry mount, for ova and parasites


name: Anaerobic bacteria, definitive identification, including gas chromatography


name: Culture for single organism, screening by commercial kit


name: Culture for multiple organisms, screening by commercial kit


name: Culture, screening by commercial kit, with colony estimation from density chart


name: Culture, screening by commercial kit, with colony count


name: Antibiotic sensitivity, tubercle bacillus


name: Antibiotic sensitivity, agar diffusion method


name: Culture identification method, required beyond primary method


name: Culture typing procedure, fluorescent method


name: Culture typing procedure, gas liquid chromatography method


name: Culture typing procedure, serologic method, agglutination grouping


name: Culture typing procedure, serologic method, speciation


name: Culture typing procedure, precipitin method, grouping


name: Bacterial endotoxin measurement, tissue homogenization for culture


name: Immunomeasurement for infectious agent antigen, single step method, qualitative or semi-quantitative


name: Immunomeasurement for infectious agent antigen, multiple step method, qualitative or semi-quantitative


name: Microbial antigen assay by radioimmunoassay method


name: Microbial antigen assay by immunofluorescence method


name: Microbial antigen assay by latex agglutination method


name: Microbial antigen assay by enzyme immunoassay (EIA) method


name: Microbial antigen assay by immunoassay method


name: Microbial antigen assay by immunodiffusion method


name: Measurement of microbial antibody using immunofluorescence


name: Microbial antibody titer by immunofluorescence method


name: Measurement of microbial antibody using enzyme immunoassay


name: Measurement of microbial antibody using immunoblot


name: Measurement of microbial antibody using immunodiffusion


name: Measurement of microbial antibody by hemagglutination inhibition


name: Latex agglutination test for infectious agent antibody


name: Microbial antibody titer by latex agglutination method


name: Microbial IgG antibody by immunoassay method


name: Microbial IgM antibody by immunoassay method


name: Particle agglutination titer for infectious agent


name: Febrile agglutinins measurement, Brucella, Francisella, Murine typhus, Q fever, Rocky Mountain Spotted Fever, scrub typhus


name: Measurement of Borrelia species antibody


name: Measurement of Borrelia burgdorferi antibody


name: Borrelia burgdorferi antibody confirmatory test


name: Measurement of Haemophilus influenzae antibody


name: Measurement of Yersinia species antibody


name: Measurement of Plasmodium species antibody


name: Measurement of Toxoplasma species IgM antibody


name: Measurement of adenovirus antibody (procedure)


name: Measurement of California encephalitis virus antibody


name: Measurement of Eastern equine encephalitis virus antibody


name: Measurement of St. Louis encephalitis virus antibody


name: Measurement of Western equine encephalitis virus antibody


name: Measurement of Human T-lymphotropic virus 1 antibody


name: Measurement of Human T-lymphotropic virus 2 antibody


name: Measurement of Hepatitis delta virus antibody


name: Measurement of Human herpesvirus 1 antibody


name: Measurement of Lymphocytic choriomeningitis virus antibody


name: Measurement of Varicella-zoster virus antibody


name: Antibody to deoxyribonuclease measurement


name: Heterophile antibody titer after absorption with beef cells


name: Heterophile antibody titer after absorption with guinea pig kidney cells


name: Complement component, activity measurement


name: Complement component, antigen measurement


name: Complement activity, cell surface-induced measurement


name: Complement membrane attack complex (c5b-c6-c7-c8-c9n) measurement


name: Complement and immunoglobulin measurement


name: Complement membrane C3b-C4b cofactor protein measurement


name: Complement C4b binding protein measurement


name: Complement C1 esterase inhibitor, total measurement


name: Complement decay accelerating factor measurement


name: Complement C3d-C3d+GG-IC3b receptors measurement


name: Homologous restriction factor measurement


name: Hepatitis A virus antibody, total measurement


name: Allergen specific IgE antibody measurement, qualitative


name: Allergen specific IgE antibody measurement, quantitative or semi-quantitative


name: Allergen specific IgA antibody measurement


name: Allergen specific IgM antibody measurement


name: Allergen specific IgG antibody measurement


name: Acetylcholine receptor modulating antibody measurement


name: Monosialoganglioside GM1 antibody measurement


name: Chorionic gonadotropin measurement, qualitative


name: Human leukocyte antigen (HLA) typing, single antigens, A, B, or C


name: Immunoassay, qualitative, multiple step method


name: Immunoassay, semi-quantitative, multiple step method


name: Immunoassay, qualitative, single step method


name: Immunoassay, semi-quantitative, single step method


name: Immunoassay, quantitative, by radiopharmaceutical technique


name: Immunoelectrophoresis, body fluid, with concentration


name: Paper chromatography measurement, 1-dimensional


name: Paper chromatography measurement, 2-dimensional


name: Western blot measurement with immunological probe for band identification, with interpretation and report


name: Western blot measurement with interpretation and report


name: Protein analysis of tissue by Western blot with immunological probe, with interpretation and report


name: 1,4-alpha-Glucan branching enzyme measurement


name: 5,10-Methylenetetrahydrofolate reductase (FADH>2<) measurement


name: 5-methyltetrahydrofolate homocysteine methyltransferase measurement


name: 6-phosphogluconate dehydrogenase measurement, erythrocytes


name: Acid mucopolysaccharides measurement, quantitative


name: Acid mucopolysaccharides measurement, screen


name: Acid phosphatase measurement, forensic examination


name: Adenosine deaminase binding protein measurement


name: Adenosine monophosphate deaminase measurement


name: ALT measurement, method with pyridoxal-5'-phosphate


name: ALT measurement, method without pyridoxal-5'-phosphate


name: CSF albumin/plasma albumin ratio measurement


name: Albumin measurement, urine, quantitative


name: Aldosterone and renin measurement following saline suppression


name: Aliphatic carboxylate C10-C26 measurement


name: Aliphatic carboxylate C14-C26 absorption measurement


name: Aliphatic carboxylate C14-C26 esters measurement


name: Aliphatic carboxylate C24-0/C22-0 measurement


name: Aliphatic carboxylate C26-0/C22-0 measurement


name: alpha>2< Retinol binding protein measurement


name: alpha-Melanocyte stimulating hormone measurement


name: Apolipoproteins E measurement (procedure)


name: Aspartate amino transferase/alanine amino transferase ratio measurement


name: beta-Melanocyte stimulating hormone measurement


name: Bilirubin measurement, stool, qualitative


name: Blood gases, including oxygen saturation by direct measurement


name: Catecholamines, fractionated, challenge tests


name: Catecholamines, total measurement, blood


name: Catecholamines, total measurement, urine


name: Intermediate density lipoprotein cholesterol measurement (procedure)


name: Chorionic gonadotropin, alpha subunit measurement


name: Chorionic gonadotropin, intact measurement


name: Cortisol and 17-hydroxypregnenolone, following ACTH stimulation, for diagnosis of 3-beta-dydroxydehydrogenase deficiency


name: Cortisol and 17-hydroxyprogesterone, following ACTH stimulation, for diagnosis of 21-hydroxylase deficiency


name: Cortisol, following ACTH stimulation, for diagnosis of adrenal insufficiency


name: Cyclic adenosine monophosphate/creatinine ratio measurement


name: Acetoacetic acid measurement, cerebrospinal fluid


name: Dihydrolipoamide acetyl transferase measurement


name: Galactose-1-phosphate uridyl transferase measurement, semi-quantitative


name: gamma-Glutamyltransferase/aspartate amino transferase ratio measurement


name: Gastric inhibitory polypeptide measurement


name: Gastrin releasing polypeptide measurement


name: Glucose CSF/glucose plasma ratio measurement


name: Glucose measurement, tolbutamide tolerance test


name: Glucose measurement, glucose tolerance test, each additional beyond 3 specimens


name: Glutamate dehydrogenase NADP measurement


name: Glucose-6-phosphate dehydrogenase measurement, screen


name: Hypoxanthine phosphoribosyl transferase measurement


name: Insulin-like growth factor binding protein 3 measurement


name: Inter alpha-trypsin inhibitor measurement


name: Iodohippuran renal clearance measurement


name: Lecithin cholesterol acyltransferase measurement


name: Lipids, phospholipid phosphorus measurement


name: Lipoprotein ultracentrifugation and quantitation


name: Lipoprotein electrophoretic separation and quantitation


name: Luteinizing hormone by color comparison method for ovulation test


name: Methylenetetrahydrofolate dehydrogenase NAD measurement


name: Methylenetetrahydrofolate dehydrogenase NADP measurement


name: Microalbumin measurement, urine, quantitative


name: Microalbumin measurement, urine, semi-quantitative


name: Phosphofructokinase F subunit measurement


name: Porphyrin measurement, fecal, qualitative or semi-quantitative


name: Porphyrins, qualitative measurement, urine


name: Pregnancy specific protein 1 measurement


name: Protein CSF/protein serum ratio measurement


name: Protein measurement, refractometric method


name: Protein measurement by electrophoretic fractionation and quantitation


name: Protoporphyrins measurement, erythrocytes, screen


name: Pyruvate dehydrogenase cytochrome measurement


name: Pyruvate dehydrogenase lipoamide measurement


name: Insulin-like growth factor-II measurement


name: Thyrotropin releasing hormone (TRH) stimulation test


name: Thyrotropin binding inhibitory immunoglobulins measurement


name: Thyroxine/thyroxine binding globulin measurement


name: Thyroxine/triiodothyronine uptake index measurement


name: Triglyceride and ester in HDL measurement


name: Triglyceride and ester in IDL measurement


name: Triglyceride and ester in LDL measurement


name: Triglyceride and ester in VLDL measurement


name: Triiodothyronine/triiodothyronine uptake index measurement


name: Urea nitrogen measurement, semi-quantitative


name: Urea nitrogen renal clearance measurement


name: Uridine diphosphate glucose-4-epimerase measurement


name: Urobilinogen measurement, urine, qualitative


name: Urobilinogen measurement, timed urine specimen, quantitative


name: Uroporphyrinogen III synthase measurement


name: Volatile substance measurement, includes acetic anhydride, carbon tetrachloride, dichloroethane, dichloromethane, diethylether, isopropyl alcohol, methanol


name: Amiodarone and desethylamiodarone measurement


name: Amitriptyline and nortriptyline measurement


name: Procainamide and N-acetylprocainamide measurement


name: Urinalysis, reagent strip with microscopy


name: Urinalysis, automated, without microscopy


name: Urinalysis, qualitative or semi-quantitative, except immunoassay, substance other than bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen


name: Intra-arterial digital subtraction angiography


name: Intravenous digital subtraction angiography


name: Transcatheter deployment of detachable balloon


name: Percutaneous insertion of intravascular filter


name: Disturbance in life pattern associated with travel


name: Living in residence with poor sanitation


name: Nuclear Magnetic Resonance, Heteronuclear


name: Nuclear Magnetic Resonance, Biomolecular


name: beta-tricalcium phosphate-monocalcium phosphate monohydrate-calcium sulfate hemihydrate mixture


name: cis-platinum dichloride bis(diethyl 4-pyridylmethylphosphonate)


name: Coxsackie and Adenovirus Receptor-Like Membrane Protein


name: Hereditary, Developmental and Congenital Associations


name: Chemicals - Chemical Elements - Chemical Products


name: Insecticides and Invertebrate Pest Poisons


name: Hypnotics, Sedatives and Psychotomimetic Agents


name: Antiseborrheic, Depilatories, Pigmenting and Depigmenting Drugs


name: Parathyroid Extracts and Calcium Related Substances


name: Diets, Alcoholic Beverages, Smoking Products and Clothing Materials


name: General Body States, Conditions and Activities


name: Body Temperature States and Skin Functions


name: General Metabolic Functions and Activities


name: Clinical Staging of Neoplasms and Other Diseases


name: Function and Functional Units of Metabolism


name: Function and Abnormal Function Associated with Reproduction


name: Functions and Abnormal Functions Associated with the Reproductive State


name: Functions and Abnormal Functions Associated with Pregnancy and Parturition


name: Functions and Abnormal Functions Associated with the Fetus


name: Newborn States and Functions of the Placenta


name: Functions and Abnormal Functions of the Placenta


name: Function and Functional Units of the Immune System


name: Functions and Abnormal Functions of the Hematopoietic System


name: Functions of Hematopoietic and Other Reticuloendothelial Cells


name: Function and Abnormal Function of the Digestive and Urinary Tracts


name: Functions and Abnormal Functions of the Digestive Tract


name: General Functions and Abnormal Functions of the Digestive Tract


name: Functions and Abnormal Functions of the Oral Cavity


name: Functions and Abnormal Functions of the Salivary Glands


name: Functions and Abnormal Functions of the Esophagus


name: Functions and Abnormal Functions of the Stomach


name: Functions and Abnormal Functions of the Exocrine Pancreas


name: Functions and Abnormal Functions of the Intestinal Tract


name: Functions and Abnormal Functions of the Anus


name: Functions and Abnormal Functions of the Liver and Biliary Tract


name: Functions and Abnormal Functions of the Urinary Tract


name: Function and Abnormal Function of the Cardiovascular and Respiratory Systems


name: Functions and Abnormal Functions of the Cardio- Vascular System


name: Functions and Abnormal Functions of the Respiratory System


name: Function and Abnormal Function of the Nervous and Musculoskeletal Systems


name: Functions and Functional Disorders of the Nervous System


name: Motion and Coordination Functions and Disorders


name: Conditioning and Stimulus Functions and Disorders


name: Functions and Disorders of Consciousness


name: Functions and Functional Disorders of the Peripheral and Autonomic Nervous Systems


name: Functions and Functional Disorders of Nervous System Receptors


name: Functions and Abnormal Functions of the Musculoskeletal System


name: Functions and Functional Disorders of Muscles


name: Functions and Functional Disorders of Bone


name: Functions and Functional Disorders of Joint and Joint Formation


name: Functions and Functional Disorders of Epiphysis and Epiphysial Formation


name: Functions and Functional Disorders of Cartilage


name: Functions and Abnormal Functions of the Psyche


name: General Emotional and Mental States and Disorders


name: Normal and Abnormal Sexual States, Social States and Related Functions


name: Sexuality Related Social States and Problems


name: Function and Abnormal Function of the Eye, Ear and Throat


name: Environmental and Forensic Circumstances Surrounding Injury or Death


name: Circumstances Related to Injury or Death


name: Ectopias Code to Topographic Site of Ectopia


name: General Category of Temporary Individual Codes


name: Chart evaluation by healthcare professional


name: Specimen Collection, Preparation and Reporting Procedures


name: Hematopoietic, Oncologic, Immunologic and Dermatologic Procedures


name: Digestive and Urinary Tract Procedures (Includes Dental and Oral Procedures)


name: Cardiovascular and Respiratory System Procedures


name: Neuromusculoskeletal System and Special Sense Organ Procedures


name: Visual Training Rehabilitation Procedures


name: Otorhinolaryngologic service or procedure


name: Procedures Related to the Psyche, Sex and Reproduction


name: Procedures and Services Related to Reproduction


name: Diagnostic Radiologic Examination and Procedures


name: Nursing, Home Care and Disability Evaluation Procedures


name: Lower Respiratory Fluids and Spaces - Pleural Fluids and Cavities


name: Cerebrospinal Fluid, Meninges and Spaces, Dural Sinus, Ventricular System and Choroid Plexus


name: Topographic Regions and Cellular Structure


name: Bone marrow, smearing, staining and interpretation (including count)


name: Autopsy case review and preparation for clinico-pathological conference (CPC), including photography


name: Special cytopathology technique, smear of feces for epithelial cells


name: Special cytopathology technique, smear of feces for meat fibers


name: Special cytopathology technique, smear of feces for starch granules


name: Special cytopathology technique, smear of feces for fat


name: Total abdominal hysterectomy with bilateral salpingo-oophorectomy


name: Clagett closure of fenestration of chest


name: Closed reduction of bone fracture and external fixation with Gissane spike fixator


name: Diagnostic radiography with contrast media


name: Enzyme/specific protein level measurement


name: Estimation of lymphocyte proliferative ability


name: {7 (terazosin 1 MG Oral Tablet) / 7 (terazosin 2 MG Oral Tablet) } Pack


name: High purity factor IX 250iu injection kit


name: ZINC OXIDE 1.6 g in 20 mL TOPICAL CREAM [Green Sunblock]


name: Soya oil+mixed lauromacrogols 82.95/15% bath oil


name: Rubella live vaccine injection (pdr)+diluent+syringe


name: Epoetin beta 5000iu injection+diluent+syringe


name: Epoetin beta 10,000iu injection+diluent+syringe


name: Boron and/or boron compound-containing product


name: o, o-Dimethyl-0, 2, 2-dichlorovinyl phosphate


name: High voltage electricity /high tension line/


name: Fibrinogen degradation product, first derivative


name: Fibrinogen degradation product, intermediate derivation


name: Receptor binding function, nervous system


name: Receptor binding, acetylcholine, nervous system


name: Receptor binding, catecholamine, nervous system


name: Receptor binding, dopamine, nervous system


name: Receptor binding, serotonin, nervous system


name: Receptor binding, polypeptide, nervous system


name: Receptor binding, narcotic drug, nervous system


name: Binocular vision, simultaneous perception


name: Visit, nursing home or extended care facility


name: Visit, office, former patient with new complaint, for diagnosis and treatment


name: Visit, hospital, initial with comprehensive diagnostic history and physical examination, including initiation of diagnostic and treatment program and preparation of patient record


name: Visit, hospital, initial, including initiation of diagnostic and treatment program and preparation of patient record


name: Visit, hospital, follow-up or initial, brief


name: Visit, hospital, follow-up or initial, intermediate


name: Visit, hospital, follow-up or initial, extended


name: Incision and resuturing of wound, plastic


name: Transplantation, bypass, autogenous transplant


name: Clubfoot cast with molding or manipulation, long or short leg, under age 24 months, single


name: Clubfoot cast with molding or manipulation, long or short leg, under age 24 months, bilateral


name: Special cytopathology technique, forensic, hanging drop technique for sperm motility


name: Antithrombin III, progressive antithrombin assay


name: Precipitation test for blood group species identification


name: Red cell sizing study and interpretation


name: White cell sizing study and interpretation


name: Platelet sizing study and interpretation


name: Anatomic pathology consultation and report


name: Autopsy, limited to single organ, system, or region, gross and microscopic examination


name: Autopsy, limited to single organ, system, or region, gross examination


name: Gross examination and description of surgical pathology specimen, small


name: Gross examination and description of surgical pathology specimen, routine large


name: Gross examination and description of surgical pathology specimen, complex


name: Gross examination, description and microscopic diagnosis, surgical pathology specimen, small


name: Gross examination, description and microscopic diagnosis, surgical pathology specimen, routine large


name: Microscopic examination and diagnosis of previously processed (by resident or other pathologist) surgical specimen, small


name: Microscopic examination and diagnosis of previously processed (by resident or other pathologist) surgical specimen, routine large


name: Microscopic examination and diagnosis of previously processed (by resident or other pathologist) surgical specimen, complex


name: Surgical pathology consultation on slides; brief review, interpretation and report


name: Surgical pathology consultation on slides; comprehensive review, interpretation and detailed report


name: Pathology examination and report, immunofluorescent study


name: Pathology examination and report, autoradiographic study


name: Cytopathology review of slides by pathologist


name: Cytopathology technique, preparation of smears after centrifugation of fluid


name: Cytopathology technique, preparation of smears with filter method


name: Cytopathology technique, centrifugation only


name: Special cytopathology technique, preparation of smears and staining


name: Special cytopathology technique, buccal smears, for chromosomal sex determination (Barr bodies)


name: Special cytopathology technique, WBC smear, sex determination, PMN cell drumstick


name: Special cytopathology technique, blended sputum concentrate and smears


name: Chromosome analysis, lymphocytes, 1 karyotype (count 1-4 cells)


name: Chromosome analysis, myeloid cells, 2 karyotypes


name: Chromosome analysis, amniotic fluid, 1 karyotype (count 1-4 cells)


name: Chromosome analysis, other tissue cells, 1 karyotype (count 1-4 cells)


name: Cytopathology clerical procedure including coding, normal or routine


name: Cytopathology clerical procedure including coding, abnormal or complex


name: Pathology examination and report, electron microscopy study


name: Identification of organism, supplementary, by computer analysis


name: Identification of organism, confirmatory, by computer analysis


name: Microbial culture, aerobic, quantitative isolation


name: Stain, acid fast, to confirm positive fluorescent stain


name: Dilution of specimen for quantitative culture


name: Subculture in multitest medium (e.g. TSI)


name: Subculture, growth inhibition (6.5 NaCl, KCN)


name: Subculture, presence of growth (e.g. from blood cultures)


name: Subculture, biochemical breakdown (e.g. IMVIC, urea, phenylalanine, nitrate, gelatin, casein, gluconate, meat, etc.)


name: Toxin-antitoxin, plate, Nagler (including controls)


name: Toxin-antitoxin, plate, Elek for C. diphtheriae (including controls)


name: Impinger, air sample collection, subculture and count


name: Slit sampler, air sample collection and count


name: Environmental swab, collection and count


name: Sensitivity, antibiotic, agar dilution method


name: Sensitivity, antibiotic, tube dilution method


name: Sensitivity, antibiotic, microtiter method


name: Sensitivity, antibiotic, subculture for bactericidal activity


name: Sensitivity, antibiotic, preparation of inoculum


name: Identification of microbial antigen, qualitative


name: Identification of microbial antigen, quantitative


name: Identification of microbial antigen, qualitative and quantitative


name: Identification of microbial antibody, qualitative


name: Identification of microbial antibody, quantitative


name: Identification of microbial antibody, qualitative and quantitative


name: Fluorescent identification of antigen, titration


name: Fluorescent identification of antibody, titration


name: Immunoperoxidase identification of antigen


name: Immunoperoxidase identification of antibody


name: Lymphocyte transformation, other mitogen


name: Identification of lymphohistiocytic cell surface markers


name: Detection of surface bound immunoglobulins (SIG)


name: Detection of human T lymphocyte antigen, with anti T


name: Electrophoresis measurement and separation


name: Urinalysis, acetoacetic acid-diacetic acid


name: Gastric fluid analysis, free and total acid


name: Unlisted chemical procedure, explain by report


name: Chemotherapy, malignant neoplasm, rotational


name: Chemotherapy, malignant neoplasm, rotational, MOPP


name: Percutaneous tests, allergenic extracts (scratch, puncture, prick)


name: Intracutaneous (intradermal) tests with allergenic extracts, immediate reaction (15-20 minutes)


name: Percutaneous tests (scratch, puncture, prick) antibiotics, biologicals and stinging insects


name: Intracutaneous (intradermal) tests with antibiotics, biologicals and stinging insects, immediate reaction (15-20 minutes)


name: Intracutaneous (intradermal) tests with allergenic extracts, delayed reaction (24-72 hours)


name: Immunotherapy under professional supervision with provision of antigen


name: Patient counseling service in use of mechanical and electronic devices


name: Patient counseling service for patient requiring climatotherapy


name: Summary conference by physician following diagnostic work-up, contact avoidance, and immunotherapy


name: Preparation of antigen for immunotherapy


name: Preparation of antigen for immunotherapy, single antigen


name: Preparation of antigen for immunotherapy, multiple antigens, single dose vials


name: Cell therapy for malignant neoplasm, autocytotherapy


name: Tumor cell therapy for malignant neoplasm, oncocytotherapy


name: Unlisted immunologic procedure, explain by report


name: Dermographia or artificial urticaria test


name: Preparation of smear from curetting or biopsy


name: Unlisted skin procedure, explain by report


name: Unlisted preventive service, explain by report


name: Amalgam restoration, two or more surfaces, primary


name: Amalgam restoration, two or more surfaces, permanent


name: Restorations, gold foil, two or more surfaces


name: Restorations, gold inlay, three surfaces


name: Restorations, onlay, per tooth (in addition to above)


name: Restorations, single, crown, plastic with metal


name: Restorations, single, crown, porcelain with metal


name: Restorations, single, crown, gold (full cast)


name: Restorations, single, crown, gold (3/4 cast)


name: Restorations, single, crown, stainless steel


name: Restorations, single, crown, temporary (fractured tooth)


name: Restorations, single, crown with pin (additional)


name: Restorations, single, crown with post (additional)


name: Unlisted restorative service, explain by report


name: Three canals (excludes final restoration)


name: Four canals (excludes final restoration)


name: Apicoectomy, performed as separate surgical procedure


name: Apicoectomy, performed in conjunction with endodontic manipulation


name: Gingival curettement, necessary for isolation of tooth with rubber dam


name: Unlisted endodontic procedure, explain by report


name: Osseous surgery (including flap entry and closure)


name: Osseous graft, single site (including flap entry and closure)


name: Osseous graft, multiple sites (including flap entry and closure)


name: Unlisted periodontic procedure, explain by report


name: Periodontal scaling and root planing, fewer than 12 teeth


name: Special periodontal appliances (including occluding occlusal guards)


name: Type II, early periodontitis, moderate pockets


name: Type III, moderate periodontitis, moderate to deep pockets


name: Type IV, advanced periodontitis, deep pockets


name: Unlisted periodontal procedure or service, explain by report


name: Partial upper or lower denture, without clasps, acrylic base


name: Partial lower denture with gold or chrome lingual bar & two clasps, acrylic base


name: Repair broken complete or partial denture, no teeth damaged


name: Repair broken complete or partial denture and replace one broken tooth


name: Replace broken tooth on denture, no other repairs


name: Adding tooth to partial denture to replace extracted tooth, each tooth


name: Replace broken pin or fixture facing with Steele's or other facing


name: Crowns, denture, plastic processed to metal


name: Crowns, denture, porcelain fused to metal


name: Unlisted prosthodontic service or procedure, explain by report


name: Unlisted dental or oral procedure, explain by report


name: Breath analysis, gastrointestinal function


name: Gastric analysis test with stimulation of gastric secretion


name: Unlisted digestive tract service or procedure, explain by report


name: Unlisted metabolic procedure, explain by report


name: Unlisted dialysis procedure, explain by report


name: Vectorcardiogram (VCG) with or without ECG


name: Unlisted electrocardiographic procedure, explain by report


name: Monitoring of pulmonary pressure, arterial or wedge


name: Unlisted cardiovascular monitoring procedure, explain by report


name: Arterial cannulization with cardiac output (independent procedure)


name: Injection procedure during cardiac catheterization including use of automatic power injectors (see P-X for radiographic procedures)


name: Intra-cardiac electrophysiological procedure with ECG


name: Spirometry, before and after bronchodilator


name: Vital capacity, total, with timed forced expiratory volume


name: Functional residual capacity or residual volume


name: Aerosol or vapor inhalations, sputum mobilization or bronchodilation


name: Arterial blood gas, at rest and exercise


name: Intermittent positive pressure breathing (IPPB) treatment, air or oxygen


name: Unlisted pulmonary function procedure or service, explain by report


name: Electroencephalogram, activation, physical or pharmacological


name: Muscle-testing, manual, extremity or trunk, with report


name: Manual muscle-testing with total evaluation of body


name: Nerve conduction velocity, each nerve, sensory


name: Nerve conduction velocity, each nerve, motor


name: Cerebral evoked potential, somatosensory testing


name: Physical medicine, review and evaluation, rehabilitation program


name: Ophthalmic examination and evaluation, diagnosis and treatment


name: Visual field examination and evaluation, tangent screen, autoplot


name: Visual field examination, quantitative perimetry with medical evaluation


name: Visual field examination, static and kinetic perimetry


name: Tonometry-tonography with water provocation


name: Visually evoked electrical response study with evaluation


name: Otorhinolaryngologic examination, diagnosis and treatment


name: Caloric vestibular test by irrigation, binaural, bithermal


name: Caloric vestibular test, bithermal stimulation, with recording


name: Unlisted ORL procedure, explain by report


name: Postpartum medical examination and care, maternal


name: Medical examination, well baby or infant


name: Diagnostic radiography, abdomen, for fetal age, fetal position and/or placental localization


name: Unlisted radiologic procedure or service, explain by report


name: Therapy dosimetry and interpretation of application


name: Isotope study, red blood cell volume determination


name: Isotope study, renal clearance, effective renal plasma flow


name: Cerebrospinal fluid leakage study (non-imaging)


name: Unlisted volume dilution study, explain by report


name: Scanning or imaging, serial, with dynamic studies


name: Unlisted diagnostic radionuclide study, explain by report


name: Unlisted radionuclide therapeutic procedure, explain by report


name: Unlisted nuclear medicine procedure, explain by report


name: Upper respiratory tract cytologic material


name: Right accessory sinus cytologic material


name: Lower respiratory tract cytologic material


name: Cytologic material from right main bronchus


name: Cytologic material from left main bronchus


name: Procedures on prostate and seminal vesicle


name: Cerebroventricular fluid cytologic material


name: Plasma membrane receptor site for adrenocorticotropic hormone


name: Segmental tubal excision and ligation, bilateral


name: Hindquarter amputation with hemipelvectomy, right


name: Hindquarter amputation with hemipelvectomy, left


name: Mastectomy, right, modified radical (without pectoral muscles)


name: Mastectomy, left, modified radical (without pectoral muscles)


name: Intubation and aspiration of small intestine


name: Split thickness graft of trunk for third degree burns


name: Surgical repair of small bowel for obstruction


name: Surgical repair of large bowel for obstruction


name: Surgical fixation of arytenoid cartilage


name: Abdominal-perineal pull through procedure


name: Chemosurgery, mechlorethamine (nitrogen mustard)


name: Qualitative microbial antigen identification, actinomyces


name: Qualitative microbial antigen identification, adenovirus


name: Qualitative microbial antigen identification, entamoeba


name: Qualitative microbial antigen identification, bordetella


name: Qualitative microbial antigen identification, brucella


name: Qualitative microbial antigen identification, candida


name: Qualitative microbial antigen identification, coccidioides


name: Qualitative microbial antigen identification, cryptococcus


name: Quantitative microbial antigen identification, actinomyces


name: Quantitative microbial antigen identification, adenovirus


name: Quantitative microbial antigen identification, entamoeba


name: Quantitative microbial antigen identification, bordetella


name: Quantitative microbial antigen identification, brucella


name: Quantitative microbial antigen identification, candida


name: Quantitative microbial antigen identification, coccidioides


name: Quantitative microbial antigen identification, cryptococcus


name: Fluorescent identification of antigen, brucella


name: Fluorescent identification of antigen, California encephalitis virus


name: Fluorescent identification of antigen, Colorado tick virus


name: Fluorescent identification of antigen, cryptococcus


name: Fluorescent identification of antigen, enteropathogenic E. coli


name: Fluorescent identification of antigen, herpes virus


name: Fluorescent identification, anti-mitochondrial antibody


name: Fluorescent identification, anti-smooth muscle antibody


name: Fluorescent identification, thyroglobulin antibody


name: Fluorescent identification, thyroid antibody


name: Immunoprecipitin test, quantitative, actinomyces


name: Immunoprecipitin test, quantitative, anti-bovine milk


name: Immunoprecipitin test, quantitative, aspergillus


name: Immunoprecipitin test, quantitative, blastomyces


name: Immunoprecipitin test, quantitative, candida


name: Immunoprecipitin test, quantitative, coccidioides


name: Detection of lymphohistiocytic cell surface bound immunoglobulins


name: Carbon dioxide combining power measurement


name: Epinephrine and norepinephrine measurement


name: Fat, total quantitative feces measurement


name: Gamma glutamyl transpeptidase, serum, measurement (GGT)


name: 5-Hydroxy indole acetic acid, quantitative measurement


name: Iron, total and combining capacity, measurement


name: Ketogenic steroids (hormone) measurement


name: Ketosteroids, total neutral, measurement


name: Ketosteroids, total and beta fraction, measurement


name: Lactate dehydrogenase, urine, measurement


name: Lactic and pyruvic acid together, measurement


name: pH, PCO2 Astrup-Anderson nomogram measurement


name: Protein, total and A/G ratio, blood, measurement


name: Measurement of Bence Jones protein (procedure)


name: Protein, quantitative, (24 hours), fluid, measurement


name: Urobilinogen (metabolism substance) level, stool


name: Carcinoembryonic antigen measurement, RIA


name: Corticoids/cortisols, blood, measurement, RIA


name: Corticoids/cortisols, urine, measurement, RIA


name: Follicle stimulating hormone measurement, RIA


name: Lysergic acid diethylamide measurement, RIA


name: Testosterone plus dihydrotestosterone measurement, RIA


name: Thyroid stimulating hormone measurement, RIA


name: Human chorionic gonadotropin (HCG), NOS, measurement, RIA


name: Human chorionic gonadotropin (HCG), alpha subunit, measurement, RIA


name: Human chorionic gonadotropin (HCG) beta subunit, measurement, RIA


name: Antibody to hepatitis surface antigen RIA


name: Alkaline phosphatase isoenzyme electrophoresis


name: Tooth extraction, complete mouth under general anesthesia


name: Extraction of all permanent teeth under general anesthesia


name: Full mouth exodontia, adult, general anesthesia


name: Breath analysis, radioactive carbon dioxide


name: Diagnostic radiography, internal auditory meati


name: Diagnostic radiography, acromioclavicular joints, bilateral


name: Diagnostic radiologic examination with fluoroscopy, larynx


name: Diagnostic radiography with contrast media, by injection, positive contrast, sinuses, paranasal


name: Diagnostic radiography, positive contrast, for fistula (M-39300) or sinus tract (M-46340) study


name: Radiologic examination, positive contrast of renal cyst


name: Angiography, coronary artery, unilateral


name: Pyelography, retrograde, unilateral, right


name: Pyelography, retrograde, unilateral, left


name: bilateral venography of upper extremities


name: Cholangiography, post-operative, positive contrast


name: Aortography, abdominal, by serialography


name: Computerized tomography, head, with IV contrast


name: Computerized tomography, head, without IV contrast followed by IV contrast and more sections


name: Measurement of alpha-fetoprotein (AFP) in serum


name: Extremity testing (strength, dexterity, stamina)


name: Ensure Plus fruits of forest liquid Tetrapak


name: Repair of ruptured spleen (splenorrhaphy) with or without partial splenectomy


name: Forceval Protein 15g/sachet strawberry powder


name: Forceval Protein 15g/sachet natural powder


name: Structure care to conserve patient's energy.


name: Provide adequate periods of rest and sleep.


name: Maintain home schedule of rest and sleep.


name: Assess patient's sleeping habits, patterns.


name: Assess usual sleeping habits or patterns at home or during previous hospitalizations.


name: Assess factors that increase risk for sleep disturbance.


name: Assess previously attempted sleep rituals and their effectiveness.


name: Assess effectiveness of interventions for sleep promotion.


name: Promote quiet, comfortable environment at bedtime and during night.


name: Encourage significant other(s) to bring items from home to promote sleep (pillow, etc.).


name: Provide comfort devices as indicated; note effectiveness.


name: Provide or encourage diversional activity or exercise during day to promote sleep at night.


name: Arrange activities to minimize sleep disruption.


name: Encourage regular and consistent bedtimes.


name: Encourage family to hold child when possible.


name: Assess need for and provide special positioning.


name: Use and teach logrolling technique when moving patient.


name: Keep neck flexed so face is toward floor when sitting or walking.


name: Use assistive devices to maintain required position.


name: Use special "shirt" at night to maintain specific position.


name: Provide cast care to maintain required position.


name: Maintain proper traction to affected body part.


name: Follow recommendations from occupational therapy for splint application.


name: Position patient to maintain tissue integrity, flexibility.


name: Encourage patient to or assist to turn and position with pillows.


name: Advance positioning per skin tolerance and occupational therapy recommendations.


name: Handle patient carefully to avoid shearing injury.


name: Provide pressure relief while patient is sitting.


name: Assist patient with progressive mobility:


name: Assist patient with specialized exercise program.


name: When patient starts to ambulate, have patient walk slightly bent over to avoid suture line tension (post abdominoplasty).


name: Assist patient to meet daily schedule of activities as posted at patient's bedside.


name: Have pediatric patient attend school when able.


name: Provide periods of structured physical activity.


name: Promote activity or exercise within patient's restrictions and ability.


name: Assess current patterns and levels of mobility and activity.


name: Assess for contributing factors to impaired mobility.


name: Anticipate duration of impaired function.


name: Restrict activity as indicated for special procedure.


name: Assess and minimize hazards of immobility.


name: Encourage patient to maintain baseline activity level.


name: Assess need for and obtain physical therapy or occupational therapy consult.


name: Teach and assist patient or family to utilize orthotic assistive devises as needed.


name: Collaborate with physician and physical therapist regarding progression of activity.


name: Teach and assist patient with progressive wheelchair mobilization.


name: Follow protocol for patient with activity intolerance.


name: Follow mobility protocol for CVA patient in rehabilitation.


name: Follow mobility protocol for spinal cord injured patient in rehabilitation.


name: Follow the protocol for the patient who is having a laminectomy.


name: Follow protocol for orthopedic positioning


name: Follow protocol for management of the impaired mobility patient.


name: Follow protocol for management of the patient with halo vest stabilization.


name: Follow protocol for management of the patient with a Philadelphia collar.


name: Follow protocol for management of the patient with thoracic shell stabilization.


name: Follow protocol for management of the patient with cervical Gardner-Wells halo traction.


name: Follow protocol for management of the patient in halo-femoral traction.


name: Follow Protocol for management of the patient with Medical Immobilization or Protective Devices.


name: Follow protocol for management of the patient with skeletal traction of lower extremities.


name: Follow protocol for management of the patient in Buck's traction.


name: Follow protocol for the management of the patient with pelvic fractures.


name: Follow protocol for management of the patient with hip surgery.


name: Follow the protocol for the management of the patient with total knee replacement.


name: Follow protocol for care of the patient experiencing a lower extremity amputation.


name: Implement patient education plan for patient in physical rehabilitation.


name: Implement patient education plan for the spinal cord injured patient in rehabilitation (low injury).


name: Implement patient education plan for the spinal cord injured patient in rehabilitation (high injury).


name: Implement the patient education plan for the patient having a myelogram.


name: Implement patient education plan for the immobilized patient.


name: Implement the patient education plan for the patient with a long bone fracture.


name: Implement the patient education plan for the patient with an external fixation device.


name: Implement the patient education plan for cast care.


name: Implement the patient education plan for the patient in skeletal traction.


name: Implement the patient education plan for the patient in lower extremity traction.


name: Implement the patient education plan for the patient t in Buck's traction.


name: Implement patient education plan for patient with total hip arthroplasty.


name: Implement the patient education plan for the patient with degenerative joint disease.


name: Implement the patient education plan for the patient with Guillain-Barre syndrome.


name: Assess bowel motility: bowel sounds, passing of flatus, abdominal distension.


name: Assess for constipation or diarrhea: frequency, color, amount, and consistency of stools.


name: Assess for effects of medications on bowel function.


name: Assess for signs and symptoms of dumping syndrome.


name: Assess for predisposing factors associated with altered bowel function.


name: Promotion of Normal or Improved Function


name: Promote maintenance or restoration of normal bowel function.


name: Ensure bowel movement at least every other day using standard bowel routine.


name: Encourage diet and fluid intake that will promote return to normal function.


name: Provide environment conducive to bowel elimination (privacy, sitting position if possible).


name: Encourage mobility as indicated and tolerated to enhance bowel motility.


name: Notify physician if no bowel movement 3 days after surgery.


name: Obtain order and administer enema as indicated.


name: Teach patient how to promote optimal bowel elimination.


name: Explain role of diet and exercise in elimination.


name: Teach how to prevent or relieve constipation.


name: Provide comfort measures for gastrointestinal distress.


name: Provide comfort measures for nausea and vomiting.


name: Follow protocol for patient with alteration in bowel elimination.


name: Follow protocol for management of the patient with a rectal tube.


name: Follow protocol for the patient with a rectal pouch.


name: Follow generic bowel training protocol for spinal cord injured persons in rehabilitation.


name: Follow protocol for management of the patient with bowel resection.


name: Follow protocol for postoperative colostomy or ileostomy care.


name: Implement the patient education plan for the patient having a colonoscopy.


name: Implement the patient education plan for the postoperative esophagectomy patient.


name: Implement patient education plan for the patient with a new ostomy.


name: Implement patient education plan for the patient with inguinal hernia repair.


name: Implement patient education plan for the pediatric patient with inguinal hernia repair.


name: Monitor central pressures (central venous pressure or pulmonary artery pressure).


name: Obtain or assess baseline 12 lead electrocardiogram


name: Inform physician of changes in electrocardiogram or cardiac rhythm.


name: Assess evolving status of acute myocardial infarction.


name: Obtain cardiac isoenzymes until peak level obtained.


name: Assess understanding to call nurse for any discomfort or pain.


name: Assess subjective and objective evidence of cardiac-related pain.


name: Assess hemodynamic document hemodynamic effect of discomfort or pain.


name: Monitor rhythm strip and obtain electrocardiogram with each episode of pain or dysrhythmia.


name: Obtain electrocardiogram following resolution of discomfort or pain.


name: Monitor for signs of cardiac decompensation.


name: Obtain family history of cardiovascular or peripheral vascular disease.


name: Assess risk factors (smoking, obesity, stress, occupation).


name: Assess history of recent vascular injury.


name: Assess for disseminating intravascular coagulopathy (DIC).


name: Insert intravenous infusion access and provide related care.


name: Discontinue intravenous infusion as ordered or indicated.


name: Convert intravenous infusion to saline or heparin lock.


name: Change arterial line tubing and transducer.


name: Designate one port of triple lumen central line for parenteral nutrition.


name: Provide care related to clearing blocked central line ports.


name: Provide care related to pulmonary artery catheter.


name: Provide pulmonary artery catheter line site care.


name: Designate one port of pulmonary artery catheter for parenteral nutrition.


name: Assess patient for proper placement and functioning of the central line via the pressure wave form configuration.


name: Operate monitoring device according to procedure.


name: Assess understanding of monitoring and teach as needed.


name: Maintain constant visual display of the pressure wave form(s).


name: Connect invasive monitoring device to the transducer and monitoring system at all times as indicated.


name: Zero and calibrate the invasive monitoring system according to procedure.


name: Maintain the alarm system, with appropriate limits set at all times.


name: Analyze the wave form and report unresolved abnormalities to the physician.


name: Discontinue monitoring devices as ordered.


name: Initiate position changes to optimize circulation.


name: Do not apply heat or massage to lower extremities.


name: Provide care and teaching related to compression stockings.


name: Keep compression stockings on at all times except for skin inspection and bathing.


name: Remove and reapply sequential compression devices or Venodyne boots or compression stockings.


name: Measure and record leg circumference and assess for change.


name: Follow protocol for management of the patient with cardiac monitoring.


name: Follow protocol for the patient with cardiac dysrhythmia.


name: Follow protocol for management of a patient to rule out myocardial infarction.


name: Follow protocol for management of the patient with myocardial infarction.


name: Follow the protocol for the patient with angina.


name: Follow protocol for management of the patient with congestive heart failure (CHF).


name: Follow protocol for management of the patient with a Sengstaken-Blakemore tube.


name: Follow protocol for care of the patient undergoing electrophysiology study.


name: Follow protocol for management of the patient with a temporary transvenous pacemaker.


name: Follow protocol for care of the patient having temporary epicardial pacing wires.


name: Follow protocol for care of the patient with an automatic implantable cardioverter-defibrillator (AICD,ICD).


name: Follow protocol for management of the patient with an intravenous infusion or central line.


name: Follow protocol for management of the patient with a peripherally inserted central line (PICC) or midline intravenous infusion catheter.


name: Follow protocol for management of the patient with an arterial catheter.


name: Follow protocol for management of the patient with a pulmonary artery catheter.


name: Follow protocol for establishing peripheral intravascular access in the surgical admission suite.


name: Follow protocol for establishing intravascular access in Labor and Delivery.


name: Follow protocol for establishing peripheral access in the Breast Center.


name: Follow the protocol for the neonate with a percutaneous central venous catheter.


name: Follow protocol for the patient undergoing cardiac angiogram or catheterization.


name: Follow protocol for care of the patient undergoing percutaneous transluminal coronary angioplasty (PTCA) or directional coronary arthrectomy.


name: Follow protocol for management of the patient with intra-aortic balloon pump (IABP) therapy.


name: Follow protocol for care of the patient after arteriogram.


name: Follow protocol for management of the pediatric cardiac catheterization out-patient (post procedure) in the surgical admission suite.


name: Follow the interdependent protocol and patient care plan for the post cardiotomy patient.


name: Follow protocol for prevention of deep vein thrombosis.


name: Follow protocol for care of the patient with use of sequential compression device (SCD's) as ordered.


name: Follow the interdependent protocol and patient care plan for the post abdominal aortic aneurysm repair and aorta bifemoral repair procedure.


name: Follow the protocol for the stroke patient in rehabilitation.


name: Follow protocol for care of the patient with a pulmonary embolism.


name: Follow protocol for management of the patient undergoing WADA Test (Intracarotid Amobarbitol test).


name: Follow the interdependent protocol and patient care plan for the post carotid endarterectomy patient.


name: Follow protocol for care of the patient experiencing post-cardiac injury syndrome or pericarditis.


name: Follow protocol for care of the patient experiencing cardiac tamponade.


name: Follow protocol for management of the patient with cardiogenic shock.


name: Follow the protocol for the patient receiving a heart transplant.


name: Follow protocol for management of the patient post heart transplant.


name: Follow protocol for care of the pre and post endomyocardial biopsy patient having undergone heart transplant.


name: Implement patient education plan for congestive heart failure or cardiomyopathy.


name: Implement patient education plan for infant with congenital heart defects or congestive heart failure.


name: Implement the patient education plan for the patient undergoing myocardial imaging or stress testing.


name: Implement patient education plan for the patient with cardiac dysrhythmia.


name: Implement patient education plan for the patient undergoing electrophysiology study (EP study).


name: Implement patient education plan for the patient with a temporary transvenous pacemaker.


name: Implement the patient education plan for permanent pacemaker.


name: Implement patient education plan for the patient with an Automatic Implantable Cardioverter Defibrillator (AICD, ICD).


name: Implement the patient education plan for myocardial contusion.


name: Implement the patient education plan for the patient with angina pectoris.


name: Implement patient education plan for the patient post-myocardial infarction.


name: Implement patient education plan for patient with home cardiac rehabilitation program.


name: Implement the patient education plan for the patient with pericarditis.


name: Implement the patient education plan for the patient with an intra-aortic balloon pump.


name: Implement patient education plan for adult cardiac catheterization.


name: Implement patient education plan for patient with percutaneous transluminal coronary angiography (PTCA) or directional coronary arthrectomy.


name: Implement patient education plan for pre-cardiac transplant.


name: Implement patient education plan for the patient post-cardiac transplant.


name: Implement patient education plan for post operative cardiac surgery patient.


name: Implement patient education plan for pediatric patient with cardiac surgery.


name: Implement the patient education plan for the patient with peripheral vascular surgery or lower extremities alteration.


name: Implement patient education plan for the patient with the post abdominal aortic aneurysm repair or aorta bifemoral repair procedure.


name: Implement the patient education plan for the post operative carotid endarterectomy.


name: Implement the patient education plan for the patient with fat emboli.


name: Perform neurological checks as indicated or ordered.


name: Assess for changes in baseline neurological status.


name: Assess mental status using Mini Mental Status exam.


name: Assess orientation to person, place, and time, as indicated.


name: Assess consciousness using Glasgow Coma scale.


name: Assess factors or circumstances surrounding alteration in patient's level of consciousness.


name: Interview family regarding changes in patient's level of consciousness.


name: Promotion of Improved Cognitive Function


name: Orient patient to person, place, time, environment.


name: Repeat basic information simply and frequently while awake.


name: Provide simple, concise instruction and explanations adapted to patient's level of consciousness.


name: Use environmental stimuli to assist in orientation.


name: Use frequent brief contacts for assessment and rapport building.


name: Follow protocol for management of the patient experiencing acute confusion.


name: Follow the protocol for the management for aggression in the cognitively impaired patient.


name: Assess affect (including possible affective disorder); monitor changes.


name: Assess thought processes; monitor changes.


name: Assess patterns of interaction; monitor changes.


name: Assess risk of violence to self or others.


name: Assess perception of the meaning and impact of loss.


name: Assess perception of disease or injuries.


name: Assess effective and ineffective coping mechanisms currently in use.


name: Assess history of prior stressors and coping mechanisms.


name: Observe family interactions and document.


name: Assess knowledge of available support systems.


name: Develop and use therapeutic professional-client relationship.


name: Display confident, calm manner and tolerant, understanding attitude.


name: Provide emotional support; give appropriate reassurance and comfort.


name: Encourage to call nurse when feeling anxious.


name: Omit false reassurance; support realistic assessment of situation.


name: Encourage patient to ask questions; provide accurate information.


name: Assure patient privacy and confidentiality.


name: Develop and foster trust in the professional-client relationship.


name: Support patient during activities that are frightening or difficult.


name: Provide role model, positive feedback for appropriate behavior.


name: Share observations of patient's behaviors with patient in a nonjudgmental way.


name: Demonstrate or discuss with patient appropriate nonverbal expressions of feelings.


name: Help patient recognize behavior that stimulates rejection.


name: Identify secondary gains from inappropriate behaviors.


name: Use diversion to redirect inappropriate behavior.


name: Provide a consistent environment of expected behaviors.


name: Employ issue-oriented interactions with patient.


name: Assist patient in exploring precipitant to illness.


name: Assist patient in identifying potentially more effective responses, developing new skills, and planning for the future.


name: Assist patient in learning constructive problem-solving techniques.


name: Promote effective interpersonal interactions.


name: Provide opportunities for socialization and for developing interpersonal relationships that promote trust.


name: Promote reality-based thought processes.


name: Do not support or reinforce hallucinations, delusions, or ideas of reference.


name: Provide limits to facilitate effective coping, appropriate behavior.


name: Offer patient quiet room; assist patient to controlled environment.


name: Minimize stress by maintaining quiet, reducing demands on patient, and limiting number of persons involved in care.


name: Inform patient or significant others of visiting and phone regulations; enforce limits.


name: Provide and encourage appropriate diversions.


name: Collaborate with recreational therapy to arrange diversional activities.


name: Encourage involvement in unit activities.


name: Facilitate coping of patient or significant others.


name: Explain procedures, progress, therapeutic plan and rationale; clarify misunderstandings.


name: Teach and encourage to use stress management techniques.


name: Assist in identifying consequences of ineffective coping.


name: Collaborate with support services to support coping.


name: Request consults as needed to aid coping, promote adjustment.


name: Arrange for lodging for the family (via social work).


name: Promote participation in appropriate support group.


name: Facilitate attendance at support group educational classes or meetings.


name: Encourage identification, verbalization, appropriate expression of concerns and feelings.


name: Encourage communication of fear, anxiety.


name: Encourage verbalization related to suicide attempt, fears.


name: Monitor patient's ability to verbalize with and without family present.


name: Encourage appropriate nonverbal expression of feelings.


name: Describe adaptive expressions of grieving and methods of coping.


name: Facilitate child's expression of feelings through appropriate play therapy.


name: Assess patient's understanding of his or her response to anxiety.


name: Assess patient's ability to modify response to anxiety.


name: Assist to examine the behaviors used to reduce anxiety in the past.


name: Assist patient to mobilize personal resources to reduce anxiety.


name: Identify developmental delays and report findings.


name: Teach age-appropriate behavior consistent with growth and development.


name: Encourage return to independence as coping mechanisms strengthen.


name: Follow protocol for management of anxious patient.


name: Follow protocol for care of the family or patient experiencing actual or anticipatory grief.


name: Follow protocol for management of dying patient (terminal care).


name: Follow protocol for care of the dying child and the family.


name: Follow protocol for management of the patient receiving electroconvulsive therapy.


name: Follow protocol for management of patient with impaired impulse control.


name: Follow protocol for noncompliant psychiatric patients.


name: Follow protocol for strict psychiatric unit.


name: Follow protocol for management of the patient with ineffective individual coping related to multiple stressors.


name: Follow protocol for management of the patient with somatization.


name: Follow protocol for management of the patient with alteration in thought process.


name: Follow protocol for patient with social isolation.


name: Implement patient education plan for the patient with a thought disorder.


name: Implement patient education plan for the patient with dissociative disorders.


name: Implement patient education plan for the patient with an adjustment disorder.


name: Implement patient education plan for the patient with an affective disorder: depressed.


name: Implement patient education plan for the patient with an affective disorder: manic.


name: Implement patient education plan for patient with ineffective coping related to disease process.


name: Monitor intake and output, discontinue as indicated.


name: Insert Foley catheter to monitor output if burns are greater than 20% or if patient fails to void.


name: Monitor signs and symptoms of electrolyte imbalance.


name: Assess for intravascular volume depletion (central venous pressures, hypotension, hemoconcentration).


name: Obtain history to identify factors contributing to fluid imbalance.


name: Maintenance or Restoration of Fluid or Electrolyte Balance


name: Assure adequate but not excessive fluid intake.


name: Assess for signs and symptoms of fluid overload.


name: Assess for signs and symptoms of dehydration.


name: Keep intake greater than output to restore fluid loss.


name: Force fluids by mouth or by nasogastric tube as ordered.


name: Keep intake less than output to reduce hypervolemia.


name: Teach about maintaining optimal fluid balance.


name: Administer intravenous infusion fluids to maintain optimal fluid balance.


name: Titrate intravenous infusion fluids to patient's urine output per physician order.


name: Titrate intravenous infusion fluids to maintain urine output at 30-60 milliliters per hour.


name: Titrate intravenous infusion fluids to maintain urine output of one milliliter per kilogram per hour.


name: Administer fluid bolus by intravenous infusion.


name: Administer fluids (Dextrose, Lactated Ringer's) according to Parkland formula.


name: Maintain and closely monitor intravenous infusion fluids.


name: Insert large indwelling intravenous infusion catheter(s) per order.


name: Maintain intravenous infusion patency with positioning and use of protective devices to prevent dislodging.


name: Discontinue intravenous infusion fluids administration.


name: Follow protocol for management of the burn patient requiring fluid resuscitation.


name: Follow protocol for Hypertensive Hypervolemic Hemodilution Therapy (HHT or Triple H Therapy).


name: Follow protocol for fluid volume excess or impaired gas exchange in the hemodialysis patient.


name: Follow protocol for fluid volume deficit or acquired hypotension in the hemodialysis patient.


name: HEALTH BEHAVIOR, HEALTH PROMOTION, AND HEALTH RESTORATION COMPONENT


name: Assess learning needs for care of patient in regards to health deviation and treatment.


name: Assess readiness, willingness, motivation to learn.


name: Assess abilities or limitations to understanding.


name: Assess functional abilities and limitations related to performing health behaviors.


name: Assess care needs in anticipation of discharge.


name: Assess availability and capabilities of support person(s).


name: Evaluate community resources to develop plan for care at home.


name: Assess the need for continuing care or home care referrals.


name: Implement a teaching plan utilizing appropriate teaching or learning principles.


name: Schedule teaching time with regards to patient's physical condition, ability to concentrate, and availability of family.


name: Incorporate teaching into each patient encounter, when possible.


name: Choose content relevant to the level of the learner.


name: Use methods or strategies or tools appropriate for the learner.


name: Utilize techniques to encourage active patient participation.


name: Have patient perform return demonstration of required skills.


name: Provide instruction related to health deviation (illness or injury).


name: Provide instruction related to medications, treatments, or procedures.


name: Provide instruction for appropriate health behaviors.


name: Provide instruction for smoking cessation.


name: Provide instruction for health-promoting dietary habits, food preparation.


name: Counsel patient regarding adapting lifestyle to illness and treatment.


name: Promote interventions to enhance adaptation and rehabilitation.


name: Promote adherence to medication or treatment regime.


name: Assess for adherence to medication or treatment regime.


name: Inform patient of potential consequences of non-adherence.


name: Assist patient in identifying causative and contributory factors to non-adherence.


name: Encourage patient to play an active role in own care and treatment.


name: Inform patient of Patient Rights and respect patient rights.


name: Explain rationale for increasing independence as tolerated.


name: Provide positive reinforcement for maintaining independence.


name: Allow and encourage patient or family control over care (when possible).


name: Instruct and assist patient or family to give own medication, including assessing and documenting as appropriate.


name: Teach patient or family signs and symptoms to report.


name: Assist patient or family to meet with treatment team to establish treatment plan.


name: Encourage patient to participate in plans for discharge.


name: Review written medication instructions with patient, primary caregiver at home.


name: Demonstrate wound care, instruct on signs, symptoms to be reported.


name: Discuss safety at home; plan for special arrangements as needed.


name: Arrange for follow-up appointments and encourage attendance.


name: Make appropriate referrals for home-based or community-based care.


name: Provide patient with name and number of contact person for assistance if needed at home.


name: Provide appropriate instruction related to home care.


name: Follow protocol for patient awaiting discharge in the Admission and Discharge Suite.


name: Follow the protocol for the care of the adult long term patient.


name: Implement patient education plan for teaching patient, family, significant other.


name: Implement patient education plan for (inpatient) postoperative discharge.


name: Implement patient education plan for ambulatory or outpatient postoperative discharge.


name: Assess for vulnerability to infection: skin integrity, nutrition, hydration.


name: Assess exposure or potential exposure to infection.


name: Assess for history of factors that could alter immune status or mask infection.


name: Assess for signs and symptoms of infection or sepsis.


name: Assess all breaks in skin for signs of infection.


name: Assess all body orifices for signs of infection.


name: Assess presence and character of drainage.


name: Monitor temperature; notify physician of change greater than two degrees from baseline.


name: Assess behavioral changes such as irritability, decreased sleep, decreased appetite.


name: Rule out possible loci of apparent infection other than wound or burn infection.


name: Consult with physician related to signs and symptoms of infection and the need for culture, other tests.


name: Obtain and report cultures as soon as possible.


name: Obtain history of recent exposure to communicable diseases.


name: Conduct skin tests as indicated or ordered to determine presence of infection or antibodies.


name: Administer immunizations as ordered or indicated.


name: Minimize opportunities for transmission of infection.


name: Maintain appropriate infection-control precautions.


name: Avoid exposing patient to persons with infectious diseases, including upper respiratory infections; or to those recently exposed or vaccinated; or to staff caring for infected patients.


name: Have patient wear mask when out of room.


name: Provide disposable personal supplies such as drinking cups, tissues, razors.


name: Scrupulously avoid irritating or breaking skin or mucosa.


name: Maintain sterile technique as required for intervention or procedure.


name: Wear mask, cap, gown, and gloves as needed for intervention or procedure.


name: Consult with professional responsible for infection control or epidemiology.


name: Teach to prevent or detect infection early.


name: Teach about patient's potential for infection.


name: Teach specific actions or precautions to prevent infection.


name: Teach to observe for signs and symptoms of infection and to notify physician.


name: Teach to initiate antipyretic therapy at home only if physician directs.


name: Prevention or Early Detection of Rejection of Transplant


name: Monitor for function or rejection of transplanted organ.


name: Monitor lab values, physical status for signs and symptoms of organ function or rejection.


name: Teach patient, significant other to recognize signs and symptoms of rejection after discharge and to report them to physician.


name: Check wall chart for cyclosporin levels prior to administration of immunosuppressant medications.


name: Follow protocol for management of the immunosuppressed patient.


name: Follow protocol for management of the immunosuppressed patient (pediatric).


name: Follow protocol for the patient for the thrombocytopenic patient.


name: Follow protocol for the patient with an infection.


name: Follow protocol for the management of the patient with acute and or chronic hepatitis.


name: Follow protocol for peritoneal dialysis exit site or tunnel infection.


name: Follow protocol for identification of peritonitis infection in peritoneal dialysis patients.


name: Follow protocol for management of the patient with pancreatitis.


name: Follow protocol for management of the patient with subacute bacterial endocarditis (SBE).


name: Follow protocol for draining wound or contact isolation or precautions.


name: Follow the protocol for the care of the patient with arthritis.


name: Implement patient education plan for home antibiotic care.


name: Implement patient education plan for the isolation patient.


name: Implement patient education plan for the immunosuppressed patient.


name: Implement patient education plan for Human Immunodeficiency Virus (HIV) infection.


name: Implement patient education plan for the transplant patient.


name: Implement patient education plan for acute rejection of transplanted organ(s).


name: Implement patient education plan for pyelonephritis during pregnancy.


name: Implement patient education plan for the patient with pancreatitis.


name: Implement patient education plan for the patient with septicemia.


name: Implement patient education plan for the patient with subacute bacterial endocarditis (SBE).


name: Implement patient education plan for patient with leukemia.


name: Implement patient education plan for pediatric patient with leukemia.


name: Implement patient education plan for pediatric patient with myringotomy (ear) tubes.


name: MEDICATIONS AND BLOOD PRODUCTS COMPONENT


name: Assess patient history of adverse reactions to medications.


name: Monitor patient with regard to need for or response to medications.


name: Evaluate the need for and effectiveness of as needed (PRN) medications.


name: Monitor for medication interaction effects.


name: Observe and report adverse effects of medication.


name: Assess need for medication and consult physician.


name: Monitor blood levels of medication to maintain within prescribed parameters.


name: Assure optimal timing of medication administration in relation to other medications, procedures, and activities.


name: Keep medication antidote or reversing agent at bedside.


name: Follow recommended cautions for administering medications requiring special care.


name: Obtain and carry out medication orders according to policy (such as oral, telephone, or standing orders).


name: Question medication administration, hold dose, consult physician as indicated.


name: Provide care related to Patient Controlled Analgesia (PCA).


name: Administer no other analgesic sedative while on PCA.


name: Monitor effects of medication on respirations, sedation.


name: Maintain continuous intravenous infusion as ordered, or normal saline at keep-open rate.


name: If intravenous infusion infiltrates and cannot be restarted, request order for pain medication.


name: Inform physician if inadequate analgesia, or side effects of patient-controlled analgesia occur (nausea or vomiting, pruritus, respirations less than 10 increasing somnolence).


name: Give Naloxone if respirations are less than 5.


name: Provide care related to medication administered via infusion pump.


name: Use continuous infusion pump, piggy-backed into main intravenous infusion line.


name: Monitor or titrate medication dosage in relation to patient response as ordered.


name: Provide care related to the induction or augmentation of labor by oxytocics.


name: Prior to administering oxytocics, assess baseline data such as fetal heart rate, resting uterine tone, frequency, duration, and intensity of contractions, and maternal blood pressure and pulse.


name: Assess maternal vital signs during the initiation and maintenance of the oxytocic infusion.


name: Avoid administration of substances noxious to patient, or poorly tolerated by patient.


name: Avoid administration of sorbitol, as in elixirs.


name: Administer blood products according to approved policy and procedure.


name: Monitor signs and symptoms of an adverse reaction in a timely manner.


name: Remain with patient for first 15 minutes of transfusion and as needed.


name: Prepare patient or family for potential or actual blood donation.


name: Prepare patient or family for autologous donation and transfusion.


name: Refer patient or family for blood donation or related services.


name: Assure the informed consent for transfusion, per policy.


name: Follow the protocol for medication administration.


name: Follow protocol for management of the patient receiving anticoagulation therapy.


name: Follow protocol for management of the patient receiving thrombolytic therapy.


name: Follow protocol for Urokinase use for clotted peritoneal dialysis catheter.


name: Follow protocol for Urokinase use for central dialysis catheter to de-clot or improve patency of dialysis catheter.


name: Follow protocol for management of the patient receiving blood and blood products.


name: Follow protocol for administration of antilymphocyte globulin (ALG).


name: Follow protocol for the management of the patient receiving Intravenous Immunoglobulin (IVIG) Therapy.


name: Follow the protocol for the patient receiving hematopoietic colony stimulating factors.


name: Follow the protocol for the patient receiving anti-arrhythmic agents.


name: Follow the protocol for the administration of digoxin.


name: Follow the protocol for the administration of intravenous potassium.


name: Follow the protocol for insulin administration.


name: Follow protocol for management of the patient receiving intravenous insulin therapy.


name: Follow the protocol for the patient receiving potentially harmful drugs.


name: Follow protocol for management of the pharmacologically paralyzed patient.


name: Follow protocol for the pharmacologically paralyzed patient monitored with the peripheral nerve stimulator.


name: Follow the protocol for the patient receiving vasoactive infusions.


name: Follow protocol for management of the patient receiving vasopressor therapy.


name: Follow protocol for vasopressin or nitroglycerine therapy of variceal hemorrhage.


name: Follow protocol for management of the patient receiving Dopamine therapy.


name: Follow protocol for management of the patient receiving Dobutamine therapy.


name: Follow the protocol for the patient receiving vasodilators.


name: Follow protocol for adding prescribed medications to peritoneal dialysis solution bags.


name: Follow the protocol for the patient receiving Total Body Irradiation.


name: Follow protocol for management of the patient receiving Chemotherapy.


name: Follow protocol for management of the patient receiving Chemotherapy - Antimetabolites.


name: Follow the protocol for management of the patient receiving Chemotherapy-Antitumor Antibiotics.


name: Follow the protocol for the patient receiving Chemotherapy - Alkylating Agents.


name: Follow the protocol for management of the patient receiving Chemotherapy - Alkaloids.


name: Follow the protocol for management of the patient receiving Iodine Radioactive Therapy.


name: Follow protocol for administration of OKT3 (Muromonab CD3).


name: Follow protocol for the patient at risk for Tumor Lysis Syndrome.


name: Follow the protocol for the administration of medications via syringe pump.


name: Follow protocol for the management of the patient receiving intravenous opiates via PCA therapy, bolus, or intravenous infusion.


name: Follow the protocol for management of the obstetrical patient receiving medications.


name: Follow the protocol for management of the obstetrical patient receiving Magnesium Sulfate Therapy.


name: Follow the protocol for management of the patient receiving Oxytocin for induction or augmentation of labor.


name: Follow protocol for management of the patient receiving Prostaglandin E2 Gel for cervical ripening.


name: Implement patient education plan for medications (general).


name: Implement patient education plan for steroid therapy.


name: Implement patient education plan for management of the patient on anticoagulant therapy.


name: Implement patient education plan for thrombolytic drugs.


name: Implement patient education plan for the patient receiving hormonal therapy.


name: Implement patient education plan for patient receiving Norplant.


name: Implement patient education plan for patient with long-term infusion catheter.


name: Implement patient education plan for management of chemotherapy.


name: Implement the patient education plan for Chemotherapy Patient, Antitumor Antibiotics.


name: Implement the patient education plan for Chemotherapy Patient, Plant Alkaloids.


name: Implement the patient education plan for the Chemotherapy Patient, Alkylating Agents.


name: Implement the patient education plan for the Chemotherapy patient receiving Taxol.


name: Implement the patient education plan for the Chemotherapy patient receiving Cisplatin.


name: Implement the patient education plan for the patient receiving external radiation therapy.


name: Monitor labs and assess on a timely basis.


name: Monitor blood chemistry (CBC) values as ordered and indicated.


name: Monitor coagulation studies as ordered and indicated.


name: Monitor blood glucose via finger stick as ordered or indicated.


name: Obtain specimens as ordered or indicated.


name: Assess for alteration in ascites (abdominal girths, tenseness).


name: Monitor for signs of hyper- or hypoglycemia.


name: Prevent or assure early detection and treatment of excessive bleeding.


name: Monitor for signs of impaired clotting, such as bleeding from gums, surgical sites, gastrointestinal tract; petechiae.


name: Minimize invasive procedures to decrease likelihood of excessive bleeding.


name: Apply direct pressure to bleeding sites when appropriate, until bleeding stops.


name: Consult clinical coordinator for diabetes.


name: Assess blood flow through dialysis access route.


name: Follow protocol for management of the patient with diabetic ketoacidosis.


name: Follow protocol for the patient with hypoglycemia.


name: Follow protocol for the patient at risk for bleeding.


name: Follow protocol for care of the patient having a liver biopsy.


name: Follow protocol for Management of the Liver Transplant Patient; Critical Care Phase.


name: Follow protocol for management of the patient having a renal biopsy.


name: Follow protocol for hemodialysis access (subclavian or femoral or Permacath) care and use.


name: Follow protocol for hemodialysis access (fistula or graft) care and use.


name: Follow protocol for use of dialysis Permacath for emergent intravenous infusion.


name: Follow protocol for flushing of Permacath vascular access.


name: Follow protocol for management of the patient receiving peritoneal dialysis or hemodialysis.


name: Follow protocol for exit site care for peritoneal dialysis catheters.


name: Follow protocol for peritoneal dialysis exit site leak.


name: Follow protocol for obtaining a sterile specimen of peritoneal dialysis fluid for culture.


name: Follow protocol for transfer set change and adapter insertion for peritoneal dialysis catheters.


name: Follow protocol for transfer set change for peritoneal dialysis catheters.


name: Implement the patient education plan for impaired glucose tolerance.


name: Implement patient education plan for the patient with adult diabetes mellitus or gestational diabetes.


name: Implement patient education plan for pediatric patient with hypoglycemia and hyperglycemia.


name: Implement patient education plan for the patient with transphenoidal surgery for pituitary tumor.


name: Implement the patient education plan for the patient undergoing ERCP; endoscopic retrograde cholangiopancreatography.


name: Implement patient education plan for chronic renal failure.


name: Implement patient education plan for patient with renal disease.


name: Implement patient education plan for patient with renal disease on medications related to end stage renal disease (ESRD).


name: Implement patient education plan for patients on dialysis (hemodialysis or peritoneal dialysis).


name: Implement patient education plan for patient with severe illness related to dialysis.


name: Implement patient education plan for patient with sexual dysfunction related to dialysis.


name: Plot nutrition parameters on growth chart (for pediatrics).


name: Assess age factors in relation to nutritional status.


name: Obtain history of recent weight changes (loss or gain).


name: Assess patient's eating patterns or adequacy of patient intake for body requirements.


name: Assess patient's dietary habits (include likes, dislikes, and allergies).


name: Assess need for supplemental feedings (per os, per tube, or per TPN).


name: Assess risk factors predisposing patient to alteration in nutrition.


name: Assess impediments to intake of adequate nutrition.


name: Maintenance or Restoration of Adequate Diet


name: Promote adequate food intake for body requirements.


name: Provide small, frequent meals for maintenance or restoration of diet


name: Offer snacks and or nutritional supplements consistent with nutritional needs.


name: Encourage patient (or family caregiver) to fill out daily menu.


name: Institute measures to alleviate factors that interfere with adequate nutrition.


name: Decrease tube feeds to nocturnal only, per physician order, when patient is taking adequate nutrition by mouth.


name: Seat patient at individual table if distractibility impairs eating.


name: Promotion of Therapeutic Diet or Adherence to Restrictions


name: Consult dietitian for plan related to nutritional status or therapeutic diet and implement plan.


name: Assist patient in planning for adoption of therapeutic diet.


name: Promote patient's tolerance for therapeutic diet.


name: Provide and encourage therapeutic diet, to include appropriate components and restrictions.


name: Promote diet with modified intake of protein.


name: Promote diet with modified intake of fat, cholesterol, triglycerides.


name: Promote diet with modified intake of carbohydrates.


name: Promote diet with modified intake of fiber.


name: Promote diet with modified intake of calories.


name: Promote diet with modified intake of concentrated sweets.


name: Promote diet with modified intake of sodium, other electrolytes.


name: Promote diet with modified chewing requirements


name: Promote comprehensive diet plan, such as American Diabetes Association plan.


name: Prevent or minimize abdominal distention.


name: Insert nasogastric tube (for gastric drainage).


name: Maintain low intermittent suction to nasogastric tube.


name: Maintain position of nasogastric tube; do not reposition.


name: Assure proper functioning of feeding tube.


name: Monitor feeding tube (placement, residual, acidity, heme).


name: Administer water bolus via feeding tube.


name: Administer total parenteral nutrition as ordered according to policy and procedures.


name: Follow protocol for management of the patient with dysphagia.


name: Follow protocol for patient with gastrointestinal dysfunction.


name: Follow the protocol for the patient with severe or prolonged nausea.


name: Follow the protocol for the management of the patient with nasogastric intubation.


name: Follow protocol for management of the patient with a percutaneous endoscopic gastrostomy (PEG).


name: Follow protocol for management of the patient with tube feedings.


name: Follow protocol for management of the patient requiring continuous tube feedings.


name: Follow protocol for management of the patient on Total Parenteral Nutrition.


name: Follow protocol for care of the patient requiring esophageal dilation.


name: Follow protocol for care of the patient experiencing a gastroesophageal anastomosis.


name: Follow protocol for management of the patient undergoing EGD endoscopy or sclerotherapy at the bedside.


name: Follow the interdependent protocol and the patient care plan for the post esophagectomy patient.


name: Implement patient education plan for patient with special diet (clear, wired jaw, renal, hepatic, pureed, etc.).


name: Implement patient education plan for home enteral feeding.


name: Implement patient education plan for home parenteral nutrition.


name: Implement patient education plan for patient with wired mandible.


name: Implement patient education plan for esophogastroduodenoscopy (EGD).


name: Implement the patient education plan for the post operative esophagectomy patient.


name: Assess vital signs; monitor and report significant changes.


name: Assess for signs and symptoms of hypertension.


name: Notify physician for change in BP of 20 millimeters mercury or more.


name: Assess causative or contributing factors for changes in body temperature.


name: Assess for signs and symptoms of increasing intracranial pressure.


name: Assess and document substance abuse history.


name: Obtain order and specimen for blood alcohol level.


name: Obtain order and urine specimen for drug abuse.


name: Monitor for signs and symptoms of drug toxicity due to prolongation of action.


name: Assess impact of alcohol and other drug use on patient's life.


name: Assess for signs and symptoms of withdrawal, including muscle spasm or tremors.


name: Teach to assess for signs and symptoms of withdrawal, including muscle spasm or tremors.


name: Initiate high-risk screen per assessment; identify maternal risk factors.


name: Assess the frequency, duration, and intensity of uterine contractions.


name: Assess the rupture of membranes noting date, time, mode of rupture, and character and amount of amniotic fluid.


name: Assess for evidence of vaginal bleeding, note amount and characteristics.


name: Monitor uterine integrity of patient undergoing vaginal delivery with a prior caesarian birth.


name: Observe and report signs and symptoms of uterine dehiscence.


name: Assess vaginal drainage (color, amount, etc.)


name: Assess well-being of fetus or infant in perinatal period.


name: Assess fetal wellbeing through the use of an electronic fetal monitoring device according to policy.


name: Assess wellbeing of neonate using APGAR or other system.


name: Follow detoxification schedule as ordered.


name: Obtain consultation for substance abuse as ordered.


name: Request Addiction Consult Team to evaluate patient.


name: Assist patient in identifying negative consequences related to use or abuse of alcohol and other drugs.


name: Assist patient in arranging follow-up treatment for substance abuse.


name: Maintenance or Restoration of Normal Body Temperature


name: Provide care to reduce body temperature.


name: Institute antipyretic therapy as ordered.


name: Observe for and note shivering (notify physician of occurrence).


name: Apply BAIR HUGGER (hot air warmer) as available.


name: Maintain warm environment (86-92 degrees F).


name: Minimize exposure of body surface area during procedures.


name: Maintain body temperature change within recommended parameters.


name: Attempt to rewarm patient at the rate of two degrees Celsius per hour.


name: Provide active rewarming methods until core temperature reaches 36.5 degrees Celsius.


name: Promote restoration or maintenance of normal body temperature of infant.


name: Control temperature in isolette as needed.


name: Follow procedure for infants in radiant warmers.


name: Assess effectiveness of interventions to alter body temperature and adjust care accordingly.


name: Teach patient or family regarding the probable cause of actual or potential alteration in body temperature.


name: Maintenance or Restoration of Normal Neurological Status


name: Avoid or minimize factors that lead to increase in intracranial pressure.


name: Follow protocol for management of the patient with hemorrhagic shock.


name: Follow protocol for management of the patient with septic shock.


name: Follow protocol for management of the patient with orthostatic hypotension.


name: Follow protocol for patient with postural hypotension (generic).


name: Follow protocol for management of the spinal cord injured patient with orthostatic hypotension.


name: Follow protocol for patient experiencing hyperthermia.


name: Follow protocol for pediatric patient with fever.


name: Follow protocol for patient experiencing malignant hyperthermia.


name: Follow protocol for patient experiencing hypothermia.


name: Follow protocol for management of the patient on a hyper- or hypothermia blanket.


name: Follow protocol for patient with a rectal temperature probe.


name: Follow protocol for management of the patient with chemical dependence withdrawal.


name: Follow protocol for management of the patient with acute drug or alcohol withdrawal.


name: Follow protocol for the obstetrical patient during fetal monitoring.


name: Follow protocol for care of the mother who is breast feeding.


name: Follow protocol for management of the trauma patient.


name: Follow protocol for management of the patient with renal trauma.


name: Follow protocol for management of the patient with compartment syndrome or crushing injury or fasciotomy.


name: Follow protocol for management of the patient with multiple trauma in the SICU.


name: Follow protocol for management of the patient with open or closed extremity fractures.


name: Follow protocol for management of the patient with a splenic or liver laceration.


name: Follow protocol for management of the patient with abdominal trauma - blunt or penetrating.


name: Follow protocol for management of the patient with pulmonary contusion or fractured ribs.


name: Follow protocol for management of the patient with head trauma.


name: Follow protocol for management of the patient with maxillofacial injuries.


name: Follow protocol for management of the patient with generalized tonic-clonic seizures.


name: Follow the protocol for the care of the patient with Status Epilepticus.


name: Follow protocol for the patient requiring Long Term EEG Monitoring.


name: Follow protocol for management of spinal cord injured patient with autonomic dysreflexia (hyperreflexia).


name: Follow protocol for management of the patient with a subarachnoid hemorrhage (SAH).


name: Follow protocol for the patient post craniotomy or craniectomy or Lobectomy.


name: Follow protocol for management of the patient with a cerebral spinal fluid drain.


name: Follow protocol for management of the patient with a Camino intracranial bolt.


name: Follow protocol for the patient with ventriculostomy intracranial pressure monitoring device.


name: Follow protocol for management for the neonate with a carotid cavernous sinus tumor (CC Fistula).


name: Implement patient education plan for the patient with hypertension.


name: Implement patient education plan for patient with (gynecological) laparoscopy.


name: Implement patient education plan for patient with dilatation and curettage, therapeutic abortion.


name: Implement patient education plan for patient with bilateral tubal ligation.


name: Implement patient education plan for antepartum teaching or home discharge teaching.


name: Implement patient education plan for the postpartum patient.


name: Implement patient education plan for care of the healthy newborn.


name: Implement patient education plan for the pediatric patient with circumcision.


name: Implement patient education plan for care of the high risk infant.


name: Implement patient education plan for the pediatric patient with PKU testing.


name: Implement the patient education plan for the patient or family in the Neonatal Intensive Care Unit.


name: Implement patient education plan for the patient with trauma.


name: Implement patient education plan for the patient with maxillofacial deformity or fracture with surgery.


name: Implement the patient education plan for the patient with a seizure disorder.


name: Implement patient education plan for long term electroencephalogram monitoring.


name: Implement the patient education plan for the patient in the Neurological Intensive Care Unit.


name: Implement patient education plan for craniotomy.


name: Implement the patient education plan for the patient with hydrocephalus.


name: Implement patient education plan for subarachnoid hemorrhage.


name: Implement the patient education plan for the patient with a carotid cavernous sinus fistula.


name: Implement patient education plan for spinal cord injured patients.


name: Implement the patient education plan for the patient with multiple sclerosis.


name: Monitor quality, rate, rhythm, and depth of respirations.


name: Monitor quality of cough and effectiveness in clearing secretions.


name: Obtain sputum specimen as indicated or ordered; assess for color, tenacity, and amount.


name: Assess for change in lab values or radiology reports (such as oxygen saturation, acid-base balance, or chest x-ray).


name: Monitor for changes in respiratory status or signs and symptoms of respiratory distress.


name: Monitor arterial blood gases (ABG's) and carboxyhemoglobin.


name: Assess for signs and symptoms of decreased oxygenation. Report findings.


name: Assess for signs and symptoms of inhalation injury.


name: Secure physician order for serial arterial blood gases and carboxyhemoglobin.


name: Monitor for dyspnea, hyperventilation, stridor, retractions, tachypnea, sneezing, hoarseness, chest pain or tightness, cyanosis.


name: Assess for possible need for intubation or mechanical ventilation; if indicated, obtain ventilation box, notify physician and respiratory therapy.


name: Assess for signs of perforation (post-laryngoscopy and or biopsy), i.e.: dyspnea, chest or shoulder pain, subcutaneous emphysema and temperature elevation.


name: Report changes in respiratory status to physician or respiratory therapist..


name: Promote maintenance or restoration of best feasible respiratory function.


name: Instruct and encourage patient to turn, cough, and deep breathe.


name: Instruct and encourage patient in use of incentive spirometry.


name: Administer nebulizer treatment as ordered or indicated.


name: Provide hydration to liquefy secretions.


name: Provide analgesia or sedation as needed to improve respirations; assess result.


name: Reinforce need for patient participation in respiratory care.


name: Teach patient or significant other(s) techniques to optimize effective respiration and gas exchange.


name: Encourage patient to use adaptive breathing techniques, to decrease work of breathing and facilitate ventilatory capacity.


name: Maintain and teach body position best suited to promote optimum ventilation.


name: Elevate head of bed as needed to promote optimum ventilation.


name: Place in high Fowler's position at meals.


name: Assist in positioning for postural drainage.


name: Make patient aware of situations that can contribute to accidental inhalation injury.


name: Stay with patient during episodes of respiratory distress, provide reassurance to allay anxiety.


name: Note amount and character of chest tube drainage.


name: Monitor and maintain chest tube patency and system vacuum.


name: Administer oxygen as ordered or indicated.


name: Add humidification to oxygen source to liquefy secretions.


name: Maintain oxygen delivery system at all times.


name: Check accuracy of oxygen therapy; such as flow rate, source, etc.


name: Monitor for response to oxygen therapy or respiratory treatments.


name: Assess patient for restlessness, confusion and irritability.


name: Assess patient for signs and symptoms of cyanosis.


name: Wean patient from supplemental oxygen to room air or least oxygen.


name: Provide care related to artificial airway.


name: Keep supplemental oxygen and equipment for intubation or tracheostomy readily available.


name: Assess effectiveness and placement of airway.


name: Assess patient's response to airway; restrain if necessary.